Citation Nr: 21071913 Decision Date: 12/01/21 Archive Date: 12/01/21 DOCKET NO. 18-48 416 DATE: December 1, 2021 ORDER Service connection for right knee osteoarthritis, as due to meningitis associated and/or conjunctive with coccidioidomycosis ("Valley Fever"), is denied. Service connection for right knee osteoarthritis, as due to meningitis associated and/or conjunctive with coccidioidomycosis, is denied. Service connection for left ankle osteoarthritis, as due to meningitis associated and/or conjunctive with coccidioidomycosis, is denied. Service connection for bilateral sensorineural hearing loss (BHL), as due to meningitis associated and/or conjunctive with coccidioidomycosis, is denied. FINDINGS OF FACT 1. Right knee osteoarthritis did not manifest in active duty or to a compensable degree within one year of separation from service. Right knee osteoarthritis is not otherwise attributable to active duty service. 2. Left knee osteoarthritis did not manifest in active duty or to a compensable degree within one year of separation from service. Left knee osteoarthritis is not otherwise attributable to active duty service. 3. Left ankle osteoarthritis did not manifest in active duty or to a compensable degree within one year of separation from service. Left ankle osteoarthritis is not otherwise attributable to active duty service. 4. BHL did not manifest in active duty or to a compensable degree within one year of separation from service. BHL is not otherwise attributable to active duty service. CONCLUSIONS OF LAW 1. The criteria for service connection for right knee osteoarthritis have not been met. 38 U.S.C. § 1101, 1110, 1113, 1131, 1137, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 2. The criteria for service connection for left knee osteoarthritis have not been met. 38 U.S.C. § 1101, 1110, 1113, 1131, 1137, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 3. The criteria for service connection for left ankle osteoarthritis have not been met. 38 U.S.C. § 1101, 1110, 1113, 1131, 1137, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 4. The criteria for service connection for BHL have not been met. 38 U.S.C. § 1101, 1110, 1113, 1131, 1137, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty in the United States Navy from July 1978 to May 1982 as a weapons technician. The Veteran also had periods of active duty for training service in the Naval Reserve as a hospital corpsman from 2001 to December 2004. These matters come before the Board of Veterans' Appeals (Board) from an appeal of a July 2017 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In February 2020, the Veteran and his spouse testified before the undersigned Veterans Law Judge (VLJ). The Veteran's claims file contains a copy of the hearing transcript. In July 2020, the Board remanded these matters for additional evidentiary development. The Board finds that there has been substantial compliance with its remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). SERVICE CONNECTION The Veteran asserts that the disabilities were incurred in, aggravated by, or otherwise attributable to service. Specifically, the Veteran contends that the four disabilities are due to meningitis associated and/or conjunctive with coccidioidomycosis. At the February 2020 Board hearing, the Veteran testified that he contracted "Valley Fever" (coccidioidomycosis) during his two weeks of Naval Reserve active duty for training at the Marine Corps Air Ground Combat Center 29 Palms. According to the Veteran, coccidioidomycosis led to meningitis or that he contracted meningitis directly from poor sanitary conditions while training in the field with a Marine unit. And either coccidioidomycosis, meningitis, or coccidioidomycosis and meningitis, caused or aggravated the Veteran's right knee osteoarthritis; left knee osteoarthritis; left ankle osteoarthritis; and bilateral hearing loss. In order to establish service connection on a direct basis, the record must contain competent evidence of: (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. Saunders v. Wilkie, 886 F. 3d 1356 (Fed. Cir. 2018). In the absence of proof of a present disability there can be no valid claim. Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F. 3d 1039, 1043 (Fed. Cir. 1994). Competent medical evidence is 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 include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. 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 lay person. 38 C.F.R. § 3.159(a)(2). Competent lay evidence may also include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). If the evidence is competent, the Board must then determine if the evidence is credible. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this regard, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511 (1995). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. Certain chronic diseases, including osteoarthritis and sensorineural hearing loss, will be presumed caused by service if they were shown as chronic in service (or within a presumptive period) and there are subsequent manifestations of the same chronic diseases; or if they manifested to a compensable degree within a presumptive period following separation from service (in this case, one year); or if they were noted in service, with continuity of symptomatology since service. See 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. The threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). Hearing loss for the purposes of VA disability compensation is considered a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, and 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, and 4000 hertz are 26 decibels or greater; or when the speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. In addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in his or her final report. Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). Evidence and Analysis The Veteran's service treatment records (STRs) include audiograms from June 1978 and March 1981. In June 1978, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 5 5 --- 5 LEFT 5 5 5 --- 4 In March 1981, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 10 5 10 LEFT --- 15 5 15 10 In an STR of April 1979, a clinician reported that the Veteran complained of a left ankle spasm. The clinician wrapped the ankle and recommended that the Veteran keep it elevated. Upon the Veteran's May 1982 separation report of medical examination, a clinician reported a normal clinical evaluation of the lower extremities. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 5 10 5 LEFT 15 15 10 10 10 In his May 1982 separation report of medical history, the Veteran indicated that he had not had and did not have trick or locked knees; lameness; arthritis, rheumatism, or bursitis; or bone, joint or other deformity. The Veteran reported that he was in good health and not taking any medication. Upon a November 2001 Reserve enlistment report of medical examination, a clinician reported a normal clinical evaluation of the lower extremities. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 0 0 0 0 LEFT 0 5 5 0 10 In his November 2001 Reserve enlistment report of medical history, the Veteran indicated that he had not had and did not have trick or locked knees; lameness; arthritis, rheumatism, or bursitis; or bone, joint or other deformity. The Veteran did report that he had fractured his left ankle (with no notation as to date); however, it was stable and presented no problems. In a November 2002 annual medical certification, a clinician noted mild knee strainnow resolved and able to perform full duty. In a December 2001 dental questionnaire, the Veteran indicated that he did not have arthritis or painful joints. In September 2016 VA received two files of private medical records applicable to the Veteran's claims. These records disclose that the Veteran sought treatment for severe bilateral knee osteoarthritis in 2015 and underwent total bilateral knee arthroplasties. By January 2016, clinicians indicated that the Veteran was doing well. These records do not provide evidence as to the causes for the Veteran's bilateral knee disabilities. The records also disclose a diagnosis of left ankle post-traumatic arthritis (as well as a surgical procedure). In a September 2016 lay statement, the Veteran noted that after being attached to multiple Marine Corps ground units, he was exposed to loud noises daily which he believes contributed to BHL significantly. The Veteran also noted that his left ankle was "completely worn out" likely attributable to all of the "humps" that were required in active and Reserve duty. In June 2017, VA received records from the National Personnel Records Center. In pertinent part, these records disclosed Reserve active duty for training in Tennessee and Ohio on several occasions in 2001-2002. In a notation on a personnel evaluation for the period March 2003 to April 2004 (signed in March 2007), the officer in charge of his Navy organization wrote that the Veteran sustained a debilitating medical incident and was in the process of evaluation. The officer cited "DES-EX 2003, 29 Palms, CA, 03Jun07-21" as a period of active duty training. In a December 2004 commanding officer report, the Veteran was discharged under honorable conditions but as not physically qualified. In July 2017, the Veteran reported for a VA ankle examination. A clinician reviewed the claims file; considered the Veteran's lay accounts of his medical history; and conducted an appropriate evaluation. The clinician diagnosed osteoarthritis. The clinician found that the Veteran's left ankle osteoarthritis (degenerative joint disease) was less likely as not incurred in caused by or the result of service. The clinician noted that the Veteran sustained a left ankle sprain in April 1979 without residuals. Moreover, in November 2001, the Veteran reported that he sustained a left ankle fracture in 1992 without residuals. Otherwise, the available evidence dates from January 2016 when the Veteran had post-traumatic left ankle arthritis. This clinician also indicated that the medical evidence of record fails to show that the Veteran's left ankle from 1992 was aggravated beyond its natural progression by any disease in service. This same month the Veteran underwent a VA audiology examination. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 25 20 25 15 25 LEFT 25 40 15 15 30 Speech recognition was 92 percent in the right ear and 88 percent in the left ear. The audiologist diagnosed BHL in the frequency range of 500-4000 Hz. The Veteran did not report that BHL functionally impacted his conditions of daily life or ability to work. Martinak, 21 Vet. App. 447. The audiologist found that BHL was not at least as likely as not caused by or a result of service because there were no significant declines on hearing acuity present in the Veteran's STRs. In a February 2020, Dr. L., a private physician, submitted a letter. She wrote that she began treating the Veteran in 2003, shortly after the Veteran's service at 29 Palms where the Veteran developed fever, headache, and severe back pain. Dr. L. reported that a university disease consultant, Dr. F., felt that the Veteran likely contracted a severe infection at 29 Palms. Also, she opined that she strongly suspects that repetitive landing on feet have significantly contributed to the Veteran's ankle "arthritis-associated deformity." The Board assigns negligible probative weight to Dr. L.'s ankle opinion as it did not include a rationale, or clinical findings that led her to her suspicions concerning the Veteran's ankle. See Sklar v. Brown, 5 Vet. App, 140 (2003). During the February 2020 Board hearing, the Veteran and his spouse testified that he contracted "Valley Fever" (coccidioidomycosis) during his two weeks of Naval Reserve active duty for training at the Marine Corps Air Ground Combat Center 29 Palms. In turn, according to the Veteran, coccidioidomycosis led to meningitis or that he contracted meningitis directly from poor sanitary conditions while training in the field with a Marine unit. And either coccidioidomycosis, meningitis, or coccidioidomycosis and meningitis, caused or aggravated the Veteran's right knee osteoarthritis; left knee osteoarthritis; left ankle osteoarthritis; and bilateral hearing loss. In February 2020, the Veteran's representative submitted documents, to include a chronology of events and a summary of the Veteran's illnesses and care; an article about meningitis without direct commentary about how the article relates to the specific facts of the Veteran's medical history; downloaded internet materials about meningitis; and a Health and Human Services (HHS) public access document addressing coccidioidomycosis (Valley Fever) at Naval bases in California. While the Board recognizes the informational value of these documents, it finds that they offer minimal insight into the facts of the Veteran's case. No medical clinician has applied these materials and their conclusions to the Veteran's medical history. Consequently, the Board assigns nominal probative weight to these generic materials. In March 2021, an official from the public health department of San Bernardino County, CA, reported that there were no records of any type of health risks including the possibility of contracting valley fever in the county, or at 29 Palms, or at the Marine Corps Air Ground Combat Center. In May 2021, Dr. F., the physician cited by the Veteran as his 2003 attending physician, provided a letter reporting on his treatment of the Veteran for a staphylococcus aureus infection with osteomyelitis of the lumbar spine. The physician made no mention of the ankle, knees or hearing loss as a residual of this infection and made no mention of "Valley Fever." In June 2021, VA sent correspondence to the Veteran which delineated the steps undertaken to obtain all the Veteran's service personnel records and STRs for Naval Reserve duty service, to include records of participation in active duty for training and inactive duty training: the U.S. Center for Disease Control (CDC) records of an investigation into the incidence of Valley Fever in July to August 2003; and records from the California Department of Public Health concerning the investigation into the occurrences of Valley Fever at Naval facilities in the state. VA indicated that it had exhausted its efforts and, as it had on prior occasions, sought any relevant records in the Veteran's possession. A review of the evidence of record fails to disclose that the Veteran submitted records responsive to this final request for such. In July 2021, the Veteran reported for a VA audiological examination. An audiologist followed VA exam protocols. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 30 15 20 15 30 LEFT 30 45 15 20 30 Speech recognition was 92 percent in the right ear and 92 percent in the left ear. The audiologist diagnosed BHL in the frequency range of 500-4000 Hz. The Veteran did not report that BHL functionally impacted his conditions of daily life or ability to work. Martinak, 21 Vet. App. 447. The audiologist found that BHL was not at least as likely as not caused by or a result of events in service. The audiologist explained that there were no significant declines on hearing acuity present in the Veteran's STRs. Additionally, the audiologist indicated that there is also no basis to draw a nexus between the Veteran current BHL to either coccidioidomycosis or meningitis, as all medical evidence concerning these entities exclusively concerns the Veteran's lumbar spine disability (and not other disabilities to include BHL). This same month, the Veteran reported for VA left ankle and VA bilateral knee examinations. The examiner reviewed the file, conducted examinations, and provided opinions as to the etiologies of the Veteran's current left ankle and bilateral knee osteoarthritis. The clinician opined that the Veteran's left ankle osteoarthritis and bilateral knee osteoarthritis were less likely than not incurred in, aggravated by, or otherwise attributable to, any aspect of active duty service or active duty service for training (including two weeks of Naval Reserve active duty for training at the U.S. Marine Corps Air Combat Center 29 Palms). Moreover, there is no medical evidence of record to support that the Veteran contracted coccidioidomycosis. The clinician emphasized that the Veteran's lumbosacral abscesses were found to be due to the bacteria staph aureus, which is not a fungal disease entity like coccidioidomycosis. Literature supports connexity between meningoccal meningitis and septic arthritisshortly after the onset of meningitis. However, the Veteran's arthritis (of the left ankle and bilateral knees) is traumatic or osteoarthritis which is degenerative in nature, likely attributable to the Veteran's career as a fire-fighter and age-related degeneration and injuries (sustained occupationally). In October 2021, the Veteran's representative submitted a brief. In pertinent part he restated the Veteran's contentions concerning an association between the Veteran's BHL and osteoarthritis of the left ankle and bilateral knees and either coccidioidomycosis, meningitis, or coccidioidomycosis and meningitis. This representative also insisted that the benefit of doubt should accrue to the Veteran. The Veteran (as well as his spouse and representative) insist that BHL, left ankle osteoarthritis, and bilateral knee osteoarthritis was incurred in service (due to meningitis associated and/or conjunctive with coccidioidomycosis). While the Board recognizes that the Veteran is competent to report discernable symptoms and report etiological opinions of competent clinicians (Jandreau, 492 F. 3d 1372; Kahana, 24 Vet. App. 428), the evidence of record fails to disclose that the Veteran has the training or expertise to render complex etiological opinions concerning fungal and bacterial entities any causative relationship to BHL or osteoarthritis. 38 C.F.R. § 3.159(a)(1). The Board assigns substantial probative weight to the VA examinations of record. In each examination instance, a medical/audiological practitioner reviewed the claims file; considered the Veteran's lay accounts of his medical history; and conducted an appropriate evaluation. Moreover, these examiners supported their wholly negative nexus opinions with consideration of the evidence of record, medical/audiological knowledge, and reference to specialized literature. The current disability element of right knee osteoarthritis, left knee osteoarthritis, left ankle arthritis, and BHL are present. However, the weight of evidence fails to establish an in-service incurrence upon which nexuses can be drawn; without these elements, service connection on a direct basis (for any of these disabilities) cannot be established. Id. As the evidence of record fails to reveal that either right knee osteoarthritis, left knee osteoarthritis, left ankle arthritis, or BHL manifested to a compensable degree within one year of the Veteran's separation from service, establishing service connection is also not possible on a presumptive basis for the 4 claimed disabilities in this case. See 38 C.F.R. §§ 3.307, 3.309. Consequently, the preponderance of evidence is against the Veteran's 4 service connection claims. As such, there is no doubt to be resolved. See 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. 49. J.W. FRANCIS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B J. Komins, 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.