Citation Nr: 21021111 Decision Date: 04/09/21 Archive Date: 04/09/21 DOCKET NO. 12-13 223 DATE: April 9, 2021 ORDER Entitlement to service connection for histoplasmosis is denied. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran’s histoplasmosis began during active service, or is otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for entitlement to service connection for histoplasmosis have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1959 to August 1963. This matter is before the Board of Veterans’ Appeals (Board) on appeal from an April 2011 rating decision issued by the Regional Office (RO) of the Department of Veterans Affairs (VA) in Nashville, Tennessee. The RO in Montgomery, Alabama currently has jurisdiction over the claim. In November 2017, the Board remanded the appeal for further evidentiary development and readjudication. The RO has substantially complied with the Board’s remand instructions, so the Board may proceed to the merits of the claim on appeal. See Stegall v. West, 11 Vet. App. 268, 271 (1998); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (noting that Stegall requires substantial compliance with remand orders, rather than absolute compliance). After the appeal returned to the Board following remand, the Veteran had a hearing before the undersigned Veterans Law Judge in February 2021. The Veteran has not raised any specific issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Therefore, the Board does not need to discuss VA’s compliance with the duties to notify and assist. The Veteran that he contracted histoplasmosis during service while removing remains of a bird from an aircraft he on which he was working. See May 2019 Written Brief Presentation; February 2021 Board Hearing Tr. at 2-3. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (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). The Veteran has a current diagnosis of histoplasmosis and eye disabilities relating to that diagnosis, and evidence shows that, giving the Veteran every benefit of the doubt, he did clean the remains of a bird (identified by the Veteran as a mallard duck) from an aircraft during service and he had in-service complaints of feeling like he had a foreign object in his eye. However, the Board concludes that the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of histoplasmosis began during service or is otherwise related to an in-service injury, event, or disease. Private treatment records do not document that the Veteran was diagnosed with histoplasmosis (specifically, ocular histoplasmosis syndrome) until 2001, several decades after separation from service. See June 2019 Private Opinion Letter (indicating the Veteran was first seen in 2001 with scarring of the retina of both eyes consistent with histoplasmosis syndrome which indicated that “the infection had occurred at some point prior to that”). While the Veteran is competent to report having experienced symptoms such as being sick with flu-like symptoms during service and reduced visual acuity since service, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of the later-diagnosed histoplasmosis or related ocular or retinal conditions. The issue is medically complex, as it requires knowledge of the presentation and course of fungal infections such as histoplasmosis, the possible causes of the subjective symptoms the Veteran has reported, the pathology of eye disorders, and the interpretation of diagnostic testing, as well as familiarity with and ability to understand relevant medical literature. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Veteran alleges that he was diagnosed with histoplasmosis in 1964 “within a year of getting out of the Air Force.” See December 2010 VA 21-4138. The record does not contain any documentation of this alleged post-service diagnosis, though there are post-service medical records documenting laboratory results and chest x-rays with “no significant abnormality” and overall description of “routine chart” without any indication of any fungal infection, eye trouble, or any prior diagnosis with histoplasmosis. See November 1967 Medical Records. In his May 2012 VA Form 9, the Veteran provided a detailed description of the 1964 diagnosis. He indicates that he left the Air Force in August 1963 and held a couple different jobs. Around the time he began a new job in February or March 1964, he needed eye glasses and went to see an eye doctor (Dr. P). The Veteran reports that during the exam, he dilated the Veteran’s eyes. He informed the Veteran that he had histoplasmosis because he could see scars in the Veteran’s eyes. The doctor told the Veteran that he had contracted histoplasmosis at some point in the past and his body had fought it off. According to the Veteran, the doctor explained that the infection was inactive at that point, but could become active again at any time. There was no indication for treatment at that time. The Veteran explained that Dr. P. moved in 1988 and the Veteran’s records were transferred to a Dr. C. Dr. C. retired from medicine in 1999 and his records were transferred to Dr. K. When the Veteran began having trouble with his eyes in 2001, he was referred to Dr. D. a retinal specialist. The Veteran reports that Dr. K. destroyed the old records in 2009. The Veteran argued that he was never around birds or chickens before he went into the Air Force and that “the only place I could have contracted this disease is in the aircraft hangars at Moody AFB, Georgia.” There were thousands of blackbirds in the area and they restricted flight so much that aircraft had to take off close to dawn before the birds left their roost. The base officials resorted to explosives to scare the birds away. Where the veteran asserts entitlement to a chronic disease but there is insufficient evidence of a diagnosis in service, service connection may be established under 38 C.F.R. § 3.303(b) by demonstrating a chronic disease was incurred during service or within the presumptive period after service and there has been a continuity of symptomatology since service, but only if the chronic disease is listed under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. 