Citation Nr: 21030392 Decision Date: 05/18/21 Archive Date: 05/18/21 DOCKET NO. 15-18 872A DATE: May 18, 2021 ORDER Entitlement to service connection for a blood disorder, to include polycythemia vera, thrombocythemia, thrombocytosis, arthritis, and erysipelas, is denied. FINDING OF FACT The Veteran's blood disorder did not originate in service, within a year of service, and is not otherwise etiologically related to the Veteran's active service. CONCLUSION OF LAW The criteria for service connection for a blood disorder have not been met. 38 U.S.C. §§ 1110, 1116, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 1967 to November 1969, with duty in the Korean demilitarized zone (DMZ). This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2011 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously before the Board in December 2018, June 2020, and February 2021 when it was remanded to the Agency of Original Jurisdiction (AOJ) for additional development. Herbicide agent exposure in Korea was conceded in the June 2020 Board decision. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. In order to establish entitlement to service connection, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may be presumed for certain chronic diseases which develop to a compensable degree within one year after discharge from service, even though there is no evidence of the disease during the period of service. That presumption is rebuttable by probative evidence to the contrary. 38 U.S.C. §§ 1101, 1137; 38 C.F.R. §§ 3.307, 3.309(a). A Veteran who served in the Republic of Vietnam between January 9, 1962, and May 7, 1975, is presumed to have been exposed to certain herbicide agents (e.g., Agent Orange) during such service, absent affirmative evidence to the contrary. 38 U.S.C. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). Service connection based on herbicide agent exposure will be presumed for certain specified diseases that become manifest to a compensable degree within a specified period in the case of certain diseases. 38 U.S.C.§ 1116; 38 C.F.R. §§ 3.307(a)(6), 3.309(e). Even if a Veteran is not entitled to presumptive service connection for a disease claimed as secondary to herbicide agent exposure, VA must also consider the claim on a direct service connection basis. When a disease is first diagnosed after service but not within the applicable presumptive period, service connection may nonetheless be established by evidence demonstrating that the disease was in fact incurred in service. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to service connection for a blood disorder is denied. The Veteran contends that his blood disorder developed as a result of Agent Orange exposure during service. Specifically, the Veteran related a specific incident during service in which he had to patrol an area that had just been treated with herbicide, and that this in-service exposure led to his development of a blood disorder. See June 2010 VA 21-4138 Statement in Support of Claim. Turning to the Veteran's service treatment records (STRs), in January 1968 the Veteran fell on his outstretched right hand during physical training. He was initially assessed with a wrist sprain; however, he later complained of a swollen arm, hand, and fingers. His wrist was swollen, tender, and red. The Veteran was assessed with cellulitis of the right hand, with possible erysipelas. The Veteran's STRs were otherwise silent regarding blood conditions, concluding with his October 1969 separation exam. See July 2014 STR - Medical, pages 6, 22, 25. 27. Turning to the Veteran's post-service medical history, in early February 2010 a private exam assessed the Veteran with thrombocytosis, along with high red blood cell distribution width (RDW), high platelets, and high Eos absolute (Eos). The doctor noted that the reason for the rising platelet levels was unknown. Later in the month, additional bloodwork revealed an inconclusive result for the JAK2 V617F mutation. Per the lab-provided literature, this mutation is associated with myeloproliferative neoplasms (MPNs), such as essential thrombocythemia and a small subset of other myeloid neoplasms. The report noted that the inconclusive result could indicate a very low level of the mutation. Additionally, CT imaging was conducted on the Veteran's abdomen, revealing a borderline prominent spleen. The exam also noted degenerative changes of the spine. See August 2010 Medical Treatment Record - Non-Government Facility (MTR- NGF), pages 28, 32, 36, 47. During a private February 2010 appointment, the Veteran was assessed with cellulitis in his right leg. He reported symptoms of swelling, tenderness, warmth, and erythremia, but no pain, no fever, and no limited range of motion. Per the Veteran, the condition had begun around one and a half weeks prior, following a fall. See August 2010 MTR - NGF, page 18. Private records show that in February 2010 the Veteran complained of back pain. See August 2010 MTR - NGF, page 5. In March 2010 the Veteran's private oncologist suspected a possible diagnosis of primary thrombocythemia. Specifically, the Veteran's equivocal but positive JAK-II inhibitor level was consistent with a relatively mild case of thrombocythemia. The oncologist noted that the elevated platelet count could be due to either iron deficiency or, alternatively, a nonspecific phase reactant. See May 2010 MTR - NGF. Private August 2010 bloodwork reports showed high white blood cell count (WBC), platelets, and RDW. The JAK2 V617F mutation was again detected. See August 2010 Third Party Correspondence. December 2010 blood labs revealed high