Back to BVA DecisionsMIXEDSpecial Benefit NO SPECIAL BENEFIT Docket No. 19-01 306
THYROID ENLARGEMENT TOXIC (GRAVES' DISEASE OR THYROTOXICOSIS)
T. BLAKE CARTER · 2023 · Case ID: 23017085
Summary
The veteran, who served from November 1980 to November 1983 and again from July 1984 to June 1998, appeals the denial of service connection for hyperthyroidism and the remand of his sleep apnea claim. The veteran contends his hyperthyroidism is related to Camp Lejeune Contaminated Water (CLCW) exposure. The Board reviewed the evidence, including a May 2021 VA examination and a May 2020 private opinion from Dr. B. The VA examiner concluded hyperthyroidism is not linked to CLCW contaminants like perchlorate or TCE, citing a 2017 ATSDR study. Dr. B. opined a link between TCE and thyroid disease, referencing medical journals and laboratory reports, but failed to identify specific abnormal results or fully explain the connection, making his opinion less probative. The Board found the VA opinion more persuasive, noting the veteran's medical training did not qualify him for an etiology opinion and that his self-interest could affect credibility. Service connection for hyperthyroidism was denied. The sleep apnea claim was remanded because the May 2021 VA examiner did not address whether the Veteran's in-service polycythemia vera onset indicated concurrent sleep apnea, despite sleep apnea potentially causing polycythemia vera. A new VA opinion is required to clarify this nexus.
Rationale
Conflicting medical opinions on CLCW link; VA opinion found no link to TCE/PCE contaminants; Private opinion lacked specific lab results and clear rationale
Full Decision Text
Citation Nr: 23017085 Decision Date: 03/20/23 Archive Date: 03/20/23 DOCKET NO. 19-01 306 DATE: March 20, 2023 ORDER Service connection for hyperthyroidism is denied. REMANDED Service connection for sleep apnea is remanded. FINDING OF FACT The evidence of record persuasively weighs against finding that hyperthyroidism began during active service or is otherwise related to an in-service injury or disease, including exposure to Camp Lejeune contaminated water (CLCW). CONCLUSION OF LAW The criteria for service connection for hyperthyroidism are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had qualifying active military service from November 1980 to November 1983 and from July 1984 to June 1998. This matter comes before the Board of Veterans' Appeals (Board) on appeal from June 2017 and July 2018 rating decisions. The Veteran testified at a Board hearing in March 2020. The above-listed issues were then remanded for additional development in May 2020. Service connection for hyperthyroidism 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 Veteran contends that he has a thyroid disability which is etiologically related to service, including his established exposure to CLCW. Initially, the Board notes that the Veteran has been diagnosed with hyperthyroidism, or alternatively, Grave's disease. Effective March 14, 2017, VA amended its adjudication regulations regarding presumptive service connection, adding certain diseases associated with contaminants present in the base water supply at U.S. Marine Corps Base Camp Lejeune, North Carolina from August 1, 1953, to December 31, 1987. The final rule establishes that veterans who served at Camp Lejeune for no less than 30 days during this period, and who have been diagnosed with any of eight associated diseases (adult leukemia, aplastic anemia and other myelodysplastic syndromes, bladder cancer, liver cancer, multiple myeloma, non-Hodgkin's lymphoma, and Parkinson's disease) are presumed to have incurred or aggravated the disease in service for purposes of entitlement to VA benefits. See 38 C.F.R. § 3.309(f). Although the Veteran has the requisite exposure, hyperthyroidism and Grave's disease are not currently on the presumptive disability list. Nevertheless, when a claimed disorder is not included as a presumptive disorder, direct service connection may nevertheless be established by evidence demonstrating that the disease was in fact "incurred" during the service. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The record contains conflicting medical opinions regarding whether the Veteran's hyperthyroidism is related to CLCW exposure. The May 2021 VA examiner opined that it was not. The rationale was that there was a strong correlation between one of the contaminants, perchlorate, and hypothyroidism, not the hyperthyroidism experienced by the Veteran. The additional contaminants, TCE and PCE, had no known associations to hyperthyroidism or Grave's disease. He cited to a 2017 study by the Agency for Toxic Substance and Disease Registry to support these conclusions. Private practitioner Dr. B. opined in a May 2020 opinion that the Veteran's thyroid disease was related to his toxic exposures. The rationale was that TCE, one of the contaminants associated with CLCW, is known to cause thyroid disease. This was based in part on medical journal articles linking contaminants to thyroid disease as well as laboratory reports in service. However, Dr. B. did not identify specific laboratory reports that were abnormal or explain what the abnormality was. The Board reviewed the service treatment records and did not find laboratory results in service regarding the hyperthyroidism or Grave's disease. He cited to a 2017 study by the Agency for Toxic Substance and Disease Registry to support these conclusions. Private practitioner Dr. B. opined in a May 2020 opinion that the Veteran's thyroid disease was related to his toxic exposures. The rationale was that TCE, one of the contaminants