2013). The Veteran’s claimed histoplasmosis is not one of the chronic diseases listed under 38 C.F.R. § 3.309(a). Therefore, service connection as a chronic disease, to include any alleged chronicity of symptomatology, is not warranted. See 38 C.F.R. §§ 3.303, 3.307, 3.309(a). For disabilities that are not service-connected under 38 C.F.R. § 3.303(b), the only avenue for service connection is by showing in-service incurrence or aggravation under 38 C.F.R. § 3.303(a), or by showing that a disease that was first diagnosed after service is related to service under 38 C.F.R. § 3.303(d). See Walker, 708 F.3d at 1338-39. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Therefore, even accepting as true that the Veteran was diagnosed with histoplasmosis in 1964, after his active service, he can only prevail by establishing that the condition diagnosed after service either began during active service or is etiologically related to an in-service event. Because the Veteran’s service records do not indicate any in-service diagnosis of histoplasmosis, the question is the etiology of his later-diagnosed histoplasmosis. The May 2017 VA examiner documented the Veteran’s report of the history of his condition. Specifically, the Veteran stated, consistent with his entrance examination, that he had no eye problems prior to his active service. During service, a bird hit an aircraft and he had to clean up the mess. He says the bird was a mallard duck, because he found the severed “green head” in the aircraft. He stated this occurred in 1961 or 1962. He remembers getting sick during active service, but does not recall whether it occurred after this incident and, if so, how long after. The Veteran reported being diagnosed with histoplasmosis in early 1964, but did not report any further symptoms, treatment, or complications of histoplasmosis until 2001 when he began “noticing distortion and missing portions of vision in the right eye.” The Veteran also reported not growing up around any birds and having first been in a chicken coop in 2003. The examiner diagnosed presumed ocular histoplasmosis, cataract (left), and pseudophakia (right, post-cataract surgery). The examiner provided a May 2017 nexus opinion that the Veteran’s presumed ocular histoplasmosis is less likely as not incurred in or caused by his service time. The examiner explained that there is no documentation of presumed ocular histoplasmosis during service. The examiner notes the Veteran’s report that he was diagnosed in 1964 and states that the report is plausible, but unfortunately there is no objective documentation or record which shows a diagnosis of ocular histoplasmosis until 2001 in his records. The examiner also noted that histoplasmosis is caused by the inhalation of spores, usually from disturbed soil or bat droppings. Droppings from chickens, pigeons, starlings, blackbirds, and bats support its growth in soil. The examiner was unable to find any documentation that a mallard duck could or could not carry histoplasmosis, which is the bird the Veteran reports that he cleaned off an aircraft in 1961 or 1962. Histoplasmosis infections often do not cause signs or symptoms or present with flu-like symptoms. Therefore, an exact timeline of contraction can be difficult. If symptoms of histoplasmosis infection occur, they start within 3 to 17 days after exposure. The examiner noted that the Veteran could not recall whether he had any symptoms after cleaning up the mallard. The examiner provided additional rationale in her December 2017 addendum opinion. The examiner explained that ocular histoplasmosis does not result in a foreign body sensation in the eyes. She concluded, therefore, that the sensation of a foreign body in the eye on July 11 and 12, 1963 was unrelated to his presumed ocular histoplasmosis. Ocular histoplasmosis is caused by inhalation of spores, not through contact, and would not manifest as a conjunctivitis as documented in the July 1963 notes. The Veteran’s Grave’s disease with ocular manifestations of “prominent eyes” (exophthalmos)/proptosis are unrelated to the presumed ocular histoplasmosis. His account of experiencing flu-like symptoms is very vague and not specific of histoplasmosis infection. The examiner noted that, according to the Center for Disease Control (CDC), only one percent (1%) of infections are symptomatic. The examiner notes the absence of any dilated eye exam during service to help confirm, deny, or pinpoint any time frame of the histoplasmosis infection. The examiner quoted extensively from information obtained from the CDC which describes histoplasmosis as an infection caused by a fungus that lives in soil that contains large amounts of bird or bat droppings. The examiner opined that, based on the fact that histoplasmosis is spread by inhalation rather than contact, usually through disturbed soil, and there are no documented retinal examinations and no known date or year of the bird clean-up, it is less likely than not that the Veteran’s presumed ocular histoplasmosis was acquired during service with the clean-up of the mallard. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The reasoning is highly persuasive and based on current medical understanding and guidance provided by the CDC. The examiner has persuasively argued that histoplasmosis is typically not transferred from birds to humans, or even from bird droppings to humans, but usually results from inhaling spores released into the air after disturbing soil in which there are large amounts of bird droppings. Therefore, it is unlikely that the claimed in-service event, cleaning up the remains of a bird, would be a means of infection with histoplasmosis. The examiner considered the Veteran’s in-service treatment as well as his statements of experiencing “flu-like” symptoms and explained why these facts were not suggestive of histoplasmosis. The Veteran challenges the opinion in several respects. See April 2019 Veteran Correspondence. First, he contests the examiner’s statement that she was unable to find documentation that a mallard could carry the histoplasmosis fungus. As the Board reads the opinion, the examiner’s inability to determine whether mallards could or could not carry the fungus did not impact her final opinion. As noted above, even assuming that a mallard could carry the fungus, the method of contraction is typically through disturbed soil contaminated with droppings. The internet article referenced by the Veteran also discusses contamination via accumulated droppings, not handling a live bird or a recently killed bird (whether duck or otherwise). These facts form the basis for