Citation Nr: 21026485 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 13-31 025A DATE: May 3, 2021 ORDER Entitlement to service connection for a thyroid disorder, to include Graves' disease, is denied. FINDING OF FACT The Veteran's thyroid disorder, to include Graves' disease, was not shown in service, or for many years thereafter and is not otherwise etiologically related to service. CONCLUSION OF LAW The criteria for entitlement to service connection for a thyroid disorder, to include Graves' disease, have not been met. 38 U.S.C. §§ 1110, 1131, 5103(a), 5103A; 38 C.F.R. § 3.102, 3.159, 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from January 1976 to July 1985. This claim was previously denied by the Board of Veterans' Appeals (Board) in an October 2017 decision. The Veteran timely appealed this decision to the Court of Appeals for Veterans Claims (Court). In a May 2019 Memorandum Decision, the Court set aside the Board's October 2017 decision and remanded the matter for further action, determining that the Board did not adequately discuss whether a February 2016 VA medical opinion rendered by a physician's assistant substantially complied with the Board's October 2015 remand directive. This directive instructed VA to obtain an opinion by the same physician who rendered a February 2014 opinion or by a physician of appropriate expertise. The Board then remanded the matter in May 2020 to obtain updated records and a medical opinion. The Board specifically instructed the regional office (RO) to schedule the Veteran with the same VA examiner who proffered the February 2014 VA medical opinion. If that examiner was unavailable, the Board instructed that the examination should be conducted by a VA physician, or, if a VA physician was unavailable, the examination should be conducted by another appropriate medical professional who is asked to confirm that they have the training and expertise necessary to conduct the examination and render the requested opinion. In the May 2020 request for physical examination, the compensation and pension clinical staff were specifically given those instructions. As a result, the Veteran was provided a VA examination in May 2020 by a VA physician. The Board notes that VA regulations do not specifically require an examiner to be a medical doctor. Under 38 C.F.R. § 3.159(2)(1), competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. A physician's assistant or nurse practitioner, having completed medical training, meets the requirement of § 3.159(a)(1) as one competent to provide diagnoses, statements, or opinions. See Cox v. Nicholson, 20 Vet. App. 563 (2007). As the RO instructed the compensation and pension clinical staff to either schedule the Veteran for an examination with a VA physician if the February 2014 examiner was unavailable, or to confirm with a non-VA professional that they have the appropriate training and expertise necessary to conduct the examination, and a medical doctor was chosen to perform the examination, the Board is satisfied there the examiner has the appropriate expertise and there was substantial compliance with the remand. See Stegall v. West, 11 Vet. App. 268 (1998). The requested development has been completed, and the appeal has returned to the Board for further appellate consideration. Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131. Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). 1. Entitlement to service connection for a thyroid disorder, to include Graves' disease The Veteran asserts that his thyroid disorder, to include Graves' disease, was caused by his mononucleosis that he acquired during service, and/or is otherwise related to active service. Specifically, he contends that Epstein-Barr Virus (EBV), which causes infectious mononucleosis, also causes autoimmune thyroid diseases, to include Graves' disease. Based on a review of all evidence of record, the Board finds that, although the Veteran has a current diagnosis of hypothyroidism and a history of Graves' Disease and toxic multinodular goiter, his claim for service connection for a thyroid disorder should be denied. The Veteran's service treatment records reflect that the Veteran had mononucleosis during service with numerous associated symptoms to include sore throat, swollen tonsils, and inability to swallow. However, there is no indication that the Veteran had or developed a thyroid disorder during active service. Specifically, in his September 1983 report of medical history, the Veteran reported that he was in "good health." Additionally, the Board notes that in July 1985, the Veteran explicitly stated that he did not desire a separation medical examination. The post-service evidence does not reflect symptoms related to a thyroid disorder, including Grave's disease, for many years after the Veteran left active duty service. Specifically, the first indication of a thyroid disorder was not until approximately 2007, when the Veteran was diagnosed with hyperthyroidism and then eventually Graves' disease. While this issue was previously adjudicated and is not specifically on appeal, the Board notes that to the extent that the Veteran claims he has residuals of his mononucleosis, independent of his thyroid disorder, the Board finds that the medical evidence does not indicate that he is suffering from residuals thereof at any point during the period on appeal. Here, the November 2009 VA examiner opined that the Veteran did not have any mononucleosis residuals and that his current complaints and symptoms were related only to his thyroid disorder. Therefore, service connection for residuals of mononucleosis, independent of his thyroid disorder, is not for application. See 38 U.S.C. § 1110; Rabideau v. Derwinski, 2 Vet. App. 141 (1992); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As part of this claim, the Board recognizes the statements from the Veteran regarding his history of thyroid symptoms since service. In this regard, while the Veteran is not competent to make a diagnosis related to a thyroid disorder, as it may not be diagnosed by its unique and readily identifiable features, and thus requires a determination that is "medical in nature," he is nonetheless competent to testify about the presence of observable symptomatology, which may provide sufficient support for a claim of service connection, if credible, regardless of the lack of contemporaneous medical evidence. Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed. Cir. 2007); See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Nevertheless, the Board determines that the Veteran's reported history of continued symptomatology since active service, while competent, is insufficient to warrant service connection solely on this basis. First, the Board notes that the Veteran only reported a history of symptoms related to a positive diagnosis of mononucleosis. Secondly, the Veteran has not continuously complained of symptoms related to his current thyroid disorder, which includes Graves' disease, since service. Thus, continuity of symptomatology has not been established by the Veteran's statements. Next, service connection may also be granted when the evidence establishes a medical nexus between active duty service and current complaints. In this case, the Board finds that the weight of the competent evidence does not attribute the Veteran's claimed thyroid disorder to active duty, despite his contentions to the contrary. Specifically, the February 2014 VA examiner opined that the Veteran's current thyroid disease, to include Graves' disease, was less likely than not related to his mononucleosis and/or otherwise related to active service. In support, the examiner indicated that, while there are "several hypotheses that are currently being pursued" regarding the link between the Veteran's thyroid disorder and mononucleosis, the medical literature is not definitive nor does it support a nexus to a 50 percent probability. Further, the examiner stated that the Veteran's thyroid condition is more likely related to risk factors such as family history and smoking. It was determined that there were outstanding medical records for treatment of the Veteran's thyroid disorder at the time the February 2014 VA examination was completed, and the Veteran submitted additional medical literature after his examination addressing the potential relationship between the mononucleosis virus and certain thyroid diseases. As such, the Board ordered a new examination. The Veteran was provided a March 2016 VA examination, but it was determined that the examiner was not a VA physician, nor was there an indication that the physician's assistant who conducted the examination had the appropriate expertise to render an opinion. Therefore, another new examination was ordered. A May 2020 VA examiner performed a detailed review of the medical literature and the Veteran's medical and military records and opined that the Veteran's thyroid disorder was less likely than not caused by mononucleosis. The examiner indicated that the Veteran was treated with iodine 131 radiation in August 2012 to treat both Graves' disease and toxic multinodular goiter after he was diagnosed with these conditions in 2007, and that he currently has residual hyperthyroidism as a result of the iodine treatment. The examiner also noted that the Veteran had mononucleosis in March 1982 during service, but that he was tested for the condition twice since service in August 2011 and November 2014 with both tests showing past infection rather than current infection. As such, the records indicate that more than 20 years passed between the Veteran's diagnosis of mononucleosis and service and his first diagnosis of thyroid conditions. Although the Veteran contends that Epstein-Barr Virus (EBV), which causes infectious mononucleosis, caused his autoimmune thyroid diseases, the examiner opined that the medical literature did not reveal sufficient evidence to make such a conclusion. The examiner stated that EBV is "a very infectious virus which infects about 95 percent of the world's population at some point in their lives, resulting in a lifelong carrier state." Although it has been widely hypothesized that EBV plays a role in autoimmune thyroid disease, the examiner notes that the theories lack sufficient supporting evidence to conclude causality. The May 2020 examiner reviewed the evidence of record, including medical literature and studies submitted by the Veteran, interviewed the Veteran over the phone, considered his contentions, and provided well-reasoned bases for the opinions provided, providing enough evidentiary basis for the claim to be adjudicated. As such, the Board finds these opinions highly probative. The Board acknowledges that the Veteran has submitted numerous medical articles which indicate that there may be some association between mononucleosis and his thyroid condition. While a medical article or treatise can provide support for a claim, it nevertheless must be combined with an opinion of a medical professional and be reflective of the specific facts of a case, as opposed to a discussion of generic relationships. Sacks v. West, 12 Vet. App. 314, 316-17 (1998). Here, no such medical opinion has been provided by the Veteran. Furthermore, as the February 2014 and May 2020 examiners discussed, the medical literature does not actually set forth any conclusive nexus between mononucleosis and his thyroid disorder. Accordingly, the referenced medical literature carries minimal probative weight for the purposes of establishing a nexus between the Veteran's thyroid disorder and service, to include as due to mononucleosis. The Board also acknowledges the statements from the Veteran and his daughter regarding the etiology of his thyroid disorder, which they assert was caused by his mononucleosis. A lay person is competent to report observable symptomatology, such as pain. Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007). However, etiology of dysfunctions and disorders is a medical determination and generally must be established by medical findings and opinion. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Thus, to the extent that the Veteran and his daughter believe that his thyroid disorder may be the result of service, including mononucleosis, they are lay persons without appropriate medical training and expertise to provide a medical nexus opinion regarding the etiology of his disorder. The Board concludes that the preponderance of the evidence is against the claim for service connection for a thyroid condition, to include Graves' disease, and there is no doubt to be otherwise resolved. Therefore, the claim for service connection must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 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. B.T. KNOPE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Veltri, Associate Counsel