Citation Nr: 21014424 Decision Date: 03/12/21 Archive Date: 03/12/21 DOCKET NO. 16-13 359 DATE: March 12, 2021 ORDER Entitlement to service connection for non-Hodgkin’s lymphoma is denied. FINDING OF FACT 1. The Veteran did not serve at Camp Lejeune during the presumptive time period (i.e., from August 1, 1953 through December 31, 1987), exposure. 2. The Veteran’s non-Hodgkin’s lymphoma did not manifest as chronic symptoms in service, to a compensable degree within the one-year presumptive period after service, or as continuous symptoms since service. 3. The Veteran’s non-Hodgkin’s lymphoma is not etiologically related to an in-service injury, disease, or event, to include hazardous environmental and/or chemical exposures or exposure to contaminants in the water supply at Camp Lejeune. CONCLUSION OF LAW The criteria for service connection for Non-Hodgkin's lymphoma have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served honorably on active duty with the United States Marine Corps from May 1988 to May 1992, including overseas service in the Southwest Asia theater of operations during the Persian Gulf War. This case was most recently before the Board in September 2018, at which time it was remanded for additional development. The case has since been returned to the Board for appellate consideration. Entitlement to service connection for non-Hodgkin’s lymphoma. The Veteran seeks service connection for non-Hodgkin’s lymphoma, which he has attributed to his service in Southwest Asia during the Persian Gulf War, and/or from drinking contaminated water at Camp Lejeune. See July 2013 Notice of Disagreement. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Service connection may also be granted for any disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303 (d). Generally, to establish service connection, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). In addition to the above regulations, service connection may also be granted on a presumptive basis for a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability, including an undiagnosed illness or a medically unexplained chronic multi-symptom illness that is defined by a cluster of signs or symptoms, such as chronic fatigue syndrome, fibromyalgia, and other functional disorders. The disability must manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021. The Southwest Asia theater of operations refers to Iraq, Kuwait, Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317 (e)(2). An undiagnosed illness is one which, by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317 (a)(1). The term “medically unexplained chronic multisymptom illness” means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. 38 C.F.R. § 3.317 (a)(2)(ii). The Board further notes that there is a presumption of service connection for certain diseases based on exposure to contaminants present in the water supply at Camp Lejeune during the period from August 1, 1953 through December 31, 1987. In order to qualify for presumptive service connection, there must be evidence of: (1) a diagnosis of one of the enumerated diseases under the new provision 38 C.F.R. § 3.309 (f), (i.e., adult leukemia, aplastic anemia and other myelodysplastic syndromes, bladder cancer, kidney cancer, liver cancer, multiple myeloma, non-Hodgkin’s lymphoma, and Parkinson’s disease), if manifest to a degree of 10 percent or more at any time after service; and (2) service of at least 30 days (consecutive or nonconsecutive) at Camp Lejeune during the pertinent time period. 38 C.F.R. §§ 3.307, 3.309. A review of the record in this case shows that while the Veteran served at Camp Lejeune, he did not enter active service until May 1988. As he did not serve at Camp Lejeune during the presumptive period (i.e., from August 1, 1953 through December 31, 1987), exposure to contaminated water during the Veteran’s service is not presume and service connection based on presumptive exposure to contaminated water at Camp Lejeune is not warranted. 38 C.F.R. §§ 3.307(a)(7)(iii) and 3.309(f). However, the Veteran had active service in Southwest Asia from August 1990 to April 1991. Therefore, he is considered a Persian Gulf veteran. 38 C.F.R. § 3.317 (e). VA treatment records and a November 2019 VA examination report show the Veteran has a diagnosis of non-Hodgkin’s lymphoma. He was diagnosed with B-Cell lymphoma after a bilateral bone marrow biopsy and aspiration in May 2012. In an opinion accompanying her November 2019 examination report, the VA examiner determined that the Veteran’s non-Hodgkin’s lymphoma is a diagnosable chronic multi-symptom illness with a partially explained etiology. As such, it is not due to undiagnosed illness or a medically unexplained chronic multisymptom illness and does not represent a qualifying chronic disability under 38 C.F.R. § 3.317. Nevertheless, the Veteran is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). Therefore, as discussed below, the Board has considered whether direct service connection for lymphoma is warranted, to include as due to hazardous environmental exposure commonly associated with service in the Southwest Asia Theater of operations. In his July 2013 notice of disagreement, the Veteran indicated that he had no family history of non-Hodgkin’s lymphoma and suggested that his lymphoma may be related to Gulf War Syndrome. In a December 2013 statement, the Veteran asserted that he has experienced fatigue, headaches, insomnia, dizziness, and memory problems that he believed were symptoms of his lymphoma since service. The Veteran’s service treatment records (STRs) are associated with the claims file and are silent for diagnosis of non-Hodgkin’s lymphoma. There is