Citation Nr: 21028533 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 16-35 240A DATE: May 11, 2021 ORDER Entitlement to service connection for histoplasmosis, to include as secondary to contaminated water exposure at Camp Lejeune, North Carolina, is denied. Entitlement to service connection for type II diabetes mellitus, to include as secondary to contaminated water exposure at Camp Lejeune, North Carolina, is denied. Entitlement to service connection for peripheral neuropathy (also claimed as nerve damage), to include as secondary to contaminated water exposure at Camp Lejeune, North Carolina, is denied. Entitlement to service connection for hypertension (also claimed as high blood pressure), to include as secondary to contaminated water exposure at Camp Lejeune, North Carolina, is denied. FINDINGS OF FACT 1. The Veteran had active service at Camp Lejeune and was exposed to water contaminants while stationed there. 2. The Veteran did not have a current respiratory disorder, to include histoplasmosis, that manifested in service or that is otherwise causally or etiologically related to his military service, to include exposure to contaminated water while serving at Camp Lejeune. 3. The Veteran's type II diabetes mellitus did not manifest in service or within one year thereafter and is not otherwise related to service, to include exposure to contaminated water while serving at Camp Lejeune. 4. The Veteran's peripheral neuropathy did not manifest in service or within one year thereafter and is not otherwise related to service, to include exposure to contaminated water while serving at Camp Lejeune. 5. The Veteran's hypertension did not manifest in service or within one year thereafter and is not otherwise related to service, to include exposure to contaminated water while serving at Camp Lejeune. CONCLUSIONS OF LAW 1. Histoplasmosis was not incurred in active service, nor may it be presumed to have been so incurred. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 2. Type II diabetes mellitus was not incurred in active service, nor may it be presumed to have been so incurred. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 3. Peripheral neuropathy was not incurred in active service, nor may it be presumed to have been so incurred. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 4. Hypertension was not incurred in active service, nor may it be presumed to have been so incurred. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from May 1972 to September 1975. These matters come before the Board of Veterans' Appeals (Board) on appeal from an August 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In November 2018, the Board remanded the case for further development. That development has been completed, and the case has since been returned to the Board for appellate review. Law and Analysis Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection for certain chronic diseases, including diabetes mellitus, a neurological disorder, and hypertension, may also be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1112, 1137; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing secondary service connection requires evidence of: (1) a current disability (for which secondary service connection is sought); (2) a service-connected disability; and (3) that the current disability was either caused or aggravated by the service-connected disability. 38 C.F.R. § 3.310(a)-(b). Effective March 14, 2017, VA amended 38 C.F.R. §§ 3.307 and 3.309 to allow presumptive service connection for certain enumerated diseases related to exposure to contaminants present in the water supply at Camp Lejeune. For purposes of this section, contaminants in the water supply means the volatile organic compounds trichloroethylene (TCE), perchloroethylene (PCE), benzene and vinyl chloride, that were in the on-base water-supply systems located at United States Marine Corps Base Camp Lejeune, during the period beginning on August 1, 1953, and ending on December 31, 1987. 38 C.F.R. § 3.307(a)(7)(i). Section § 3.307(a)(7) provides that a veteran, or former reservist or member of the National Guard, who had no less than 30 days (consecutive or nonconsecutive) of service at Camp Lejeune during the period beginning on August 1, 1953, and ending on December 31, 1987, shall be presumed to have been exposed during such service to the contaminants in the water supply, unless there is affirmative evidence to establish that the individual was not exposed to contaminants in the water supply during that service. 38 C.F.R. § 3.307(a)(7)(iii). The enumerated diseases which are deemed to be associated with exposure to contaminated water at Camp Lejeune are kidney cancer; liver cancer; Non-Hodgkin's lymphoma; adult leukemia; multiple myeloma; Parkinson's disease; aplastic anemia and other myelodysplastic syndromes; and bladder cancer. 38 C.F.R. § 3.309(f). The diseases listed in § 3.309(f) shall have become manifest to a degree of 10 percent or more at any time after service. 