Citation Nr: 22016198 Decision Date: 03/21/22 Archive Date: 03/21/22 DOCKET NO. 18-19 322 DATE: March 21, 2022 ORDER Service connection for hemolytic anemia due to the aggravation of glucose-6-phosphate dehydrogenase (G6PD) deficiency is granted. FINDING OF FACT Resolving reasonable doubt in the Veteran's favor, the Veteran's G6PD deficiency was aggravated beyond its natural progression in service resulting in hemolytic anemia. CONCLUSION OF LAW The criteria for service connection for hemolytic anemia due to the aggravation of G6PD deficiency are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1968 to August 1971, including service in the Republic of Vietnam. This case is before the Board of Veterans' Appeals (Board) on appeal from an August 2014 rating decision from a Department of Veterans Affairs (VA) Regional Office (RO). In January 2020, the Veteran testified at a Board hearing. The transcript of the hearing has been associated with the record. The Board notes the Veteran also has open claims for service connection for nerve damage, sleep apnea, and prostate cancer, but those issues are not yet before the Board as VA has not yet certified that appeal; therefore, the Board currently lacks jurisdiction over those issues. The Board remanded the matter of service connection for G6PD deficiency for further development in February 2020, July 2021, and December 2021, including for an opinion as to whether the Veteran's G6PD deficiency is a congenital defect or disease. Service Connection Service connection will be granted for a current disability that resulted from an injury, disease, or aggravation while in active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Generally, service connection requires (1) a present disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the present disability and the in-service incurrence or aggravation of a disease or injury. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A veteran will be considered to have been in sound condition when examined, accepted, and enrolled for service except as to defects, infirmities, or disorders noted at the time or where clear and unmistakable evidence or medical judgment establishes that an injury or disease preexisted service. 38 U.S.C. § 1111, 38 C.F.R. § 3.304(b). When no preexisting medical condition is noted upon entry into service, a veteran is presumed to have been sound upon entry. 38 U.S.C. § 1111; Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). If the presumption of soundness attaches, the burden falls on the government to rebut the presumption by clear and unmistakable evidence that a disorder was both preexisting and not aggravated by service. Wagner, 370 F.3d at 1096; Bagby, 1 Vet. App. at 227. Clear and unmistakable evidence is defined as obvious or manifest. 38 C.F.R. § 3.306(b). Clear and unmistakable evidence means that the evidence "'cannot be misinterpreted and misunderstood, i.e., it is undebatable.'" Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009). Under VA's regulatory framework, congenital or developmental diseases are eligible for service connection, but congenital or developmental defects are not. 38 U.S.C. § 1110; 38 C.F.R. § 3.303; VAOGCPREC 82-90. Defects are defined as "structural or inherent abnormalities or conditions that are more or less stationary in nature." VAOPGCPREC 82-90. On the other hand, a disease is defined broadly as "any deviation from or interruption of the normal structure or function of any part, organ, or system of the body..." and "a condition considered capable of improving or deteriorating." Id. "Any worseningany change at allmight demonstrate that the condition is a disease, in that VA considers defects to be 'more or less' static and immutable." Quirin, 22 Vet. App. at 395 (citing VAOGCPREC 82-90). Defects are defined as "structural or inherent abnormalities or conditions that are more or less stationary in nature." VAOPGCPREC 82-90. Diseases, conversely, are defined broadly as "any deviation from or interruption of the normal structure or function of any part, organ, or system of the body..." and "a condition considered capable of improving or deteriorating." Id. "Any worsening any change at all might demonstrate that the condition is a disease, in that VA considers defects to be 'more or less' static and immutable." Quirin, 22 Vet. App. at 395 (citing VAOGCPREC 82-90). Temporary or intermittent flare-ups during service of a preexisting injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition, as contrasted to symptoms, is worsened. Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). In the absence of an increase in the underlying severity, the occurrence of symptoms does not constitute aggravation of the disability. Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002). Evidence of the Veteran being asymptomatic on entry into service, with an exacerbation of symptoms during service, does not constitute evidence of aggravation. Green v. Derwinski, 1 Vet. App. 320, 323 (1991). A preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service (presumption of aggravation) unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153. In such claims, a veteran (the evidence of record) must show an increase in disability during service to trigger the presumption of aggravation. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). "If the presumption of aggravation under section 1153 arises, the burden then shifts to the government to show a lack of aggravation by establishing 'that the increase in disability is due to the natural progress of the disease.'" Wagner, 370 F.3d at 1096 (citing 38 U.S.C. § 1153). This requires the government to show by clear and unmistakable evidence that any increase in disability was due to the natural progress of the condition. See Cotant v. Principi, 17 Vet. App. 116, 130-32 (2003); see also 38 C.F.R. § 3.306(b). The Veteran is competent to report symptoms and experiences he can observe. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). VA must give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed Cir. 2009). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 C.F.R. § 3.102. Entitlement to service connection for G6PD deficiency. The Veteran seeks service connection for his G6PD deficiency. He argues that the G6PD deficiency was triggered by the malaria medication he took while serving in Vietnam. Alternatively, he contends that his G6PD deficiency was caused or aggravated by a blood transfusion he received in service with the blood of a wrong or incompatible type. See January 15, 2020, Hearing Transcript. The record contains a competent diagnosis of a G6PD deficiency with symptoms of hemolytic anemia; accordingly, competent evidence of a current disability is found. August 7, 2012, Medical Treatment Record - Non-Government Facility. G6PD deficiency is the most common inborn error of metabolism, an x-linked enzyme deficiency causing varying degrees of hemolytic anemia in many millions of people worldwide. It can cause favism, and some drugs induce hemolytic anemia or chronic nonspherocytic hemolytic anemia. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY at 781 (33d ed. 2019). The Veteran's April 1968 pre-induction examination is negative for any G6PD deficiency, anemia, or other blood disorder. March 27, 2014, STR - Medical. Thus, the Veteran is presumed to have been sound at entrance. A May 1970 in-service consultation sheet shows the Veteran was seen for complaints of malaise, weakness, dizziness spanning over two weeks. The clinician noted the Veteran's conjunctiva was pale and that he reported taking malaria pills "religiously." The clinician placed a request to evaluate for possible anemia reaction from dapsone. See id. The Veteran's August 1971 separation examination noted the Veteran had a diagnosis for G6PD deficiency by history and that it was asymptomatic. Id. Private treatment records show post-service treatment for symptoms of hemolytic anemia due to G6PD deficiency, such as dizziness and weakness. See August 7, 2012, Medical Treatment Record - Non-Government Facility. An August 2020 VA examiner opined that the Veteran's G6PD deficiency was less likely than not incurred in or caused by the claimed in-service injury or disease, including taking malaria medication. The August 2020 VA examiner's rationale was that G6PD deficiency is a genetic disorder that results from mutations in the G6PD gene. This gene provides instructions for making an enzyme called glucose-6-phosphate dehydrogenase. As G6PD deficiency leads to increased oxidative stress in red blood cells, this may negatively influence the parasite. As such, individuals who possess this mutation have some protection against malaria. There is no substantial medical evidence and literature to show that malaria medication can cause G6PD deficiency. An October 2021 VA examiner came to the same conclusion as the August 2020 VA examiner and also opined that it is less likely than not that the Veteran's G6PD deficiency was aggravated beyond its normal progression or that it is a disability due to disease or injury that was incurred in service is superimposed on the congenital defect, including the impact of his taking malaria pills and the impact if he was given blood of a different or incompatible type during his in-service blood transfusions. The October 2021 VA examiner noted the following in support of his conclusion: that the August 1971 separation examination reported a history of pre-service G6PD deficiency and no history for blood transfusions, the Veteran's medical records revealed no continuous ongoing medical treatment or aggravation of acute or chronic pre-service G6PD deficiency during the time of discharge from active military service to present day, and G6PD deficiency is an inherited condition. The January 2022 VA examiner opined that there is no uncertainty regarding the hereditary etiology of G6PD deficiency and noted the following: G6PD deficiency is a genetic disorder that most often affects males, it is more common in those of African and Mediterranean descent, it occurs when the body doesn't have enough of the G6PD enzyme, and G6PD can cause hemolytic anemia when clinically manifest. Regarding whether the Veteran's G6PD deficiency was aggravated in service, the January 2022 VA examiner provided that there is insufficient evidence to establish any continuity of symptoms with military service as the Veteran's separation examination noted his G6PD deficiency was asymptomatic. The examiner further stated that based on the evidence of record, there is insufficient evidence to establish a nexus, with greater than 50 percent probability, that the Veteran had a disease or injury superimposed upon his congenital G6PD deficiency while in service or that it was aggravated beyond its natural progression by military service, noting the Veteran was completely asymptomatic. The Board acknowledges the VA examiners' opinions that it is less likely than not that the G6PD deficiency had its onset in or is otherwise related to the Veteran's periods of service, but assigns those opinions diminished probative weight as they fail to discuss the May 1970 in-service consultation sheet demonstrating symptoms of anemia following intake of dapsone. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (finding a medical opinion must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions). No weight can be afforded to the October 2021 VA examiner's opinion as he provided no rationale, only conclusions. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The January 2022 VA examiner's rationale focusing on the separation examination's note that the Veteran's G6PD deficiency was asymptomatic is misguided given the evidence that the Veteran was treated for symptoms of anemia in service. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that a medical opinion based upon an inaccurate premise has no probative value). Three VA examiner opinions regarding the etiology of the G6PD deficiency with a notice of the adequacy requirements were solicited. Still, all the opinions were inadequate as they failed to consider the service treatment records and were only based on the fact that G6PD deficiency is a congenital genetic disorder. Indeed, no examiner has answered the question of whether G6PD deficiency is a disease or defect or discussed hemolytic anemia due to G6PD deficiency. The Board finds that the Veteran's G6PD deficiency is a defect that preexisted service but was aggravated during service. Indeed, the Veteran's G6PD deficiency manifested in hemolytic anemia in 1970 following the use of malaria medication in service. The resulting hemolytic anemia is a disease. See Quirin, 22 Vet. App. at 395. The evidence of record does not show by clear and unmistakable evidence that any increase in disability was due to the natural progress of the condition. See Cotant, 17 Vet. App. ad 130-32; 38 C.F.R. § 3.306(b). A disability need not require an extraordinary treatment or special procedure to be service connected. The competent lay and medical evidence demonstrate the Veteran had symptoms attributable to hemolytic anemia due to G6PD deficiency in service; he was first diagnosed with G6PD deficiency in service, and he has occasionally experienced hemolytic anemia since. Therefore, service connection for hemolytic anemia due to the in-service aggravation of G6PD deficiency is granted. R. FEINBERG Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Costa, 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.