Citation Nr: 19113088 Decision Date: 02/22/19 Archive Date: 02/22/19 DOCKET NO. 09-15 862 DATE: February 22, 2019 ORDER Entitlement to service connection for systemic lupus erythematosus is granted. Entitlement to service connection for a disability resulting in dry eyes, to include Sjogren’s syndrome is granted. Entitlement to service connection for coronary artery disease is granted. FINDINGS OF FACT 1. Affording the benefit of the doubt to the Veteran, the competent medical evidence supports a finding that the symptoms associated with the Veteran’s systemic lupus erythematosus first manifested during the Veteran’s period of active military service. 2. The competent medical evidence of record supports a finding that the Veteran’s disability resulting in dry eyes, to include Sjogren’s syndrome is proximately due to or the result of his service-connected systemic lupus erythematosus. 3. The competent medical evidence of record supports a finding that the Veteran’s coronary artery disease is proximately due to or the result of his service-connected systemic lupus erythematosus. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for systemic lupus erythematosus have been met. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2018). 2. The criteria for entitlement to service connection for Sjogren's syndrome have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.310 (2018). 3. The criteria for entitlement to service connection for coronary artery disease have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.310 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from August 1966 to May 1968; from June 1989 to September 1989, and in April 2003. The Veteran also had almost twenty-two years of service with various reserve components from May 1986 to May 2005. The case was previously before the Board, most recently in December 2014, when it was remanded for additional records. Accordingly, a review of the record does not disclose that the Veteran and his representative have specifically raised any procedural issues to the AOJ or the Board, even when construing the Veteran’s contentions liberally. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (Board required to address only those procedural arguments specifically raised by the Veteran, though at the same time giving the Veteran’s pleadings a liberal construction). The Board has reviewed all of the evidence in the Veteran’s claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. In this regard, the Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Service Connection 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 be granted, on a secondary basis, for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995) (holding that service connection on a secondary basis requires evidence sufficient to show that the current disability was caused or aggravated by a service-connected disability). In order to prevail under a theory of secondary service connection, there must be: (1) evidence of a current disorder; (2) evidence of a service-connected disability; and, (3) medical nexus evidence establishing a connection between the service-connected disability and the current disorder. See Wallin v. West, 11 Vet. App. 509, 512 (1998). 1. Entitlement to service connection for systemic lupus erythematosus The Veteran seeks entitlement to service connection for systemic lupus erythematosus (SLE), asserting that he suffered symptoms and manifestations of the diagnosis while on active duty. During a February 1968 medical examination, the Veteran was assessed as normal but reported defects of hyperhidrosis and hyperopic astigmatism. In May 1968, the Veteran sought medical treatment and was assessed with hyperhidrosis, gastroenteritis, and an upper respiratory infection (URI), which the Veteran’s representative argues are the first manifestations of the symptoms associated with his lupus diagnosis. He was also noted to have been diagnosed with pneumonia, organism undermined in September 1966. On the Veteran’s June 1994 report of medical history form he reported frequent indigestion, foot trouble, broken bones, sinusitis, eye trouble, ear/nose/throat trouble, and skin diseases, though he was also assessed as normal by the examiner. In late 2000’s the medical records reflect that the Veteran’s anti-nuclear antibody (ANA) panel was positive and that he was going to be tested for lupus. Subsequent medical records from November 2001, reflect that the Veteran was recently diagnosed with SLE. Moreover, a July 2003 record noted that the Veteran had multiple musculoskeletal complaints that could not be directly tied to an autoimmune process, and were unrelated to the Veteran’s ANA and DNA antibody. The physician stated that unless the Veteran developed additional symptoms to suggest lupus, they should stop testing his ANA. In September of that same year, the Veteran was described