38 C.F.R. § 3.307(a)(7)(ii). However, notwithstanding the foregoing presumption provisions for exposure to contaminated water at Camp Lejeune, a claimant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); see also Ramey v. Gober, 120 F.3d 1239, 1247-48 (Fed. Cir. 1997), aff'g Ramey v. Brown, 9 Vet. App. 40 (1996); Brock v. Brown, 10 Vet. App. 155, 160-61 (1997). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when 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; 38 C.F.R. § 3.102. 1. Histoplasmosis The Veteran has contended that he developed histoplasmosis due to his exposure to contaminated water while he was serving at Camp Lejeune. In considering the evidence of record under the laws and regulations as set forth above, the Board finds that the Veteran did not have a current disability of histoplasmosis at the time he filed the claim on appeal and has not had such a disability since that time. A review of the Veteran's service treatment notes showed that he was treated for complaints of chest pain for one week and diagnosed with chest congestion in October 1972. He was also treated for a viral infection with a productive cough in December 1972 and an upper respiratory infection in February 1974. In a June 1975 service treatment note, the Veteran stated that he woke at night in a cold sweat with dyspnea which was relieved by walking outside. He reported that he had been woken by his roommate for heavy breathing or with difficulty breathing. The Veteran also complained of vague chest pains in a June 1975 service treatment note. In another June 1975 service treatment note, the Veteran reported episodic black outs beginning in 1971 in which he woke "gasping for air" and it felt "like his heart [was] going to stop." However, in a September 1975 separation examination report, a normal clinical evaluation of the Veteran's lungs and chest was noted. In a February 1988 private treatment note, the Veteran's treating primary care physician, Dr. R.G., noted that the Veteran worked as a pest control agent and that he was exposed to numerous chemicals, including phosphates. A February 2000 private chest x-ray showed clear lungs and the impression was non-acute chest. In February 2001 private correspondence, Dr. R.G., sought a referral from another private physician at the University of Cincinnati Medical Center for an evaluation of the Veteran for elevated liver enzymes and possible hepatitis C. Dr. R.G. indicated that the Veteran had a positive histoplasmosis titer and that he sent the Veteran for evaluation by pulmonary physicians who were somewhat uncertain as to the activity of any histoplasmosis. Dr. R.G. stated that the Veteran's clinical picture was complicated by the fact that the Veteran worked as an exterminator and had been exposed to numerous toxins and pesticides over the years, as well as exposure to histoplasmosis. The Veteran was afforded a VA respiratory conditions examination in January 2020. During the examination, the Veteran stated that he had a cough and wheeze in approximately 2000, that he was evaluated, and that a chest x-ray showed histoplasmosis. He related that he was prescribed an oral antifungal medication, that he completed the regiment, and that he had not had any symptoms or recurrence since that time. The VA examiner noted that an October 2018 chest x-ray revealed no acute disease. The examiner indicated that the Veteran's histoplasmosis was no longer present. The examiner opined that the Veteran's claimed histoplasmosis was less likely than not incurred in or caused by service. The examiner noted that the Veteran provided a history of histoplasmosis which was successfully treated with medication. The examiner related that no documentation was available regarding the Veteran's presentation and treatment of the condition; however, an October 2018 chest x-ray showed no sign of histoplasmosis, past (presence of granulomas) or present. The examiner explained that histoplasmosis is a lung infection due to the inhalation of bird or bat droppings that is common in the Ohio River Valley and can be contracted simply by walking in barns, parks, or on city sidewalks where birds perch on buildings throughout the city. In a subsequent July 2020 VA opinion, the examiner noted that the diagnosis of histoplasmosis was rendered at the January 2020 VA examination based on lay testimony of the Veteran alone. She noted that review of the available medical records does not show any diagnosis or treatment for histoplasmosis. She noted that his most recent January 2020 chest x-ray also does not show any active or healed histoplasmosis and therefore the Veteran's histoplasmosis diagnosed post service, in 2000, and treated at that time by the Veteran's statement is not currently active as the chest x-ray done in January 2020 was normal. The Veteran did not submit or identify any evidence of a currently diagnosed respiratory disorder, including histoplasmosis, for which service connection may be granted. Rather, during the January 2020 VA examination, the Veteran stated that he was diagnosed with histoplasmosis and treated with oral antifungal medication in 2000. He reported that he had not had any symptoms or recurrence since that time. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. § 1110, 1131; see Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). Evidence must show that the Veteran currently has the disability for which benefits are being claimed. Because the evidence shows that the Veteran has not had a current respiratory disorder, to include histoplasmosis, during the pendency of the appeal, the Board concludes that service connection is not warranted, and no discussion of the remaining elements is necessary. See Coburn v. Nicholson, 19 Vet. App. 427, 431 (2006) (the absence of any one element will result in denial of service connection). As the preponderance of the evidence is against the claim for service connection for histoplasmosis, the benefit-of-the-doubt rule does not apply, and the claim must be denied. See 38 U.S.C. § 5107 (b) (2012). 2. Diabetes The Veteran has contended that he developed type II diabetes mellitus due to his exposure to contaminated water while he was serving at Camp Lejeune. In considering the evidence of record under the laws and regulations as set forth above, the Board finds that the Veteran is not entitled to service connection for diabetes. The Veteran's service treatment records are negative for any complaints, treatment, or diagnosis of diabetes. In fact, in the September 1975 separation examination report, a normal clinical evaluation of the endocrine system was noted. A sugar lab test was negative. Rather, an October 2018 VA treatment note indicated that the Veteran was diagnosed with diabetes in approximately 1999 when he was in his 40s. To determine that a chronic disease was "shown in service," the disease identity must be established and the diagnosis not subject to legitimate question. 38 C.F.R. § 3.303(b); Walker, supra. The service treatment records do not show that the Veteran had diabetes mellitus during service. Therefore, chronicity is not established in service. Moreover, the record contains no indication that the disorder manifested to a compensable degree within one year of the Veteran's military service. The Veteran has not contended otherwise. Instead, he has claimed service connection for diabetes mellitus on the basis of exposure to contaminated water while he was serving at Camp Lejeune. In January 2020, the Veteran was afforded a VA diabetes mellitus examination in connection with his claim. The VA examiner noted that the Veteran was diagnosed with type II diabetes mellitus in 1999. The examiner opined that the Veteran's type II diabetes mellitus was less likely than not incurred in or caused by service. The examiner acknowledged that the Veteran was contending that his type II diabetes mellitus was due to exposure to contaminated water at Camp Lejeune from 1972 to 1975. The examiner noted that the Veteran was diagnosed with diabetes in 1999, which was nearly 25 years after his separated from service at Camp Lejeune. The examiner stated, "Other than a reference in one of the [service treatment records] that the Veteran did not have a history of Diabetes, there is no other documentation referencing any signs or symptoms of Diabetes mellitus type 2 that is directly service connected." The Board finds the opinion of the VA examiner to be highly probative, as the examiner considered the Veteran's medical history and provided rationale for their conclusion. Moreover, there is no medical opinion otherwise relating the Veteran's type II diabetes mellitus to his military service, to include exposure to contaminated water at Camp Lejeune. The Board does acknowledge the Veteran's own statements that his diabetes is related to his exposure to contaminated water at Camp Lejeune. The Veteran is certainly competent to report observable symptoms he experiences and their history. Layno v. Brown, 6 Vet. App. 465 (1994); Buchanan v. Nicholson, 454 F.3d 1331 (Fed. Cir. 2006); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In addition, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). However, in this case, the question of the etiology of the Veteran's diabetes falls outside the realm of common knowledge of a lay person, particularly in light of the delayed onset. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The disease involves a complex internal process as opposed to an external process or something capable of lay observation. The Veteran has not been shown to possess the requisite medical training, expertise, or credentials needed to render a competent opinion on medical causation. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Moreover, even assuming the Veteran's lay assertions regarding the etiology of the diabetes were competent, the Board nevertheless finds that the medical opinion provided by the VA examiner is more probative, as it was based on a review of the record and the examiner's own medical expertise, knowledge, and training. The examiner also provided a thorough rationale in support of the conclusion reached. For these reasons, the Board finds that the competent and most probative evidence shows that the Veteran's type II diabetes mellitus is not related to his military service, to include any exposure to contaminated water at Camp Lejeune. As the preponderance of the evidence is against the claim of service connection for diabetes, the benefit-of-the-doubt doctrine does not apply, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Peripheral Neuropathy The Veteran has contended that he developed nerve damage due to his exposure to contaminated water while he was serving at Camp Lejeune. In considering the evidence of record under the laws and regulations as set forth above, the Board finds that the Veteran is not entitled to service connection for nerve damage, to include peripheral neuropathy. The Veteran's service treatment records are negative for any complaints, treatment, or diagnosis of nerve damage or peripheral neuropathy. In fact, in the September 1975 separation examination report, a normal clinical evaluation of the upper and lower extremities and feet were noted. In addition, a normal neurologic evaluation was reported. Following service, in a March 2018 VA treatment note, a VA podiatrist noted that the Veteran had neuropathy in both feet secondary to diabetes. The Veteran was afforded a VA peripheral neuropathy examination in January 2020. During the examination, the Veteran stated that he began noticing burning and pins and needles sensations in his feet in the late 1990's. He indicated that he was subsequently diagnosed with peripheral neuropathy secondary to diabetes by his neurologist. The examiner opined that the Veteran's peripheral neuropathy was less likely than not incurred in or caused by service. The examiner noted that the Veteran was contending that his peripheral neuropathy was due to exposure to contaminated water at Camp Lejeune. The examiner reported that the Veteran's peripheral neuropathy was secondary to his nonservice-connected diabetes. The Board finds the opinion of the VA examiner to be highly probative, as the examiner considered the Veteran's medical history and provided rationale for their conclusion. Moreover, there is no medical opinion otherwise relating the Veteran's peripheral neuropathy to his military service, to include exposure to contaminated water at Camp Lejeune. The Board does acknowledge the Veteran's own statements that his peripheral neuropathy, claimed as nerve damage, is related to his exposure to contaminated water at Camp Lejeune. The Veteran is certainly competent to report observable symptoms he experiences and their history. Layno v. Brown, 6 Vet. App. 465 (1994); Buchanan v. Nicholson, 454 F.3d 1331 (Fed. Cir. 2006); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In addition, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). However, in this case, the question of the etiology of the Veteran's peripheral neuropathy falls outside the realm of common knowledge of a lay person, particularly in light of the delayed onset. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The disease involves a complex internal process as opposed to an external process or something capable of lay observation. The Veteran has not been shown to possess the requisite medical training, expertise, or credentials needed to render a competent opinion on medical causation. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Moreover, even assuming the Veteran's lay assertions regarding the etiology of the peripheral neuropathy were competent, the Board nevertheless finds that the medical opinion provided by the VA examiner is more probative, as it was based on a review of the record and the examiner's own medical expertise, knowledge, and training. The examiner also provided a thorough rationale in support of the conclusion reached. Additionally, as the Veteran's treatment records do not reflect a diagnosis of or treatment for neurological disability listed under 38 C.F.R. § 3.309(a) for many years following separation from service, this presumption is not available to the Veteran. For these reasons, the Board finds that the competent and most probative evidence shows that the Veteran's peripheral neuropathy is not related to his military service, to include any exposure to contaminated water at Camp Lejeune. As the preponderance of the evidence is against the claim of service connection for peripheral neuropathy, the benefit-of-the-doubt doctrine does not apply, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 4. Hypertension In considering the evidence of record under the laws and regulations as set forth above, the Board finds that the Veteran is not entitled to service connection for hypertension. In this decision, the blood pressure measurements are noted in units of pressure in millimeters of mercury (mmHg). For VA compensation purposes, the term hypertension means that the diastolic blood pressure is predominantly 90 or greater; and isolated systolic hypertension means that the systolic blood pressure is predominantly 160 or greater with diastolic blood pressure less than 90. In addition, hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. 