Citation Nr: 20005689 Decision Date: 01/23/20 Archive Date: 01/23/20 DOCKET NO. 11-23 740A DATE: January 23, 2020 ORDER Entitlement to service connection for sarcoidosis, to include as a result of exposure to chemical substances in the water at Camp Lejeune, is denied. FINDINGS OF FACT 1. The Veteran was treated in service for asthma, bronchitis, and pseudofolliculitis barbae, but not sarcoidosis. 2. There is no competent evidence demonstrating that the Veteran’s in-service breathing and skin symptoms were early manifestations of the sarcoidosis diagnosed a decade after service. 3. There is no competent evidence relating the Veteran’s currently diagnosed sarcoidosis to his active military service, to include conceded exposure to chemical substances in the water at Camp Lejeune. CONCLUSION OF LAW The criteria to establish service connection for sarcoidosis are not met. 38 U.S.C. §§ 1110, 1131; 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from February 1983 to April 1990. In September 2017, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge at the Central Office in Washington, DC. A transcript of that hearing is associated with the claims file ad has been reviewed. The Board requested a medical expert opinion, which was received in June 2018. The pulmonologist reviewed the claims file and opined that the Veteran’s sarcoidosis was not related to his conceded exposure to chemical substances in the water at Camp Lejeune. Nevertheless, in September 2018 correspondence in response to the medical opinion, the Veteran submitted lay statements along with copies of evidence from medical journals. He specifically indicated that does not waive RO consideration for the submitted evidence. As a result, in October 2018, the Board remanded the claim for readjudication by the AOJ. Thereafter, in October 2019, the RO issued a supplemental statement of the case, and the case was returned to the Board for further appellate review. Service Connection for Sarcoidosis 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). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In order to establish presumptive service connection for a disease associated with exposure to contaminated water at Camp Lejeune, a claimant must show the following: (1) that the veteran served at Camp Lejeune for no less than 30 days (either consecutive or nonconsecutive) from August 1, 1953 to December 31, 1987; (2) that the veteran suffered from a disease associated with exposure to contaminants in the water supply at Camp Lejeune enumerated under 38 C.F.R. § 3.309(f); and (3) that the disease process manifested to a degree of 10 percent or more at any time after service. 38 C.F.R. §§ 3.307(a)(7), 3.309(f). For the showing of chronic diseases in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). In addition, the law provides that, where a veteran served ninety days or more of active service, and certain chronic diseases become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant. Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011). This includes weighing the credibility and probative value of lay evidence against the remaining evidence of record. See King v. Shinseki, 700 F.3d 1339 (Fed. Cir. 2012); Kahana, 24 Vet. App. at 433-34. The Court has held that “generally, an attempt to establish a medical nexus to a disease or injury solely by generic information in a medical journal or treatise is too general and inconclusive.” Mattern v. West, 12 Vet. App. 222, 228 (1999) (citing Sacks v. West, 11 Vet. App. 314, 317 (1998)). Medical treatise evidence may indicate enough of a basis of a generic relationship to establish “a plausible causality based on objective facts.” Mattern, 12 Vet. App. at 228 (citing Wallin v. West, 11 Vet. App. 509, 514 (1998)). A Veteran bears the evidentiary burden to establish all elements of a service connection claim, including the nexus requirement. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). In making its ultimate determination, the Board must give a veteran the benefit of the doubt on any issue material to the claim when there is an approximate balance of positive and negative evidence. Id. at 1287 (quoting 38 U.S.C. § 5107(b)). Turning now to the relevant evidence of record, clinical evaluation of the Veteran’s lungs was normal at entrance, as reflect on his February 1983 Report of Medical Examination. Service treatment records (STRs) dated in April 1985 reflect that the Veteran was treated for an asthma flare after he was transferred to the Camp Lejeune area. It was further noted that his “asthma remitted at age 13, and he had no further problems until transfer to camp Lejeune around December 1984, where he started noticing intermittent wheezing with exertion.” Examination of the lungs revealed “occasional slight forced expiratory wheezes diffusely.” Chest x-rays and pulmonary