Citation Nr: 21069270 Decision Date: 11/18/21 Archive Date: 11/18/21 DOCKET NO. 12-16 513 DATE: November 18, 2021 ORDER Entitlement to service connection for chronic fatigue syndrome, to include as due to an undiagnosed illness or other qualifying chronic disability and/or as due to exposure to chemical and/or environmental hazards during Gulf War service, is denied. Entitlement to service connection for chronic lymphocytic leukemia, to include as due to exposure to chemical and/or environmental hazards during Gulf War service, is granted. FINDINGS OF FACT 1. A preponderance of the evidence does not reflect a current diagnosis for chronic fatigue syndrome or a medically unexplained chronic multi-symptom illness related to fatigue. 2. The evidence is in relative equipoise as to whether the Veteran's chronic lymphocytic leukemia was incurred in service or manifested within one year of service separation. CONCLUSIONS OF LAW 1. The criteria for service connection for chronic fatigue syndrome have not been met. 38 U.S.C. §§ 1110, 1117, 1131, 5107(b); 38 C.F.R. §§ 3.303(a), 3.317. 2. The criteria for service connection for chronic lymphocytic leukemia have been met. 38 U.S.C. §§ 1110, 1112, 1117, 1137, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1983 to August 2003, to include service in the Southwest Asia theater of operations. These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 2009 Rating Decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran's May 2012 substantive appeal initially requested a hearing before the Board at a local RO. However, in February 2016, the Veteran's representative submitted a statement that the Veteran no longer wanted a hearing before the Board. As such, the Board considers the Veteran's request for a hearing to be withdrawn. See 38 C.F.R. § 20.704 (e). The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93; 38 C.F.R. § §§ 3.102, 3.156(a), 3.159, 3.326(a). Here, the Veteran has not raised any issues with regard to the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381(Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). This case was remanded by the Board for additional development in February 2021. Specifically, this Remand directed that the RO obtain updated VA treatment records, secure any relevant outstanding private treatment records, undertake efforts to substantiate the Veteran's claim of being exposed to depleted uranium during active service, and obtain addendum opinions regarding the etiology of the Veteran's claimed disabilities. Additional VA treatment records were added to the claims file in August 2021. In March 2021, the RO sent the Veteran correspondence requesting him to complete a VA Form 21-4142, Authorization to Disclose Information to the VA, and to provide any additional evidence to substantiate his claim of being exposed to depleted uranium during active service; however, it does not appear that the Veteran responded to these requests. See Hayes v. Brown, 5 Vet. App. 60 (1993) (VA's duty to assist is not a one-way street; if a veteran wants help, he/she cannot passively wait for it in those circumstances where his own actions are essential in obtaining evidence). Additionally, in August 2021, the RO obtained multiple opinions regarding the etiology of the Veteran's claimed disabilities. As such, the Board finds that there has been substantial compliance with its February 2021 Remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict compliance with the terms of a remand request, is required). Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty from active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service' the so-called nexus' requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that which is pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases, including leukemia, may 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). To establish service connection under this provision, there must be evidence of a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307), and subsequent manifestations of the same chronic disease; or if the fact of chronicity in service is not adequately supported, by evidence of continuity of symptomatology after service. The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology, however, can be applied only in cases involving those conditions explicitly enumerated under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). VA will also pay compensation to a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability that manifests during service on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more before December 31, 2026. 38 U.S.C. § 1117; see 38 C.F.R. § 3.317(a); 86 Fed. Reg. 51,00-01 (Sept. 15, 2021) (extending the presumptive period for compensation for Gulf War veterans from December 31, 2021 to December 31, 2026). A qualifying chronic disability is as a chronic disability that results from an undiagnosed illness or a medically unexplained chronic multisymptom illness such as chronic fatigue syndrome, fibromyalgia, or a functional gastrointestinal disorder (excluding structural gastrointestinal diseases). 38 C.F.R. § 3.317(a)(2)(i). A medically unexplained chronic multisymptom illness has been defined as a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. 38 C.F.R. § 3.317 (a)(2)(ii). Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. Id. Along with the three examples of a medically unexplained chronic multisymptom illness provided by section 1117(a)(2)(B), VA regulations provide a list of signs or symptoms that may be a manifestation of a medically unexplained chronic multisymptom illness that includes: skin symptoms, headaches, muscle pain, joint pain, neurologic symptoms, neuropsychological symptoms, respiratory system symptoms, sleep disturbances, gastrointestinal symptoms, cardiovascular symptoms, abnormal weight loss, and menstrual disorders. 38 U.S.C. § 1117(g); 38 C.F.R. § 3.317(b). 1. Chronic fatigue syndrome The Veteran contends that he has suffered from chronic fatigue syndrome due to his active military service, to include his service in the Southwest Asia theater of operations during the Persian Gulf War. A review of the Veteran's service treatment records does not reveal diagnoses of or symptoms related to chronic fatigue syndrome. To the contrary, on his May 2003 Report of Medical History at separation from service, the Veteran reported that he was currently in good health and never experienced frequent trouble sleeping. The Board notes private medical records submitted by the Veteran from April 2008 and May 2009 indicated diagnoses of chronic fatigue syndrome. However, the Veteran's records also indicated that his chronic fatigue syndrome, or his symptoms of chronic fatigue, may be medically explained. For instance, April 2008 records from Lakeland Regional Cancer Center in Lakeland, Florida, indicated that an Epstein-Barr infection may be the cause of his "chronic fatigue syndrome." Treatment records from January 18, 2008, and April 18, 2008, indicated that the Veteran was hospitalized at Lakeland Regional Cancer Center on from January 12, 2008, to January 13, 2008, due to an Epstein Barr infection that had been associated with his claimed symptoms of chronic fatigue. Additionally, the Veteran's psychiatric examinations in April 2011 and February 2016 attributed symptoms of sleep impairment, including insomnia, to his service-connected posttraumatic stress disorder (PTSD). The Veteran was provided with a VA Gulf War examination in November 2011, at which time the examiner opined that "there is no diagnosis of chronic fatigue syndrome" and that medical data did not support this condition. However, in its September 2016 Remand, the Board found this opinion to be inadequate on account of its failure to acknowledge the chronic fatigue symptoms noted in the Veteran's private treatment records. Pursuant to the Board's September 2016 Remand directives, the Veteran underwent another Gulf War examination in November 2016. However, in the examination report, the VA examiner did not address the Veteran's chronic fatigue syndrome, and did not complete a Disability Benefits Questionnaire specifically for chronic fatigue syndrome. The examiner did not address whether the Veteran had met the requirements for a diagnosis of chronic fatigue syndrome at any point during the period on appeal. However, the examiner did include a brief discussion of the etiology of chronic fatigue syndrome in his medical opinion provided on the Disability Benefits Questionnaire for the Veteran's chronic lymphocytic leukemia. The examiner stated that it would be resorting to mere speculation to opine whether or not the Veteran's chronic fatigue syndrome was caused or aggravated to any degree by environmental exposures in Southwest Asia during the Gulf War or his military service. The examiner also noted in this opinion that although Gulf War environmental exposures can cause chronic fatigue syndrome, the Veteran's diagnosis of Epstein-Barr infection was the most likely source of his current chronic fatigue syndrome. The examiner did not provide a supporting rationale for his conclusion, nor explain how a virus diagnosed almost 10 years prior would be responsible for the Veteran's present symptoms of chronic fatigue syndrome. As such, in a June 2018 Remand, the Board found that the November 2016 VA opinion regarding chronic fatigue syndrome was inadequate and directed that a new etiological opinion be obtained. Pursuant to the Board's June 2018 Remand directives, the Veteran was provided with a VA Chronic Fatigue Syndrome examination in October 2020, at which time he was diagnosed as having chronic fatigue syndrome in addition to Epstein-Barr syndrome. However, the examiner then opined that the chronic fatigue syndrome was less likely than not incurred in or caused by an in-service injury, event, or illness. Curiously, in support of this conclusion, the examiner explained that: It does not appear that CFS was a valid diagnosis. He had positive serology for convalescent Epstein Barr infection per medical oncology note dated 4/18/2008 at a medical oncology follow-up from Lakeland Regional Cancer Center. It was felt that Epstein Barr infection was the cause of his symptoms. This was not a problem occurring while in the military as there was no record of him with an illness that tested positive for Epstein Barr infection while in the military. Again, in its February 2021 Remand, the Board found the October 2020 VA examination and its supporting rationale to be inadequate. Specifically, the examiner noted an onset date of 1993 "per patient history," but identified the source of the Veteran's fatigue as an Epstein Barr viral infection he contracted in 2008. The examiner did not explain how a viral infection contracted in 2008 could cause symptoms that began in 1993, 15 years prior to the infection. Similarly, the examiner