Citation Nr: 21031153 Decision Date: 05/20/21 Archive Date: 05/20/21 DOCKET NO. 14-43 333 DATE: May 20, 2021 ORDER Entitlement to service connection for residuals of Dengue fever is denied. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran currently has residuals of Dengue fever that began during active service, or are otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for residuals of Dengue fever are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 1963 to June 1968. The Veteran had a hearing before the undersigned Veterans Law Judge in April 2018. In June 2018, the Board granted service connection for bilateral hearing loss and remanded the Dengue fever residuals service connection claim. The Board again remanded this matter in April 2020 and October 2020. 1. Entitlement to service connection for residuals of Dengue fever. The Veteran contends that he had Dengue fever in service and that continues to have recurring symptoms. In his August 2010 claim, he indicated that he believed he contacted it in Thailand and has recurring fevers from it. During his Board hearing, the Veteran reported that he does not seek medical treatment for the disorder when it recurs as there is no cure. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. Service treatment records, including his May 1968 separation examination, are silent as to complaints of, or treatment for, Dengue fever. The records do, however, include a May 1966 notation of treatment for vomiting. An April 2011 lay statement from the Veteran's fellow service member, P.F.R., noted that he had served with the Veteran in Thailand and that he recalled that the Veteran had become ill and bedridden for weeks with what he had considered to be Malaria, based on his cycles of chills and fever. In a May 2011 lay statement, the Veteran similarly reported falling ill with cycles of chills and fever while in Thailand. After service, he reported living in California and having another attack of Dengue fever. In an October 2011 notice of disagreement, he clarified that this bout happened in the 1970s, a couple of years after service and that he had been treated by an aviation physician. Giving the Veteran the benefit of the doubt, the Board finds that the Veteran may have had Dengue fever in service. The question thus turns to whether the Veteran has any residuals of Dengue fever. An October 2011 private blood test indicated that the Veteran had Dengue fever antibodies in is blood, below the reference range for active disease. As explained by the May 2019 VA examiner, these test results confirmed the presence of Dengue fever IgG and IgM, but "the values are below levels for active disease and can only confirm some prior exposure to the past." As such, the 2011 findings show that the Veteran did not have current Dengue fever at that time, but only showed past exposure to the disorder, which the Board has conceded as having occurred in service. In a May 2014 letter, Dr. F.P.G-G., an aviation physician, recalled that the Veteran reported had a severe episode of Dengue fever during service and noted a blood test that had shown persistent viral antibodies indicating prior disease. Based on the Veteran's description, the physician indicated that he had Dengue fever in service. The May 2019 VA examiner found, after thorough review of databases, that there was no evidence that Dengue Fever develops into a chronic relapsing illness as described by the Veteran. The examiner noted that the disease generally runs its course in 2-3 weeks with up to 6 weeks of convalescence afterward, which is the Veteran's report of illness in service. However, given that Dengue Fever is not a chronic relapsing illness and there was no documentation in his available civilian records to corroborate his history of recurrent fevers, the examiner concluded that it was less likely than not that the Veteran has any residuals of Dengue Fever related to an in-service disease. The examiner noted alternate explanations for his symptomatology which include his history of prostate cancer with radiation therapy resulting in hypogonadism, which may present with similar symptoms. In a June 2019 letter, Dr. T.M.S., an epidemiologist with the CDC, indicated that the Veteran's report of Dengue years after service is "certainly well outside the norm, but I would not say that it is impossible." In a July 2019 letter, Dr. T.M.S. further indicated that if there is confirmatory evidence of current Dengue virus infection (most likely documented by an RT-PCR positive test result, or possibly by an NS1-positive test result) and confirmed that the Veteran had not travelled to a location where Dengue is a risk 14 days before recent illness, then the physician would assess that it is more likely than not that the Veteran had an extremely rare recurrence of Dengue resulting from a prior infection. A June 2020 VA examiner found nothing in the medical record to confirm that an appropriate RT-PCR or NS1 test had been recently done to confirm current infection with Dengue fever. There is no objective evidence to support a diagnosis for the claimed condition. The examiner noted that the diagnosis of Dengue fever made in 1966 was a presumptive diagnosis made by a military corpsman. The RT-PCR or NS1 test suggested by Dr. T.M.S. as a definitive test for persistence of Dengue antibodies in this veteran's blood has not been performed. The Veteran complained that, over time between 1966 and 2020, he has had three peaks (one in 1966, one in the