Citation Nr: 21003145 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 20-23 280 DATE: January 19, 2021 ORDER Entitlement to service connection for granulomatous disease of the lungs, due to toxicant exposure, is granted. Entitlement to service connection for thyroid cancer with postoperative hypothyroidism is granted. FINDINGS OF FACT 1. The Veteran was exposed to asbestos and toxicants (hydraulic oil, fire suppressant foam) in service. The preponderance of the evidence supports that he developed granulomatous disease as a result of his in-service exposures. 2. Resolving reasonable doubt in the Veteran’s favor, his thyroid cancer was present, but not-yet detected, in service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for granulomatous disease of the lungs, due to toxicant exposure, have been met. 38 U.S.C. §§ 1110, 1111, 5107(b) (2014); 38 C.F.R. §§ 3.102, 3.303(a) (2020). 2. The criteria for entitlement to service connection for thyroid cancer with postoperative hypothyroidism have been met. 38 U.S.C. §§ 1110, 1111, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Navy from November 1988 to July 2015. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an October 2017 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran appeared and testified at a personal hearing in January 2021 before the undersigned Veterans Law Judge. A transcript of the hearing will be associated with the electronic claims file. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Service connection for certain diseases, such as malignant tumors, may be also be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). The Board must determine the value of all evidence submitted, including lay and medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). 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(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to service connection for granulomatous disease of the lungs, due to toxicant exposure, is granted. The Veteran contends that he is entitled to service connection for granulomas of the lungs due to his military service. He has argued both that the granulomas were diagnosed during service, in 1998, and that they were caused by his exposure to asbestos and different oils and greases during service. The Veteran served in engineering, initially as a machinist mate and later as an engineering warrant officer. Service treatment records include a July 2004 chest x-ray that showed old granulomatous disease without evidence of any acute chest abnormality. The chest x-ray was taken because the Veteran was a new PPD (purified protein derivative) converter and they were ruling out active tuberculosis. A May 2015 Report of Medical Assessment included the Veteran’s report of worsening arthritis, and that he was going to seek VA benefits for “Bell’s palsy, back, ear pain, sinus, hemorrhoids, dermatitis, and anxiety.” The Veteran did not provide any respiratory complaints. An April 2015 retirement medical history completed by the Veteran included that he had a chronic cough, problems with wheezing, and tuberculosis. In explanation, he reported he had a failed tuberculosis test, and pollen allergies/allergies. He also noted that his service included exposure to “asbestos, Fyrquel (triphenyl phosphate) (aircraft elevator hydraulic oil.” He health official participating in the retirement examination noted that the Veteran had a positive PPD test followed by a negative test; the positive PPD test was a false positive. He wheezed when exposed to pollen. The examiner noted that the Veteran had been tested for mesothelioma, and had been exposed to Fyrquel, but had not been treated according to his medical records. The retirement medical examination included a normal evaluation of the lungs. In December 2015, the Veteran participated in a VA respiratory examination. He was diagnosed with granulomatous disease (asymptomatic) in 1998. He was noted to have been exposed to asbestos for over 10 years, while working in a shipyard during service. He denied symptoms, but had negative screenings several times for symptoms of asbestosis/mesothelioma. He reported symptoms of wheezing, that “occurred randomly…however, the symptoms [were] mostly noted upon exposure to some allergens.” He had not been evaluated for this condition. He had no symptoms associated with his granulomatous disease. “In regard to the asbestos exposure, intermittent mild symptoms of wheezes, self-resolving.” In the remarks section, the examiner noted that the diagnosis of granulomatous disease was provided in the medical record, and “granulomatous condition was secondary to asbestos exposure.” Pulmonary function testing was not provided because the Veteran did not have an “active disease” and his chest x-ray was negative. In October 2017, the Veteran participated in a second VA respiratory examination. The examiner found that the Veteran had never been diagnosed with a respiratory condition and did not have a current respiratory condition. The examiner noted that the Veteran’s claimed disorder was histoplasmosis based on a chest x-ray in Japan for routine asbestos surveillance. However, the Veteran denied a history of histoplasmosis or a respiratory illness in the past other than colds and flus. He did not recall an illness for which he had to take anti-infective medication such as for histoplasmosis. A chest x-ray taken in conjunction with the examination showed “clear and well-expanded lungs with sharp costophrenic sulci. Question small calcified granuloma at the left lower long, more peripherally.” Urine testing for histoplasma antigen and serologies were negative. The examiner noted that there was insufficient evidence to warrant or confirm a diagnosis of a current respiratory condition. The Veteran was asymptomatic, and his chest x-ray was negative except for the small calcified granulomas noted, which the examiner found were “likely not clinically significant.” The examiner provided a negative nexus opinion for the Veteran’s claim of entitlement to service connection for histoplasmosis, noting that the Veteran did not have a current diagnosis of histoplasmosis and that histoplasma was not caused by asbestos, but by histoplasma fungus. In January 2021, the Veteran’s attorney submitted a positive nexus opinion related to the Veteran’s granulomatous disease from private physician S.R.B. The December 2020 opinion included Dr. S.R.B.’s self-introduction as a practicing vision specializing in internal medicine with a PhD in Pharmacology. He was provided copies of the Veteran’s