Citation Nr: 21000963 Decision Date: 01/06/21 Archive Date: 01/06/21 DOCKET NO. 16-29 427 DATE: January 6, 2021 ORDER Service connection for rheumatic fever residuals is denied. FINDING OF FACT The preponderance of the evidence is against the finding that the Veteran has rheumatic fever residuals or had rheumatic fever at any point during the pendency of the claim. CONCLUSION OF LAW The criteria for entitlement to service connection for residuals of rheumatic fever have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from September 1974 to November 1974. This matter is before the Board of Veterans’ Appeals (the Board) on appeal from a June 2015 Department of Veterans Affairs (VA) Regional Office (RO) rating decision. The rating decision, inter alia, denied service connection for rheumatic fever. The Veteran’s Notice of Disagreement (NOD) was received in June 2015. The Statement of the Case was issued in May 2016 and the Veteran’s VA Form 9, substantive appeal to the Board was received in June 2016. In September 2019, the Veteran appeared before the undersigned Veterans Law Judge (VLJ) for a Board videoconference hearing. The transcript is of record. In November 2019, the Board remanded the claim for additional development and adjudication. Entitlement to service connection for rheumatic fever residuals. The Veteran seeks service connection for rheumatic fever. At the September 2019 hearing, the Veteran testified that while he was in service, he was hospitalized for rheumatic fever and as a result is suffering from residuals. Specifically, the Veteran testified that as a result of rheumatic fever, he has a heart murmur and is continually having heart problems for which he has to carry medications. The Veteran testified that other residuals of rheumatic fever include rashes on his arms and a neurological disorder that causes shaking. Service connection may be established for disability due to disease or injury that was incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. To establish service connection for a claimed disability, there must be evidence of: (i) a present claimed disability; (ii) incurrence or aggravation of a disease or injury in service; (iii) and a causal relationship between the present disability and the disease or injury in service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a layperson. 38 C.F.R. § 3.159 (a)(2). Competent medical evidence is necessary where the determinative question requires medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. Competent medical evidence may also include statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. A claim will be denied if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). The Veteran’s service treatment records (STRs) do not contain diagnosis or treatment for rheumatic fever. The Veteran’s STRs indicate that in September 1974 the Veteran developed hemolytic strep throat. The STRs indicate that the Veteran was hospitalized from September 26, 1974 to October 1, 1974 with lower lobe pneumonia. His hospital treatment was noted to be uneventful. The Veteran was medically discharged from the military in November 1974 due to an unrelated congenital orthopedic condition. A September 1992 private treatment note from Dr. S.T. indicates that the Veteran was seen for a nasal lesion. The Veteran reported being concerned with a mass on his nose and wished to rule out cancer. He also reported problems with sore throats and enlarged tonsils. The Veteran reported jaw surgery and thumb repair. He also reported having a heart murmur secondary to rheumatic fever. Upon examination, the Veteran’s heart was noted to be normal without a murmur. The Veteran underwent a biopsy of the nasal lesion and tonsillectomy. An August 1996 private treatment note from Dr. M.S. indicates that the Veteran was admitted with biliary tract symptoms and underwent an uneventful laparoscopic cholecystectomy. The Veteran reported a history of rheumatic fever as a child, with no history of a murmur, or history of any shortness of breath or cardiac lesion. Under review of symptoms, chest and cardiac was negative, and Dr. M.S. noted that the Veteran had a history of rheumatic fever as a child but no rheumatic carditis. It was also noted that genitourinary, neurological, skin, and endocrine systems were all normal. The Veteran’s heart rate was noted to be normal and there was no heart murmur. A March 1997 private treatment note from Dr. C.H. indicates that the Veteran was seen for pancreatitis and a review of systems was negative for respiratory, cardiovascular, gastrointestinal or endocrine, musculoskeletal, psychological, neurological, and integument disorders. A February 2003 private treatment note from Dr. B.S. indicates that the Veteran was admitted for abdominal pains, bloating, nausea, and vomiting, and was diagnosed with acute pancreatitis with abnormal liver tests. Under past medical history, the Veteran reported having rheumatic fever many years ago and never needing to take antibiotics