Citation Nr: 21076559 Decision Date: 12/27/21 Archive Date: 12/27/21 DOCKET NO. 13-34 271A DATE: December 27, 2021 ORDER Service connection for a lymph node disability, to include as due to exposure to herbicide agents or to contaminated water at Camp Lejeune, is denied. FINDING OF FACT The Veteran's lymph node disability is not related to exposure to herbicide agents or contaminated water at Camp Lejeune and are not otherwise related to service. CONCLUSION OF LAW The criteria for service connection for a lymph node disability, to include as due to exposure to herbicide or contaminated water at Camp Lejeune, are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1961 to July 1965 and from January 1966 to January 1968. This appeal is before the Board of Veterans' Appeals (Board) from a February 1997 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. In his substantive appeal received in August 1997, the Veteran requested a hearing before the Board in Washington, DC. Before such a hearing was scheduled, the Veteran withdrew his request in a March 2015 communication from his representative. In March 2018, the Board denied an earlier effective date for an award of service connection for peripheral neuropathy and remanded the issue currently on appeal with instruction to obtain current treatment records and a VA medical opinion. The appropriate treatment records were obtained, and a VA examiner provided an opinion in July 2019. In July 2020, the Board found the opinion to be inadequate and remanded for a new medical opinion. Another opinion was obtained in August 2020. In May 2021 the Board again found the opinion to be inadequate and again remanded for an addendum opinion. Additional opinions were obtained in July 2021 and August 2021. The Board is therefore satisfied that the instructions in its remands of March 2018, July 2020, and May 2021 have been satisfactorily complied with. See Stegall v. West, 11 Vet. App. 268 (1998). The Veteran also has pending appeals on the issues of entitlement to service connection for a blood disorder and for a gastrointestinal disability. These issues were most recently remanded by the Board in a September 2021 decision, and the ordered development has not yet been completed. These issues will therefore not be further addressed in this decision. Entitlement to service connection for a lymph node disability, to include as due to exposure to herbicide or contaminated water at Camp Lejeune The Veteran claims service connection for a lymph node disability. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For certain diseases with a relationship to herbicide agent exposure, a presumption of service connection arises if the disease manifests to a degree of 10 percent or more following service in the Republic of Vietnam any time during the period from January 9, 1962 to May 7, 1975. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307, 3.309(e). For certain diseases, a presumption of service connection arises if the disease manifests to a degree of 10 percent or more following exposure to contaminants present in the water supply at Camp Lejeune. Service at Camp Lejeune means no less than 30 days of service within the borders of the entirety of the United States Marine Corps Base Camp Lejeune and Marine Corps Air Station New River, North Carolina, during the period beginning on August 1, 1953, and ending on December 31, 1987, as established by military orders or other official service department records. 38 C.F.R. §§ 3.307, 3.309(f). 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 claimant 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. Service treatment records do not reflect any diagnosis of any chronic lymph node disability, to include no such abnormality noted at the Veteran's January 1968 separation examination. Service records reflect that the Veteran served in Vietnam and was also stationed at Camp Lejeune for over 300 days, as such exposure to herbicides and contaminated waters is presumed. Private treatment records reflect that in August 1991 the Veteran underwent a biopsy of the left axilla after being diagnosed with left axillary lymphadenopathy, rule-out non-Hodgkin's lymphoma based on his history of exposure to herbicide agents. After the biopsy he was diagnosed with chronic lymphadenitis. His axillary fat was submitted for testing and was positive for dioxin at 971 parts per trillion. In a September 1991 statement, the Veteran asserted that his diagnosed lymphadenitis was the result of his exposure to Agent Orange. Private treatment records reflect that in February 1996 the Veteran was being treated for chronic obstructive pulmonary disease (COPD), and a CT scan of the chest showed incidental axillary adenopathy. In July 1996 his physician noted that he had a lymph node drained. He reported discomfort and was diagnosed with an infected hair follicle with slight increase in the size of the lymph node in the left axillary area. In August 1996 this condition was noted to be resolved. The Veteran underwent a VA examination in February 1997. The examiner noted that he had a diagnosis of chronic lymphadenitis that was biopsied at a private hospital and found to positive for dioxins. The lymphatic system was normal on physical examination without adenopathy. No etiology opinion was given. In his August 1997 substantive appeal, the Veteran maintained that he had a lymph node condition due to exposure to Agent Orange. VA treatment records reflect that in November 2012 the Veteran presented to the emergency room reporting ear pain. He was diagnosed with an ear infection, and his physician noted a swollen nodule consistent with a swollen lymph node. He was instructed to follow up with his primary care provider to confirm resolution of lymphadenopathy. Three days later his primary care physician diagnosed lymphadenitis. After ten days, he again presented to the emergency room. He stated that he went to an ear, nose, and throat doctor who diagnosed an enlarged lymph node and told him if he wanted it gone it would need to be surgically excised. His emergency room physician diagnosed mild lymphadenopathy. A biopsy