medical records, which were reviewed in conjunction with his analysis and opinion. He noted that the Veteran served in the Navy from November 1988 to July 2015. During his service, he was exposed to “numerous toxicants including asbestos, Fyrquel (triphenyl phosphate), and aircraft elevator hydraulic oil. His service treatment records included a finding of “old granulomatous disease.” An October 2016 record from John Parrish SD Pulmonary Clinic was cited regarding the Veteran’s asbestos surveillance chest x-ray showing probably calcified mediastinal notes. A CT scan showed thyroid nodules, renal cysts, and calcified mediastinal lymph nodes. It was noted that the Veteran’s brother had a history of calcified lymph nodes associated with prior histoplasma infection. The Veteran was then assessed with calcified mediastinal lymph nodes consistent with prior histoplasma infection. However, Dr. S.R.B. noted that the December 2015 and October 2017 noted prior granulomatous disease and calcified granuloma “likely not clinically significant.” Following a review of these records, and more, Dr. S.R.B. opinion that the Veteran had granulomatous disease due to his in-service toxicant exposure. Dr. S.R. B. noted that the Veteran was incidentally found to have granulomas while in service in 1998. The granulomas had “progressively increased, and a CT scan of hit thorax showed granulomas which were on his lymph nodes, lungs, and spleen.” Dr. S.R.B. noted that the 2016 medical providers had determined that the Veteran had overcome histoplasmosis infection; however, serologies in 2017 denied the theory of histoplasmosis infection. Dr. S.R.B. opined that the Veteran’s calcified, and faint granulomas were at least as likely as not due to toxicant exposure in service. Dr. S.R.B. noted that granulomas were small areas of inflammation in response to a persistent inflammatory stimulus. Macrophages were recruited to the site of the inflammation, and if unable to remove the inflammatory stimulus efficiently, the macrophages would form a tight aggregate around the inflammatory stimulus and may become surrounded by a peripheral cuff of lymphocytes. The inflammatory focus then is known as a granuloma. Dr. S.R.B. described granulomas as a “defense mechanism” that “‘wall[ed] off’ foreign invaders.” Dr. S.R.B. noted that the Veteran’s exposure to asbestos, Fyrquel, and aircraft elevator hydraulic oil could have resulted in the formation of granulomas in his lungs. Although the Veteran was currently asymptomatic related to his granulomas, the “accumulation of [those] toxicants, over the years, caused a disease burden on him” and the granulomas should be recognized as “benign early signs.” In contrasting the medical opinions of record, the Board is cognizant that CAVC has stressed that "[i]t is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." See generally Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Here, the 2015 and 2020 evaluators diagnosed granulomatous disease. The 2015 examiner noted that the Veteran’s granulomatous disease was due to his asbestos exposure, but that it was asymptomatic. The 2020 examiner similarly noted that the granulomatous disease was asymptomatic, but that it was an early, benign condition due to his toxicant exposures (including asbestos) in service. In contrast, the 2016 examiner found that the Veteran did not have a current lung disorder. The 2016 examiner cited an x-ray that showed granulomas, but noted that they were not “clinically significant.” The 2016 examiner provided a negative nexus opinion related to histoplasmosis, but did not provide an opinion related to granulomatous disease. The Board finds that the 2020 private medical opinion provides a more fully articulated reasoning in support of service connection than the 2016 examiner provided. As the 2015 and 2020 examiners have diagnosed granulomatous disease, and both agree that it was due to toxicant exposure in service (including asbestos), the nexus between a lung granulomas and service is met. Although the 2016 examiner indicated that the granulomas were not “clinically significant,” and therefore arguably not a current disability. However, the Veteran has reported occasional wheezing, and the 2020 private physician has noted that his granulomas have progressed and are an “early” marker of his exposure. The Board will resolve reasonable doubt in the Veteran’s favor that the granulomatous disease warrants service connection. 2. Entitlement to service connection for thyroid cancer with postoperative hypothyroidism is granted. In January 2021, the Veteran’s attorney submitted a private medical opinion in support of the Veteran’s claim of entitlement to service connection for thyroid cancer. In January 2021, Dr. A.A. of Scripps Clinic Anderson Medical Pavilion Diabetes and Endocrinology noted that the Veteran was being seen for management of thyroid cancer and postoperative hypothyroidism. Dr. A.A. had been provided with some of the Veteran’s treatment records for review. He noted that the Veteran retired from military service in December 2015 and was diagnosed with thyroid cancer in June 2016. “It is more likely than not that his thyroid cancer developed during the time of his service.” Dr. A.A. explained that thyroid nodules “generally take months or years to develop into a sizable mass and then to develop into thyroid cancer.” Dr. A.A. noted that it was “much more likely” that the Veteran’s cancer was undetected, but present, during his service. Additionally, Dr. A.A. noted that his thyroid cancer was at least as likely as not related to his exposures during service, “but data on exposures and thyroid cancer is weaker.” The Board notes that the Veteran retired from service in July 2015, and not in December 2015 as noted in Dr. A.A.’s medical opinion. Luckily, Dr. A.A. provided a helpful rationale for his opinion that the Veteran’s thyroid cancer began in service, which noted that thyroid nodules could take years to develop into a sizeable mass and then to develop further into thyroid cancer. As such, the opinion that his cancer likely began developing during service is still supported by the rationale even with the incorrect retirement date. Also, the Veteran was diagnosed with thyroid cancer within one year of discharge from service. See 38 C.F.R. § 3.309(a). As such, entitlement to service connection for thyroid cancer, with postoperative hypothyroidism, is warranted. KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. H. Stubbs, 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.