as not having a diagnosis of systemic lupus. A letter from Dr. Deweerd from January 2004, recounts that the Veteran was recently diagnosed with SLE with positive ANA, double stranded DNA, arthralgias, chronic fatigue, and recurrent bronchitis; and in April 2004, the Veteran was medically evaluated and recommended for separation from the armed forces due to his diagnosed SLE. The memoranda mentioned that the Veteran’s issues began in 2001, and had worsened since then. The claims file includes multiple medical opinions, including one from the Veteran’s private physician, Dr. Bash. Dr. Bash submitted a letter in December 2007 in support of finding that the Veteran’s disability was related to service, with a high degree of medical certainty. Specifically, Dr. Bash noted that he had special knowledge in autoimmune disorders, though his specialty was in neuro-radiology. In the letter, he stated that the Veteran entered service fit for duty, experienced symptoms of hyperhidrosis, dermatitis, gastritis, colitis, intestinal spasms, URI, sinusitis, bronchitis, and pneumonia consistent with SLE during service. Additionally, he stated that medical literature documents an association between early symptoms and end stage disease, and lastly there is no more likely etiology for the symptoms that the Veteran exhibits other than SLE related complications. Moreover, Dr. Bash noted that the Veteran’s in-service chest readings are consistent with early stages of SLE. Thus, based on the Veteran’s medical history, medical literature, and his specified training in the area, he determined that the onset of the Veteran’s SLE began with his early stage symptoms beginning from 1966 to 1968. In an accompanying letter from the Veteran’s primary care provider, Nurse Practitioner (NP) Searle, she stated that due to the nature of lupus, it is difficult to obtain a definitive diagnosis and the average time of diagnosis is seven years. She added that the Veteran’s in-service symptoms of hyperhidrosis, chronic lupus-like dermatitis, gastrointestinal problems, and upper respiratory problems including chronic sinusitis, pneumonia, and chronic bronchitis were either precursors to, or included within the diagnosis of SLE. The Veteran had these symptoms since his early twenties, and though his diagnosis of SLE came much later, the forestated symptoms were manifestations of his current diagnosis of lupus. The Veteran underwent VA examination in November 2010, where the examiner opined that the Veteran that the Veteran did not have SLE, because his variety of different illnesses and medical conditions did not fit the American College of Rheumatology (ACR) criteria for a diagnosis of SLE. The examiner stated that the Veteran did not have at least four of the eleven ACR criteria. Specifically, the examiner noted that the Veteran had arthritis, but did not have any adverse skin pathology beyond eczema. Likewise, the Veteran did not have renal involvement, blood cell deficits, oral ulcers, spontaneous serositis, higher ANA titers, or positive antibodies to double strand DNA. Lastly, the examiner stated that the Veteran’s history of gastroenteritis, pneumonia, sinusitis, intestinal spasms, and irritable bowel syndrome do not qualify as ACR criteria for SLE; and as the Veteran does not have a current diagnosis, the disability could not be due to military service. An additional medical opinion was sought in November 2011, where the examiner noted that at one-time ANA antibodies were present in significant titers and a single ant-DNA titer was mildly elevated. However, repeat anti-DNA testing was negative and the Veteran was not diagnosed with SLE. The Veteran was seen again in 2004, and the physician did not opine a diagnosis of SLE. Thus, the examiner opined that after a review of the Veteran’s medical records, including earlier rheumatologists’ opinions, the Veteran did not have a diagnosis of SLE. This examiner added, that the diagnoses from Dr. Bash and NP Searle, must have assumed that the diagnosis was correct in providing their opinions which this examiner chose to discount. Treatment records from Dr. Oparanaku from April 2014, also reflect the Veteran’s diagnosis of SLE with photosensitive rash, oral sores, pleuritic chest pain, neurologic symptoms, positive ANA, and double strand DNA. The Board points out that in addition to the medical opinions of record, the Veteran’s VA treatment records are full of notations reflecting that he has a medical history and diagnosis of lupus, and indications that he was being treated for the condition as well. November 2014 VA treatment records state that the Veteran will be “restarted on his lupus medication and will go home with a prescription for Ambien” while he sought treatment for malaise fatigue amongst other things. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). In this regard, the Board finds that the medical opinion evidence is in relative equipoise as to whether the Veteran exhibits a current diagnosis of SLE. However, taken in conjunction with the Veteran’s service personnel records and VA treatment records, the Board finds that the Veteran has a diagnosis of SLE, which first manifest during active service. Thereby, warranting entitlement to service connection. 2. Entitlement to service connection for a disability resulting in dry eyes, to include Sjogren's syndrome 3. Entitlement to service connection for coronary artery disease The Veteran claims entitlement to service connection for a dry eye disability and coronary artery disease (CAD) as secondary to his SLE. As such, the Board recognizes that the Veteran’s claims file includes diagnoses of both conditions, as the Veteran has multiple notations of dry eyes, sicca, and Sjogren’s syndrome encompassing his dry eye current disability. Moreover, VA treatment records note that the Veteran has coronary artery disease status post percutaneous transluminal coronary angioplasty (PTCA) with stent. Thus, the remaining issue before the Board is whether the Veteran’s claimed disabilities are proximately due to, or aggravated by his service-connected SLE. Dr. Bash provided etiological opinions for the Veteran’s eye and cardiac disabilities. Specifically, he stated that the Veteran’s cardiac problem was described as acute coronary insufficiency, left anterior descending artery stenosis with 3.5mm stent expansion have all be significantly contributed to by his longstanding SLE. He noted that the Veteran entered service fit for duty, his cardiac condition antedates his diagnosis of SLE, and SLE is known to cause the type of cardiac problems that Veteran experiences per medical literature. Pertinently, Dr. Bash cites Goldman-Cecil’s Medicine textbook noting that “SLE is a multisystemic autoimmune disease that results in immune system-mediate tissue damage. Manifestations of SLE can involve the skin, joints, kidney, central nervous system, and cardiovascular system…” He adds that the Veteran’s disease process is highly heterogenous and can include manifesting a variable combination of clinical features including a waxing and waning clinical course, although some patients may demonstrate a pattern of chronic activity. In sum, he stated that the Veteran’s cardiac disability is the result of his SLE, as part of the course of the autoimmune disability, also noting that there is no other diagnosis that his cardiac disability would be attributed to. Accordingly, the Board finds that the competent medical evidence of record labels the Veteran’s currently diagnosed coronary artery disease as the result of his service-connected SLE. Thus, entitlement to service connection for coronary artery disease is also warranted. Dr. Bash also provided a statement regarding the Veteran’s eye disability, noting that the Veteran’s eye disability antedates his diagnosis of SLE. Additionally, as SLE is known to cause that type of vision problems per Dr. Marchant and medical literature, it is most likely his dry eyes are caused by his SLE, as they cannot be attributed to any other medical condition contained in the Veteran’s medical records. To this point, in a final sentence of the November 2011 medical opinion, the VA examiner stated that the Veteran’s attribution of sicca (dryness) complaints and coronary artery disease as secondary to SLE, although pertinent to people who truly have SLE, is invalid in this case, as the Veteran does not have a diagnosis of SLE to begin with. Thereby affirming a positive medical association between the two conditions. Lastly, in an October 2014 statement from Dr. Marchant, Doctor of Optometry, he noted that the Veteran had been a patient for over fifteen years and has increasingly suffered from dry eyes oftentimes referred to as tear film instability. The instability of the Veteran’s tear film causes variable vision discomfort and occasionally watering of the eyes. The Veteran’s lupus diagnosis was approximately seven to eight years ago, and his dry eye problem began around the same time. The physician stated that the Veteran’s dry eye disability is secondary to the underlying systemic condition, lupus. More specifically, he stated that oftentimes, lupus patients suffer from dry eye which is corroborated by medical literature noting the high correlation between the two conditions. Finally, the physician opined that the primary cause of the Veteran’s dry eyes is his diagnosis of SLE. Consequently, the Board also finds that entitlement to service connection is warranted for a disability resulting in dry eyes, to include Sjogren’s syndrome, as the medical evidence competently shows that the Veteran’s dry eye disability is due to his service-connected SLE disability. ROBERT C. SCHARNBERGER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J.L. Reid, Associate Counsel