Citation Nr: 21028901 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 16-36 556 DATE: May 12, 2021 ORDER Service connection for residuals of splenectomy, as due to pre-existing hereditary spherocytosis, is denied. Service connection for abdominal surgical scar status post splenectomy is denied. FINDING OF FACT Hereditary spherocytosis, which led to the splenectomy, clearly and unmistakably existed prior to active service and clearly and unmistakably was not aggravated by active service. CONCLUSIONS OF LAW 1. The criteria for service connection for residuals of splenectomy, as due to pre-existing hereditary spherocytosis, have not been met. 38 U.S.C. §§ 1110, 1111; 38 C.F.R. §§ 3.303, 3.304. 2. The criteria for service connection for abdominal surgical scar status post splenectomy have not been met. 38 U.S.C. § 1110, 5107; 38 C.F.R. § 3.310. REASONS AND BASES FOR FINDING AND CONCLUSIONS The Appellant served in the United States Army from October 31, 1966 to December 16, 1966. In January 2019, the Board remanded the case for further development. The record reflects substantial compliance with the remand requests. Dyment v. West, 13 Vet. App. 141 (1999). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). 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). Service connection requires competent evidence of (1) a current disability; (2) the incurrence or aggravation of a disease or injury during service; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may be granted for disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disability, and not due to the natural progress of the nonservice-connected disease or injury, will be service connected. 38 C.F.R. § 3.310(b). Thus, service connection is permitted not only for disability caused by a service-connected disability, but also for the degree of disability resulting from aggravation by a service-connected disability. The presumption of soundness provides that an Appellant shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). To rebut the presumption of soundness, VA must show by clear and unmistakable evidence that (1) the disease or injury existed prior to service and (2) the disease or injury was not aggravated by service. VAOPGCPREC 3-2003 (July 2003). The claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. VAOPGCPREC 3-2003 (July 2003); Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). Residuals of splenectomy The Appellant asserts that the rigors of basic training resulted in the enlargement of his spleen which led to the splenectomy. He acknowledges that he had hereditary spherocytosis prior to service but asserts that it was aggravated by service. The Appellant's service entrance examination notes, and private treatment records confirm, that prior to his enlistment into active service he had a history of jaundice starting around 1964. Private treatment records from April 1966 show complaints of abdominal pain and vomiting with a diagnosis of splenomegaly (enlargement of the spleen). In May 1966, the Appellant was diagnosed with acute and chronic cholecystitis with cholelithiasis (inflammation of the gallbladder) and subsequently underwent a cholecystectomy (removal of the gallbladder). The treating physician at the time also noted splenomegaly. The Appellant's cholecystectomy was noted on his entrance examination. Medical board proceedings dated on December 6, 1966 concluded that the Appellant's diagnosis of hereditary spherocytosis existed prior to his entry into active service. In arriving at that medical opinion, the examiners on the medical board noted that the Appellant's grandmother, mother, and sister had their gallbladders removed at a young age and that his mother and sister have anemia. The examiners acknowledged the Appellant's positive osmotic fragility test (a blood test commonly used to diagnose spherocytosis) and his history of being admitted to a hospital for evaluation of splenomegaly without jaundice in September 1966, shortly before entering service. The Appellant reported to the examiners on the medical board that he felt fine until November 3, 1966 when he became nauseated and vomited during his first week of basic training. He was diagnosed with hereditary spherocytosis. The diagnosis, prognosis, and therapy (splenectomy) were discussed, but the Appellant elected to be released from active service. He was medically discharged on December 16, 1966, and he underwent a splenectomy on January 14, 1967. In an October 2019 medical opinion, a VA examiner noted that the gene mutations that result in hereditary spherocytosis cause red blood cells to have an abnormal, spherical shape and that these misshapen red blood cells are called spherocytes. The examiner stated that spherocytes are taken out of circulation and sent to the spleen to be destroyed (hemolysis), which results in a shortage of red blood cells (anemia). The examiner noted that the disease typically causes anemia, yellowing of the eyes and skin (jaundice), and an enlarged spleen (splenomegaly), which can occur anytime from early childhood to adulthood. The examiner also noted that half of affected individuals develop