Citation Nr: 21074399 Decision Date: 12/15/21 Archive Date: 12/15/21 DOCKET NO. 12-29 149 DATE: December 15, 2021 ORDER Entitlement to service connection for dermatomyositis, to include as due to exposure to anthrax vaccine, is denied. FINDING OF FACT The Veteran's dermatomyositis did not manifest during service and is not shown to be causally or etiologically related to an in-service event, injury, or disease. CONCLUSION OF LAW The criteria for service connection for dermatomyositis have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 1112, 1113, 1116, 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 military service from November 1983 to November 1986 and from June 1987 to May 1992. The Veteran died in March 2013. See July Death Certificate. The appellant is the Veteran's surviving spouse and has been properly substituted in this case. See March Correspondence. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The appellant testified before the undersigned Veterans Law Judge at a hearing in May 2018. By way of background, in June 2018, January 2020, November 2020, and May 2021, the Board remanded the issue on appeal for further evidentiary development and adjudication. That development has been accomplished, and the claim has now been returned to the Board for further action. Service Connection Generally, to establish service connection 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." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Entitlement to service connection for dermatomyositis, to include as due to exposure to anthrax vaccine, is denied. Having carefully reviewed the evidence of record, the Board finds that the criteria for service connection for dermatomyositis are not met. The most persuasive evidence of record is against finding that dermatomyositis is etiologically related to service to include exposure to anthrax vaccine. In the October 2011 VA examination, the examiner diagnosed dermatomyositis. As such, the first element of service connection is met. The records confirm that the Veteran's dermatomyositis affected the lung and vocal cord. See October 2012 CAPRI. Additionally, in an October 2012 VA treatment record, it was noted that he had dermatomyositis with different pattern of weakness distally in his hands atypical for diabetes mellitus and more likely due to effort limited by pain. See May 2019 CAPRI. As for the second element of service connection, the Board finds that there is no dermatomyositis related in-service event, injury, or disease. A review of the service treatment records (STRs) shows that in a November 1986 STR, the Veteran complained of having shortness of breath at rest. See August 2016 STR Medical. In an August 1987 STR, he was noted to have multiple cherry angioma on his back and chest. In a March 1988 STR, he was again noted to have cherry angioma on his back and chest. In an August 1991 STR, he had rash on his groin and legs and was diagnosed with tinea cruris. In a January 1992 STR, he complained of itchiness around his right shoulder area in the back. On examination, there was an area of redness on his chest. It was noted that it was a possible codeine allergy. The STRs also show that in December 1987 he complained of weight loss. However, the records show that his weight fluctuated with a gradual increase from 187 pounds to 208 pounds. The STRs do not show any complaints of regurgitation or fatigue. In a July 1992 post-service VA treatment record, about two months after separation, he exhibited decreased grip on his right arm and had rash on his legs. He was diagnosed with tinea/candida rash. See August 1992 Medical Treatment Record Government Facility. In an August 1992 VA treatment record, he was noted to have numbness, loss of feeling, and loss of strength in his bilateral hands. He was not diagnosed with dermatomyositis until October 2011, about nine years after service. In a July 2012 VA treatment record, a doctor in rheumatology noted that "it should be considered that his autoimmune condition may be related to his vaccines." See October 2012 CAPRI. In the September 2012 Notice of Disagreement, he claimed that he was diagnosed with dermatomyositis due to his contact with the anthrax vaccine. He contended that scientific studies found that his conditions are related to the anthrax vaccine. However, he did not submit these scientific studies. In fact, he admitted that his disabilities did not appear until many years after service, but that due to his exposure to the anthrax vaccine in service his dermatomyositis manifested later in life. The Veteran was afforded a VA examination in October 2011 with addendum medical opinions in April 2019, February 2020, November 2020, and July 2021. In the October 2011 VA examination, the examiner diagnosed dermatomyositis and opined that the Veteran's condition is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the rash identified during service is different from the rash diagnosed at present time which is one of the pathognomic features of dermatomyositis. In June 2018, the Board remanded the issue as the examiner did not opine as to whether the Veteran's dermatomyositis was caused by his exposure to the anthrax vaccine. In the April 2019 VA addendum opinion, the examiner opined that his dermatomyositis was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the Veteran's in-service rash was allergy related and was treated with Benadryl and tinea cruris was resolved with antifungal cream. However, the rash diagnosed in October 2011 was dermatomyositis. In January 2020, the Board remanded the issue as the examiner again did not address whether the Veteran's dermatomyositis is etiologically