also did not explain how the 2008 infection could still be causing the Veteran's symptoms in 2020, 12 years after the infection. In addition, it was unclear whether the examiner's statement "per patient history" meant he based the 1993 diagnosis date of chronic fatigue syndrome merely on the Veteran's own report or on other evidence of record. Upon a review of the record, the Board did not identify any evidence that established a diagnosis of chronic fatigue syndrome in 1993. In addition, the examiner also noted an Epstein Barr viral infection in 1995; however, that appeared to be a typographical error as his rationale only referenced a 2008 infection and the Board found no evidence of a 1995 infection. Also confusing to the Board was the examiner's self-contradictory statement that "it does not appear that CFS was a valid diagnosis" after providing a diagnosis of chronic fatigue syndrome. As such, the Board remanded the matter again for adequate opinions. Pursuant to the Board's February 2021 Remand directives, an additional VA opinion was obtained from a VA physician assistant dated early August 2021. With respect to the question of whether either chronic fatigue syndrome or Epstein Barr at least as likely as not had its onset in service or was otherwise related to service, to include as a result of presumed environmental exposures therein, as well as any confirmed uranium exposure therein, the August 2021 physician assistant explained that: The records dated 05/13/2009 clearly document. "He a fatigue, diagnosed with chronic fatigue syndrome and apparently has positive Epstein-Barr titers" UpToDate states, "Chronic fatigue syndrome (CFS), also known as myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), is an illness of uncertain cause. While underlying objective findings involving the central and autonomic nervous systems, the immune system, and energy metabolism have been described, these objective abnormalities have not yet led to a clear understanding of pathophysiology or to a diagnostic test of adequate sensitivity and specificity [1]." The veteran's symptoms started shortly after his time in the Gulf. Therefore, it is at least as likely as not that the veteran's claimed chronic fatigue syndrome is due to the exposure events in service during the Gulf War. With respect to the question as to how contracting an Epstein Barr viral infection in 2008 could explain symptoms that originated in 1993, the August 2021 physician assistant explained that, "The symptoms of chronic fatigue syndrome and Epstein Barr are overlapping." With respect to the question as to how the 2008 Epstein Barr viral infection could explain the Veteran's symptoms in 2020, the August 2021 physician assistant explained that: Epstein Barr infections can cause acute symptoms. They less than likely than not cause chronic ones. However, EBV has been associated with other cancer development later in life. The veteran has been diagnosed with chronic lymphocytic leukemia (CLL). The symptoms of his EBV have at least as likely as not resolved. Clinical manifestations and treatment of Epstein-Barr virus infection Author: John L Sullivan, MD Section Editors: Martin S Hirsch, MD Sheldon L Kaplan, MD Deputy Editor: Jennifer Mitty, MD, MPH Contributor Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Jul 2021. | This topic last updated: May 26, 2021. INTRODUCTION Epstein-Barr virus (EBV) is a widely disseminated herpesvirus that is spread by intimate contact between susceptible persons and asymptomatic EBV shedders. EBV is the primary agent of infectious mononucleosis (IM), persists asymptomatically for life in nearly all adults, and is associated with the development of B cell lymphomas, Tcell lymphomas, Hodgkin lymphoma, nasopharyngeal carcinoma, and gastric carcinomas in certain patients. Reactivation disease is not a prominent issue with EBV, in contrast to other common herpesviruses, but it has been associated with an aggressive lymphoproliferative disorder in transplant recipients [1]. (See "Treatment and prevention of post-transplant lymphoproliferative disorders".) With respect to the question as to how CFS could be present in 1993 but not be a current valid diagnosis, the August 2021 physician assistant explained that: The veteran's current symptoms of fatigue are at least as likely as not overlapping with his other medical conditions. However, chronic fatigue syndrome is not known to resolve with time. He was diagnosed with CFS in 1993, as such it is at least as likely as not that the still has a condition of chronic fatigue syndrome. Again, although the August 2021 physician assistant referenced a 1993 diagnosis of chronic fatigue syndrome, this is not supported by the contemporaneous medical evidence of record. The Board is uncertain whether the physician assistant's analysis was based on previous statements of the Veteran and/or previous statements made by prior examiners. In either event, there is no basis for a 1993 diagnosis of chronic fatigue syndrome in the record. As such, the Board affords these opinions from the August 2021 physician assistant little probative weight. For reasons unclear from the record, the RO obtained another medical opinion later in August 2021 from a physician with a specialty in internal medicine. The August 2021 physician opined that: I have noted the VA's standing guidance that if it has been determined that the original diagnosis for a claimed disability