deposits in the gallbladder called gallstones, which typically occur from late childhood to mid-adulthood. In a separate medical opinion, the examiner reviewed the Appellant's claims file and concluded that there is clear and unmistakable evidence that his spherocytosis is a hereditary disease and that any increase in symptoms around the time of his service was due to the natural progress of the disease. Citing to medical treatises by the National Institutes of Health, the examiner reported that hereditary spherocytosis is the most common form of hemolytic anemia and that most children have a mild form of the disease, can live a normal life, and do not require a splenectomy. The examiner noted that a parvovirus B19 infection can cause an acute aplastic phase (when not enough new blood cells are produced), but without recurrence. The examiner noted that a splenectomy is reserved for those with severe disease or those who develop symptomatic gallstones and that a cholecystectomy should be performed at the same time. In a third opinion, the examiner concluded that the Appellant's pre-existing hereditary spherocytosis was clearly and unmistakably not aggravated beyond its natural progression by service. The examiner noted it is less likely than not the Appellant's hereditary spherocytosis was aggravated beyond its natural progression by his time in service because service treatment records clearly document that he had severe symptoms with jaundice prior to service and within the first week after enlistment. The examiner noted that the Appellant was expediently diagnosed with spherocytosis and did not require a splenectomy in service. Given the above, while the Appellant seeks service connection for residuals of a splenectomy, the Board observes that the underlying disability at issue is hereditary spherocytosis, which led to the splenectomy. In that regard, a VA examiner opined that the Appellant's hereditary spherocytosis clearly and unmistakably existed prior to active service. As the examiner's opinion was based on the current medical knowledgebase on hereditary spherocytosis and a review of the medical evidence of record, which shows symptoms of the disease prior to service, the Board finds the examiner's opinion to be of great probative value. Hayes v. Brown, 9 Vet. App. 67 (1996). There is no contrary medical opinion of record. Thus, the Board finds that the Appellant's hereditary spherocytosis, which led to the splenectomy, clearly and unmistakably existed prior to active service. The VA examiner further opined that the Appellant's hereditary spherocytosis clearly and unmistakably was not aggravated by active service. The examiner also opined that any increase in the Appellant's symptoms around the time of service was due to the natural progress of the disease. For reasons previously noted, the Board again finds the examiner's opinion to be of great probative value. Id. There is again no contrary medical opinion of record. Thus, the Board also finds that the Appellant's hereditary spherocytosis, which led to the splenectomy, clearly and unmistakably was not aggravated by active service. The Board notes that the examiner used the term "less likely than not" in providing the rationale for the opinion on aggravation. However, the Board observes that a medical opinion should be viewed in its full context and not characterized solely by the medical professional's choice of words. Acevedo v. Shinseki, 25 Vet. App. 286 (2012). Here, the examiner chose the response option corresponding to the opinion that the disability clearly and unmistakably was not aggravated by service. The examiner also concluded in a separate medical opinion that any increase in the Appellant's symptoms around the time of service was due to the natural progress of the disease. Together, the Board finds that it is the examiner's opinion that the Appellant's hereditary spherocytosis clearly and unmistakably was not aggravated by service. As discussed above, pre-service treatment records showing that the Appellant had splenomegaly, and was even admitted to a hospital for it one month prior to service, and post-service treatment records showing that he opted for a splenectomy one month after discharge support the finding that there is clear and unmistakable evidence that the underlying hereditary spherocytosis was not aggravated by service. The Board concludes that service connection for residuals of splenectomy, as due to pre-existing hereditary spherocytosis, is not warranted. Abdominal surgical scar status post splenectomy Given the above decision that service connection for residuals of splenectomy is not warranted, service connection for a scar associated with the splenectomy on a secondary basis is simply not warranted. Thus, the Board concludes that service connection for an abdominal surgical scar status post splenectomy is not warranted. As the preponderance of the evidence is against this claim, the claim must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). THERESA M. CATINO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. W. Kim, 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.