functions testing were normal. STRs dated in June 1985 showed impression of impression of active peptic ulcer disease on the anterior wall of the duodenal bulb, as well as impression of mild adynamic ileus in the right lower quadrant. A July 1985 STR showed that the Veteran was treated at the Naval Hospital in Camp Lejeune for exercise-induced asthma. In December 1985, he complained of wheezing and coughing with a questionable assessment of an upper respiratory infection or bronchitis, though not confirmed. A June 1986 Report of Medical History notes that the Veteran had asthma and shortness of breath with frequent severe headaches. STRs dated in October 1987 showed upper left quadrant, chest pain. An October 1987 Report of Physical Examination reflected that the Veteran was not qualified for duties on foreign shores due to asthma. He separated from service in April 1990. Years later, in 2000, the Veteran was officially diagnosed with sarcoidosis by biopsy. VA treatment notes from the Indianapolis VAMC dated from April 2009 to present, show constant complaints treatment of shortness of breath, skin lesions, and headaches related to the Veteran’s sarcoidosis. VA treatment notes f dated in February 2012 from the Lee County Community-Based Outpatient Clinic indicated that CT findings were consistent with sarcoidosis and did not appear to be an acute process. During the pendency of this appeal, to include during his September 2017 hearing testimony, the Veteran has reported that the symptoms of his childhood asthma completely resolved (with the last asthma attack occurring when he was only 13 years old). He believes that the symptoms he experienced at Camp Lejeune were not similar to the symptoms he experienced with his childhood asthma. He further testified that while at Camp Lejeune, he developed scars along the right side of his nose, above his eyelid, left shin, left shoulder and forearm. He reported post-service symptoms such as excessive sweating, fatigue, sharp eye pain, and tingling of the arm “feeling like fire.” He believes that his breathing, skin and other problems experienced in service have continued after service and are related to his current sarcoidosis. Lastly, he indicated that he was prescribed medications at Camp Lejeune after going to sick-call, but those did not clear his lungs, so instead he began self-treating with over the counter steroidal medication, which provided some relief. In November 2013, the Veteran underwent a VA examination to help determine the likely etiology of the diagnosed sarcoidosis. The examiner opined that there was no evidence linking sarcoidosis with chemicals found in Camp Lejeune. The examiner explained that the causative factors of the Veteran’s sarcoidosis were unclear and added that sometimes sarcoidosis was caused by family history or certain occupations with exposure to mold and pesticides. Nevertheless, the examiner failed to identify any evidence of family or work history that could be attributed to this Veteran’s diagnosis of sarcoidosis. Furthermore, the examiner cited to one 2008 National Research Council’s report assessing potential health effects due to the water contamination at Camp Lejeune and indicated that since sarcoidosis was not one of the diseases listed, it must be that a possible link was not found. However, the Board found the opinion inadequate, as it was conclusory (“no possible link” due to sarcoidosis not being listed), insufficient (only relying on one medical literature while disregarding others), and speculative (suggesting that family and occupational history can be factors but failing to attribute any specific ones to this Veteran). Moreover, the examiner did not consider medical literature submitted by the Veteran in May 2010, which suggested that pulmonary sarcoidosis symptoms may mimic symptoms of reactive airway disease and a decline of hospitalized sarcoidosis incidents in the Navy could be reflected in the increase of asthma or other lung diseases with symptoms similar to sarcoidosis over this time period. In September 2015, the Veteran underwent an additional VA examination. The examiner opined that the currently diagnosed sarcoidosis was not related to the reported in-service respiratory symptoms, since these symptoms were consistent with asthma, and that the reported in-service and post-service skin conditions were not the type associated with sarcoidosis. The examiner added that literature showed that people who have been diagnosed with sarcoidosis usually had no signs or symptoms, and the disease is often found by x-rays. Lastly, it was noted that since there was no evidence of sarcoidosis in service and no evidence of continuous treatment thereafter, the current diagnosis was not related to service. The Board found that this opinion was also inadequate. First, the examiner inappropriately based