Citation Nr: 18157656 Decision Date: 12/13/18 Archive Date: 12/13/18 DOCKET NO. 11-20 602 DATE: December 13, 2018 ORDER Entitlement to service connection for sarcoidosis, claimed as lung disease and breathing problems, is denied. FINDING OF FACT The evidence of record fails to support a finding that the Veteran’s sarcoidosis, claimed as lung disease and breathing problems, had its onset in service or is etiologically related to active military service. CONCLUSION OF LAW The criteria for entitlement to service connection for sarcoidosis, claimed as lung disease and breathing problems, have not been met. 38 U.S.C. §§ 1110, 1117, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active military service from July 1981 to January 1994. 1. Entitlement to service connection for sarcoidosis, claimed as lung disease and breathing problems The Veteran seeks entitlement to service connection for sarcoidosis and/or lung and breathing problems which he contends began in-service as due to environmental exposures in the Gulf War, and continues to present day. As the Veteran served in the Persian Gulf area from August 1990 through April 1991, the Board concedes such environmental exposures. At the outset, the Board notes that the Veteran’s representative, in a May 2018 Written Brief Presentation, argued that VA did not fulfill its duty to the Veteran by suggesting to the Veteran to submit records from “Dr. Gaeton D. Loreno.” It was noted that a May 2017 treatment record referenced an evaluation by Dr. Loreno in 2010. However, in September 2010, VA received records from Dr. Gaeton Lorino of Montgomery Pulmonary Consultants, P.A., which included the initial evaluation performed on May 24, 2007 as well as additional follow-up consultations. The Board is not aware of any further relevant records from this physician. As such, the Board finds VA has satisfied its duty to the Veteran in obtaining records from Dr. Lorino. The Board also notes that the Veteran’s representative argued inadequacy of a November 2017 VA opinion. The Board has cured the inadequacies by obtaining expert medical opinion from the Veterans Health Administration (VHA). There has been no argument that this opinion is inadequate. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d, 78 F.3d 604 (Fed. Cir. 1996). Service connection may also be established for a Persian Gulf veteran who exhibits objective indications of a chronic disability resulting from an undiagnosed illness or a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal complaints (excluding structural gastrointestinal disorders)) that is defined by a cluster of signs or symptoms, or any diagnosed illness that the Secretary determines, in regulations, warrants the presumption of service connection resulting from an illness or from any combination of illnesses manifested by one or more signs or symptoms such as those listed below. The symptoms must be manifest to a degree of 10 percent or more during the presumptive periods prescribed by the Secretary or by December 31, 2016. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Objective indications of a chronic disability include both “signs,” in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. A chronic disability resulting from an undiagnosed illness referred to in this section shall be rated using evaluation criteria from the VA Schedule for Rating Disabilities for a disease or injury in which the functions affected, anatomical localization, or symptomatology are similar. A disability referred to in this section shall be considered service-connected for the purposes of all laws of the United States. 38 C.F.R. § 3.317(a)(3-5). Signs or symptoms which may be manifestations of an undiagnosed illness or a chronic multisymptom illness include, but are not limited to: fatigue, signs or symptoms involving the skin, headache, muscle pain, joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, or menstrual disorders. 38 C.F.R. § 3.317(b). If signs or symptoms have been medically attributed to a diagnosed (rather than undiagnosed) illness, the Persian Gulf War presumption of service connection does not apply. VAOPGCPREC 8-98. As an initial matter, the Board has considered the fact that the Veteran served in the Southwest Asia Theater of operations during the Persian Gulf War. Nevertheless, as discussed below, the Veteran is currently diagnosed with a known clinical diagnosis as to sarcoidosis. Therefore, this does not constitute qualifying chronic disability, and the provisions of 38 U.S.C. § 1117 and 38 C.F.R § 3.317 do not apply to this issue. By way of background, the Veteran underwent multiple in-service examinations where he was assessed as normal and denied trouble breathing, and shortness of breath. On examination in June 1982, the Veteran denied experiencing shortness of breath after climbing one flight of stairs, but reported Tuberculosis in 1981. The April 1993 examination was when the Veteran first reported experiencing shortness of breath when climbing one flight of stairs. At separation in January 1994, the report of medical history form reflects that the Veteran indicated “don’t know” with regards to Tuberculosis, but stated that he experienced shortness of breath when sleeping and running. The examiner added that the Veteran has not had an episode of shortness of breath in the last month since he moved out of the barracks. The Veteran underwent a Persian Gulf War examination in August 1997, where he reported occasional shortness of breath and fatigue, and stated that during service he was exposed to oil wells, fires, blowing smoke, fumes, and chemical alarms. He mentioned having full protective gear, but would unmask when there was no detection of chemicals. The Veteran reported really starting to have breathing issues in 2007, where he worked in a lumber yard, a poultry plant, and as a corrections officer doing light physical activity when his condition started to worsen. Around this time, the Veteran has a biopsy confirming his diagnosis of sarcoidosis. Treatment records from July 2008 note that the Veteran complained of tiredness and shortness of breath with minimal