related to this. The Veteran’s physical examination revealed regular heart rate and rhythm with no noted murmurs or gallop. A November 2013 private emergency department note from Dr. B.H. indicates that the Veteran complained of cough, fatigue, body aches, and fever. His symptoms lasted for one week and worsened, and he presented to the emergency room. The Veteran reported a history of pneumonia and indicated that he was worried that he contracted it again. The Veteran’s skin was normal on examination. He underwent an EKG which was normal. It was noted that the Veteran likely had a viral illness and was discharged. A September 2014 private treatment note from Dr. D.J. indicates that the Veteran was treated for a growing pigmented lesion on his shoulder. A biopsy was taken. A March 2015 private treatment note from Dr. D.J. indicates that the Veteran was seen for a recurrent rash with hives, itchiness, pain, and redness. The Veteran had a slight fever. Another biopsy was taken. A March 2015 private pathology report from Dr. D.J.’s office indicates the Veteran’s shoulder lesion was attributed to be a dermal hypersensitivity reaction while the Veteran’s March 2015 rash was attributed to be sparse perivascular infiltrate. A July 2015 private treatment note from Dr. W.J. indicates that the Veteran presented recently over sedated. Dr. W.J. noted that the Veteran had not taken more of anything, but it was noted that he looked “drugged.” The Veteran reported having rheumatic fever in 1974. He reported having military experience where he saw rape, assault, and a drill sergeant that dropped out of a building that killed him. The purpose of the visit was to follow up for labs. Dr. W.J. indicated that the Veteran had concerns for rheumatic fever complications and was reassured that he had an echocardiogram done last year and there was no evidence of cardiac complications from rheumatic fever. A March 2016 private treatment note from Dr. A.C. indicates that the Veteran was hospitalized for chest pains and that his echocardiogram was normal. The Veteran was diagnosed with labyrinthitis and Dr. A.C. indicated that this was not likely of cardiac nature. A March 2016 private treatment note by Dr. B.M. indicates that the Veteran was seen for neck, shoulder, left hip, and lower back pain with a slipped lower back disk. The Veteran reported this pain starting after July 1981 when a tire blew up in his face, throwing him back, injuring his back, and requiring surgery. The Veteran was diagnosed with an annular tear and a disc bulge at L4-L5. Treatment with lumbar epidural steroid injection was recommended. Dr. B.M.’s private treatment records indicate that the Veteran was seen on June and July 2019 for the same issues with no new complaints. A December 2019 private treatment note from Dr. B.M. indicates that the Veteran complained of a mitral valve murmur due to rheumatic fever in the armed forces. Dr. B.M. noted that the Veteran was recommended to undergo an echocardiogram. The December 2019 private treatment note from Dr. B.M. also indicates the Veteran’s cardiac review of symptoms was negative, with no abnormal sounds detected. A February 2020 private treatment note from Dr. B.M. indicates that the Veteran reported knee and shoulder joint pain due to rheumatic fever in 1981. Under significant changes, it was noted that the Veteran reported having more painful joints due to rheumatic fever. A March 2020 private treatment note from Dr. B.M. indicates that the Veteran reported having knee, neck, back, wrist, and shoulder pain. The Veteran reported more pain due to previous rheumatic fever from arthritis in joints, which was severe. An August 2018 private hospital admission note indicates that the Veteran reported past medical history of cervical radiculopathy, hypertension, chronic neck pain, pancreatitis, rheumatic fever and transient ischemic attack. The Veteran was admitted with abdominal pain with a history of pancreatitis. An October 2019 statement from U.C., the Veteran’s sister, indicates that the Veteran contracted rheumatic fever when he was in the Army. U.C. stated that the Veteran was 18 years old and she remembers doctors calling her parents from the hospital telling them that the Veteran had rheumatic fever and would not make it through the night as his fever was high and medications have not started working. U.C. stated that the Veteran’s parents were not able to visit him in the hospital. She also stated that the Veteran got better over time, but the fever had taken a toll on his body and he was never the same after that. She stated that the Veteran had rashes on his body and shakes in his hands. U.C. stated that she believes the rheumatic fever damaged the Veteran’s nervous system and that the hospital took a picture of him recovering and send it to her parents. An October 2019 statement from J.H., the Veteran’s sister indicates that the Veteran contracted rheumatic fever in the Army and was in critical condition. J.H. stated that the