her opinion that it is less likely than not that cleaning up the remains of a bird (even including presumed fecal matter in the bird or fungus on the feathers) is an unlikely method of contracting histoplasmosis. Her inability to specifically rule in ducks as capable of carrying the fungus was not central or crucial to her opinion. Second, the Veteran argues that the opinion is inadequate or unconvincing because it only references “cleaning the remains from the windshield.” The Board disagrees with the Veteran’s interpretation. The examiner specifically referenced the Veteran’s report that he found the severed head of the mallard inside the aircraft. The only plausible reading of this is that the examiner understood that there were remains of the duck inside the aircraft and the Veteran had to clean up the inside as well as the outside of the aircraft. And, again, the examiner’s central rationale is that the most likely mode of transmission is through breathing air from disturbed soil contaminated with bird droppings, not via remains of a bird (whether inside an enclosed space or not). Third, the Veteran argues that the examiner made no reference to his 1962 sick call. The examiner specifically noted that “flu-like symptoms” is too vague to be of much use in determining whether the symptoms indicated an infection with histoplasmosis. Moreover, the examiner expressly noted the timeframe for onset of the symptoms and that the Veteran was unable to say whether the in-service “flu-like” symptoms occurred within that time after the clean-up incident. Fourth, the Veteran references a reprint from the CDC website on histoplasmosis. Notably, the final sentence on the page states: “On the other hand, fresh bird droppings on surfaces such as sidewalks and windowsills have not been shown to present a health risk” for histoplasmosis. To the extent this article has probative value, it is against finding that fresh droppings such as would result from a duck being hit by an aircraft, are a likely source of histoplasmosis infection. The Board has not given this any probative weight, but points out that this evidence from the CDC website does not support his hypothesis and, instead, would weigh against his claim if given any weight at all. The Veteran has submitted letters from private physicians in support of his claim. In a September 2015 private opinion letter, a physician noted the Veteran’s report of an incident in 1961 to 1962 when a bird struck the windshield of an airplane resulting in damage to the aircraft. The Veteran was assigned to clean up the remains of the bird and the windshield debris. The physician stated: “Prior to this incident, the patient did not have any ocular problems nor findings of ocular histoplasmosis. Sometime thereafter, [the Veteran] developed ocular complications of histoplasmosis resulting in his visual disability.” Unfortunately, this letter does not provide an opinion regarding the approximate date of infection. While it can be read as indicating that it is possible the Veteran was infected during service, the only opinion offered is that the alleged incident occurred sometime between 1961/62 and the onset of ocular complications of histoplasmosis were sometime thereafter. The letter has no probative value on the etiological question at issue. The record also includes a June 2019 private opinion letter from the Veteran’s treating physician. The physician described the course of the Veteran’s condition since 2001 when the Veteran initially presented to the physician for treatment. The physician then explained that ocular histoplasmosis is a condition caused by infection from the yeast form of the fungus Histoplasmosis Capsulatum. The fungus is carried in the feathers and droppings of birds. Humans are infected by inhalation of the fungus, which is then disseminated in the bloodstream. Systemic infection usually is minimal and subsides quickly, leaving ocular scarring. The scarring often becomes a problem years later when choroidal neovascular vessels grow through the scars causing enlarging blind spots and additional vision damage. Treatment is directed at stopping the bleeding/choroidal neovascularization. The physician opined that the infection occurred at some point prior to his 2001 initial presentation for treatment and “cannot specifically be determined as to when and where, but it is known that the fungus is carried by birds.” The private physician’s opinion letter provides some helpful information about the Veteran’s condition and how the infection with histoplasmosis occurs, but fails to provide any opinion regarding whether the Veteran as likely as not contracted the ocular histoplasmosis during his active service. The physician only opines that the infection occurred “at some point” prior to 2001, which is nearly four decades after the Veteran’s discharge. While the context of this opinion includes the Veteran’s detailed and convincing discussion of his 1964 diagnosis, it still does not provide a link to any event, injury, or disease during the Veteran’s service prior to his discharge in August 1963. The physician did not state that it is at least as likely as not that the Veteran’s contracted histoplasmosis during his active service. In short, the only medical opinion stating a conclusion to the requisite degree of medical certainty is that of the May 2017 VA examiner and it is against the Veteran’s claim. The Veteran believes his presumed ocular histoplasmosis is related to an in-service injury, event, or disease, and he has provided a logical basis for his belief. However, he is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the method of infection, how the infection affects the body, the likely onset and course of the infection after initial exposure. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the opinion of the VA examiner. The greater weight of the evidence is against the Veteran’s claim of entitlement to service connection for histoplasmosis. The evidence fails to establish, to the requisite degree of certainty (at least as likely as not) an etiological link between the condition first diagnosed after his active service and an event, injury, or disease during his active service. Entitlement to service connection for histoplasmosis is denied. MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Kerry Hubers 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.