Citation Nr: 21063975 Decision Date: 10/18/21 Archive Date: 10/18/21 DOCKET NO. 16-12 316 DATE: October 18, 2021 ORDER Service connection for vertigo and dizziness is denied. FINDING OF FACT The preponderance of the evidence is against a connection between the Veteran's in-service streptomycin shot and his current condition manifesting in vertigo and dizziness. CONCLUSION OF LAW The criteria for entitlement to service connection for vertigo and dizziness have not been met. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1954 to January 1975. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) denying service connection for vertigo and dizziness. In the lengthy history of this matter, most recently the Board remanded the claim in July 2021 at the request of the Veteran's representative for consideration of whether his condition could be secondary to his Parkinson's disease, for which he had been newly service connected. As that directive has been complied with, the Board will now adjudicate the claim on the merits. Dyment v. West, 13 Vet. App. 141, 14647 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1998). Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Establishing service connection generally requires evidence of (1) a current disability, (2) an in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the claimed in-service event, injury, or disease and the present injury or disease. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for a current disability that is proximately due to or aggravated in severity beyond its natural progression by a service-connected injury or disease. 38 U.S.C. § 1110; 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995). The evidence reflects that the Veteran currently has vertigo episodes daily, which last hours and cause an unsteady gait and falls. The Veteran's wife has submitted diary entries from 2007 supporting that the Veteran has experienced ongoing vertigo and dizziness. Across the record, the Veteran's condition has been diagnosed as benign paroxysmal positional vertigo (BPPV) and peripheral vestibular disorder. At a February 2019 Board hearing, the Veteran testified that in the past a doctor had diagnosed him with Meniere's disease, although the records from that time had since been destroyed and were unavailable. The Veteran's contention is that his vertigo and dizziness condition was caused by a streptomycin injection he received while serving in June 1967. A series of service treatment records beginning on June 26, 1967, show that the Veteran was diagnosed with an abscess in his right little finger. On June 28, 1967, he was seen in the emergency room for the same condition. On the same day, another note indicated prescription medication for the infected right little finger. A note from June 29, 1967, shows that the finger had worsened, so a streptomycin injection had been administered intramuscularly. The Veteran has described that "approximately 2 hours after the shot I had a severe allergic reaction" including "very loud ringing in both ears, dizziness, weakness, nausea, and numbness." He stated he returned to the dispensary and the medical staff immediately gave him a different shot to counteract the streptomycin shot. In a letter received April 2013, the Veteran stated that he was sent to hospital on the same day of the streptomycin shot. Service treatment notes from June 29, June 30, and July 1, 1967, show that the Veteran returned for soaking and redressing of the wound. Of record is a June 29, 1967 letter from the Veteran to his wife in which he wrote, "The [doctor] gave me a shot of streptomycin this morning and it has caused me a lot of trouble as it made me dizzy and nauseous also.... I am still shaky from it all." Months later, letters from the Veteran to his wife dated in 1967 and 1968 detail that the Veteran became dizzy when riding in the back of a fast-driving truck up and down a mountain in Vietnam. In a February 2021 letter, the Veteran wrote that the mountain was "not a straight road but full of sharp curves." On an April 1973 in-service report of medical history, the Veteran answered No to whether he at that time had dizziness. At the Veteran's March 1974 retirement examination all body systems were found to be normal. The Veteran has explained in many statements across the record as well as at the Board hearing that he never experienced vertigo or dizziness until after receiving the streptomycin shot on June 29, 1967, and that from that date he has continued to have bouts of vertigo and dizziness. He insists that "[t]he vertigo attacks I have experienced after the streptomycin shots are identical to the one I had the day of the shot." In a March 2016 letter, the Veteran's physician, Dr. D.K., wrote that the Veteran had been a long-term patient who fights with vertigo, dizziness, and ringing in his ears, which the Veteran had told Dr. D.K. had been ongoing since 1967 when he was in service. The Veteran was provided with a C&P examination in September 2019. The examiner explained that "[a]ccording to mainstream medical literature, vestibular dysfunction in association with streptomycin is cumulatively related to the total daily dose. Particularly those who are renally impaired or elderly, when 1.8 to 2 grams per day are administered, symptoms of ototoxicity become apparent within 4 weeks of ongoing treatment. With early detection, vestibular symptoms are reversible with cessation of the medication within 2-3 months. The Veteran had a one-time dose of 1 gram of streptomycin making ototoxicity and permanent symptoms of vertigo less likely as the majority of streptomycin related ototoxicity cases were seen with high serum concentrations after prolonged administration." In order for further consideration to be given to the Veteran's in-service letters describing dizziness riding in the back of a truck several months after the shot, a new examination and opinion were provided in August 2020. The examiner remarked, "The Vet[eran] did have an adverse immediate reaction to the streptomycin shot, but symptoms would not continue based on one injection. The reason is that the blood level of streptomycin would not reach a