Citation Nr: 21013046 Decision Date: 03/08/21 Archive Date: 03/08/21 DOCKET NO. 13-06 591 DATE: March 8, 2021 ORDER Entitlement to service connection for tumid lupus erythematosus (TLE) is denied. FINDING OF FACT TLE was not present during the Veteran’s active service, and is not otherwise etiologically related to such service, to include exposure to contaminated water while serving at Camp Lejeune; and systemic lupus erythematosus was not present to a compensable degree within one year of the Veteran’s separation from active service. CONCLUSION OF LAW The criteria for service connection for TLE are not met. 38 U.S.C. §§ 1112, 1113, 1131, 1137, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service in the United States Marine Corps (USMC) from July 1983 to July 1986. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from an August 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO in Louisville, Kentucky. The Veteran had a Board hearing in February 2019. A transcript of this hearing has been associated with the claims file. This case was previously before the Board in May 2019, at which time the issue currently on appeal was remanded for additional development. The case has now been returned to the Board for further appellate action. Service Connection – TLE The Veteran contends that his current diagnoses of tumid lupus erythematosus (TLE) is related to his exposure to contaminated water during his service at Camp Lejeune. He specifically refers to the contaminant trichloroethylene (TCE). He has provided multiple articles in support of his claim. Veterans who were stationed at Camp Lejeune during the time period of August 1, 1953, through December 31, 1987, are eligible for presumptive service connection for a limited set of diseases. Diseases associated with exposure to contaminants in the water supply at Camp Lejeune maintain a special presumptive service connection. 38 C.F.R. § 3.307(a)(7), 3.309(f) (2019). The Veteran has verified service at Camp Lejeune during the presumptive period. However, TLE is not among the disease that are presumed to be related to contaminated water exposure a Camp Lejeune; nor is any other variation of lupus. Regardless, the Veteran may still show that his diagnosed disability is related to contaminated drinking water at Camp Lejeune. See generally 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (d); see also Combee v. Brown, 34 F.3d 1039, 1044 (Fed. Cir. 1994). The Veteran has reported that while he was in active service, he began to develop cysts all over his body. He reported that continuous skin problems, along with chronic joint pain and fatigue persistent over the years and were manifestations of his later diagnosis of lupus in the late 2000’s. The Board notes that it appears that not all of the Veteran’s service treatment records (STRs) are available for review. The STRs that are of record are silent for complaints of or treatment for a chronic skin issue, or other symptoms that could be associated with the Veteran’s later diagnosis of TLE. Post-service medical evidence of record shows that the Veteran was seen in January 1998 for lump on the right side of his penis that he reported had been present for approximately two years. Examination revealed what was suspected to be an irritated nodule in the skin itself with an obvious central clogged pore, which was likely as sebaceous gland. There was no other significant dermatological lesion, and the Veteran was referred for surgical excision of the cyst, which appears to have been performed in February 1998. In January 2004, the Veteran was seen for a rash on his left shin and lower leg that had been present for several months. He reported that he worked around chemicals and wondered if the rash was an exposure issue, but he did not have similar symptoms on his right leg. Further, the Veteran did not report a history of any other similar lesions. At that time, the examiner diagnosed eczematous dermatitis of the left leg, and he was prescribed a cream for treatment. In a February 2004 follow-up treatment note, it was noted that the prescribed cream had helped, but that he did still have patches of slightly raised, erythematous or purplish skin on his left leg. The Veteran was referred to dermatology at that time for further treatment. Ultimately, in October 2007, the Veteran had a skin biopsy that was found to be warranted for a recurrent rash that was unresponsive to treatment. At that time, the results of the skin biopsy were consistent with tumid lupus. In July 2008, the Veteran was seen as his rash had continued to recur, mostly involving his back and inner arms. He reported at that time that he felt sweat made his rash worse. The Veteran was prescribed medication for treatment. In September 2008, the Veteran was seen for follow-up, at which time he reported that following treatment, his rash had all but completely resolved, with flare-ups only when out in the sun. The Veteran was continued on medication at that time, and counseled on sun exposure, the use of sun protection, and smoking cessation. The Veteran has continued to receive treatment for TLE from various providers since that time. In support of his claim that his exposure to contaminated water while serving at Camp Lejeune resulted in his later development of TLE, the Veteran has submitted several articles regarding the link between exposure to TCE and development of TLE. In the May 2019 remand, the Board directed that VA medical opinions be obtained to determine the nature and etiology of the Veteran’s TLE, to include consideration of the scientific articles submitted by the Veteran in support of his appeal. In June 2019, the Veteran was afforded a VA examination. At that time, the Veteran reported that he broke out in a rash in approximately 2004, that ultimately resulted in a skin biopsy and a diagnosis of TLE. The examiner noted the diagnosis of TLE from 2009. A medical opinion was not provided at that time. In September 2019, an attempt to obtain an addendum medical opinion was made. However, it noted that there was no subject matter expert on site to provide an opinion regarding whether the Veteran’s TLE was related to his contaminated water exposure at Camp Lejeune, and ultimately, an opinion was not provided. In January 2020, an addendum opinion was obtained. At that time, the examiner (a nurse practitioner) found that it was as likely as not that the Veteran’s TLE was incurred in or caused by the claimed in-service