Veteran was hospitalized, and her parents were informed of the hospitalization but were not able to visit. She also stated that the Veteran was hospitalized for a while and was later released with an honorable discharge. She then stated that the Veteran arrived home very ill, remained sickly and weak, and developed shaking in his hands and body, a heart murmur, difficulty sleeping, and never truly recovered from rheumatic fever. J.H. stated that the Veteran was treated by several physicians for ailments due to contracting rheumatic fever. In a March 2020 VA medical opinion, the examiner indicated a review of the Veteran’s records, and the September 1974 diagnosis of beta hemolytic strep throat was confirmed. Under history, the VA examiner indicated that the Veteran developed hemolytic strep throat in September 1974 and as admitted to the hospital on September 26, 1974 with right lower lobe pneumonia. The VA examiner noted that there were no documented symptoms of rheumatic fever and that the Veteran did not meet the revised Jones criteria for acute rheumatic fever. The VA examiner noted that there was no joint pain, no rash, no cardiac inflammation, and no skin nodules. The VA examiner indicated that the Veterans disease became inactive in October 1974 and did not have any current symptoms or residuals. The VA examiner concluded that the Veteran did not have a diagnosis of rheumatoid fever due to pneumonia in service. The VA examiner indicated that the Veteran did not have any documented rheumatic fever symptoms, did not meet the Jones criteria, did not have rheumatic heart disease. The VA examiner also indicated that there was no etiology for rheumatic fever and that the Veteran never had it. In an August 2020 VA medical opinion, the examiner reviewed the Veteran’s records, and the VA examiner concluded that it is not likely at all that the Veteran had residuals from strep throat and pneumonia, to include a heart disorder, a neurological shaking disorder, or a skin rash. The VA examiner indicated that the Veteran underwent a CT scan in 2018 showing no heart damage, no scarring, no pericardial fluid and normal lungs. The VA examiner also cited a November 2018 private visit with Dr. C. which did not mention a heart, neurological, or skin disability. The VA examiner noted that the Veteran has never had rheumatic fever and that it is not consistent with any medical studies that his current joint pain has a relationship to a single episode of strep throat or pneumonia. The VA examiner also concluded that the Veteran did not have any residuals from an illness that occurred in service. Additionally, the Veteran submitted several medical articles on rheumatic fever. A March 2020 medical article from National Institute of Health indicates that rheumatic fever is an autoimmune disease that may develop after strep throat infection, but does not affect all individuals who have had a strep throat infection. The article indicates that the revised Jones criteria helps physicians make the clinical diagnosis of rheumatic fever. The article also indicates that rheumatic fever may cause long-term damage to the heart and its valves. The Veteran’s Social Security Administration records indicate that he applied for disability due to arthritis, knee pain, back pain, neck pain, depression, anxiety, and memory loss. Finally, the Veteran submitted a photo of himself laying in a bed with what appears to be a hospital identification bracelet on his hand. The handwritten caption on the photo states “Picture of Billy D. Hogue Rhematic [sic] Fever Fort Ord, CA.” The threshold matter that must be addressed here is whether there is probative evidence that the Veteran has (or during the pendency of the claim has had) the disability for which service connection is sought. In this case, the record does not show that the Veteran ever had rheumatic fever. The Veteran has not submitted any probative evidence showing a rheumatic fever diagnosis or evidence of suffering from any residuals from an illness that occurred in service. The Veteran’s STRs do not contain a diagnosis of rheumatic fever and merely indicate that he was hospitalized for 5 days with pneumonia after developing strep throat. Records following his hospitalization indicate that he returned to duty without follow up treatment prior to his discharge. Moreover, the STRs indicate that the Veteran’s hospital treatment was uneventful. The Veteran’s post-discharge private treatment records do not contain a diagnosis for rheumatic fever or any residuals thereof. There are numerous self-reported mentions of prior history of rheumatic fever, none which were corroborated with diagnostic testing, and all of which were contradicted by the medical records in this case. More significantly, the Veteran’s private treatment records contain several competent private medical opinions by the Veteran’s treating physicians indicating that the Veteran did not have residuals of rheumatic fever. See July 2015 private treatment note from