Citation Nr: 21029618 Decision Date: 05/14/21 Archive Date: 05/14/21 DOCKET NO. 16-19 921 DATE: May 14, 2021 ORDER Entitlement to service connection for myasthenia gravis (MG), to include as secondary to service-connected hypertension, is denied. FINDING OF FACT The Veteran's MG is not secondary to service-connected hypertension and is not otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for entitlement to service connection for MG, to include as secondary to service-connected hypertension, are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303(a)(b), 3.307(a)(3), 3.309(a), 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from March 1981 to February 1985. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Veteran advances the following: [T]he [MG episodes]and symptoms are documented numerous times in my service medical records starting in March 1981. The dates are March 30, 1981, March 31,1981, July 10,1981, 11 March 1984, February 11, 1985. On each of these dates I was diagnosed with the primary symptoms of [MG]. I started having bilateral leg pain mild quad muscle weakness, tenderness, muscle spasms, and other muscle ailments that are all symptoms of the Disability. Again, even though the doctors did not formally diagnose this disability all the [signs]and symptoms are present before discharge. May 30, 2014, Notice of Disagreement (NOD); see also April 29, 2016, Form 9. This claim most recently was remanded by the Board in August 2020. The Board instructed VA to obtain multiple medical opinions. A new secondary opinion was required because the September 2019 opinion of record was deemed inadequate; the new opinion was to address a December 2011 VA examiner's statement that that the Veteran's hypertension "could" affect his MG. An original direct opinion was required, asking whether the Veteran's in-service complaints of lower extremity pain and muscle cramping were related to his MG. Lastly, the Board requested an opinion regarding whether the Veteran's MG developed within a year after separation from service or produced symptoms during service into the present. These opinions were obtained in February and March of 2021. Thus, with VA substantially having complied with the prior remand directives, the Board now may adjudicate this claim on the merits. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998). 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 other than 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. § 1131. 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). For certain chronic diseases, including MG, a presumption of service connection arises if the disease is manifested to a degree of ten percent within one year following discharge from service. When a chronic disease is not shown to have manifested to a compensable degree within one year after service, there is required, under 38 C.F.R. § 3.303(b), a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. When the fact of chronicity in service is not adequately supported, a showing of continuity after discharge is required to support a claim for such diseases; however, such continuity of symptomatology may only support a claim for those chronic diseases listed under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331, 1336 (Fed. Cir. 2013); 38 C.F.R. § 3.303(b), 3.307(a)(3), 3.309(a). To establish secondary service connection, a veteran must provide evidence of (1) a current, non-service-connected disability, (2) a current service-connected disability, and (3) evidence that the non-service-connected disability is either (i) proximately due to or the result of a service-connected disability or (ii) aggravated (increased in severity) beyond natural progression by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 446 (1995); 38 C.F.R. § 3.310. 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, 133537 (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. Service treatment records (STRs) from March 1981 reveal that the Veteran complained of bilateral knee pain. March 1984 entries note muscles spasms of the bilateral calves and legs. The assessment was muscle strain. The November 1984 separation examination did not reveal any problems with the Veteran's lower extremities or a diagnosis of MG. Post-service private treatment records from December 2008 reveal that the Veteran was experiencing muscle cramps. An August 2009 entry shows that the Veteran called in complaining of muscle cramps, which subsided after he increased his fluid intake. Private and VA medical records through 2013 reveal that the Veteran continually received medication for his MG. In a December 2011 VA examination for the Veteran's hypertension, the examiner noted that the Veteran's blood pressure "COULD LEAD TO STRESS ON THE BODY WHICH IMPACTS [THE] VETERAN'S [NON-SERVICE-CONNECTED] MG." As noted above, a September 2019 secondary medical opinion was obtained, but it previously has been deemed inadequate, so it herein will not be discussed. The February and March 2021 direct and presumptive opinion, respectively, obtained on remand stated the following: In response, it is less likely than not that the claimant's myasthenia gravis (MG) condition is incurred in or caused by his military service. There is no documentation that the claimant was specifically medically evaluated, diagnosed and treated for a MG condition in the medical service records provided for review today. Without actual documentation of such evidence in his service records an objective association with the present diagnosis is difficult. The service note mentioning 3/11/1984 "muscle spasms bilat calves...tender gastrocnemius" is not reasonable evidence that this represented MG. The typical presentation of MG is not consistent with calf spasm. More than 50 percent of patients present with ocular symptoms of ptosis and/or diplopia. Approximately 15 percent of patients present with bulbar symptoms. These include dysarthria, dysphagia, and fatigable chewing. Less than 5 percent present with proximal limb weakness alone. Emphasis should be added that this is proximal limb (hips, shoulders) weakness not distal limb weakness (hands, feet, forearm, lower leg). It also worth noting that 3/11/1984 doesn't actual mention any weakness rather spasm. In fact, the claimant's initial diagnosis of MG by Baucchus & Vaughan Neurology 7/27/2011 notes that the claimant did in fact present with the classic ocular symptoms of MG a month previously, "possible facial weakness and diplopia...first became symptomatic in early June 2011...pattern appears to be most in keeping with a myasthenic or neuromuscular transmission disorder." This 2011 note accurately reflects the typical presentation of MG and dates its development to that time period and not his military service. Lastly, the natural progression of