IRON DEFICIENCY ANEMIA

WILLIAM H. DONNELLY · 2026 · Case ID: 26003708

MIXED

Summary

The Veteran, a U.S. Navy and Army Reserve member who served from March 1978 to September 1983, July 2005 to July 2008, and September 2010 to January 2012, appeals the denial of service connection for anemia, splenomegaly, and myelofibrosis. The Board granted service connection for anemia, finding that while it pre-existed service, the evidence showed an increase in disability during service that was not rebutted by the presumption of aggravation. For splenomegaly, the Board denied service connection, finding it pre-existed service and was not aggravated during service, with the weight of evidence against the claim. Myelofibrosis was also denied, as the Board found it pre-existed service and was not incurred or aggravated during service, despite the Veteran's claims of in-service vaccinations causing the condition. The Board noted that while the Veteran had toxic exposures from his service in Kuwait, Qatar, and Afghanistan, affirmative evidence showed his myelofibrosis pre-existed these exposures. The Board also addressed procedural issues regarding the appeal system and previous remands, ultimately finding the Veteran's claims for splenomegaly and myelofibrosis not service-connected.

Rationale

Anemia pre-existed service; Increase in anemia during service; Increase not due to natural progression

Service Branch

NAVY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

16-35 282A

Full Decision Text

Citation Nr: 26003708
Decision Date: 03/23/26 Archive Date: 03/23/26

DOCKET NO. 16-35 282A
DATE: March 23, 2026

ORDER

Service connection for anemia is granted.

Service connection for splenomegaly is denied.

Service connection for myelofibrosis is denied.

FINDINGS OF FACT

1. Anemia, splenomegaly and myelofibrosis did not have their onset and are not otherwise related to the Veteran's first period of active duty service. These diseases pre-existed his second period of service.

2. Anemia increased in severity during a period of active duty service, and this increase was not due to the natural progression of his disease.

3. Splenomegaly did not increase in severity during a period of active duty service.

4. Myelofibrosis did not increase in severity during a period of active duty service.

CONCLUSIONS OF LAW

1. The criteria for service connection anemia are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306.

2. The criteria for service connection for splenomegaly are not met. 38 U.S.C. §§ 1110, 1131, 1168, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306.

3. The criteria for service connection for myelofibrosis are not met. 38 U.S.C. §§ 1110, 1131, 1168, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran was a member of the Reserves who served on active duty in the U.S. Navy from March 1978 to September 1983 and in the U.S. Army from July 2005 to July 2008 and September 2010 to January 2012.

This matter is before the Board of Veterans' Appeals (Board) on appeal from a July 2013 rating decision issued by an agency of original jurisdiction (AOJ) of the Department of Veterans Affairs (VA).

This appeal has been remanded three times previously, most recently in December 2023, for additional development to obtain updated VA treatment records and nexus opinions. The case now returns to the Board after substantial compliance with the ordered development. Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008).

In April 2025, after this appeal had been docketed at the Board in the Legacy appeal system, the Board advised the Veteran that in order to continue to pursue this appeal, he was required to file a VA Form 10182 Notice of Disagreement (NOD), a form required in the modernized appeal system. This was incorrect. The Veteran did so and responded to subsequent communications from the Board regarding this VA Form 10182. However, no appeal of these issues has been docketed in the modernized appeal system. The Board respects and effectuates the choices of veterans, including the decision to opt their Legacy appeal into the modernized appeal system. In this case, however, the record shows that the Veteran only submitted the VA Form 10182 because the Board wrongly told him this was required to continue to pursue his appeal. In light of the particular circumstances of this case, including the pendency of this appeal for over a decade, the Board finds the Veteran did not intend to opt this appeal into the modernized system. Adjudication in the Legacy system would not be prejudicial to the Veteran, as it allows for consideration of an expanded evidentiary window and prevents further delay.

As explained in the December 2023 Board order, the claims for service connection of anemia and splenomegaly have been recharacterized to include a claim for service connection of myelofibrosis. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009).

Despite efforts to obtain complete service treatment records (STRs), some of these records are unavailable. In such cases the Board has a heightened obligation to explain its findings and conclusions and to carefully consider the benefit-of-the-doubt rule where applicable. See O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). This does not, however, lower the legal standard for proving a claim for service connection but rather increases the Board's obligation to evaluate and discuss in its decision all the evidence that may be favorable to the claimant. See Russo v. Brown, 9 Vet. App. 46 (1996).

VA has met all statutory and regulatory notice and duty-to-assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. Neither the Veteran nor his representative has advanced any procedural arguments in relation to VA's duty to notify and assist. Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015).

In December 2023, the Board remanded service connection for disabilities of the right and left foot. At a subsequent VA examination, the Veteran was diagnosed with a variety of foot disabilities, including metatarsalgia and arthritis. Service connection for other disabilities has been granted, and they are rated under the Diagnostic Codes applicable to metatarsalgia and arthritis, and service connection for such has been effectively granted. Therefore, as the benefit sought has been granted, these issues are no longer before the Board. AB v. Brown, 6 Vet. App. 35 (1993). The specific rating for these conditions is a downstream issue and would require the Veteran to file the appropriate claim or notice of disagreement with the AOJ.