the opinion, at least in part, on the lack of continuous medical treatment for sarcoidosis since service to concluded that the current diagnosis was not related to service. Second, the examiner did not explain how the Veteran’s childhood asthma that was specifically noted to be in “full remission” prior to service was suddenly triggered upon arrival at Camp Lejeune, nor was any consideration given to the Veteran’s credible and competent lay assertions that the symptoms he experienced in-service were not the same as those of his childhood asthma. Furthermore, as noted above, no explanation was provided as to the fact that there was no post-service treatment for any asthma related symptoms, but rather only complaints and treatments of the later diagnosed sarcoidosis. In support of his claim, the Veteran submitted numerous medical literature articles in May 2010, December 2014, and April 2017 (titled in VBMS as Web/HTML documents, VA Memo, and Correspondence, respectively). The May 2010 medical literature suggests that pulmonary sarcoidosis symptoms may mimic symptoms of reactive airway disease and the decline of hospitalized sarcoidosis incidents in the Navy could be reflected in the increase of asthma or other lung diseases with symptoms similar to sarcoidosis over this time period. The December 2014 and April 2017 literature shows that, despite extensive research, the etiology of sarcoidosis still remains unclear. Given the above evidence, the Board obtained a June 2018 expert opinion authored by a Board-Certified medical doctor specializing in pulmonary disease, internal medicine, and critical care medicine. The expert opined that it is less than a 50 percent probability that the Veteran’s sarcoidosis was due to his active duty service, to include due to conceded exposure to the contaminated water at Camp Lejeune. In addition, the expert opined that the respiratory, skin, and other symptoms treated and reported during service were less likely than not early manifestations of the currently diagnosed sarcoidosis. In finding so, the expert stated that the Veteran’s asthma and pseudofolliculitis (PFB) treated in service while in his 20’s were not likely early signs of his sarcoidosis diagnosed at age 35. The expert reviewed all of the evidence of record, noting that the medical literature provided by the Veteran actually confirmed that the causes of sarcoidosis remain unknown. The expert explained that sarcoidosis is a rare disease of unknown cause that leads to inflammation, while asthma is a common disease also associated with inflammation. The examiner stated that the Veteran’s presence of asthma in service when he was 20-22 years old does not show that he had sarcoidosis during service, or early manifestations thereof. The examiner further opined that there is no association between exposure to contaminated water at Camp Lejeune and asthma or sarcoidosis and reiterated that the presence of asthma is not a diagnostic criterion for a diagnosis of sarcoidosis. The examiner further observed that the Veteran had normal chest x-rays and a normal pulmonary function test during service. Additionally, the expert reiterated that while the Veteran is clearly diagnosed with sarcoidosis, the cause of it is not known, and found it implausible that the exposure to contaminated water at Camp Lejeune caused this Veteran’s sarcoidosis or that the exercise-induced asthma and bronchitis he had during service was evidence of misdiagnosed sarcoidosis in service. The expert explained that the re-emergence of “childhood asthma” in service is common and is likely due to the increased physical demands associated with his military service at the time. The examiner recognized the Veteran’s assertion that the pulmonary symptoms he experienced in service were not the same as those of his childhood asthma but stated that those symptoms are not criterion for the diagnosis of sarcoidosis. Again, it was noted that the Veteran’s chest x-rays and pulmonary function testing were normal in service. The Veteran continued to assert that his sarcoidosis was caused by his service at Camp Lejeune. In support, he has submitted additional medical literature, which in part, notes that sarcoidosis could be related to occupational, environmental, and exposures to inflammatory stimuli triggers. He also stated that his own treating physician has more experience than that of the June 2018 expert. Analysis The Veteran’s primary contention is that he had early manifestations of sarcoidosis while serving at Camp Lejeune and those manifestations led to the current diagnosis of sarcoidosis. The Board has reviewed all evidence, and for the reasons expressed below, finds the preponderance of the evidence is against the claim. The Veteran’s medical evidence clearly confirms a current diagnosis of sarcoidosis. Moreover, his service at Camp Lejeune