Citation Nr: 21072455 Decision Date: 12/03/21 Archive Date: 12/03/21 DOCKET NO. 19-32 157 DATE: December 3, 2021 ORDER Entitlement to service connection for Reiter's syndrome is denied. REMANDED Entitlement to service connection for bilateral hearing loss is remanded. FINDING OF FACT The Veteran's Reiter's syndrome was not manifested in service or within the Veteran's first post service year; and it is not shown to be related to his active service. CONCLUSION OF LAW The criteria for entitlement to service connection for Reiter's syndrome have not been met. 38 U.S.C. §§ 1131, 1112, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service in the United States Air Force from March 1959 to September 1959. This appeal comes to the Board of Veterans' Appeals (Board) from an April 2018 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The issue was remanded by the Board in December 2019 for further development. The Board finds that the development ordered by the Board for the issue decided herein (namely seeking to obtain private and VA treatment records and obtaining a VA examination and opinion) has been completed; the Board finds substantial compliance with its remand instructions. 1. Entitlement to service connection for Reiter's syndrome. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). A disorder diagnosed after discharge may be service connected if all the evidence establishes that the disorder was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases, to include arthritis, may be service-connected on a presumptive basis if manifested to a compensable degree within a specified period of time following separation. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Under 38 C.F.R. § 3.303(b), service connection will be presumed where there are either chronic symptoms shown in service or continuity of symptomatology since service for diseases identified as "chronic" in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331, 1338-40 (Fed. Cir. 2013) (holding that continuity of symptomatology is an evidentiary tool to aid in the evaluation of whether a chronic disease existed in service or an applicable presumptive period). With a chronic disease shown as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent cause. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, 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 fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Furthermore, it is the responsibility of the Board to assess the credibility and weight to be given to the evidence. Hayes v. Brown, 5 Vet. App. 60 (1993). The Veteran asserts that his disability started abruptly one night in 1959 at a chow hall when he evidently ate a rotten or contaminated salad and got deathly ill that night. He had been in the military 6 or 7 weeks at that time. He had a terrible night throwing up and knew he had a high temperature. At that time, he did not think it was related to food poisoning and did not want to tell anybody about it for fear he would interrupt his plan to continue training. The next week, while he was marching in the parade, the Veteran felt a sharp pain in his lower right back. It was not until 1976 when the Veteran was in the hospital that he was diagnosed with Reiter's syndrome. He had a swollen knee, iritis in his eye, and stiffness and pain all over. See March 2018 Correspondence and February 2021 Correspondence. The Veteran also asserts that the physicians did not know about Reiter's syndrome or reactive arthritis at the time of his discharge, so his physical disability was classified as severe nervousness. See April 2021 Correspondence. The Veteran's March 1959 Report of Medical Examination for enlistment was silent for any joint conditions, arthritis, back conditions, or a diagnosis of Reiter's syndrome. A clinical record in June 1959 revealed that the Veteran was diagnosed with neurotic depressive reaction. The Veteran's August 1959 Report of Medical Examination was silent for any joint conditions, arthritis, back conditions, or a diagnosis of Reiter's syndrome. In December 1959, the Veteran had a VA examination. The examiner noted that two years ago, the Veteran hurt his lower back when a horse tripped and rolled over him. The Veteran was diagnosed with residuals of a back injury. A VA treatment record showed that the Veteran had Reiter's syndrome in 1976. A February 1977 VA treatment record showed that the Veteran had acute right knee arthritis possible due to Reiter's syndrome, but it was resolving. In January 2021, the Veteran was afforded a VA examination for his Reiter's syndrome. The examiner noted that the Veteran's Reiter's syndrome had resolved without residuals. The VA examiner opined that the Veteran's Reiter's syndrome was less likely than not incurred in or caused by the Veteran's claimed in-service injury, event, or illness. The examiner explained that the Veteran reported that his back pain during service was the initial symptom of Reiter's syndrome that was diagnosed in 1976. The examiner determined, however, that the Veteran's back pain before and during service was unrelated. Evidence for this was that Reiter's syndrome (reactive arthritis) generally presented with oligoarthritis of peripheral joints such as he presented with in 1976. Also, there was a clear cause for the back pain before and during service involving an incident with a horse for one. The findings related to the back during service were of a nature consistent with a strain, which was the diagnosis, and not of an inflammatory back condition. The Veteran clearly had an acute onset of Reiter's syndrome in 1976, which was very typical for this condition, with the eye and urethral and joint symptoms presenting in close proximity. Records were negative for any recurrent back symptoms or previous symptom of the joints involved in his Reiter's syndrome in 1976, which was the knees and shoulder. The records clearly support that these were separate, and in addition, were separated in time by 16 years which was also not consistent with Reiter's having an onset during service. If Reiter's had been caused by something during service such as contaminated food, it would have presented then and not 16 years later. Records were consistent with an acute episode or Reiter's with significant improvement over the following year so that by October 1977 there had not been any flare or significant problem following the initial episode in 1976. This was consistent as well with the Veteran's current history obtained from the Veteran, which was negative for chronic or recurrent symptoms following the episode in 1976 to 1977, and with recent medical records noting a history of Reiter's syndrome but syndrome being negative for recurrence or current treatment. This was common that the condition would resolve without residuals with only a small minority of Veteran's developing a chronic form of arthritis related to