38 C.F.R. § 4.104, Diagnostic Code 7101. The Veteran's service treatment records document treatment following a syncopal episode in June 1975. The Veteran's blood pressure was checked after he reported that he "blacked out" while walking off-post. Blood pressure readings of 148/110, 130/70 (lying down), and 120/70 (sitting) were recorded at that time. During the September 1975 separation examination, a blood pressure reading of 124/82 was recorded. To determine that a chronic disease was "shown in service," the disease identity must be established and the diagnosis not subject to legitimate question. 38 C.F.R. § 3.303(b); Walker, supra. In this case, the service treatment records do not establish that the Veteran had hypertension during service. Therefore, chronicity is not established in service. Moreover, the evidence does not show that hypertension manifested to a compensable degree within one year of the Veteran's military service. In fact, there is no evidence showing that he had diastolic pressure predominantly 100 or more; systolic pressure predominantly 160 or more, or; a history of diastolic pressure predominantly 100 or more and required continuous medication for control. 38 C.F.R. § 4.104, Diagnostic Code 7101. In addition to the lack of evidence showing that hypertension manifested during active service or within proximity thereto, the weight of the evidence of record does not link the Veteran's current disorder to his military service. The Veteran was afforded a VA hypertension examination in January 2020 in connection with his claim. The examiner noted that the Veteran was diagnosed with hypertension in the late 1990s. During the examination, the Veteran reported that he was evaluated for recurrent headaches in the late 1990s and that he was subsequently diagnosed with hypertension. The examiner opined that the Veteran's hypertension was less likely than not incurred in or caused by service. The examiner acknowledged the Veteran's contention that his hypertension developed as a result of exposure to contaminated water during his service at Camp Lejeune. The examiner noted that there was a single isolated, elevated blood pressure reading recorded in the Veteran's service treatment records; however, the examiner also reported that the remaining blood pressure readings noted throughout the service treatment records and recorded in the separation examination report were all normal. The Board finds the opinion of the VA examiner to be highly probative, as the examiner considered the Veteran's medical history and provided rationale for their conclusion. Moreover, there is no medical opinion otherwise relating the Veteran's hypertension to his military service, to include the contaminated water at Camp Lejeune. The Board does acknowledge the Veteran's own statements that his hypertension is related to his exposure to contaminated water at Camp Lejeune. The Veteran is certainly competent to report observable symptoms he experiences and their history. Layno v. Brown, 6 Vet. App. 465 (1994); Buchanan v. Nicholson, 454 F.3d 1331 (Fed. Cir. 2006); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In addition, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). However, in this case, the question of the etiology of the Veteran's hypertension falls outside the realm of common knowledge of a lay person, particularly in light of the delayed onset. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The disease involves a complex internal process as opposed to an external process or something capable of lay observation. The Veteran has not been shown to possess the requisite medical training, expertise, or credentials needed to render a competent opinion on medical causation. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Moreover, even assuming the Veteran's lay assertions regarding the etiology of the hypertension were competent, the Board nevertheless finds that the medical opinion provided by the VA examiner is more probative, as it was based on a review of the record and the examiner's own medical expertise, knowledge, and training. The examiner also provided a thorough rationale in support of the conclusion reached. For these reasons, the Board finds that the competent and most probative evidence shows that the Veteran's hypertension is not related to his military service, to include any exposure to contaminated water at Camp Lejeune. As the preponderance of the evidence is against the claim of service connection for hypertension, the benefit-of-the-doubt doctrine does not apply, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. A.M. CLARK Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Osegueda, 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.