Citation Nr: 21025869 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 17-56 635 DATE: April 29, 2021 ORDER Entitlement to service connection for small fiber neuropathy with associated fibromyalgia and chronic fatigue syndrome (CFS) is denied. FINDING OF FACT The evidence of record is against finding that the Appellant’s small fiber neuropathy with associated fibromyalgia and CFS occurred in, or is the result of, her period of active duty for training (ACDUTRA). CONCLUSION OF LAW The criteria for entitlement to service connection for small fiber neuropathy with associated fibromyalgia and CFS are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303(a). REASONS AND BASES FOR FINDING AND CONCLUSION The Appellant served in the Air National Guard from May 2011 to February 2016 with a period of ACDUTRA from October 2011 to July 2012. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. A Board hearing was conducted at the RO in Louisville, Kentucky. A transcript of this hearing is contained within the electronic claims file. The Appellant’s theory of entitlement is that, while on ACDTURA, she experienced bronchitis. This episode of bronchitis, as purportedly relayed to the Appellant by her doctors, affected her “immune system to where [her] body [was] attacking [her] nerve endings consistently,” leading to the development of the conditions herein. November 5, 2019, Hearing Transcript (Tr.) at 5. The Board previously remanded this claim in February 2020. There, the Board noted that a June 2016 VA opinion, as well as a private opinion from Dr. K.F., at least indicated that the Veteran’s small fiber neuropathy could be related to her bronchitis but otherwise were insufficient for adjudication purposes. Remanded was required so that an adequate opinion could be obtained. In March 2020, VA obtained the necessary opinion (discussed below). Thus, the Board finds that VA substantially has complied with the prior remand directives and now may proceed to adjudicate this appeal. See D’Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998). Generally, to qualify for VA benefits, a claimant must be a veteran. Dingess v. Nicholson, 19 Vet. App. 473, 484 (2006) One of the benefits administered by VA that is reserved specifically for veterans is disability compensation, and a claim for such disability has five elements: (1) veteran status, (2) existence of a disability, (3) service connection of that disability, (4) degree of disability, and (5) effective date of the disability. D’Amico v. West, 209 F.3d 1322, 1326 (2000). Accordingly, in order to establish his entitlement to disability compensation benefits, he or she must first establish “veteran” status. The term “veteran” is defined in 38 U.S.C. § 101(2) as “a person who served in the active military, naval, or air service, and who was discharged or released therefrom under conditions other than dishonorable.” The term “active military, naval, or air service” includes (1) active duty, (2) any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and (3) any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty. 38 U.S.C. § 101(24); Biggins v. Derwinski, 1 Vet. App. 474, 477–78 (1991); 38 C.F.R. § 3.6(a). ACDUTRA is defined, in part, as “full-time duty in the Armed Forces performed by reserves for training purposes.” 38 U.S.C. § 101(22); 38 C.F.R. § 3.6(c). The term INACDUTRA is defined, in part, as duty, other than full-time duty, under sections 316, 502, 503, 504, or 505 of title 32 United States Code or the prior corresponding provisions of law. 38 U.S.C. § 101(23); 38 C.F.R. § 3.6(d). For disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service, during a period of war, the United States will pay to any veteran thus disabled and who was discharged or released under conditions other than dishonorable from the period of service in which said injury or disease was incurred, or preexisting injury or disease was aggravated, compensation as provided in this subchapter, but no compensation shall be paid if the disability is a result of the veteran’s own willful misconduct or abuse of alcohol or drugs. 38 U.S.C. § 1110. To establish service connection, there must exist medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013); 38 C.F.R. § 3.303(a). In rendering a decision on appeal, the Board must analyze the competency, credibility, and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Buchanan v. Nicholson, 451 F.3d 1331, 1335–37 (Fed. Cir. 2006). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall resolve all reasonable doubt in favor of the claimant. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990); 38 C.F.R. § 3.102. Albeit detailed, the Board finds it appropriate to provide the March 2020 examiner’s entire medical opinion so that the Board’s decision adequately is supported. A full review of all available medical records confirms that the Veteran was diagnosed with small fiber neuropathy by biopsy in 2015. It is also confirmed that she has diagnoses of Fibromyalgia (FM) and Chronic Fatigue Syndrome (CFS). The records are all consistent that the initial symptoms of FM and CFS were in 2014 when she was still in the military, but this appears to be National Guard, not VA qualifying active duty service. There is no indication of any symptoms or findings consistent with FM, CFS, or neuropathy during her active duty service from 10/31/11 to 7/19/12. The Veteran’s contention is that an episode of bronchitis while on active duty affected her immune system to where her body was attacking her nerve endings consistently leading to her claimed neuropathy. The Veteran submitted a medical opinion from K.F. MD, neurologist at Coastal Neurology Services, Dover NH dated 7/17/18 indicating that it is not uncommon for this condition (small fiber neuropathy) to start after infections such as upper respiratory tract infection. “In this case the small sensory and autonomic nerve fibers are attacked by the immune system which has been initially activated to fight off the infection.” As noted in the BVA Decision Dr. F. did not provide any additional rationale or cite any medical references to support the conclusion. Review of STRs during her active duty period shows that on 11/20/2011 she presented with symptoms of productive cough, and sore throat for several days. There was no report of shortness of breath, wheezing or chest pain. She was unsure about fevers though did note some chills. Exam showed she was essentially