injury, event, or illness. In so finding, the examiner noted that the Veteran had no issues related to his claimed disability prior to his active service, and that the disability had its onset during the Veteran’s service, and was documented in the STRs. The examiner noted that skin disease occurred within 2-5 weeks exposure to TCE, and the Veteran in this case had skin abscesses requiring lancing and packing, and ongoing care over the course of his three intermittent years at Camp Lejeune. The Board finds that the January 2020 is not adequate for adjudication purposes. In this regard, the Board notes that the examiner did not provide a sufficient rationale for the conclusion reached. In fact, the examiner relied on an inaccurate factual premise to support the opinion provided. First, the examiner noted that the STRs documented skin abscesses requiring lancing and packing during the Veteran’s service. That is simply not the case. While the Veteran has reported cystic lesions during service, diagnosis and treatment of such is not documented in the STRs. Further, the Veteran himself denied a history of issues with a rash when receiving treatment in 2004 for the first manifestations of the rash that ultimately led to his diagnosis of TLE. As the opinion is supported by an inaccurate factual, it is not adequate and cannot serve as the basis of a grant of entitlement to service connection. As such, the opinion is assigned no probative value. An additional addendum opinion was obtained in July 2020 from an internal medicine specialist. At that time, the examiner opined that it was less likely as not that the Veteran’s TLE was incurred in or caused by the claimed in-service injury, event, or illness, to specifically include the Veteran’s exposure to contaminated water while serving at Camp Lejeune. In so finding, the examiner noted that a complete review of the record was performed, to include the scientific literature supported by the Veteran in support of his appeal. The examiner also cited to a wealth of scientific and medical literature that was consulted in forming the medical opinion provided. The examiner noted that the Veteran had a family history of autoimmune disorders, s his mother had rheumatoid arthritis and his cousin had sarcoidosis. Further, the Veteran was a pack per day smoker for more than 20 years, worked outdoors with significant sun exposure, and had post-service occupational chemical exposure to unknown quantities of unknown chemicals. The examiner explained that TLE was a rare disorder triggered by ultraviolet (UV) light exposure, and found in a disproportionate number of smokers compared to non-smokers. TLE was known to be associated with exposures to solvents, but had been associated with exposure to certain drugs such as thiazide diuretics, angiotensin converting enzyme inhibitors, and anti-tumor necrosis factor (TNF)-alpha agents. Further, the examiner explained that of particular note was the timing between the known exposures and appearance of TLE rashes was typically measured in days or weeks, not years. The Veteran’s exposure in this case was well within the permitted exposure level for workers as set forth by the Occupational Safety and Health Administration (OSHA), and lasted slightly less than two years. As the Veteran’s development of TLE occurred approximately 19 years after he left Camp Lejeune, it was less likely that his TLE was caused by that exposure than by ore recent exposures, or just by the inherent nature of the manifestation of the disease. Of particular important, when determining the Veteran’s possible exposure level to TCE while serving at Camp Lejeune, the examiner considered the Veteran to have had the highest possible amount of exposure for his service at that installation, and even still, his level of exposure would have been under the recommended exposure levels as set by the American Conference of Governmental Industrial Hygiene (ACGIH). The examiner specifically noted the review conducted by the Agency for Toxic Substances and Disease Registry (ATSDR), which found not elevated risk between exposure to TCE and benzene and the later development of TLE. Further, the examiner noted that in this case, the Veteran was actually exposed at much lower levels and for a much shorter time period than those workers in whom no elevated risk was identified in the numerous studies reviewed in the ATSDR report. The Board finds that the July 2020 VA medical opinion is adequate. In this regard, the examiner thoroughly reviewed and discussed the relevant evidence, considered the contentions of the Veteran, and provided a supporting rationale for the conclusions reached. Barr v. Nicholson, 21 Vet. App. 303 (2007); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). As such, the July 2020 VA medical opinion is the most probative evidence of record. While the Veteran believes his TLE is related to an in-service injury, event, or disease, including the contaminated water at Camp Lejeune, he is not competent to provide a nexus opinion in this case. This issue is medically complex, and it requires specialized medical education/knowledge of autoimmune disorders and the specific circumstances at Camp Lejeune. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence of record. Further, the first evidence of record showing the Veteran to have symptoms associated with the rash that ultimately led to his diagnosis of TLE was 2004. The Veteran himself reported that he had no prior history of a rash until his treatment for such in 2004. The Veteran’s ultimate diagnosis was not until 2007. As such, there is no indication from the record that the Veteran had TLE that was present to a compensable degree within one year of his separation from active service. Further, the record does not support continuity of symptoms since service. As discussed, the Veteran himself reported that he had not experienced rash symptoms until 2004, almost a decade following his separation from service. As such, presumptive service connection for a chronic disease is not warranted. 38 C.F.R. § 3.309 (a). (Continued on the next page)   Accordingly, the Board finds that the preponderance of the evidence is against the claim and entitlement to service connection for TLE is not warranted. 38 U.S.C. § 5107 (b) (2018); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Kristin Haddock Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Andrew Ledman II 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.