Service Connection

Service connection will be granted if it is shown that the Veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C. §§ 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994).

When no preexisting medical condition is noted on examination for into service, a veteran is presumed to have been sound in every respect. 38 U.S.C. § 1132; 38 C.F.R. § 3.304 (b); Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). However, when a veteran is not examined prior to entry into service, the presumption of soundness does not apply. Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). Here, the evidence does not show that the Veteran was examined prior to his second or third periods of active service. Such is consistent with the circumstances of his service as an activated Reserve member. Therefore, the presumption of soundness does not apply to the Veteran's second or third periods of service.

Where an injury or disease pre-existed service and there is an increase in the disability during service, the injury or disease will be presumed to have been aggravated by service 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; 38 C.F.R. § 3.306(a).

Toxic exposures, including exposure to fine particulate matter, is presumed for veterans who served in the Southwest Asia theater of operations after August 2, 1990. 38 C.F.R. § 3.320. Kuwait, Qatar, and Afghanistan (after September 19, 2001) are among those locations. As the Veteran served on active duty in Kuwait and
there is an increase in the disability during service, the injury or disease will be presumed to have been aggravated by service 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; 38 C.F.R. § 3.306(a).

Toxic exposures, including exposure to fine particulate matter, is presumed for veterans who served in the Southwest Asia theater of operations after August 2, 1990. 38 C.F.R. § 3.320. Kuwait, Qatar, and Afghanistan (after September 19, 2001) are among those locations. As the Veteran served on active duty in Kuwait and Qatar after August 2, 1990, and Afghanistan after September 19, 2011, he is presumed to have toxic exposures, including exposure to fine particulate matter. For veterans with these toxic exposures, including exposure to fine particulate matter, service connection may be presumed for certain diseases, including myelofibrosis, unless there is affirmative evidence that the disease was not incurred or aggravated during active military service. 38 C.F.R. § 3.320b.

In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in approximate balance, with the Veteran prevailing in either event, or whether the weight of the evidence is persuasively against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

STRs show that at his entrance examination in December 1977, the Veteran described his health as good and physical findings were normal, except for a left shoulder scar. No separation examination for the Veteran's naval service is associated with the claims file. Between 1985 and 1988, the Veteran was a member of the U.S. Naval Reserve, and physical examinations conducted during this time were normal except for scars, and in October 1987 a healing tooth socket. The Veteran subjectively described his health as good, excellent, or great at these examinations.

The Veteran's second term of active service, with the Army, began in July 2005. There is no record of examination of the Veteran on entrance in July 2005, and so the presumption of soundness does not apply.

Treatment records from July 2005 document that the Veteran sought emergency treatment with symptoms of joint swelling, severe fatigue and an inability to run after receiving several vaccinations. Testing showed that the Veteran's hematocrit was 22 percent, and he was severely anemic. Providers reviewed records from a civilian provider that indicated the Veteran's hematocrit had gradually decreased from 38 percent in 1997 to 32 percent in February 2005, and a computerized tomography (CT) scan in 2000 showed splenomegaly. Providers diagnosed the Veteran with severe chronic anemia. The Veteran was prescribed iron supplements. The Veteran told providers that he had been previously treated for anemia since a least 1998, and had managed it by taking iron, but had discontinued his iron supplements around March 2004 on the advice of a doctor. He reported that he had passed a physical training (PT) test in March 2005 despite not being able to train for the test. The Veteran mentioned that at the March 2005 PT test, he had been on the low end of the weight requirements. Since March 2005, he had been running two to three miles several times a week. An August 2005 lymph node biopsy to assess spleen enlargement showed benign reactive lymphoid hyperplasia. By September 2005 the Veteran's hematocrit was 25.9 percent. A note from October 2005 stated that the Veteran's spleen had been measured to the brim of his pelvis in the past and was currently measured at 20 centimeters. The splenomegaly was significantly asymptomatic, apart from low appetite and early satiety. His splenomegaly was characterized as chronic. The Veteran was ultimately deployed to Kuwait.

VA treatment records from 2009 to 2010 show that the Veteran's anemia was characterized as asymptomatic and a May 2009 CT scan showed his spleen had not changed size since 2007.

At retirement in September 2011, the medical officer noted that the Veteran had a history of anemia secondary to splenomegaly and was instructed to follow
the Veteran's spleen had been measured to the brim of his pelvis in the past and was currently measured at 20 centimeters. The splenomegaly was significantly asymptomatic, apart from low appetite and early satiety. His splenomegaly was characterized as chronic. The Veteran was ultimately deployed to Kuwait.

VA treatment records from 2009 to 2010 show that the Veteran's anemia was characterized as asymptomatic and a May 2009 CT scan showed his spleen had not changed size since 2007.

At retirement in September 2011, the medical officer noted that the Veteran had a history of anemia secondary to splenomegaly and was instructed to follow up with hematology and oncology as needed. An October 2011 physical examination did not evaluate the Veteran's hematic system.