was rendered in error, I have been instructed to provide a rationale supported by the clinical evidence of record that refutes the previous exam(s) which originally diagnosed the condition. In direct adherence to this guidance, upon diligent review of the evidence of record, several inherent errors with this claim for chronic fatigue syndrome have been discovered. Based on review of the available medical evidence, there is insufficient evidence to support any current diagnosis of chronic fatigue syndrome. As explicitly defined by the VA, the diagnosis of Chronic Fatigue Syndrome requires the exclusion, by history, physical examination, and laboratory tests, of ALL other clinical conditions that may produce similar symptoms. Unfortunately, this was NOT done; all other clinical conditions that may produce similar symptoms were NOT excluded. In this pt's case, his CURRENT subjective symptoms of fatigue are explained and clinically attributable to his Chronic Lymphocytic Leukemia and or its treatment / residuals, which, per Oncology TRs 1/18/2008, was first diagnosed Jan 12, 2008 - half a decade after separation. Purely coincidentally, this was also the same time that pt's oncologist felt he was recovering from a recent acute Epstein Barr viral infection. Thus, based on review of the evidence of record, there is insufficient evidence to support any current diagnosis of any Chronic Fatigue Syndrome. The pt does NOT meet VA diagnostic criteria. With respect to the previous examination report's diagnosis of Epstein Barr viral infection in 1995, the August 2021 physician explained that: Based on the review of the evidence of record, this was a typographical error. Pt's acute Epstein Barr viral infection occurred in 1/2008. Additionally, based on the review of the evidence of record, there is insufficient evidence to support any diagnosis of Epstein Barr viral infection or chronic fatigue syndrome at any point since August 2009. Furthermore, I have noted the VA's standing guidance that if it has been determined that the original diagnosis for a claimed disability was rendered in error, I have been instructed to provide a rationale supported by the clinical evidence of record that refutes the previous exam(s) which originally diagnosed the condition. In direct adherence to this guidance, upon diligent review of the evidence of record, several inherent errors with this claim for chronic fatigue syndrome have been discovered. Based on review of the available medical evidence, there is insufficient evidence to support any current diagnosis of chronic fatigue syndrome. As explicitly defined by the VA, the diagnosis of Chronic Fatigue Syndrome requires the exclusion, by history, physical examination, and laboratory tests, of ALL other clinical conditions that may produce similar symptoms. Unfortunately, this was NOT done; all other clinical conditions that may produce similar symptoms were NOT excluded. In this pt's case, his CURRENT subjective symptoms of fatigue are explained and clinically attributable to his Chronic Lymphocytic Leukemia and or its treatment / residuals, which, per Oncology TRs 1/18/2008, was first diagnosed Jan 12, 2008 - half a decade after separation. Purely coincidentally, this was also the same time that pt's oncologist felt he was recovering from a recent acute Epstein Barr viral infection. Thus, based on review of the evidence of record, there is insufficient evidence to support any current diagnosis of any Chronic Fatigue Syndrome. The pt does NOT meet VA diagnostic criteria. The Board notes that neither the August 2021 physician assistant opinion nor the August 2021 physician opined were obtained following a physical examination of the Veteran; rather, they were based on reviews of the claims file. Significantly, however, the Board finds that the August 2021 physician opinions are based upon a review of the Veteran's treatment records and consideration of his reported history, and they are accompanied by specific rationales that are consistent with the evidence of record. Therefore, the August 2021 physician opinions are adequate and entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). To the contrary, the August 2021 physician assistant opinion is afforded little probative value as it did not explain the bases for its conclusions, i.e., the basis for determining that there was a diagnosis of chronic fatigue syndrome in 1993 that continued into the present day. Indeed, based on a totality of the evidence, the Board finds the Veteran does not have a diagnosis of chronic fatigue syndrome at any time during the period on appeal, from August 2009 to the present. Although symptoms of chronic fatigue and reference to "chronic fatigue syndrome" were indicated in private treatment records prior to August 2009, these symptoms were attributed to a 2008 Epstein Barr viral infection. Additionally, the Veteran's psychiatric examinations in April 2011 and February 2016 attributed symptoms of sleep impairment, including insomnia, to his service-connected posttraumatic PTSD, for which he is already compensated. The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Simply put, the record does not reflect a disability manifested by chronic fatigue that is separate and distinct from the Veteran's other diagnosed disabilities. As concluded by the August 2021 VA physician, there is no confirmed diagnosis of chronic fatigue syndrome since the Veteran filed his claim in