RDW, high Eos, and high platelets. See March 2011 MTR-NGF (1), (2). February 2011 private bloodwork showed the Veteran had high RDW and a high platelet count. See March 2011 MTR NGF (3). A VA medical opinion was obtained in May 2015. After a review of the Veteran's file, the examiner opined that it was less likely than not that the Veteran's primary thrombocythemia was caused by or a result of the Veteran's service. The examiner reasoned that, as the cause for the condition was unknown, the events of January 1968 could not be responsible for its development or have been suggestive of the condition while the Veteran was on active duty (The Board finds that "January 1968" most likely references the Veteran's in-service fall, wrist sprain, and subsequent cellulitis). Furthermore, the examiner noted that the conditions of the January 1968 incident were transitory in nature and did not show any persistence by the time of the Veteran's military discharge, nor did post-service records show contamination. See May 2015 C&P Exam. The May 2015 VA examiner also opined that it was less likely than not that the Veteran's current arthritis was caused by or a result of the events and aftermath of January 1968. The examiner noted that during the Veteran's service, no imaging studies were completed to confirm presence of degenerative arthritis. This is a requirement for VA purposes. Moreover, since this was a relatively recent diagnosis mentioned in 2010, it would be more likely that the cumulative effect of the wear and tear process over so many years would have been responsible for the degenerative arthritis changes as compared to the modest events in the services. See May 2015 C&P Exam. Further, the May 2015 VA examiner opined that the Veteran's recent erysipelas was less likely than not caused by or a result of the events and aftermath of January 1968. The examiner observed that x-rays of the hand at the time did not reveal the presence of a fracture in the area, and there were no further visits for the right hand reflected in the STRs. The examiner noted that the in-service occurrence of erysipelas was recognized, treated, and the condition responded to treatment; moreover, erysipelas could be a readily acquired condition in everyday life. The examiner elaborated that areas of skin trauma, venous insufficiency, stasis ulcerations, inflammatory dermatoses, dermatophyte infections, insect bites, and surgical incisions were common ways in which the condition could be required. See May 2015 C&P Exam. A private lab conducted in May 2019 detected the JAK2 V617 mutation. See October 2020 C&P Exam. A private June 2019 biopsy revealed that the bone marrow was hypercellular with atypical megakaryocytic hyperplasia and myeloid hyperplasia. A JAK2 V617F mutation was detected. Flow cytometry showed no evidence for an abnormal or neoplastic leukocyte population. In the view of the examiner these findings, in combination with persistent thrombocytosis, were most consistent with the diagnosis of essential thrombocythemia. See September 2019 MTR - NGF Private July 2019 records show the Veteran complained of bilateral joint pain of the wrists and elbows. See September 2019 MTR - NGF. Also in July 2019, private records show the physician had an impression of JAK2 and essential thrombocythemia. The Veteran was noted to have iron deficiency with microcytic anemia and absent iron stains on the bone marrow. See September 2019 MTR - NGF. At an August 2020 VA examination for hematologic and lymphatic conditions, including leukemia, the examiner determined that the correct diagnosis for the Veteran's condition was polycythemia vera. The examiner stated there was no evidence of the claimed thrombocytosis leukemia with bone marrow infection or erysipelas blood disorder. See October 2020 C&P Exam (3). The examiner went on to opine that the Veteran's polycythemia vera was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that polycythemia vera is not a presumptive Agent Orange condition, and further noted that there was no pathophysiological evidence to support the claim that the condition was secondary to herbicide exposure. October 2020 C&P Exam (6). In August 2020 the Veteran also underwent a VA examination for arthritis. While the Veteran reported pain with movement of the wrists, hands, and ankles, upon review of diagnostics it was determined that the Veteran did not have non-degenerative arthritis and any joint abnormalities or arthritis diagnosed in those joints were not considered secondary to the claimed blood disorder. See October 2020 C&P Exam (4). Private bloodwork from August 2020 revealed the Veteran's WBC, RDW, platelets, and neutrophils were at high levels. See October 2020 C&P Exam (1). VA records show that private September 2020 imaging of the right wrist revealed radial carpal osteoarthritis, early SLAC wrist deformity, and subtle erosion of the ulnar epiphysis versus old traumatic deformity. See October 2020 C&P Exam (1), In March 2021 an additional VA medical opinion was obtained for the Veteran's claimed conditions; namely, polycythemia vera, primary thrombocythemia, arthritis, thrombocytosis (leukemia), with bone marrow infection, and erysipelas (blood disorder). Ultimately, the examiner opined that the Veteran's claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. To support this opinion, the examiner noted that a review of current medical literature was silent for any causal relationship between herbicide exposure and the subsequent development of the above conditions. See March 2021 C&P Exam. Additionally, a review of the Veteran's record did not reveal mention