Citation Nr: 21021975 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 17-37 827 DATE: April 14, 2021 ORDER Service connection for systemic mastocytosis, to include as secondary to coronary artery disease with coronary artery bypass graft surgical residuals is denied. FINDINGS OF FACT 1. The Veteran has verified service in the Republic of Vietnam and is presumed to have been exposed to herbicide agents. 2. The Veteran’s systemic mastocytosis is not secondary to service-connected coronary artery disease with coronary artery bypass graft surgical residuals and is not etiologically related to an in-service event, injury, or disease, to include exposure to herbicide agents.   CONCLUSION OF LAW The criteria for service connection for systemic mastocytosis, to include as secondary to coronary artery disease with coronary artery bypass graft surgical residuals have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from February 1966 to February 1969. He died in February 2016. In May 2017, the Veteran’s wife was determined to be a proper substitute claimant by the Agency of Original Jurisdiction. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an August 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In March 2018, the appellant testified at a videoconference hearing before a Veterans Law Judge (VLJ) who is no longer available. VA regulations require that the VLJ who conducted a hearing on appeal must participate in any decision made on that appeal in the legacy appeal system. 38 U.S.C. § 7107(c); 38 C.F.R. § 20.604. The appellant was notified in a February 2021 letter of her options and was provided 30 days to respond, or else the Board assumed she did not wish for another hearing. As a response was not received within 30 days, the Board will proceed with adjudication under the assumption that the appellant did not want another hearing. Entitlement to service connection for systemic mastocytosis, to include as secondary to coronary artery disease with coronary artery bypass graft surgical residuals. At the time of the Veteran’s death, service connection was, in pertinent part, in effect for coronary artery disease (CAD) with postoperative residuals of coronary artery bypass grafting (CABG). The Veteran’s heart surgery was performed in September 2013. The appellant contends that the Veteran’s systemic mastocytosis condition was secondary to service-connected CAD with postoperative residuals of heart surgery. In the alternative, she contends the Veteran’s presumed exposure to herbicide agents compromised his immune system that led to the systemic mastocytosis condition. See July 2014 VA Form 9. In general, to establish service connection for a present disability, the claimant must show the existence of a present disability, an in-service incurrence or aggravation of a disease or injury, and a causal relationship or “nexus” between the present disability and the in-service injury or disease. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Alternatively, certain conditions will be presumed service-connected if a Veteran was exposed to herbicide agents in service, even if there is no record of the disease during service. 38 C.F.R. §§ 3.307(a)(6), 3.309(e). This presumption requires exposure to an herbicide agent and manifestation of the disease to a degree of 10 percent or more within the time period specified for each disease. 38 C.F.R. § 3.307(a)(6)(ii). In this case, the Veteran was diagnosed with systemic mastocytosis prior to his death and during the pendency of the appeal. See August 2017 private treatment records. As his military service records verified service in the Republic of Vietnam, exposure to herbicide agents is conceded. However, systemic mastocytosis is not one of the listed conditions under Section 3.309(e) to warrant service connection on a presumptive basis. Notwithstanding the above, an appellant may establish direct service connection by establishing direct actual causation as due to the presumed exposure to herbicide agents. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). While a current disability and exposure to herbicide agents are established, the question remains as to whether a causal relationship has been shown between military service, including the presumed herbicide agent exposure, and the systemic mastocytosis. The question also remains as to whether the evidence shows that the systemic mastocytosis was proximately caused by or aggravated by the service-connected CAD with postoperative residuals of coronary artery bypass grafting. After review, the Board finds that service connection for systemic mastocytosis is not warranted on either a direct or secondary basis. As discussed in greater detail below, the competent and probative medical evidence shows systemic mastocytosis was not incurred during service and it is not related to service or the service-connected CAD disability. The Veteran’s separation examination was not available for review, but his service treatment records showed one complaint of chest pain in December 1968. The clinician diagnosed him with influenza. The service treatment records were otherwise absent of any signs or symptoms of systemic mastocytosis. The June 2011 and March 2015 VA contract heart examinations reflected diagnoses of ischemic heart disease and atherosclerotic cardiovascular disease/coronary heart disease. The 2011 examination report noted the Veteran had a history of percutaneous