August 2009. Additionally, the Veteran does not meet the criteria for an undiagnosed illness or medically unexplained chronic multi-system illness. The totality of the medical evidence and opinions suggest that any symptoms of fatigue are part of diagnosable conditions, such as Epstein Barr viral infection, PTSD, and chronic lymphocytic leukemia. To reiterate, the law states that chronic multisymptom illnesses of partially understood etiology and pathophysiology are not considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). Therefore, service connection based on the theory of chronic fatigue being part of an undiagnosed illness or medically unexplained chronic multi-system illness is not warranted. Additionally, lay evidence may be competent on a variety of matters concerning the nature and cause of disability. However, the dispositive question presented in this case (i.e., whether any relationship exists between symptoms of fatigue and service, to include chemical exposures) is a question as to internal medical processes which extend beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377, n. 4 (Fed. Cir. 2007) ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). An opinion as to whether there is a link between the Veteran's claimed disability and his potential chemical exposures in service is one requiring specialized knowledge and testing to understand the complex nature of the body systems. The Veteran has not indicated that he has such experience. His opinion on the question of nexus is therefore not competent evidence in this instance. There is no other evidence of a current diagnosis of chronic fatigue syndrome, nor evidence of a relationship between fatigue symptoms and service, and neither the Veteran nor his representative have alluded to the existence of any such evidence. Thus, the preponderance of the evidence is against a finding that the Veteran's claimed disability had its onset during active service, or that it is otherwise related to service. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application, and service connection for chronic fatigue syndrome is not warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 2. Chronic lymphocytic leukemia The Veteran contends that he has suffered from chronic lymphocytic leukemia due to his active military service, to include his service in the Southwest Asia theater of operations during the Persian Gulf War. A review of the Veteran's service treatment records reveals lymph count of 59.3 and white blood cell count of 7.94 in June 2000, lymph count of 50.5 and white blood cell count of 10.3 in October 2002, and lymph count of 71.6 and white blood cell count of 10.7 in May 2003. Additionally, in March 1989, the Veteran complained of lymph node enlargement for a duration of nine months. However, on his May 2003 Report of Medical History at separation from service, the Veteran reported that he was currently in good health. Private post-service treatment records show diagnoses of chronic lymphocytic leukemia. A private treatment record dated in August 2009 from Winter Haven Hospital in Winter Haven, Florida, indicated that, "It has been suggested by the VA officials that he may have some health-related effects of exposure to depleted uranium." However, this appears to be based on the Veteran's own report, and does not suggest that leukemia, in particular, was caused by in-service exposure to depleted uranium. In correspondence dated in November 2010, the Veteran's private oncologist, J. Pinilla, M.D., PhD, implied a possible relationship between the Veteran's diagnosis of chronic lymphocytic leukemia and his history of exposure to toxins during the Gulf War. Again, however, the Board emphasizes the Dr. Pinilla did not explicitly assert a causal relationship between the Veteran's leukemia and in-service exposure to toxins; rather, he merely rendered a diagnosis and then stated that the Veteran had a history of exposure to toxins during the Gulf War. The Veteran was afforded a VA Hairy Cell and Other B-Cell Leukemias examination in November 2011, at which time he was diagnosed as having chronic lymphocytic leukemia in remission as well as elevated lymphocyte level with normal white cell count. However, the examiner opined that it was less likely than not that the Veteran's chronic lymphocytic leukemia was incurred in or caused by a progression of the Veteran's abnormal blood work noted on active duty. The examiner noted that the Veteran had an elevated lymphocyte count (71.6) at the time of discharge from service in 2003, but stated that his white blood cell count was normal at that time (71.6) and his white blood cell count in 2009 was significantly higher (105 thousand). The examiner also noted that lymphocyte elevation in June 2000 was not pertinent because lymphocyte levels in October 2002 were normal. However, in its September 2016 Remand, the Board found that this opinion was inadequate. Specifically, the Board found that the VA examiner did not provide any explanation for why the Veteran's "normal" white blood cell count at discharge indicated that the Veteran's chronic lymphocytic leukemia was not related to these elevated in-service findings. While it may have been indicative that the Veteran's chronic lymphocytic leukemia did not manifest during his active service, it did not explain why his chronic lymphocytic leukemia was less likely than not a progression of those abnormal findings. Furthermore, the