Citation Nr: 21014982 Decision Date: 03/16/21 Archive Date: 03/16/21 DOCKET NO. 15-21 443 DATE: March 16, 2021 ORDER Entitlement to service connection for leukopenia/neutropenia, claimed as a low white blood cell count, is denied. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran’s leukopenia/neutropenia began during active service or are otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for entitlement to service connection for leukopenia/neutropenia have not been met. 38 U.S.C. §§ 1131, 1132, 1153, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.306. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1983 to June 1987. This matter comes before the Board of Veterans’ Appeals (Board) from a July 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In January 2017, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. The case was last before the Board in August 2018 and has returned to the Board for further appellate review. 1. Entitlement to service connection for leukopenia/neutropenia Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. Generally, to prove service connection there must be: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by service. 38 U.S.C. § 1111. A pre-existing injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless clear and unmistakable evidence shows that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306. The presumption of soundness applies only when a disease or injury not noted upon entry to service manifests in service, and a question arises as to whether it preexisted service. Gilbert v. Shinseki, 26 Vet. App. 48, 55 (2012), aff’d 749 F.3d 1370 (Fed. Cir. 2014). In this case, there is a question as to whether the Veteran’s leukopenia/neutropenia, diagnosed as benign ethnic neutropenia (BEN), preexisted his military service from September 1983 to June 1987.   The Veteran’s December 1982 entrance examination is absent of any notations of defects, infirmities, or disorders. The Veteran’s service treatment records show that his white blood cell count was low in May 1984 and May 1986. Laboratory tests conducted in June 1986 also note a low white blood cell count and a diagnosis of neutropenia. As the Veteran’s BEN was not noted on entrance, the presumption of soundness attaches. 38 C.F.R. § 3.304(b). Because the presumption of soundness attaches with respect to this disability, there must be clear and unmistakable evidence that the disorder both pre-existed service and was not aggravated in service. Id.; see also Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). The Veteran underwent a VA examination in February 2019, at which time the examiner indicated that the Veteran has a diagnosis of benign ethnic neutropenia (BEN). The examiner opined that there is clear and unmistakable evidence the Veteran’s condition existed prior to service. In a July 2019 addendum opinion, a VA examiner opined that the Veteran’s condition is genetic in origin. Additionally, in October 2020, Dr. Y.R., a hematologist, opined that the Veteran’s condition clearly and unmistakably existed prior to service, agreeing with the February 2019 and July 2019 opinions. Dr. Y.R. explained that BEN is present at birth and is unchanged over the course of a lifetime. The examiner explained that leukopenia refers to overall white blood cell count that is low and neutropenia specifically narrows down which type of white blood cell is low, the neutrophils. Thus, the most probative evidence of record shows that there is clear and unmistakable evidence that the Veteran’s BEN preexisted service. 38 U.S.C. § 1132; 38 C.F.R. § 3.304(b). As the Veteran’s BEN has been shown by clear and unmistakable evidence to preexist service, consideration must now be given to whether clear and unmistakable evidence exists to show that his BEN was not aggravated during service, to fully rebut the presumption of soundness. Id. The government may show a lack of aggravation by establishing by clear and unmistakable evidence “that there was no increase in disability during service or that any “increase in disability [was] due to the natural progress of the preexisting condition. Wagner, 370 F.3d at 1096 (quoting 38 U.S.C. § 1153). Temporary or intermittent flare-ups during service of a pre-existing injury or disease are not sufficient to be considered “aggravation in service” unless the underlying condition, as contrasted to symptoms, is worsened. Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). The occurrence of symptoms, in the absence of an increase in the underlying severity, does not constitute aggravation of the disability. Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002). Evidence of the veteran being asymptomatic on entry into service, with an exacerbation of symptoms during service, does not constitute evidence of aggravation. Green v. Derwinski, 1 Vet. App. 320, 323 (1991). If the disorder becomes worse during service and then improves due to in-service treatment to the point that it was no more disabling than it was at entrance into service, the disorder has not been aggravated by service. Verdon v. Brown, 8 Vet. App. 529 (1996). During the Veteran’s February 2019 VA examination, the examiner opined that there is clear and unmistakable evidence that the Veteran’s BEN was not aggravated beyond its natural progression by service. In support of her opinion, the examiner explained that there is no evidence the Veteran has in the past been treated with chemotherapy, antiviral drugs, quinidine, procainamide, oxacillin, or antipsychotic medications which could cause pronounced neutropenia. Moreover, the October 2020 VA examiner also opined that the Veteran’s BEN was clearly and unmistakably not aggravated beyond its natural progression by service. The examiner explained that the Veteran’s white blood cell count and absolute neutrophil count have fluctuated over the decades, as expected given the nature and function of white blood cells, but the levels have remained relatively stable, even rising in recent years. As Veteran’s BEN has remained unchanged over time, the examiner concluded that there is no aggravation due to any cause, including any time or event in service. The Board finds the most probative evidence of record illustrates that there is clear and unmistakable evidence that the disability was not aggravated by military service. Thus, the presumption of soundness is rebutted in its entirety. As the presumption of soundness is rebutted, the second element of service connection is not met and entitlement to service connection is not warranted.   In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. As the preponderance of the evidence is against the claim, the doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102 (2018); see also Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). K. A. BANFIELD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Lance, Associate 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.