Citation Nr: 18159796 Decision Date: 12/20/18 Archive Date: 12/19/18 DOCKET NO. 15-06 476 DATE: December 20, 2018 ORDER Entitlement to service connection for lupus is denied. FINDING OF FACT Lupus did not manifest in service, within the one-year presumptive period, or for many years thereafter, and is otherwise unrelated to service. CONCLUSION OF LAW The criteria for establishing service connection for lupus have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, a veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010). In addition, for veterans with 90 days or more of active service during a war period or after December 31, 1946, certain chronic diseases, including systemic lupus erythematosus, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Pursuant to 38 C.F.R. § 3.303(b), where a chronic disease is shown as such in service, subsequent manifestations of the same chronic disease are generally service connected. If a chronic disease is noted in service but chronicity in service is not adequately supported, a showing of continuity of symptomatology after separation is required. Entitlement to service connection based on chronicity or continuity of symptomatology pursuant to 38 C.F.R. § 3.303(b) applies only when the disability for which the Veteran is claiming compensation is due to a disease enumerated on the list of chronic diseases in 38 U.S.C. § 1101(3) or 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran in this case claims entitlement to service connection for lupus, which she relates to her period of active duty service from January 1991 to August 2001. Specifically, she contends that she experienced many markers of lupus during active duty including severe fatigue and joint pain (particularly in the hips) and therefore symptoms of her currently diagnosed lupus onset during active duty. She claims that she began to notice these symptoms sometime before her first pregnancy which occurred in 1996. Alternatively, she contends that her lupus was drug induced, resulting from six months of isoniazid therapy she underwent during active duty following a positive TB test. An April 1996 service treatment record shows that she complained of feeling tired and weak; a June 1997 record notes that she had a long history of fatigue which mainly involved wanting to sleep a lot; a June 2000 record shows complaints of fatigue and lack of energy; a December 2000 record notes some fatigue and insomnia; and a February 2001 record notes that she still fatigues easily. Service treatment records also reveal complaints of muscle and joint pain although in most cases this was attributed to an acute or chronic musculoskeletal injury. Service treatment records also show that she received isoniazid therapy from approximately February to August 1999. Post-service, at a February 2002 VA general medical examination, she reported that for about three years she always felt fatigued although she denied experiencing “undue fatigue” at the time of the examination. She reports that she was formally diagnosed with lupus in 2006 and records from 2007 confirm regular treatment for systemic lupus erythematosus. A VA opinion was obtained in October 2014; however, the examiner there stated that she was unable to offer an opinion without resorting to speculation. Accordingly, in June 2018, the Board sought a medical expert opinion from the Veterans Health Administration to address the etiology of the Veteran’s lupus. In August 2018, a rheumatologist opined, after reviewing the claims file, that it was less likely than not that the appellant’s lupus manifested to a compensable degree within one year of separation from service, had shown a continuity of symptomatology after separation from service, or was otherwise related to service, to include the six months of isoniazid therapy following the positive TB test. She observed that although there were symptoms of fatigue and malaise in service, such symptoms began prior to her receipt of isoniazid and there were no documented clinical findings of pathology related to lupus until serologies and renal biopsy findings in 2006. She additionally observed that although a positive ANA, which is one of the 17 criteria required for classification for lupus, may occur in up to 22 percent of individuals treated with isoniazid, actually developing the disease from the administration of the drug is exceedingly rare, and any subsequent development of lupus is considered a coincidence. Based on the above, the Board finds that a preponderance of the evidence is against the claim. As the August 2018 opinion was provided by a medical professional trained in rheumatology and was supported by rationale that is consistent with the evidence of record, the Board affords it significant probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). The opinion indicates that the examiner fully considered all potentially relevant medical evidence as well as the Veteran’s contentions. See Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012). There is no contrary opinion. To the extent the Veteran has offered her opinion that lupus had its onset during service or is otherwise related to service, to include isoniazid therapy, this testimony pertains to a medical process which extends beyond an immediately observable cause-and-effect relationship. Opinions of this type have been found to be beyond the competence of lay witnesses. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (“sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer”). To the extent she is competent to so opine, the specific, reasoned opinion of the August 2018 examiner is of greater probative weight than any such general lay assertion. Further, the probative evidence of record shows that systemic lupus erythematosus did not onset during service or for many years thereafter. 38 C.F.R. § 3.309(a). The evidence, as interpreted by the August 2018 rheumatologist, shows that systemic lupus erythematosus did not manifest and was not “noted” in service. Thus, the provisions of 38 C.F.R. § 3.303(b) pertaining to chronicity or continuity of symptomatology are not for application. Accordingly, the weight of the evidence is against the claim and the claim must be denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the claim, the doctrine is not for application. 38 U.S.C. § 5107. GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Matthew Schlickenmaier, Counsel