MG must be considered. The time span between his separation from service 2/25/1985 and initial diagnosis by Baucchus & Vaughan Neurology 7/27/2011 is [twenty-six] years. The progression of [MG] usually peaks within a few years of disease onset. In a case series from the United States of 1976 patients with [MG], the maximum extent of weakness was reached within two years in 82 percent of patients. It would be extremely unlikely that that claimant had MG during service or within a year of service based on our understanding of MG's clinical course. The secondary opinion stated the following: In response, it is less likely than not that the claimant's current myasthenia gravis (MG) condition is proximately due to or the result of his hypertension condition. [MG] is a long-term neuromuscular disease that leads to varying degrees of skeletal muscle weakness by neutralizing the effect of the neurotransmitter acetylcholine at the synaptic cleft. MG is an autoimmune disease which results from antibodies that block or destroy nicotinic acetylcholine receptors (AChR) at the junction between the nerve and muscle. Hypertension has not been found to somehow cause one's immune system to somehow view AChR as foreign substance resulting in an antibody response to it. The note Eileen Martinez NP 12/6/2011 does not appear to state that the claimant's MG is due to his hypertension, she appears to only hesitantly state that hypertension might aggravate this condition. It is worth noting that even this statement of possible aggravation does not include any reference to any study showing causality or references any established medical library. The Board recognizes that the Veteran has a current diagnosis of MG, so the first element of service connection on a direct and secondary basis have been established. Romanowsky, 26 Vet. App. at 293; Allen, 7 Vet. App. at 446; 38 C.F.R. §§ 3.303(a), 3.310. While MG is a chronic condition that qualifies for presumptive service connection, it is not applicable here, as the most recent VA examiner noted that the Veteran was diagnosed with MG in 2011. See 38 C.F.R. § 3.307(a)(3), 3.309(a). The examiner also noted that MG usually peaks within a few years, so the twenty-six-year gap between separation from service and the diagnosis of MG does not lead to the conclusion that the Veteran was experiencing MG during service until his formal diagnosis in 2011. Thus, the application of presumptive service connection for continuity of symptomatology also is inapplicable. See 38 C.F.R. § 3.303(b). Returning to the principles of direct service connection, the Board recognizes that the Veteran had in-service complaints of lower extremity pain and cramping. Thus, the second element of direct service connection has been established. See Romanowsky, 26 Vet. App. at 293; 38 C.F.R. § 3.303(a). Regarding the third element of direct service connection, the Board finds the evidence of record insufficient. The VA examiner thoroughly explained why the Veteran's in-service complaints of lower extremity pain and cramping are unrelated to his MG. First, the examiner noted that only a small percentage of individuals with MG experience proximal limb weakness. The Veteran experienced only spasms (not weakness) of the his distal (not proximal) limbs, so it is not likely that these were a sign or symptom of MG. Next, the Veteran presented with the most common symptom of MG, facial weakness, and diplopia, in 2011 shortly before his initial diagnosis. Lastly, the examiner explains that MG typically peaks within a few years after on set. The twenty-six-year gap from separation to initial diagnosis further leads to the conclusion that the Veteran's in-service spasms of the lower extremities are not related to his MG. While the Veteran believes otherwise, he does not have the necessary training and education to offer such a complex medical opinion, so he is not competent on this point. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (Fed. Cir. 2007). There is no other competent and credible evidence to contradict the findings of the February 2021 direct VA opinion. Thus, the Board affords it considerable probative value on appeal. Therefore, the Board finds that the third element of direct service connection has not been established. See Romanowsky, 26 Vet. App. at 293; 38 C.F.R. § 3.303(a). Transitioning to secondary service connection, the Board recognizes that the Veteran is service connected for hypertension, so the second element has been established. See Allen, 7 Vet. App. at 446; 38 C.F.R. § 3.310. Like with direct service connection, the third element on a secondary basis also is lacking. The February 2021 VA examiner abundantly was clear that MG is not related to hypertension. He adequately explained that MG is a long-term neuromuscular disease that leads to varying degrees of skeletal muscle weakness by neutralizing the effect of the neurotransmitter acetylcholine at the synaptic cleft. MG is an autoimmune disorder, and hypertension in no way has been linked to any sort of antibody response. This examiner discredits the December 2011 VA examiner's reference that hypertension could aggravate MG, as she cited to no medical literature to support that contention and otherwise did not explain her rationale. The Board agrees with the February 2021 VA examiner. This opinion gives the Board a clear understanding of what MG is and how it comes to exist and operate within the body. Based on that explanation, this examiner stated that hypertension is not known to have any sort of connection or interplay with the type of condition that MG is or how it comes into existence. The December 2011 examiner does not provide the Board with any sort of helpful rationale or explanation; she merely provides a conclusive statement without further explaining her belief. Thus, in weighing the two medical opinions, the Board affords the February 2021 VA opinion considerable probative value and little probative value to the December 2011 opinion. While the Veteran also may believe his MG is secondary to his service-connected hypertension, like with direct service connection, he is not competent to offer that complex medical opinion. See Jandreau, 492 F. 3d at 1377. Thus, the Board finds that the third element for secondary service connection has not been established. See Allen, 7 Vet. App. at 446; 38 C.F.R. § 3.310. Because the evidence of record does not support the Veteran's claim for entitlement to service connection for MG, to include as secondary to service-connected hypertension, the Veteran's appeal is denied. The Board is unable to find an approximate balance of the positive and negative evidence submitted to warrant for the Veteran 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), 3.310. 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.