a single entry in September 1990 indicating the Veteran reported a throbbing headache and feeling “slightly dizzy” in conjunction with a sore throat, but there is no indication the symptoms were chronic. Subsequent reports of medical examination, including the Veteran’s February 1992 discharge examination and a January 1993 report of medical history from the Reserves were silent for fatigue, headaches, insomnia, dizziness, memory problems, or other symptoms the Veteran has attributed to his current non-Hodgkin’s lymphoma. During his November 2019 VA examination, the Veteran reported that he had always had abdominal pain and fatigue, which he suggested started when he was in the Marine Corps. He reported that he never really worried about it until later in life, when he sought treatment in 2012 and was diagnosed with non-Hodgkin’s lymphoma. The examiner noted that the Veteran had been diagnosed with follicular lymphoma, typically a slow-growing or indolent form of non-Hodgkin’s lymphoma that arises from B-lymphocytes, making it a B-cell lymphoma. The examiner noted that common symptoms of follicular lymphoma include enlargement of the lymph nodes in the neck, underarms, abdomen, or groin, as well as fatigue, shortness of breath, night sweats, and weight loss. In an accompanying opinion, the VA examiner determined that the Veteran’s non-Hodgkin’s lymphoma was less likely than not incurred in or caused by an in-service injury, event, or illness. The examiner explained that review of the record did not show reported symptoms or findings suggesting the Veteran had any indication of non-Hodgkin’s lymphoma dating back to his discharge from service in May 1992. The examiner further explained that it is not known what causes follicular and other non-Hodgkin’s lymphomas; unlike some cancers, they are not passed down in families. She noted that in some cases, radiation or cancer-causing chemicals or certain infections may be a cause, and that research shows it is more likely to be diagnosed with increased age. She noted that the Veteran’s type of low-grade follicular lymphoma are usually indolent tumors that may persist for many years, producing bulky adenopathy. She further noted that a variety of symptoms can be related to follicular lymphomas, but abdominal pain is the most common. The examiner explained that there is no evidence through research studies or medical literature proving that environmental exposures or hazards experienced by service members in Southwest Asia, such as dust, oil well fires, pesticides, infectious diseases, inhalation of solvents, fuel fumes, ultra-fine grain sand, or administration of vaccines cause lymphoma. Accordingly, the examiner concluded that the Veteran’s diagnosis was unrelated to exposure to environmental hazards experienced during his Gulf War service. The examiner also noted that the Veteran’s STRs included normal physical examinations during service, during which the Veteran denied stomach, liver, or intestine trouble and denied trouble sleeping, loss of weight, and loss of memory or amnesia. The examiner also noted that STRs did not show complaints related to abdominal pain, unexplained fever, findings of abnormal lymph nodes, or any repetitive specific or unspecific symptoms or worrisome complaints during active service. Overall, after careful review of the record, the Board finds that the evidence is against a finding that the Veteran’s currently diagnosed non-Hodgkin’s lymphoma was incurred during service or is otherwise related to service, including to his service in Southwest Asia during the Persian Gulf War or alleged exposure to contaminated water at Camp Lejeune. As previously discussed, the Veteran’s non-Hodgkin’s lymphoma is not due to undiagnosed illness or a medically unexplained chronic multisymptom illness and does not represent a qualifying chronic disability under 38 C.F.R. § 3.317. Moreover, the Veteran did not serve at Camp Lejeune during the period for which presumptive exposure to contaminated water is permitted. Further, the weight of the evidence does not show that it manifested in service or to a compensable degree within a presumptive period following separation from service. STRs are silent for reports of or treatment for non-Hodgkin’s lymphoma or symptoms thereof. Available post-service treatment records show the Veteran was not diagnosed with non-Hodgkin’s lymphoma until May 2012—decades after discharge from active service. In reaching this conclusion, the Board acknowledges the Veteran’s belief that his non-Hodgkin’s lymphoma is related to active service, to include his Gulf War service or exposure to contaminated water at Camp Lejeune. However, as a lay person, the Veteran is not competent to provide an opinion concerning the etiology of his disability and its relationship to service. This is an issue that is medically complex, as it requires specialized medical education and knowledge of the interaction between multiple organ systems in the body and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board assigns more probative weight to the competent medical evidence of record. While the Board understands the Veteran honestly believes that his non-Hodgkin’s lymphoma is related to either his Gulf War service or his service at Camp Lejeune, there is no competent evidence in the claims file to support such a conclusion. Therefore, based on the foregoing, the Veteran’s claim of entitlement to service connection for non-Hodgkin’s lymphoma must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b) and 38 C.F.R. § 3.102. Tiffany Dawson Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. T. Raftery, 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.