Citation Nr: 21026224 Decision Date: 04/30/21 Archive Date: 04/30/21 DOCKET NO. 17-56 838 DATE: April 30, 2021 ORDER Service connection for residuals of histoplasmosis, pulmonary nodules and restrictive lung disease, is granted. FINDING OF FACT Resolving reasonable doubt in the Veteran’s favor, residuals of histoplasmosis, pulmonary nodules and restrictive lung disease, is at least as likely as not related to service. CONCLUSION OF LAW The criteria for service connection for residuals of histoplasmosis, pulmonary nodules and restrictive lung disease, are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from May 2008 to May 2013. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In January 2021, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A hearing transcript is associated with the claims file. The undersigned VLJ held the record open for a 60-day period following the hearing to allow for the submission of additional evidence. Thereafter, the Veteran submitted a medical opinion from a non-VA nurse practitioner in support of her claim for service connection. Service connection for residuals of histoplasmosis, pulmonary nodules and restrictive lung disease, is granted. The Veteran contends that she developed permanent lung nodules caused by a histoplasmosis infection during service. She also claims residual symptoms such as shortness of breath, fatigue, coughing up mucus, and night sweats. See e.g. VA Form 9 (October 2017) & Hearing Transcript at 5-7 (January 2021). Compensation may be awarded for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131. Service connection basically means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 C.F.R. § 3.303. 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). Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a), (d).Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Board concludes that service connection is warranted for histoplasmosis. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. First, the record establishes that an in-service disease occurred. The Veteran’s service treatment records (STRs) demonstrate she was hospitalized for histoplasmosis for four days in June 2011. A CT scan of the chest revealed a subcarinal mass extending to the right pleural space along the right lower lobe adjacent to the spine measuring 4.3 x 2.5 cm and a right hilar mass measuring 2.8 x 1.8 cm and non-calcified right hilar lymph node measuring 2.8 x 1.8 cm. A follow-up hospital report dated in June 2011 shows diagnoses of histoplasmosis and subcarinal lymphadenopathy and right lower lobe pulmonary nodule. It was noted that the chest imaging and laboratory work suggested recent acute histoplasma infection which should resolve on its own without any specific treatment. In the year following the Veteran’s hospitalization for histoplasmosis, she continued to complain of chest pain but was unable to undergo any testing because she was pregnant. A chest CT was obtained in May 2012 and compared to the findings of the June 2011 chest CT. It was noted that there was no change in the right hilar and subcarinal lymphadenopathy for almost one year and no further follow-up was advised unless the Veteran experienced new symptoms. Second, the evidence of record establishes that since separation from service in 2013, the Veteran has continuously been found to have pulmonary nodules in the right lung consistent with a prior histoplasmosis infection. The Veteran testified, and the record reflects, that following service, she was seen by the VA pulmonology clinic annually for pulmonary function testing (PFT) and CT chest scans. In July 2015, she was noted to have a history of pulmonary nodules. An April 2016 CT chest scan showed possible calcified mediastinal lymphadenopathy or masses that were stable compared to previous examination. Nodular right lower lobe airspace and 3 mm right upper lobe nodule seen with no change. A May 2016 Pulmonary Clinic note states the Veteran reported mild dyspnea on exertion. The examining physician noted a constellation of calcified mediastinal/pulmonary nodules with calcified splenic granuloma consistent with prior histoplasmosis infection with no significant airway/vessel invasion and less likely fibrosis mediastinitis. In May 2017, it was noted that per the pulmonary clinic, the Veteran had a history of histoplasmosis of the right lung in 2011, status post bronchoscopy, and the Veteran was asymptomatic. A July 2018 VA Pulmonary Clinic note indicates the Veteran has a history of biopsy proven pulmonary histoplasmosis with associated partially calcified lymphadenopathy, mild restrictive lung disease, stable pulmonary nodules and mild dyspnea with exertion which has been unchanged from previous years. A CT of the chest dated in July 2018 showed moderate to prominent partially calcified right hilar and subcarinal lymph nodes that are grossly stable. A bronchoscopy revealed histoplasmosis. The findings indicated prior granulomatous infection/disease without any evidence of fibrosing mediastinitis. Third, the record contains sufficient evidence to support a link between current clinical findings for pulmonary nodules and restrictive lung disease, and the Veteran’s histoplasmosis infection diagnosed during service. The Veteran submitted a favorable medical opinion dated in March 2021 from a non-VA nurse practitioner concluding that it is more likely than not that the Veteran’s lung nodules and mild restrictive lung disease are the result of her history of histoplasmosis diagnosed in June 2011. The opinion includes an accurate and detailed recitation of the Veteran's medical history, beginning from the in-service diagnosis of histoplasmosis via CT chest scan and bronchoscopy in 2011 to her VA CT chest scan and PFT in 2018. The medical opinion is based on review of the Veteran's history and relevant medical records and is supported with appropriate rationale. In addition, as the Veteran's lay reports are consistent with other evidence of record, the Board finds her testimony describing the onset and treatment of her respiratory symptoms following the histoplasmosis infection are credible and entitled to probative weight. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board finds the August 2014 VA respiratory examination report is inadequate because it is internally inconsistent, does not contain a comprehensive medical opinion and does not reflect full consideration of the medical evidence. Here, the examiner remarked the Veteran had a histoplasmosis-fungal infection in the right lung in 2011 that had resolved and there was no current evidence of active infection on examination. The examiner essentially relied on a chest x-ray obtained in May 2014 showing a normal, clear chest. Thus, the examiner’s remarks are directed at whether the Veteran had an active infection rather than whether there were any current residuals. The Board also finds the VA examination report is internally inconsistent insofar as the section entitled “pulmonary conditions,” indicates the Veteran has a mycotic lung infection and notes reported symptoms of fatigue and intermittent, non-productive cough with slight wheezing associated with mycotic lung disease. The examiner indicated the Veteran did not have multiple respiratory conditions and stated the pulmonary function test (PFT) conducted in August 2014 accurately reflected the Veteran’s current pulmonary function. While the conclusions of a physician are medical conclusions that the Board cannot ignore or disregard, see Willis v. Derwinski, 1 Vet. App. 66 (1991), the Board is free to assess medical evidence and is not compelled to accept a physician's opinion. See Wilson v. Derwinski, 2 Vet. App. 614 (1992). Given the medical evidence demonstrating the presence of pulmonary nodules and restrictive lung disease consistent with a history of histoplasmosis since service, the evidence is at least in relative equipoise as to whether the Veteran has current residuals of histoplasmosis that are at least as likely as not related to in-service histoplasmosis. (Continued on the next page)   Accordingly, resolving all doubt in favor of the Veteran, the Board finds that service connection for residuals of histoplasmosis is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Krunic, 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.