activity and, reported that he snored at night with increased breathing difficulty. In October 2008, the Veteran complained that the fumes from his job tended to make him experience some instances of shortness of breath. Despite this, the pulmonologist noted that the Veteran’s sarcoidosis was stable, irrespective of the presence of a mild degree of restrictive lung disease. The Veteran was advised to lose weight, to alleviate some symptoms. August 2009 records note that the Veteran noticed some wheezing over the past couple of weeks which lasted one to two days, associated with symptoms of reflux. However, the Veteran was noted to have returned to baseline, as his condition was in remission. Similarly, an April 2010 X-ray showed mild fibrosis bilaterally, unchanged when compared to previous films. Notably, the Veteran’s sarcoidosis was described as in remission. With respect to the claim, the Veteran underwent VA examination in October 2017 where the examiner opined that the Veteran’s diagnosis of sarcoidosis was less likely related to service, but more likely related to the risk factors of his race and age at the time his shortness of breath began. Moreover, the examiner stated that while the exact etiology and pathogenesis of sarcoidosis remains unknown, there are no known environmental triggers for sarcoidosis. Lastly, the examiner indicated that the Veteran reported reduced exercise tolerance which persisted immediately after separation and thus the August 1997 X-ray (taken three years post-service) should have shown sign of pulmonary sarcoidosis, but it did not. Following that examination, the Veteran through his representative submitted a May 2018 informal hearing presentation arguing opinion based on several arguments. The representative asserted that the VA examiner did not consider the Veteran’s shortness of breath report at separation and since service. The representative cited to a “significant” finding in the 2005 treatise Gulf War and Health, vol. 3: Fuels, Combustion Products and Propellants prepared by the National Academies of Sciences, Engineering and Medicine that “development of diseases related to exposure to fuels and combustion products is that there is often a latency period of ten or more years before symptoms develop.” It was further noted that the “Statement on Sarcoidosis” described five roentgenographic (x-ray) stages of sarcoidosis in the lungs.” Based on this information, the representative indicated that the normal x-ray three years after service was “neither surprising nor particularly relevant.” The representative next argued that the VA examiner erred in making a definitive statement that the Veteran’s latent tuberculosis (TB) infection in service “had absolutely nothing to do with sarcoidosis.” In support of this argument, there was a citation to the “Statement on Sarcoidosis of the American Thoracic Society” regarding “Etiology and Pathogenesis of Sarcoidosis” which identified “three different lines of evidence supporting the idea that sarcoidosis results from exposure of genetically susceptible hosts to specific environmental agents.” The representative further argued that the VHA examiner did not sufficiently discuss the Veteran’s race as it pertained to the likelihood of service connection. Based on this argument, the Board sought an additional medical opinion in June 2018 to address all relevant medical literature pertinent to the Veteran’s condition of sarcoidosis. The August 2018 opinion of record stated that the initial sarcoidosis diagnosis in 2006/2007 was made “appropriately on a constellation of clinical history and exam findings, radiologic imaging findings, lung biopsy findings, and mediastinal lymph node biopsy findings.” This examiner concurred with the 2017 examiner’s findings, noting that the Veteran’s sarcoidosis is less likely related to an event or exposures during service and less likely to have had an in-service onset. First, the examiner stated that there is no proven association between exposures in the Persian Gulf and the development of sarcoidosis, despite their being well-founded associations between other respiratory syndromes such as asthma, chronic bronchitis, and bronchiolitis-related syndromes. Second, the examiner stated that based on the records provided, it appeared that the Veteran developed sarcoidosis approximately fifteen-years after his exposures. The Veteran had a normal chest X-ray in 1997 shortly after service, which would be very unusual for sarcoidosis, and suggestive that he did present with active sarcoidosis in 1997. Clinical, radiologic, and biopsy findings of sarcoidosis did not appear until 2006/2007, approximately fifteen-years following Persian Gulf exposures. The examiner continued, stating that the etiology of sarcoidosis is unknown, but the preponderance of evidence suggests an immunologic response to inhaled environmental antigens in the presence of genetic susceptibility. Although there could be a substantial delay in the manifestations of certain pulmonary disease that occur in relation to environmental exposures, with lung disease due to asbestos exposure being a prototypical example, it would be unlikely in his judgment that pulmonary sarcoidosis would manifest in such manner. A fifteen-year lag-time between an exposure which ceased and development of a well-established immune-mediated disease would be unlikely. Last, the examiner concluded that based on the record provided it appeared that the Veteran resided in the Southeast region of the United States (Alabama and Georgia) following his discharge from active service – which the Board finds is factually correct. Sarcoidosis is very common in men of his age, as the Veteran was approximately forty-three at the time of diagnosis, and those who live in the Southeastern United States, which is likely due to a combination of environmental and genetic factors. Thus, it would be scientifically inaccurate to conclude that his active service exposures were causal in the development of his sarcoidosis, since those exposures are unproven as a cause of the disease, and because it would not have been unusual for the Veteran