afebrile with temperature of 99 degrees, oxygen saturation was normal at 100%. There was mucoid nasal discharge, erythematous throat without exudates and lungs showed some rhonchi without wheezes or rales. Given the symptoms and exam findings she was diagnosed with acute bronchitis and prescribed a 5-day course of antibiotic-azithromycin. Given the foregoing documentation, the diagnosis of acute bronchitis appears medically reasonable. STRs do not indicate any further problems with bronchitis. No follow-up visits were required and there is no documentation of any complications subsequent to her initial treatment. It is reasonable to presume that her acute bronchitis fully resolved which would be the expected course for this diagnosis in a 19-year old non-smoker with no history of asthma or other underlying health problems. It is not medically plausible that such an acute respiratory infection would result in a chronic immune response following resolution that would continually and consistently “attack” nerve endings as contended. She did present to the emergency department on 3/6/12 with symptoms of chest tightness and shortness of breath. The record shows that this was diagnosed as an anxiety reaction and there was no evidence of any heart or lung disease or infection. The remainder of STRs do not show any evidence of symptoms or findings indicating chronic bronchitis, neuropathy, FM, CFS, or any other chronic infectious or inflammatory/immune process during active duty or in the first 12 months following active duty. There is no indication of any conditions known to cause neuropathy including heavy metal or other toxic exposure, malignancy, metabolic issues such as diabetes, hypothyroidism, chronic liver or kidney disease, or vitamin deficiencies, chronic vascular/rheumatic disease, infections known to cause chronic neuropathy such as Lyme disease, leprosy, herpes zoster, chronic hepatitis B or C, or HIV, sarcoidosis or drug use associated with neuropathy. An online literature search by this examiner looking for evidence of an association of acute bronchitis and small fiber neuropathy, FM or CFS came up “empty handed.” No scientific articles were identified that would show or support the Veteran’s contentions regarding the causation of her neuropathy, FM or CFS. It is well known that acute peripheral neuropathy can follow certain infectious diseases, including influenza-like infections. This neuropathy however is of the Guillain-Barre type. The cardinal clinical features of Guillain-Barré syndrome (GBS) are progressive, fairly symmetric muscle weakness accompanied by absent or depressed deep tendon reflexes. Patients usually present a few days to a week after onset of symptoms. The weakness can vary from mild difficulty with walking to nearly complete paralysis of all extremity, facial, respiratory, and bulbar muscles. The [Appellant’s] neuropathy is clearly not of the GBS type. Small fiber neuropathy has a poorly understood pathology. It can be a result of a variety of diseases, including diabetes mellitus, autoimmune disorders such as Sjögren or sarcoidosis, paraproteinemia, and paraneoplastic syndrome, with diabetes mellitus being the most common cause of SFN. In many cases a specific cause cannot be identified which is likely the case in this [Appellant]. As noted above there is no evidence that the [Appellant] had any of the conditions known to cause small fiber neuropathy or any other type of neuropathy during active duty service. As to the examiner’s opinion of June 2016 that there is a non-universally accepted theory that some FM patients may have small fiber neuropathy as a contributing factor, there is some medical literature evidence in support of this. However, even if this is accepted, it is less likely as not that the [Appellant’s] small fiber neuropathy is due to any event during active duty service for reasons discussed above. I am unable to find any medical literature that would support small fiber neuropathy as playing a causative role in CFS. In its prior decision, the Board acknowledged that the Appellant currently suffers from small fiber neuropathy and that she experienced bronchitis during her period of ACDUTRA. Thus, the first two elements of service connection have been established. See Romanowsky, 26 Vet. App. at 293; 38 C.F.R. § 3.303(a). With respect to the third element of service connection, the Board finds the evidence of record insufficient. The Board discussed in its previous remand why it found the other medical opinions of record to be inadequate, and it will incorporate those reasons herein. The March 2020 examiner provided an extremely detailed opinion discussing why the Appellant’s small fiber neuropathy is not related to her bronchitis experienced during ACDUTRA. This examiner adequately responded to Dr. K.F.’s opinion, noting (as the Board did) that she did not cite any medical literature to support her conclusion. This examiner, however, indicated that a search of medical literature did not reveal any relationship between small fiber neuropathy and bronchitis. The VA examiner also discussed GBS, which sometimes can follow influenza-like symptoms, but noted that the Appellant’s small fiber neuropathy is not of the GBS type. The opinion further discusses that the Veteran had no exposure during service to any sources that are known to cause small fiber neuropathy, such as heavy metal or toxic exposures. This examiner ultimately concluded that the cause of the Veteran’s small fiber neuropathy likely is unknown, as is the case most times with this condition. For the reasons discussed, the Board finds the March 2020 VA opinion to be the most probative on the matter before it. Thus, the Board finds that the third element of service connection has not been established. See Romanowsky, 26 Vet. App. at 293; 38 C.F.R. § 3.303(a). Because the evidence of record does not support the Appellant’s claim for entitlement to service connection for small fiber neuropathy with associated fibromyalgia and CFS, the Appellant’s appeal is denied. The Board is unable to find an approximate balance of the positive and negative evidence submitted to warrant for the Appellant a favorable decision. See 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 53; 38 C.F.R. §§ 3.102, 3.303(a). (SIGNATURE ON NEXT PAGE) JONATHAN B. KRAMER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Trevor T. Bernard, 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.