Citation Nr: 21042135 Decision Date: 07/12/21 Archive Date: 07/12/21 DOCKET NO. 17-05 703 DATE: July 12, 2021 ORDER Entitlement to service connection for fatigue, as secondary to service-connected asthma, is granted. FINDINGS OF FACT 1. The Veteran served in the Southwest Asia theater of operations during the Persian Gulf War. 2. The evidence of record raises a reasonable doubt as to whether the Veteran's claimed symptom of fatigue is proximately due to or caused by her service-connected asthma. CONCLUSION OF LAW The criteria for entitlement to service connection for fatigue have been met. 38 U.S.C. §§ 1101, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from April 1981 to November 1988 and from November 1990 to May 1991, including service in Southwest Asia. This appeal was previously before the Board in December 2018, at which time the Board remanded the claim on appeal in order to obtain a medical opinion. All requested development has been conducted and the appeal has been returned to the Board for further consideration. Entitlement to service connection for a disability manifested by fatigue, claimed as due to an undiagnosed illness or as secondary to service-connected asthma Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 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 service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Service connection may also be granted on a presumptive basis for a Persian Gulf War veteran who exhibits objective indications of qualifying chronic disability that became manifest during either active service in the Southwest Asia Theater of Operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021, and cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317 (a)(1). In claims based on qualifying chronic disability, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1 (2004). A qualifying chronic disability means a chronic disability resulting from an (A) undiagnosed illness; (B) the following medically unexplained chronic multi-symptom illnesses that are defined by a cluster of signs or symptoms: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) IBS; or (4) any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multi-symptom illness; or (C) any diagnosed illness that VA determines warrants a presumption of service connection under 38 U.S.C. § 1117(d). 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i)(B). In this case, the Veteran's DD Form 214 reflects that she served in Southwest Asia from January to May 1991 and received the Southwest Asia Service Medal. Therefore, the Veteran is considered a Persian Gulf War veteran with qualifying active service sufficient to trigger the application the laws and provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317(a)(1). The Veteran has reported having chronic fatigue since serving in the Gulf War and she has stated that she believes her fatigue is a result of her exposure to environmental hazards during her Gulf War service. In the alternative, she has asserted that her fatigue is associated with her asthma disability, as her asthma causes restless nights and difficulty falling asleep, which contributes to her fatigue. In this regard, the Veteran has stated that she is always tired no matter how much she sleeps and that she believes the lack of oxygen she experiences as a result of asthma contributes to her fatigue. See June 2015 notice of disagreement. The Veteran's service treatment records (STRs) do not contain any complaints, treatment, or diagnoses related to fatigue. However, the Veteran has asserted that her fatigue began in 1991 when she returned from Saudi Arabia and, in this regard, the Board notes the Veteran's statements in this regard are considered competent and credible lay evidence. Nevertheless, the evidence of record shows the Veteran's fatigue has been attributed to a known clinical diagnosis. As an initial matter, the Board notes that the preponderance of the evidence reflects that the Veteran does not meet the criteria for a diagnosis of chronic fatigue syndrome. In this regard, the Board notes that the Veteran's complaints of fatigue have not been diagnosed as CFS and, in June 2020, a VA physician specifically enumerated the criteria for a diagnosis of CFS and noted that, based on the available medical evidence, there is insufficient evidence to support a diagnosis of CFS. See e.g., March 2010 private treatment record; January 2020 VA treatment record; June 2020 VA opinion. Nevertheless, in December 2019, a VA clinician examined the Veteran and noted her reported symptoms of fatigue due to poor sleep patterns, including difficulty falling and staying asleep due to coughing and shortness of breath, which the examiner noted are symptoms associated with asthma. The VA examiner noted that multiple cross-sectional, quantitative studies have been performed with results associating the symptom of fatigue in asthma patients with reports of tiredness, lack of energy, and daytime sleepiness. As a result, the VA examiner opined that it is as likely as not that the Veteran's chronic fatigue can be attributed to her service-connected asthma. See December 2019 VA opinion. The Board acknowledges that the December 2019 VA examiner's opinion specifically refers to the Veteran's fatigue as "chronic fatigue syndrome" which, as noted, has not been diagnosed in this case. Nevertheless, the Board notes that the rationale provided in support of the opinion remains valid and provides evidence in support of a finding that the Veteran's fatigue is proximately due to or a result of her service-connected asthma disability. Indeed, the December 2019 opinion is competent, credible, and probative evidence, as the VA examiner provided a complete rationale in support of her opinion that considered the lay and medical evidence of record, as well as medical studies. In evaluating this claim, the Board acknowledges that the VA physician who provided the June 2020 opinion stated that the Veteran's symptoms of fatigue are explained by her morbidly obese body habitus; however, this opinion does not address or exclude the possibility that the Veteran's fatigue is related to asthma or any other condition. Indeed, the Board finds the lay and medical evidence of record raises a reasonable doubt as to whether the Veteran's fatigue is proximately due to or a result of her service-connected asthma disability. In view of the foregoing, the Board finds that a basis upon which to grant service connection for fatigue has been presented. Therefore, service connection for fatigue as secondary to service-connected asthma. 38 C.F.R. § 3.310. Jenna Brant Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Turnipseed, 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.