examiner also stated that the Veteran's high lymphocytes findings from June 2000 were not pertinent due to normal lymphocytes findings in October 2002, but did not address Lymph% findings from the same October 2002 report that were noted to be high. Pursuant to the Board's September 2016 Remand directives, the Veteran underwent a VA Hematologic and Lymphatic Conditions examination in November 2016. The VA examiner stated it would be resorting to mere speculation to opine whether or not the Veteran's chronic lymphocytic leukemia was caused or aggravated to any degree by environmental exposures in Southwest Asia during the Gulf War or his military service. In his rationale, the examiner noted that the Veteran's service treatment records showed elevated white blood cell counts during service (although, he did not specifically identify them); however, he concluded that there was no evidence that these counts were more than acute and transitory events or that they could have caused or aggravated his current chronic lymphocytic leukemia. No further explanation for this finding was given. Moreover, the examiner did not address the Veteran's in-service complaint of enlarged lymph nodes. The examiner also stated that although Gulf War environmental exposures do cause temporary alterations in white blood cell counts, current medical literature did not support a cause and effect relationship between these exposures and any subsequent development of chronic lymphocytic leukemia. The examiner did not address the Veteran's claimed exposure to depleted uranium, or relevant medical evidence that suggested a link may exist between such exposure and chronic lymphocytic leukemia. As such, in June 2018, the Board again remanded the matter for an adequate VA opinion. Pursuant to the Board's June 2018 Remand directives, the Veteran was provided with a VA Hematologic and Lymphatic Conditions examination in October 2020, at which time he was diagnosed as having chronic lymphocytic leukemia as well as lymphocytosis. However, the examiner opined that the chronic lymphocytic leukemia was less likely than not incurred in or caused by an in-service injury, event, or illness. In support of this conclusion, the examiner explained that, "There is no evidence suggesting the leukemia diagnosis in 2007 was caused by an IN-SERVICE INJURY, the oncologist at Lakeland Regional Cancer Center Stated in a note dated 4/18/2008: 'I initially diagnosed him with chronic lymphocytic leukemia based on laboratory work when he was hospitalized in January 2008. He also had positive serology for convalescent Epstein Barr infection.'" The examiner further elaborated that: Chronic lymphocytic leukemia is not a disability presumed to have been caused by service due solely to participating or serving in Kuwait Service. A connection for leukemia may be presumed to have incurred or been caused by military service if it was diagnosed within one year of military separation. His CLL was not diagnosed within 1 year of military separation. Though the veteran's elevated lymphocyte and Lymph% counts in June 2000 and June 2003 (shortly before discharge), and his high Lymph% count in October 2002; as well as complaints of enlarged lymph nodes in March 1989 are unusual, there is no evidence that this was causally related to the CLL he subsequently developed. Again, in its February 2021 Remand, the Board found that October 2020 VA examination and its supporting rationale to be inadequate. Specifically, the examiner opined that "there is no evidence" that elevated lymphocyte and lymph% counts in June 2000 and June 2003, an elevated lymph% count in October 2002, and enlarged lymph nodes in March 1989 were causally related to the chronic lymphocytic leukemia the Veteran developed in 2007. However, the Board noted it was unclear what type of evidence would be needed to establish this link. If elevated lymphocyte and lymph% counts were potentially indicative of chronic lymphocytic leukemia, then an opinion was needed to address whether a diagnosis of chronic lymphocytic leukemia could be precipitated by elevated lymphocytes and lymph% counts, to include even slight elevations. Furthermore, the examiner did not discuss the possibility that the Veteran's diagnosis of chronic lymphocytic leukemia could have been caused by hazardous environmental exposures while serving in the Southwest Asia theater of operations (Saudi Arabia and Kuwait) during the Persian Gulf War, to include possible exposure to depleted uranium. Rather, the examiner merely stated, without supporting rationale, that "[t]here is no evidence suggesting the leukemia diagnosis in 2007 was caused by an in-service injury." As such, the Board remanded the matter again for adequate opinions. Pursuant to the Board's February 2021 Remand directives, an additional VA opinion was obtained in early August 2021 from a VA physician assistant. The physician assistant opined that the chronic lymphocytic leukemia was at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. In support of this opinion, the physician assistant explained that: The diagnosis of CLL is often insidious as this type of cancer is slow growing. The symptoms in service of noted lymphadenopathy and abnormal labs are classic findings in patients who are later diagnosed with CLL. It is at least as likely as not that the Veteran's elevated lymphocyte and Lymph% counts in June 2000 and June 2003, elevated Lymph% count