Dr. W.J. indicating that the Veteran was reassured that he did not have cardiac complications from rheumatic fever citing a recent echocardiogram. All this is corroborated by the March 2020 and August 2020 VA medical opinions which provide adequate rationales for the conclusions reached and are afforded probative value. The medical articles submitted by the Veteran do not establish a diagnosis in this case, as they do not pertain to the Veteran’s specific etiology. Furthermore, the Veteran does not possess the medical expertise to provide a rheumatic fever diagnosis. In this case, the Veteran contends that he contracted rheumatic fever in service, was hospitalized for it, and suffers from residuals including a cardiac murmur, skin rashes, and a neurologic disability. In this regard, the Veteran has not been a credible historian. In an August 1996 private treatment note from Dr. M.S., the Veteran reported having rheumatic fever as a child, with no history of a heart murmur, or other cardiac symptoms. In a February 2003 private treatment note from Dr. B.S., the Veteran reported having rheumatic fever many years ago and never needing to take antibiotics. In a December 2019 private treatment note from Dr. B.M., the Veteran reported having rheumatic fever in the military and having a mitral valve murmur as a result. The record contains numerous inconsistent statements by the Veteran indicating that he was diagnosed with rheumatic fever at different points in his life and providing inconsistent details about having residuals. Interestingly, as noted in the November 2013 private emergency department note from Dr. B.H., when the Veteran was seeking treatment for suspected pneumonia or a viral disease, he only reported having a history of pneumonia, and not rheumatic fever. There are also inconsistencies with respect to the Veteran’s reported symptoms and residuals. Aside from having a documented history of providing contradictory statements to his various private treatment providers (See e.g. September 1992 reports of having a heart murmur and August 1996 reports of not having a heart murmur), there is evidence that the Veteran pivoted as to what is causing his joint pain symptoms. A review of Dr. B.M.’s pain management records indicates that in March 2016 the Veteran began treatment for neck, shoulder, left hip, and lower back pain, which he attributed to a July 1981 injury. In February 2020, the Veteran reported to the same provider that his knee, neck, back, wrist, and shoulder pain is from previous rheumatic fever. Of note, while there is evidence that the Veteran was treated for rashes and other conditions that he alleges to be residuals of rheumatic fever, the Veteran’s private treatment records indicate that these symptoms were attributed to other conditions. For example, following the March 2015 biopsy, the Veteran’s recurring rash was attributed to be a dermal hypersensitivity reaction. With respect to contentions that the Veteran suffered from a neurological disorder that caused shakes or a cardiac murmur, the Veteran’s private treatment records contradict these assertions. Indeed, these records contain numerous systems checks, echocardiograms, and other competent diagnostic tests indicating that the Veteran did not have a heart murmur or any other cardiac problem and did not have a neurologic disability. The only evidence in support of the Veteran’s assertion that he was diagnosed with rheumatic fever is the Veteran’s own self-reported history, and lay statements that were provided by family members. Certainly, the Veteran, as a lay person, is competent to report observable symptoms such as pain. See Barr v. Nicholson, 21 Vet. App. 303, 308-310 (2007). However, it is clear, based on a detailed review of the statements overall, that the Veteran and his family do not have medical expertise to provide a diagnosis of rheumatic fever. A rheumatic fever diagnoses requires specialized medical knowledge and specific diagnostic 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 lay statements regarding his medical history and diagnosis, are lacking in probative value, and are far outweighed by other evidence of record showing no in-service treatment or diagnosis for rheumatic fever and no post-discharge residuals of any disability that began in service. In other words, even if the Veteran sincerely believes that he suffered from rheumatic fever during service, these assertions are outweighed by the competent medical evidence of record which shows that the Veteran’s in-service illness was not rheumatic fever. In light of the foregoing, the preponderance of the evidence is against a finding that the Veteran was diagnosed with rheumatic fever in service, or any in-service illness that resulted in current residuals. Accordingly, service connection for rheumatic fever, and any residuals thereof, is not warranted. L. B. CRYAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Kuksova, Kseniya 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.