from March 1985 to February 1987 is confirmed, and as such, his exposure to contaminated water at Camp Lejeune is conceded. However, there are no complaints, treatment, and/or diagnoses of sarcoidosis in service. Additionally, sarcoidosis is not among the diseases identified in 38 C.F.R. § 3.309(f) as being associated with exposure to contaminated water at Camp Lejeune. Therefore, the presumption under 38 C.F.R. § 3.309(f) is not for application. There is also no competent evidence relating the Veteran’s sarcoidosis to his military service, to include water contamination at Camp Lejeune, breathing and skin conditions and other symptoms including excessive sweating, fatigue, and tingling sensations. On the question of etiology, the Board assigns high probative weight to the June 2018 expert opinion that the Veteran’s currently diagnosed sarcoidosis was less likely than not related to service, to include the conceded exposure to contaminated water at Camp Lejeune, as well as the breathing, skin and other symptoms he experienced during service. In finding so, the expert had the benefit of a complete and detailed review of the record. Additionally, the expert possesses medical expertise and training in the relevant area of medicine here, namely pulmonary disorders. The expert found it implausible to relate the Veteran’s sarcoidosis to exposure to contaminated water at Camp Lejeune. The expert explained that the conditions related to such water contamination are not in any way etiologically or mechanistically related to sarcoidosis, asthma, inflammation or infections. The expert recognized that while the Veteran’s in-service asthma and his post-service sarcoidosis both cause inflammation, they are not similar conditions in that the re-emergence of childhood asthma in service is very common, while sarcoidosis is considered a rare disease. The expert stated that the asthma in service is not considered criteria to establish a diagnosis of sarcoidosis. The expert also noted that sarcoidosis is often found on chest x-rays, which in the Veteran’s case, were normal in service. Pulmonary function testing was also normal in service. With regard to the medical articles referred to, and submitted by, the Veteran, the Board finds that they are general in nature and of little probative value as to the question of whether this Veteran’s sarcoidosis is related to his contaminated water exposure at Camp Lejeune. The Board finds those medical articles too general to establish a nexus in this case. In other words, the articles are not specific to this Veteran. Ultimately, the medical articles are outweighed by the June 2018 competent medical expert opinion that is specific to this Veteran’s case. The Board concludes that the 2018 expert’s opinion was demonstrably fully informed of the pertinent factual premises of the case and provided a fully articulated opinion with supporting reasoned analysis explaining why a link could not be established. See Nieves-Rodriguez, 22 Vet. App. 295, 303-304 (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). Although the Veteran believes that his treating physician possesses more experience than the expert in this case, he has not submitted any favorable medical opinion from his physician or from any other medical professional. There is also no competent evidence of sarcoidosis being diagnosed within the first post-service year, as the medical evidence shows that he was not diagnosed until 2000, approximately ten years after separation from service. Chronic symptoms of sarcoidosis in service and/or continuity of symptoms after service have not been established. The STRs show breathing complaints attributed to asthma and an upper respiratory infection, as well as skin rash on his face diagnosed as PFB. Moreover, the Veteran has competently reported having had other symptoms in service, such as excessive sweating, fatigue, and tingling sensations in the arm. As a layperson, he is competent to report those observable symptoms, but he is not competent to medically relate those symptoms to his now diagnosed sarcoidosis. To the contrary, the June 2018 medical expert possesses the medical expertise to render a competent opinion in this matter, and as determined, has rendered a highly probative etiology opinion. The 2018 medical expert ultimately determined that the Veteran’s symptoms in service were not early manifestations of his currently diagnosed sarcoidosis. The Board finds that the probative expert opinion outweighs the Veteran’s lay statements with regard to chronicity and/or continuity.   In sum, the weight of the competent and credible evidence is against the claim. A preponderance of the evidence is against the claim of service connection for sarcoidosis, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Yaffe, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.