in October 2002, enlarged lymph nodes in March 1989, and the noted cysts in the liver and periaortic node from 10/15/2005, could be early indicators of the CLL that was diagnosed in 2007. Staging and prognosis of chronic lymphocytic leukemia Authors: Kanti R Rai, MD Stephan Stilgenbauer, MD Section Editor: Richard A Larson, MD Deputy Editor: Rebecca F Connor, MD Contributor Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Apr 2021. | This topic last updated: Apr 26, 2021. NATURAL HISTORY The natural history of CLL/SLL is extremely variable, with survival times from initial diagnosis that range from approximately 2 to 20 years, and a median survival of approximately 10 years [1,2]. Some patients experience a rapid deterioration and die within two to three years from complications or causes directly related to CLL/SLL. Others follow a clinically benign course for 5 to 10 years, followed by a terminal phase lasting one to two years. A minority of patients (<30 percent) follow a clinically benign course for 10 to 20 years, and the eventual cause of death may be unrelated to CLL/SLL. Spontaneous clinical regression has been reported, but it is rare [3]. During the initial asymptomatic phase, patients maintain their usual lifestyles, but during the terminal phase the performance status is poor, with recurring need for hospitalization. The most frequent causes of death are severe systemic infection (especially pneumonia and septicemia), bleeding, and inanition with cachexia. During this terminal phase there is considerable morbidity, both from the disease itself and from complications of therapy. (See "Overview of the complications of chronic lymphocytic leukemia".) https://rarediseases.org/rare-diseases/chronic-lymphocytic-leukemia/ Because CLL usually progresses so slowly, many patients do not need immediate treatment and some do not even require it in their lifetime. Treatment is still based primarily on symptoms or worsening blood counts, not on these prognostic factors. Signs & Symptoms Approximately 50-75% of patients with chronic lymphocytic leukemia have no symptoms when first diagnosed. The disease is discovered during a routine exam or blood test. Symptoms can be similar between the two subdivisions of CLL, Ig-mutated and Ig-unmutated, although when Ig-unmutated CLL progresses, typically sooner, more symptoms may ensue. Symptoms of chronic lymphocytic leukemia may include fatigue, weight loss, loss of appetite (anorexia), labored breathing, low-grade fever, a feeling of fullness in the abdomen due to an enlarged spleen, and night sweats. Bacterial infections such as skin infections, fluid and inflammation of the lungs (pneumonia), and inflammation of the sinuses (sinusitis) often occur. As the disorder advances, the patient loses the ability to fight off infections. Viral infections become an increasing concern. In the later stages of the disorder, the liver, spleen, and lymph nodes may steadily increase in size. Chronic lymphocytic leukemia may also invade other tissues such as the skin, eye socket (orbit), mucous membrane that lines the inside of the eyelids (conjunctivae), lungs, sacs that line the chest (pleura), heart, and gastrointestinal tract. Swelling and a yellow pigment of the skin (jaundice) may also occur. The National Cancer Institute has published a six-step description of the staging of this disorder. The staging determines the treatment and management plan. Stage 0: An abundance of lymphocytes in blood but no other sign of leukemia; lymph nodes, spleen, liver, red blood cells and platelets are normal. Stage I: Too many lymphocytes; lymph nodes swollen; spleen and liver are normal as are erythrocytes and platelets. Stage II: Too many lymphocytes; lymph nodes, spleen and/or liver swollen. Stage III: Too many lymphocytes; too few red blood cells (anemia); lymph nodes swollen; spleen and/or liver may be swollen. Stage IV: Too many lymphocytes; too few platelets (difficult blood clotting); lymph nodes, spleen and liver may be swollen; too few red blood cells (anemia). Refractory: CLL does not respond to standard treatments. Causes The exact cause of chronic lymphocytic leukemia is not known. Multiple genetic mutations occur in the DNA of blood-producing cells. These mutations cause the blood cells to produce abnormal lymphocytes, which are not effective at fighting infection. Usually, an abnormal chromosome is present in a patient with CLL. Most often this abnormality is a deletion, or the loss of part of a chromosome. The loss of part of chromosome 13 is the most common deletion, as well as chromosome 11 and 17 deletions. Sometimes there is an extra chromosome 12 (trisomy 12). Other rarer chromosome abnormalities have also been reported. Scientists know these abnormalities are important in the causation of CLL, but it's not yet clear which genes are involved in the development of CLL. The common chromosomal abnormalities are important prognostically, however, with deletions of chromosomes 11 and 17 predicting rapid disease progression. First-degree relatives of someone who has been diagnosed with CLL, namely parents, siblings or children, have a 5-7 times greater chance of developing CLL. Affected Populations Chronic lymphocytic leukemia is the most common type of leukemia found in multiple family members. It is twice as common in males as in females and the average age of onset in patients is 72. It is also more common in people that are white, or of