of either rheumatoid arthritis or arthritis thrombocytosis (rheumatoid arthritis complication), leading the examiner to conclude that a diagnosis of arthritis thrombocytosis was not possible. Id. Furthermore, regarding the claimed thrombocythemia, the examiner pointed out that this condition was later determined to be primary polycythemia, also known as polycythemia vera. Id. Regarding the confirmed diagnosis of polycythemia vera, the examiner noted the condition is more common as a person ages, and it typically presents for the first time around 60 years old, occurring more frequently in men. The condition has also been associated with JAK2 and TET2 genes. Id. Finally, regarding claims of degenerative arthritis and cellulitis or erysipelas, the examiner noted that while the Veteran had a history of falling down during service, injuring his right hand and wrist, and developing cellulitis and possibly erysipelas, the remainder of the Veteran's STRs concluding with his October 1969 separation examination were silent for continued, chronic treatment. Id. After a review of the evidence of record, the Board finds that service connection for a blood disorder is not warranted. The Board notes that this claim involved multiple medical conditions; namely, polycythemia vera, thrombocythemia, thrombocytosis, arthritis, and erysipelas. The Board has considered the medical evidence of record for all of the above-named conditions in making this decision. In the present case, there is sufficient evidence that the Veteran meets the threshold criterion for service connection of a current disability. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000). Specifically, in February 2010 the Veteran was acknowledged to have cellulitis, the May 2015 examiner acknowledged that the Veteran had a diagnosis of arthritis, and the August 2020 VA examiner diagnosed the Veteran with polycythemia vera. Accordingly, the first requirement for service connection has been met. Concerning the second requirement, an in-service event or incurrence, the Board observes that in June 2020 the Board conceded Agent Orange exposure during his service in the DMZ. The Board also notes that the Veteran's January 1968 wrist sprain and resulting cellulitis is documented in the STRs. As such, the second element of an inservice incurrence and/or injury has also been met. Therefore, it remains for the Board to determine if the Veteran's blood disorder conditions are related to his service. As a preliminary matter, the Board has considered presumptive entitlement to service connection based on exposure to Agent Orange. However, the Veteran's claimed conditions are not among those contemplated by 38 U.S.C. § 1116. As such, presumptive service connection based on exposure to herbicides is not warranted. Regarding entitlement to service connection on a direct basis, the Board finds the May 2015, August 2020, and March 2021 VA medical opinions to be probative. To this end, the May 2015 VA medical examiner determined that the Veteran's conditions were not related to the Veteran's in-service wrist sprain and resulting cellulitis. The examiner based their decision on a review of the record and noted that the in-service sprain and cellulitis were transitory in nature and the records did not reflect the persistence of a related chronic condition. Such finding is corroborated by the STRs, which ostensibly showed no further treatment, complaints, or diagnoses for any condition related to that injury for the remainder of the Veteran's active duty, to include no notation on his separation examination. The October 2020 VA examiner found that the Veteran's conditions were not presumptive conditions for herbicide exposure, and further noted that there was no pathophysiological evidence to support a relationship between herbicide exposure and the Veteran's conditions, further noting that erysipelas could be incurred for a myriad of reasons. The March 2021 medical opinion elaborated that the Veteran's polycythemia vera and arthritic conditions were consistent with age, and that erysipelas was a relatively common bacterial infection of the skin. Thus, the Board finds that the three above medical opinions were based on thorough reviews of the Veteran's file, discussed the available medical evidence, and cited current medical knowledge, and provided adequate supporting rationales for the conclusions reached. Barr v. Nicholson, 21 Vet. App. 303 (2007); Stefl v. Nicholson, 21 Vet. App. 120 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board acknowledges the Veteran's assertions that his blood disorder and the other bundled conditions were related to herbicide exposure in-service. The Veteran is competent to report symptoms and observations because this requires only personal knowledge as it comes through an individual's senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, the Veteran in this case is not competent to determine the cause of his symptoms because he has not been shown by the evidence of record to have medical training or skills to do so. (Continued on the next page) Based on the foregoing, the Board finds that the third requisite for element for service connection has not been met. Although the Veteran is entitled to the benefit-of-the-doubt where the evidence is in approximate balance, the benefit-of-the-doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim for service connection for a blood disorder. The claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990). Zi-Heng Zhu Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Slomka, 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.