this. The VA examiner stated that in his opinion, the Veteran's Reiter's syndrome less likely than not began during service or manifested within one year after discharge from service and was less likely than not related to any in-service injury or disease, including exposure to contaminated food or joint problems or back problems during service. The examiner cited to medical literature. The onset of reactive arthritis was usually acute. Patients typically presented with an asymmetric oligoarthritis, usually one to four weeks following the inciting infection. The characteristic symptoms of the enteric or genitourinary infections that could cause reactive arthritis were diarrhea or urethritis. The typical picture of peripheral arthritis, seen in rheumatology clinics, was an acute-onset asymmetric oligoarthritis, often affecting the lower extremities, especially the inflammatory low back pain, was seldom the only presenting symptom. The course of reactive arthritis varied considerably. The typical disease duration was three to five months. Most patients either remitted completely or had little active disease within 6 to 12 months after presentation, but 15 to 20 percent might experience more chronic persistent arthritis. The course of reactive arthritis varied considerably. The typical disease duration was three to five months. Most patients either remitted completely or had little active disease within 6 to 12 months after presentation, but 15 to 20 percent might experience more chronic persistent arthritis. The Board finds the January 2021 VA medical opinion to be adequate and probative in value. Thus, it weighs against the Veteran's claim. The January 2021 VA examiner discussed the Veteran's lay statements and contentions, reviewed the Veteran's medical history, and provided a sufficient rationale supported by conclusions citing to medical literature. Based on this examination and opinion, the Board finds that it is less likely than not that the Veteran's claimed Reiter's syndrome had its onset during or is otherwise related to his active service. The Veteran has consistently maintained that his disability began during service from a bout of suspected food poisoning, and that claimed in-service symptoms were early manifestations of that disability. The January 2021 opinion, however, strongly weighs against such a finding, providing a well-reasoned rationale as to why the Veteran's claimed symptoms were not early manifestations of his condition, and why the later diagnosis of this disability was not related to his active service. As for the lay statements that he had Reiter's syndrome ever since service, the Board finds that the Veteran's statements are not credible. The Board acknowledges that the Veteran is able to report symptoms of pain and discomfort. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Veteran's post service treatment records do not show that the Veteran was diagnosed with Reiter's syndrome after the 1970s. Additionally, the January 2021 VA examiner reported that although the Veteran's recent medical records noted a history of Reiter's syndrome, the Veteran's medical records were negative for recurrence or current treatment. Moreover, there is no indication that the Veteran was diagnosed with Reiter's syndrome 1 year after service. The Veteran's August 1959 Report of Medical Examination during separation is silent for any related symptoms. It was not until the 1970s that the Veteran was diagnosed with Reiter's syndrome. Although the Veteran claims that he should have been diagnosed prior to this, the Board finds the Veteran's medical records and January 2021 VA examination show otherwise. The Veteran is not competent to diagnose Reiter's syndrome or to make etiological opinions because he is not shown to have the requisite medical training. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Thus, presumptive service connection is not warranted. Service connection based on the theory of continuity of symptomatology is not warranted either. See 38 C.F.R. § 3.307. Based upon the foregoing, the preponderance of the evidence is against a finding of a nexus between the Veteran's Reiter's syndrome and his military service. Accordingly, the appeal seeking service connection for Reiter's syndrome must be denied. REASONS FOR REMAND 1. Entitlement to service connection for bilateral hearing loss is remanded. Most recently, VA medical opinions were obtained in December 2020 and February 2021. These opinions were negative. The Veteran provided lay statements that he began experiencing issues with his hearing when he started to wear headphones for a Morris Code Interceptor Operator's class. In an October 2021 Appellate Brief, the Veteran argued that the December 2020 and February 2021 examiner's opinions were inadequate because they failed to take into account the Veteran's lay statements. Additionally, the Board notes that the Veteran is currently service-connected for tinnitus. In a February 2021 VA addendum medical opinion, the examiner notes that the Veteran's tinnitus was a symptom associated with hearing loss, but simply having tinnitus did not meet any diagnostic criteria for hearing loss. Based on the foregoing, a remand is warranted for a new VA medical opinion that addresses the Veteran's lay statements and whether the Veteran's hearing loss is secondary to his service-connected tinnitus. The matters are REMANDED for the following action: 1. Obtain a VA addendum medical opinion to determine the nature and etiology of the Veteran's bilateral hearing loss. If an opinion cannot be rendered without performing a VA examination, then a VA examination must be conducted. A copy of this remand and claims file must be reviewed. The VA examiner must address the following questions: a) Is it at least as likely as not that the Veteran's bilateral hearing loss is related to his active service? The VA examiner must consider and discuss the Veteran's statement that he began experiencing issues with his hearing when he started to wear headphones for a Morris Code Interceptor Operator's class. See October 2021 Appellate Brief. b) Is it at least as likely as not that the Veteran's bilateral hearing loss is caused by, proximately due to, and or aggravated by his service-connected tinnitus? The Board notes that a VA examiner opined that the Veteran's tinnitus was associated with the Veteran's bilateral hearing loss, but it is not clear whether that means that tinnitus is secondary to hearing loss, or that his hearing loss may be secondary to his now service-connected tinnitus. See February 2021 C&P Exam. (Continued on next page) All medical opinions must be supported by a sufficient rationale. A negative medical opinion cannot be solely based on the absence of medical evidence. Evan M. Deichert Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Crawford, 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.