associated with CLCW, is known to cause thyroid disease. This was based in part on medical journal articles linking contaminants to thyroid disease as well as laboratory reports in service. However, Dr. B. did not identify specific laboratory reports that were abnormal or explain what the abnormality was. The Board reviewed the service treatment records and did not find laboratory results in service regarding the Veteran's TSH, T3, or T4. It is therefore unclear which laboratory results Dr. B. found to be manifestations of thyroid disorder in service. Further, Dr. B. did not fully explain the basis for the assertion that the Veteran's thyroid disorder was related to the chemical exposure. He referenced medical journal articles but did not explain the significance of the articles as they relate to the specific facts of this case. Indeed, a brief excerpt from one article appears to discuss thyroid disease and perchlorate, but without any further explanation. This opinion is less probative than the VA examiner's opinion. Dr. B's opinion relies on laboratory test results which are not shown in the record, and vague references to medical treatises without further clarification. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). Consequently, the Board gives more probative weight to the May 2021 VA opinion. The Veteran believes his hyperthyroidism is related to his CLCW exposure. He had service as a corpsman, and therefore possesses some medical knowledge and training. Nevertheless, the issue is medically complex, as it requires knowledge of pathology and the effect of various toxins on the body. There is no indication that his medical training extended to a level that would render him competent to provide an etiology opinion on this issue. The Board also notes that the Veteran's self-interest can affect the credibility of his assertions. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) (a pecuniary interest or bias may be found to affect the credibility of testimony). For these reasons, the evidence persuasively weighs against a finding that the Veteran's thyroid disability is etiologically related to service, and therefore service connection is not warranted. REASONS FOR REMAND Service connection for sleep apnea The Veteran is seeking service connection for sleep apnea and is currently diagnosed with the condition. He is also presently service-connected for "secondary" polycythemia vera. The evidence clearly establishes that sleep apnea can cause or aggravate polycythemia vera. See May 2021 VA opinion. The Board previously determined that polycythemia vera had its onset during service. The Veteran contends that this occurred because sleep apnea was also present during service. To that end, the Board remanded the matter to obtain a VA medical opinion which addresses whether the onset of polycythemia vera during service meant he also had sleep apnea in service. A VA opinion was obtained in May 2021. The examiner addressed several other questions posed by the Board, including whether claimed headache symptoms in service were evidence of sleep apnea, and whether sleep apnea was proximately due to or aggravated by polycythemia vera. However, the examiner did not address whether the onset of polycythemia vera during service supported the conclusion that sleep apnea was present during service. Therefore, another remand is required Stegall v. West, 11 Vet. App. 268, 271 (1998). The matter is REMANDED for the following actions: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's sleep apnea is related to service, to include consideration of whether the onset of polycythemia vera during service establishes the presence of sleep apnea during service. The examiner is advised that the Veteran's current treatment records establish a diagnosis of "secondary" polycythemia vera, as well as a current diagnosis of sleep apnea. The examiner is further advised that a May 2021 VA opinion already established that sleep apnea can cause secondary polycythemia. The examiner must provide a rationale to support the opinion. If an opinion cannot be provided without resort to speculation, the examiner should explain whether the inability to provide the opinion is due to the limits of medical knowledge generally, inadequate information or ician regarding whether the Veteran's sleep apnea is related to service, to include consideration of whether the onset of polycythemia vera during service establishes the presence of sleep apnea during service. The examiner is advised that the Veteran's current treatment records establish a diagnosis of "secondary" polycythemia vera, as well as a current diagnosis of sleep apnea. The examiner is further advised that a May 2021 VA opinion already established that sleep apnea can cause secondary polycythemia. The examiner must provide a rationale to support the opinion. If an opinion cannot be provided without resort to speculation, the examiner should explain whether the inability to provide the opinion is due to the limits of medical knowledge generally, inadequate information or evidence, a lack of expertise from the examiner, or another reason. 2. Then, review all examination reports and medical opinions provided to ensure that the requested information was provided. If any report or opinion is deficient in any manner, the AOJ must implement corrective procedures. 3. Then, readjudicate the claim. If the decision is adverse to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then, return the case to the Board. T. Blake Carter Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Patel, Shamil 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.