early-1980s and the last in April 2018). The examiner found no objective evidence to support a diagnosis for the claimed condition. Dengue fever is a mosquito borne self-limited disease that, overwhelmingly cures itself without treatment, and completely leaves the body free of infectious agents and antibodies in the body once the disease is over in about 6 weeks. The examiner opined that it is highly unlikely residual symptoms related to the disease are happening in this veteran. U.S. Public Health Service epidemiologist Dr. T.M.S. provided an opinion that stated vital to a determination of whether his transient symptoms of fatigue, nausea and a feeling of being hot are residuals of Dengue fever depended upon confirmation of the Veteran having not traveled recently to a tropical area where re-infection could occur and the results of a recently performed test for Dengue fever called a RT-PCR or NS1 test that would confirm current infection. An October 2020 VA medical opinion provider indicated agreement with the 2019 comment of Dr. T.M.S. indicating that residuals of Dengue fever is dependent on a new test that shows the presence of Dengue antibodies. Based off the records, such a confirmatory test had not been performed recently, and thus he could not affirm residuals of Dengue fever. Dengue fever normally would have resolved within six weeks of initial exposure. It has been years since the last test, which would not be a "recent" test. Based off the acute condition and without a current test, medical records do not support a rationale that the current symptoms experienced by the Veteran represent residuals of Dengue Fever. In November 2020, the same VA medical opinion provider further clarified that it had been strongly recommended by epidemiologist Dr. T.M.S. that a determination of whether or not this veteran had residuals of Dengue fever depended upon results of a current specific test (RT-PCR or NS1). If the test was positive, a current diagnosis could be made. Without such a test, no determination could be made. Since the examiner could not find any evidence a test was currently done and diagnostics of for Hepatitis E virus are all negatives, his diagnosis and medical opinion could not support finding current residuals of an infection that occurred fifty years ago. The Board notes that although the requested RT-PCR or NS1 test has not been obtained, in March 2021 the most recent VA examiner explained that such testing was not possible by that facility. As the examiner has otherwise provided the requested opinion, the Board finds there has effectively been substantial compliance with the remand directives. Furthermore, there is sufficient evidence of record to make a determination on this claim such that additional remand would needlessly delay this matter. To that end, the Board further notes that the May 2019 VA examiner found that there are alternate explanations for his symptomatology, which include his history of prostate cancer with radiation therapy resulting in hypogonadism, which may present with similar symptoms. That VA examiner thus effectively found that the Veteran's current symptoms are not due to an infection from over 50 years ago. Additionally, the only possibly positive medical evidence of record is from Dr. T.M.S. who indicated that evidence of a current Dengue virus infection was necessary to consider the possibility of a rare recurrence of Dengue fever. As indicated above, there is no evidence of record of a current infection since his separation from service. Indeed, even as recently as 2011, the Veteran did not have a then current infection as required by Dr. T.M.S. to have an "recurrence of Dengue resulting from a prior infection." As noted above, the May 2019 VA examiner explained that the 2011 test results confirmed the presence of Dengue fever IgG and IgM, but "the values are below levels for active disease and can only confirm some prior exposure to the past." Similarly, the Veteran's private physician Dr. F.P.G-G., who treated the Veteran during his initial claimed peak after service, also did not indicate a current infection at that time. Rather, he indicated that "I distinctly remember a blood test which showed persistent viral antibodies indicating prior disease." There is no probative evidence that the Veteran has had current or active period Dengue fever since his separation from service in the 1960s. The Board finds that given the multiple negative medical opinions by VA examiners, as well as, Dr. T.M.S. requiring current evidence of Dengue and there being no evidence of record of such a current finding since the Veteran's separation from service, the most probative evidence of record is against the Veteran's claim. The VA examiners' opinions are probative, because they are based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Veteran's lay nexus opinion is that he believes he currently has residuals of Dengue fever related to an in-service injury, event, or disease. The issue is medically complex, as it requires extensive knowledge of a disease process. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the opinions of the medical professionals. (Continued on the next page) As the preponderance of the most probative evidence of record is against the claim, the benefit of the doubt rule does not apply. Service connection for residuals of Dengue fever is denied. H.M. WALKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Lindio 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.