as a younger man in the Southeastern United States to have developed sarcoidosis in the absence of any concerning prior in-service exposures. Regarding the Veteran’s in-service notation of Tuberculosis, the examiner also agreed with the 2017 examiner in stating that there was no clinical evidence of active pulmonary Tuberculosis, but rather the Veteran was treated for latent Tuberculosis with isoniazid (INH) monotherapy for one year in 1981/1982. Thus, in the examiner’s clinical judgment, there would be no association between the development and treatment of latent Tuberculosis and the subsequent development of sarcoidosis. The Board notes that the Veteran is competent to testify as to a condition within his knowledge and personal observation. See Barr v. Nicholson, 21 Vet. App. 303, 308-10 (2007). He reported shortness of breath at service separation. However, he is not shown to have specialized knowledge of medicine in general, or pulmonology more particularly, to associate that shortness of breath as the manifestation of sarcoidosis or to medically associate his current sarcoidosis as being caused by environmental exposures in the Persian Gulf. In this regard, he is not competent to diagnose or opine as to the etiology of sarcoidosis; as that opinion requires specialized medical knowledge and specific testing. See 38 C.F.R. § 3.159(stating that competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). As such, the Veteran’s statements to the effect that his sarcoidosis is caused by in-service environmental exposures and/or a previous Tuberculosis diagnosis are lacking in probative value. As sarcoidosis is not deemed a “chronic” disease under 38 C.F.R. § 3.309(a), the Veteran’s report of continuity alone is insufficient to establish service connection. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board has also considered the medical treatise material cited by the representative. The representative cited to a “significant” finding in the 2005 treatise Gulf War and Health, vol. 3: Fuels, Combustion Products and Propellants prepared by the National Academies of Sciences, Engineering and Medicine that “development of diseases related to exposure to fuels and combustion products is that there is often a latency period of ten or more years before symptoms develop.” It was further noted that the “Statement on Sarcoidosis” described five roentgenographic (x-ray) stages of sarcoidosis in the lungs.” Based on this information, the representative indicated that the normal x-ray three years after service was “neither surprising nor particularly relevant.” The Board finds that this evidence has some probative value in establishing that sarcoidosis due to service exposures may have latently developed. However, the VHA examiner specifically reported an understanding of medical literature regarding associations between exposures in the Persian Gulf and respiratory diseases which particularly described the development of respiratory syndromes such as asthma, chronic bronchitis and bronchiolitis-related syndromes, but noted no well-founded association with sarcoidosis. The VHA examiner also did not rely exclusively on the normal x-ray in 1997 but noted the normal appearance “would be very unusual.” The examiner further stated “[a]lthough there can be substantial delay (or lag-time) in the manifestation of certain pulmonary diseases that occur in relation to environmental exposures, with lung disease due to asbestos exposure being a prototypical example, it would be unlikely in my judgment that pulmonary sarcoidosis would manifest in such a manner.” The representative has argued that the Veteran’s latent tuberculosis infection in service may be a causal factor by citing to a “Statement on Sarcoidosis of the American Thoracic Society” regarding “Etiology and Pathogenesis of Sarcoidosis” which identified “three different lines of evidence supporting the idea that sarcoidosis results from exposure of genetically susceptible hosts to specific environmental agents.” The representative also argued that the Veteran’s race may be a pertinent factor as to the likelihood of service connection. The Board finds that this evidence also has some probative value in establishing a potential service-related cause. However, the Board finds the most recent VHA examiner’s opinion to be most probative in that the examiner based the opinion upon pertinent medical literature, specific knowledge and training as a pulmonologist, as well as all available medical information including the Veteran’s lay statements as to the origin of the condition. In this respect, the VHA examiner cited all of these factors in rendering an opinion based on the specific facts of this case. It was noted that the diagnosis of sarcoidosis was made “appropriately on a constellation of clinical history and exam findings, radiologic imaging findings, lung biopsy findings, and mediastinal lymph node biopsy findings” – not just a single finding such as shortness of breath or the normal x-ray in 1997. The concept of delayed manifestation due to environmental exposures was considered but considered unlikely in the Veteran’s case. The latent TB infection and the Veteran’s race were considered, and the most likely environmental factors found in this particular case was the Veteran’s genetic factors, age and home in the Southeast region of the United States (Alabama and Georgia) following his discharge from active service. Overall, the Board finds that the VHA opinion holds significantly greater probative weight than the medical treatise articles which are not based on the specific facts of this case. Although sympathetic to the Veteran’s claim, as the evidence of record reflects that the Veteran’s currently diagnosed sarcoidosis has been dissociated with active military service, including environmental exposures, the claim must be denied. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). Accordingly, as the preponderance of the evidence is against the Veteran’s claim, the benefit-of-the-doubt rule does not apply. 38 U.S.C. §5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J.L. Reid, Associate Counsel