was tentatively scheduled for January 2013. The biopsy was cancelled in December 2012 when it resolved after a course of corticosteroids. In March 2014, his cardiologist noted slightly enlarged bilateral axillary lymph nodes which may represent reactive nodes in a CT scan for chest pain. At an April 2014 pulmonary consultation, he was diagnosed with bilateral axillary lymphadenopathy unlikely related to the lung nodules being treated. A May 2014 CT scan showed prominent though nonenlarged axillary lymph nodes likely reactive in nature, as well as calcified mediastinal and hilar lymph nodes with accompanying calcified granulomas suggesting old granulomatous change. His pulmonologist diagnosed bilateral axillary non-hypermetabolic lymphadenopathy. In October 2014 he presented to the emergency room with pharyngitis, and his physician noted tender submandibular lymphadenopathy. His pulmonologist continued his lymphadenopathy diagnosis in multiple records through March 2018. A June 2017 CT scan showed prominent bilateral axillary lymph nodes. Private treatment records reflect that in March 2018 the Veteran underwent a left upper lobectomy to treat his lung cancer along with mediastinal lymph node dissections. Lymph node biopsies were negative for malignancy. VA treatment records include an April 2019 CT scan showing no supraclavicular, axillary, or mediastinal adenopathy with some calcified mediastinal and bilateral hilar lymph nodes. A medical opinion was obtained from a VA examiner in July 2019. The examiner opined that the Veteran's lymph node disability was less likely than not related to exposure to contaminated water at Camp Lejeune. This opinion was based on the rationale that the Veteran had a diagnosis of chronic lymphadenitis in 1991 that was not ongoing given repeated normal lymph node examinations thereafter. The examiner explained that the Veteran has occasional enlarged lymph nodes due to infection, which is a normal physiological response and not a disease. The examiner further noted his 2018 diagnosis of calcified lymph nodes and granulomas. The examiner stated that there was no medical literature showing a relationship between Camp Lejeune contaminants and such lymph node disease, and a possible etiology was his history of melanoma and squamous cell carcinoma. Another medical opinion was obtained from a VA examiner in August 2020. The Veteran was diagnosed with chronic lymphadenitis and/or noted lymphadenopathy. The examiner opined that the lymph node disability was less likely than not related to exposure to contaminated water at Camp Lejeune. This opinion was based on the rationale that chronic lymphadenitis refers to chronically swollen lymph nodes, usually occurring as a result of infection from bacteria or viruses. The examiner stated that swollen lymph nodes are rarely caused by cancer. The Veteran's 1991 diagnosis of chronic lymphadenitis was not documented to be an ongoing diagnosis after that point given repeatedly normal examinations with no enlarged lymph nodes. His squamous cell carcinoma was a risk factor to his calcified lymph nodes. A medical opinion was obtained from another VA examiner in July 2021. The examiner opined that a lymph node disability was less likely than not related to exposure to herbicide agents. This opinion was based on the rationale that there was no support in the medical literature for a relationship between the Veteran's lymph node diagnoses and exposure to herbicide agents. As to his lymph node calcifications, the examiner explained that these most often resulted from prior granulomatous infections, especially tuberculosis and histoplasmosis. Less common causes included sarcoidosis, silicosis, amyloidosis, and calcifications secondary to the treatment of lymphomas. As to lymphadenitis, the examiner explained that this is related to infection by a bacteria, virus, or fungus. A medical opinion was obtained from another VA examiner in August 2021. This examiner opined that the Veteran's lymph node disability was less likely than not caused or aggravated by his squamous cell carcinoma. This opinion was based on the rationale that the Veteran's lung cancer lacked associated metastasis and did not have associated lymphadenopathy in a February 2018 PET scan. The Board finds that the evidence weighs against a finding that the Veteran's lymph node diagnoses are related to exposure to herbicide agents, are related to contaminated water at Camp Lejeune, or are otherwise related to service. Over the appeal period he has been diagnosed with chronic lymphadenitis and lymph node calcifications. Neither is a condition for which VA recognizes a presumptive relationship to exposure to either herbicide agents or contaminated water at Camp Lejeune. The Veteran understandably believed such a relationship to herbicide agents was likely based on his lymph nodes testing positive for dioxin. The July 2021 VA examiner, however, gave a probative opinion explaining that there is no known relationship between the Veteran's diagnoses and exposure to herbicide agents. Furthermore, both the July 2019 and August 2020 VA examiners gave probative opinions explaining that there is no known relationship between the Veteran's diagnoses and exposure to contaminated water at Camp Lejeune. While the July 2019 VA examiner stated that his service-connected squamous cell carcinoma was a possible cause, the August 2021 VA examiner gave a probative opinion explaining that such a relationship was less likely than not given the specific findings of the Veteran's lung cancer diagnosis. There is no medical evidence in the record to contradict these findings, and there is no medical opinion on the record which shows any relationship to service. For these reasons, the Board finds that the evidence weighs against a finding that the Veteran's lymph node diagnoses are related to exposure to herbicide agents, are related to contaminated water at Camp Lejeune, or are otherwise related to service. Service connection is therefore denied. Zi-Heng Zhu Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Gallagher, 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.