high enough level to cause ototoxicity. Ototoxicity only occurs with high blood levels of streptomycin, which would not be achieved with a single injection." The examiner supported his conclusion with citations to current medical literature. An addendum opinion in December 2020 reiterated that "[t]he single injection of streptomycin would not cause . . . ongoing episodes of vertigo. . . . Only if the Vet[eran] had repeated episodes of streptomycin would he have such symptoms." After another complete review of the Veteran's contentions and history, a clinician in April 2021 opined that "[t]hough the Vet[eran] experienced an early reaction to the streptomycin injection he received in the military, since it was a single injection, it is unlikely that that is the cause of his subsequent symptoms of the claimed condition. Though the symptoms the Vet[eran] is claiming are similar to those of ototoxicity of streptomycin, a single dose would be unlikely to cause a permanent and irreversible ototoxic effect. One usually sees aminoglycoside (streptomycin) ototoxicity after at least one week of treatment. Further, streptomycin is not given for any type of treatment as a single dose as the half life is short and usually it is given every eight hours. A single dose would not reach an effective therapeutic level. He received a single intramuscular injection that would not reach such a serum level to cause ototoxicity." Quotations to several supporting articles were included with the opinion. Following a March 2021 argument from the Veteran's representative that the Veteran's symptoms could be related to his Parkinson's disease, for which he had recently been service connected, the Board requested an opinion. In July 2021, a clinician explained that the Veteran's symptoms are due to his diagnosed condition of BPPV, for which he continues to be treated, and that BPPV is an inner ear condition not caused or aggravated by the Veteran's Parkinson's disease. Based on all the evidence of record, the Board finds that the preponderance of the competent evidence of record is against a connection between the Veteran's current condition and his service. To begin, the Board makes clear that it believes the Veteran's many statements and hearing testimony that he had symptoms of vertigo and dizziness in reaction to the streptomycin shot in service, and the Board also believes the Veteran's statements that his current experiences of vertigo and dizziness feel similar or identical to the vertigo and dizziness that he felt in service in reaction to the streptomycin shot. However, as to the specific etiological cause of the Veteran's current condition, the weight of the competent evidence supports that the current condition is not due to the same in-service shot that caused the in-service symptoms, and the Veteran has not offered any evidence that he has the education, training, or experience to opine on the etiology of his current symptoms, which is a medically complex issue beyond observation by the senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Board acknowledges the letter from Dr. D.K. that stated the Veteran had experienced symptoms since service, but the Board finds that to the extent Dr. D.K.'s letter was intended as a statement that the Veteran's current condition was caused by the in-service shot, it is outweighed by the other competent evidence of record with citations to medical literature supporting the contrary conclusion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008). In this matter, there have been multiple examinations and opinions in order to explore all avenues of the Veteran's contentions, and the preponderance of the resulting competent evidence is that the Veteran's current condition is not directly related to the in-service shot. See Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed. Cir. 2006) (reaffirming that the Board's role is to assess the weight of all evidence). The Board finds that there is no other basis for entitlement to service connection. Though the June 2021 informal hearing presentation contended that there is some incidence of Parkinson's disease manifesting in symptoms of vertigo and dizziness, the July 2021 opinion explained that, in this Veteran's case, his symptoms are due to his diagnosed BPPV, which is a condition not caused or aggravated by Parkinson's disease or Parkinsonism. Therefore, service connection is not warranted as secondary to Parkinson's disease. 38 U.S.C. § 1110; 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995). Accordingly, without sufficient evidence to support that the Veteran's condition is connected to his service or secondary to a service-connected condition, entitlement to service connection for vertigo and dizziness is denied. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.310(a). As a final matter, the Board acknowledges a new contention by the Veteran's representative in an October 2021 informal hearing presentation that the Veteran's "private doctor stated that [the Veteran] has hand and lip tremors from his Parkinson's disease and fine motor impairment" and requesting that the Veteran "should be service connected for tremors secondary to his service-connected Parkinson's Disease." Up until this new October 2021 filing, the submissions throughout the course of this matter from the Veteran and his representative make clear that the Veteran has sought service connection for a condition manifesting in symptoms of vertigo and dizziness, without mention of tremors or tremor-like symptoms. Thus, the Board does not find that the Veteran's claim underlying this appeal reasonably would have been expected to include a claim for a condition manifesting in tremors. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). In turn, the Board does not presently have jurisdiction to consider entitlement to service connection for tremors. If the Veteran and his representative seek service connection for the Veteran's tremors associated with his service-connected Parkinson's disease, he is invited to file a new claim. K. Parakkal Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Davis, 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.