related to his anthrax vaccine. In the February 2020 VA addendum opinion, the examiner opined that the Veteran's dermatomyositis is less likely as not caused by or related to his military service, specifically due to his in-service anthrax vaccine. The examiner explained that dermatomyositis is an idiopathic inflammatory condition characterized by autoimmunity and inflammatory involvement of the muscle fibers (i.e., myositis) resulting in muscle weakness. A review of medical literature did not reveal a definitive association between anthrax vaccine and dermatomyositis. In the November 2020 VA addendum opinion, the examiner opined that the Veteran's diagnosed dermatomyositis is less likely as not caused by or related to his military service, specifically due to his in-service anthrax vaccine. The examiner supported his opinion by stating that the Veteran had unremarkable general examination (i.e., no skin rashes, no weight loss, or muscle weakness) in the August 1992 separation examination. In May 2021, the Board remanded the issue as the examiner did not address the multiple cherry angioma on his back and chest and decreased grip of his right arm and numbness and loss of strength of the bilateral arms. In the July 2021 VA addendum opinion, the examiner opined that the claimed condition is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that any reaction due to any injection is likely to manifest at that time or proximate to it and not 44 years later. There is no evidence in the current, widely accepted, peer reviewed literature that remote anthrax inoculation causes dermatomyositis. This review includes Up-to-Date, a respected medical resource wherein one may access current professional treatises and studies. No additional pertinent studies were returned. The article found no relationship between autoimmune/connective tissue disorders and anthrax vaccine. Therefore, it is less likely than not that the Veteran's dermatomyositis is due to or incurred in reception of the anthrax vaccine while in service. The examiner continued that the 2012 VA provider's suggestion that it could be due to the vaccine almost certainly would have manifest proximate to that exposure. There was no dermatologic condition at separation and absolutely no evidence of dermatomyositis at separation. It is medically implausible the Veteran could have gone a span of 44 years (or 25 years if 1992 is conceded) with the condition without manifestations requiring evaluation and or treatment. The cherry hemangiomas are irrelevant. They are not related to dermatomyositis. They are benign vascular growths associated with aging and are not associated with anthrax vaccine. They are less likely than not due to service and are likely due to heredity/genetics and aging. They likely arose in and around 1988 and again documented in 1992. They are not a condition per se, and they cause no pathological dysfunction. Their only potential issue is cosmetic. The examiner added that the 1992 reference does not alter this opinion. The 2011 diagnosis was consistent with the common presentation and it is unlikely the Veteran would have gone a span from 1992 to 2011 with the condition without manifestations, making the 1992 events less likely than not related to the dermatomyositis and the 1992 complaints were clearly related to carpal tunnel syndrome (CTS), per the 1992 VA examination. CTS is due to impingement of the median nerve at the wrist and is completely unrelated to the matter myositis/polymyositis. The Board gives great probative value to all the VA examiners' medical opinions as they are based on the examiner's medical knowledge, training, and experience. The Veteran conceded that his dermatomyositis manifested many years after service. Although he claimed that his dermatomyositis manifested as a result of his anthrax vaccine, he and the appellant failed to submit any medical evidence in support of their claim. The July 2021 examiner stated that current medical literature does not support a relationship between dermatomyositis and anthrax vaccine. The Board affords great probative value to all the VA examiners' medical opinions and finds that the Veteran's dermatomyositis was not etiologically related to service, to include anthrax vaccine. The Board notes that the July 2021 examiner referenced a 44-year period (or 25 years if 1992 is conceded). The Board finds that this is a scrivener's error as a 44- year period would be outside the Veteran's service date. Further, the Board finds that this error is harmless as it would not change the examiner's determination that a reaction from anthrax would have manifested proximate to that exposure. Further, the current medical knowledge does not find a relationship between autoimmune/connective tissue disorders and anthrax vaccine. As such, the Board finds that the examiner's calculation is a harmless error. The Board affords little to no probative value to the December 2012 rheumatologist opinion that the Veteran's autoimmune condition may be related to his vaccines as his opinion is too speculative. Tirpak v. Derwinski, 2 Vet. App. 609, 610 (1992) (doctor's letter stating probability in terms of "may or may not" was speculative); Bostain v. West, 11 Vet. App. 124, 127-28 (1998), quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993), (a medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish a causal relationship). In sum, the criteria for service connection for dermatomyositis have not been met. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Thus, the claim is denied. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Noh, 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.