coronary intervention (PCI) in 1999 and 2000. Other than his scars from the procedures, there were no other pertinent findings, complications, conditions, signs, and/or symptoms noted on these reports. Private treatment records showed the Veteran’s heart surgery was performed in September 2013. On follow-up, he was noted, in pertinent part, to have elevated white blood cell count and significantly elevated ferritin. Private treatment records were significant also recording an increased white blood cell count in January 2015. A March 2015 VA treatment record noted a “significantly left shifted myeloid population with monocytosis and elevated [alkaline phosphatase],” warranting a marrow biopsy. The marrow biopsy was performed in June 2015, and the Veteran was diagnosed with systemic mastocytosis with associated clonal hematological non-mast cell lineage disease (SM-AHNMD) with KIT D816V mutation. A late June 2015 private discharge summary noted that the Veteran had been diagnosed with chronic leukocytosis (elevated white blood cell count) with increased fatigue and weight loss since January 2015; bone marrow biopsy results showed systemic mastocytosis with coexisting myeloproliferative disease. The appellant submitted a December 2016 letter from the private treatment provider that performed the Veteran’s 2013 heart surgery. The letter addressed a potential infection risk for patients who have received open-heart cardiac surgeries. Specifically, the letter stated there was a possibility for a rare bacterial infection caused by nontuberculous mycobacterium (NTM) that led to symptoms of night sweats, muscle aches, weight loss, fatigue, and unexplained fever. However, of the approximately 1200 patients who have had open heart surgery at this facility, the private provider was ‘unaware of any patient(s) who have developed this infection.’ VA oncology notes indicated the Veteran had SM-AHNMD and discussed treatment plans but did not provide any etiology opinions. A January 2016 VA palliative care note reflected that the Veteran’s health continued to decline as evidenced by weight loss, decreased strength, and appetite. At the March 2018 Board hearing, the appellant testified that since the Veteran’s heart surgery, he exhibited symptoms of night sweats, muscle aches, weight loss, fatigue, and unexplained fever. This led to a bone biopsy after an emergency room visit due to pain and the resulting diagnosis was ischemic mastocytosis. See Hearing Transcript, page 7. The appellant asserted the December 2016 private treatment provider letter corroborated her assertions that those with heart conditions and compromised immune systems are susceptible, at risk for this infection from open heart surgery, and the Veteran had a compromised immune system. The ischemic mastocytosis was because he underwent the heart surgery. See Hearing Transcript, pages 12 and 16. An April 2018 letter from a private hospice facility showed that the Veteran was admitted and passed away in February 2016, but did not address etiology of the systemic mastocytosis condition. In May 2019 a VA examiner opined that it was less likely than not that systemic mastocytosis was related to or aggravated by coronary artery disease, to include the residuals of CAD with postoperative infection. The examiner explained that the Veteran’s systemic mastocytosis was diagnosed in June 2015. This is a rare genetic disease caused by mutation or changes in the KIT gene and not associated with infections or CAD. Regarding the December 2016 letter from the private treatment provider, the examiner noted that there was no documentation of the Veteran having contracted an infection post bypass surgery. Mastocytosis is not related to infections; his heart surgery was in 2013, and the diagnosis was not until 2015. The Board remanded matter in October 2019 for a VA medical opinion to address whether systemic mastocytosis was related to exposure to herbicide agents and to address the concept of aggravation by his CAD. Pursuant to the remand, a VA contract medical opinion was obtained from a hematologist in October 2020. The examiner opined that there was no evidence based on the December 2016 letter that any infections occurred from the aforementioned NTM at the provider that performed the Veteran’s September 2013 heart surgery. Also, his systemic mastocytosis and/or myelodysplastic disease was less likely than not caused by the Veteran’s presumed in-service herbicide agent exposure, as the condition was completely unrelated to exposure to Agent Orange and had no bearing upon any possible infection. There also was no evidence of any relationship between any disease state caused by Agent Orange and the systemic mastocytosis. In addition, the examiner opined that it was less likely than not the systemic mastocytosis was caused or aggravated by the service-connected CAD. The rationale was that there was no relationship between CAD and the systemic mastocytosis, to include residuals of the CABG surgery with post-operative infection. The systemic mastocytosis is a proven KIT disease. There was no evidence that this condition had any direct or indirect effect with his ischemic heart disease. As the information from the letter stated that no infections have been found at the private provider’s facility, it was less likely than not that the claimed condition is proximately due to CAD, to include residuals of the heart surgery with post-operative infections. Dr. J.D. submitted a letter in support of the claim. He attested to knowing the Veteran as a friend and that he possessed a ‘Doctor of Medicine degree from the Royal Karolinska Institute of Medicine & Surgery, Sweden’s equivalent of the National Institute[s] of Health.’ Dr. J.D. stated that he visited the Veteran after the September 2013 heart surgery and noted he had a ‘sluggish, protracted postoperative course’ and that his stamina was markedly reduced. He asserted that he was concerned about the ‘potential contamination of the device used for regulating temperature of the blood used’ in the heart surgery. In considering the evidence, the preponderance of the evidence weighs against finding that the Veteran’s systemic mastocytosis condition was secondary to service-connected CAD with postoperative residuals of heart surgery, or due to his presumed exposure to herbicide agents (to include Agent Orange). The service treatment records showed that complaint of chest pain was attributed to contracting influenza; there was no other indication during service of symptoms or signs of systemic mastocytosis. The current competent medical evidence does not support a finding that the current systemic mastocytosis was related to his presumed exposure to herbicide agents. When considered together, the Board finds the May 2019 and October 2020 VA opinions most probative because they were based on evaluation of the Veteran’s medical records and was supported by adequate rationale; their reasoning was not outweighed by any other piece of evidence. The 2019 VA examiner explained that systemic mastocytosis is a rare genetic disease caused by mutation or changes in the KIT gene; this was corroborated by the June 2015 bone marrow biopsy report that showed ‘KIT D816V’ mutation. The 2020 VA contract examiner stated the systemic mastocytosis is a proven KIT disease that has no relationship between this condition and Agent Orange. The Board has considered the appellant’s assertion that the presumed exposure to herbicide agents compromised his immune system and led to post-operative infections to include the systemic mastocytosis condition. However, the appellant has not proffered evidence to support this link. In addition, her statement regarding the relationship between this condition and the Veteran’s presumed exposure to herbicide agents (to include Agent Orange) is not competent as she does not possess the medical training or expertise to make such a determination on such a complex medical matter. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). For these reasons, the preponderance of the competent evidence is against service connection on a direct basis. Service connection is also not warranted on a secondary basis. Again, the Board finds the June 2011, March 2015, May 2019, and October 2020 VA and VA contract opinions most probative in this regard; there is no medical evidence to the contrary. The 2011 and 2015 VA contract heart examination reports showed there were no other pertinent findings, complications, conditions, signs and/or symptoms resulting from the Veteran’s CAD. The 2019 and 2020 reports address the December 2016 private provider letter and note that the provider indicated there were no infections out of the 1200 patients who received open heart surgery--there was no documentation he contracted an NTM-related infection. The Board has considered the appellant’s 2018 testimony regarding the symptoms such as weight loss, decreased strength, and fatigue that was listed on the December 2016 letter that may be due to an NTM infection; however, the Board also notes that these symptoms were attributed to his systemic mastocytosis condition and not to a post-operative infection. See January 2016 VA palliative care note. While the Board is sympathetic to the appellant’s belief that the September 2013 heart surgery and CAD condition led to systemic mastocytosis, she, as a lay person, is not competent to relay medical opinions as to complex questions. See Jandreau, 492 F.3d at 1377. Finally, the Board also fully considered the letter from Dr. J.D. but assigned little to no weight to his letter. Dr. J.D. stops short of offering an unequivocal medical nexus opinion in his capacity as a physician as to whether the Veteran’s systemic mastocytosis is due to service or a service-connected disability. To the extent the letter was proffered as favorable medical evidence, it is of very little probative weight, if any. Dr. J.D. does not appear to have been privy to the Veteran’s medical records or to have otherwise been personally involved in his medical care to fully inform his view in this matter; his ‘opinion’ was speculative in nature and without an adequate rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting that the central issue in determining probative value of a medical opinion is whether the examiner was informed of the relevant facts); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (holding that a medical opinion must be supported by an analysis that the Board can consider and weigh against contrary opinions). In sum, the competent and persuasive evidence is against the claim. There is no doubt to be resolved. The Board is grateful for the Veteran’s honorable service; however, service connection systemic mastocytosis is not warranted. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Tang, 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.