Russian and Eastern European Jewish heritage. The rate of incidence of the disorder increases with age. CLL almost never affects children and is rare under the age of thirty. In the United States, it is thought that three out of every 100,000 people will develop CLL, but this may be an underestimate For reasons unclear from the record, the RO obtained another opinion from a VA physician in late August 2021. Following a review of the record, this physician explained that: Based on the evidence of record, it is LESS LIKELY than not [ . . .] that this pt's elevated lymphocyte and Lymph% counts in June 2000 and June 2003, elevated Lymph% count in October 2002, enlarged lymph nodes in March 1989 could be early indicators of the CLL. This pt was diagnosed with CLL half a decade after separation. Even so, at the time of diagnosis, pt was in stage 0 and not requiring any immediate therapy. If the labs markers from half a decade prior were indicative of CLL, it would have been at a far more advanced state at the time of diagnosis. Additionally, there is no evidence of chronicity, including record of persistently abnormal labs, in the half decade between separation and initial diagnosis of CLL. The August 2021 examining physician also explained that: I have been asked to offer a medical opinion as to whether this pt's CLL was caused or is otherwise related to active service, to include, but not limited to, elevated lymph nodes in March 1989, hazardous environmental exposures incurred while serving in the Southwest Asia theater of operations (Saudi Arabia and Kuwait) during the Persian Gulf War, and any confirmed uranium exposure therein. While Dr P's efforts to assist the pt are appreciated, the opinion does not appear to include the requisite review of STRs / VBMS. Consequently, these reports can not accurately be relied upon for objectivity. Findings of fact unequivocally demonstrate that STRs show normal WBC count and elevated lymphocyte count (71.6) at time of separation in 2003. The slight lymphocytosis in 2000 is moot, as the lymphocyte count in 1/2002 was normal. Most significant is the fact that there were NO abnormal WBC counts in service. WBC count at time of diagnosis of CLL was 105K per pt's wife. VA labs from 9/2010 showed a WBC of 100K. Pt had NO abnormal WBC counts in service. Additionally, there is no evidence of chronicity, including record of persistently abnormal labs, in the half decade between separation and initial diagnosis of CLL. Thus, based on the evidence of record, there is insufficient evidence to establish a nexus, with greater than 50% probability, that this pt's CLL was caused or is otherwise related to active service, to include, but not limited to, elevated lymph nodes in March 1989, hazardous environmental exposures incurred while serving in the Southwest Asia theater of operations (Saudi Arabia and Kuwait) during the Persian Gulf War, and any confirmed uranium exposure therein. The Board notes that neither the August 2021 physician assistant opinion nor the August 2021 physician opined were obtained following a physical examination of the Veteran; rather, they were based on reviews of the claims file. Nonetheless, the Board finds that the August 2021 physician assistant opinion and the August 2021 physician opinion are of relatively equal probative value. Significantly, the August 2021 physician assistant rendered a positive nexus opinion, indicating that in-service findings of lymphadenopathy and abnormal labs were classic findings in patients who were later diagnosed with chronic lymphocytic leukemia, and that it was at least as likely as not that the Veteran's elevated lymphocyte counts in June 2000, October 2002 and June 2003; enlarged lymph nodes in March 1989; and the noted cysts in the liver and periaortic node from October 2005 could be early indicators of the chronic lymphocytic leukemia that was diagnosed in 2007. However, the August 2021 physician rendered a negative nexus opinion, concluding it was less likely than not that these in-service findings could be early indicators of the chronic lymphocytic leukemia on the basis that the Veteran's chronic lymphocytic leukemia would have been at a far more advanced state at the time of diagnosis if the in-service lab markers from half a decade prior were indicative of the disease. However, as cited by the physician assistant, because chronic lymphocytic leukemia usually progresses so slowly, many patients do not need immediate treatment and some do not even require it in their lifetime. In sum, while there are medical opinions against a finding that the Veteran's chronic lymphocytic leukemia first manifested in service or within a year of service separation, there are also medical opinions relating that the disease first manifested in service or within a year of service separation. Both August 2021 opinions were based on a review of the record and supported by medical principles. As such, the Board finds that the evidence in this case is so evenly balanced as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. For the reasons discussed above, as the evidence here is in relative equipoise (meaning that the evidence for and against the Veteran's claim is essentially equal), entitlement to service connection for chronic lymphocytic leukemia is granted. Tiffany Dawson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Anthony M. Flamini 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.