At the October 2012 VA examination, diagnoses of anemia, neutropenia and splenomegaly were noted. The VA examiner, a medical doctor, noted 1995 dates of diagnoses for anemia and splenomegaly, but did not record a diagnosis date for neutropenia. The Veteran said that a doctor found anemia in 1995 and told him he probably had an enlarged spleen. He was diagnosed with severe anemia and splenomegaly was detected in July 2005 after he received vaccinations. The Veteran reported that his splenomegaly and anemia have stayed stable over the years.

Subsequent VA treatment records show that the Veteran was diagnosed with myelofibrosis after a March 2014 bone marrow biopsy. At an April 2014 oncology appointment, the Veteran said that he felt good with no fevers or night sweats and attributed his somewhat low energy level to a new job. The oncologist and nurse practitioner characterized the Veteran's condition as myelofibrosis with symptomatic splenology. His hematocrit was 31 percent. The Veteran started medication for myelofibrosis. By August 2014 the Veteran discontinued the medication due to worsening splenomegaly and the Veteran's impression that he was not benefiting from it. In September 2014, the Veteran said that he was feeling up to par, as he did prior to starting the drug therapy. His hematocrit was 31 percent. The oncologist noted that the Veteran was not interested in a stem cell transplant, and that the Veteran may have had low grade myelofibrosis that over time had become more prominent. In November 2014, the Veteran required inpatient admission for a gastrointestinal bleed that resulted in significant blood loss and transfusion. By January 2015, the Veteran had declined further bone marrow biopsies or drug therapy, and his oncologist noted that his disease was progressing.

The Veteran sought a second opinion from a private oncologist in March 2015. He wrote that the Veteran was found to have anemia and splenomegaly in 1998, and the Veteran reported that his anemia had been relatively stable since 1998, with a few exacerbating episodes, including one during service. The private oncologist noted that the Veteran's anemia was improving without transfusion requirements and recommended continued observation as he was currently asymptomatic and his blood counts were recovering. In November 2015, Dr. MP, the Veteran's private oncologist, wrote that it was not implausible that the Veteran's in-service "severe exacerbation" of his anemia was an unanticipated side effect of his vaccinations, as vaccinations are poorly studied in patients with myelofibrosis. At a follow-up appointment in July 2016, the private oncologist noted that the Veteran had no signs or symptoms suggestive of disease progression and recommended ongoing monitoring. The Veteran continued to be monitored by the private oncologist through March 2018, when his oncologist wrote that the Veteran had been "incredibly stable" over the past few years with no evidence of progression or significant changes in his splenomegaly, and recommended that the Veteran have annual testing to monitor his condition.

At the March 2019 VA examination, the Veteran told the VA examiner, a nurse practitioner, that he had been diagnosed with anemia and an enlarged spleen in 1993, and subsequently diagnosed with myelofibrosis in 2014. The Veteran said that he had not had symptoms of these diseases in the past, apart from rare episodes of fatigue. He continued to be followed by hematology and actively participated in physical activity. The examiner concluded that the Veteran's splenomegaly and anemia were less likely than not related to his active duty service based on the Veteran's statement that he was diagnosed in
enomegaly, and recommended that the Veteran have annual testing to monitor his condition.

At the March 2019 VA examination, the Veteran told the VA examiner, a nurse practitioner, that he had been diagnosed with anemia and an enlarged spleen in 1993, and subsequently diagnosed with myelofibrosis in 2014. The Veteran said that he had not had symptoms of these diseases in the past, apart from rare episodes of fatigue. He continued to be followed by hematology and actively participated in physical activity. The examiner concluded that the Veteran's splenomegaly and anemia were less likely than not related to his active duty service based on the Veteran's statement that he was diagnosed in 1993, which was not during a period of active service, and the service treatment record did not document a new diagnosis of splenomegaly or anemia during active service.

Subsequent VA records show that providers consistently characterized the Veteran's myelofibrosis as stable, and the Veteran denied symptoms such as fatigue. He reported playing competitive baseball, running regularly, and golfing.

In an October 2021 addendum opinion, the VA examiner, a physician's assistant, rendered negative nexus opinions as direct service connection and aggravation of a pre-existing condition for anemia and splenomegaly. As explained by the Board in its December 2023 order, these opinions lacked an adequate rationale.

In September 2023, his primary care physician noted that the Veteran had had no oncology follow up in three years, and his labs have shown no progression, and his hemoglobin was actually trending up. The plan was to continue surveillance with his primary care provider.

In February 2024, the VA examiner, a nurse practitioner, rendered a number of nexus opinions. He concluded, in pertinent part, that it was less likely than not that the Veteran's myelofibrosis was incurred in or caused by service because the Veteran was not diagnosed until after service, and that the Veteran's splenomegaly did not cause the Veteran's myelofibrosis during service. In addition, he rendered a negative opinion on aggravation of a pre-existing condition, explaining that since the Veteran's myelofibrosis was not diagnosed until after service, it did not clearly and unmistakably pre-exist his service. The VA examiner wrote that there was no clear evidence that myelofibrosis was caused by anemia, splenomegaly, anemia or vaccinations. In support of his conclusion, he listed information from the Mayo Clinic's website about the causes, symptoms and risk factors for myelofibrosis, anemia and splenomegaly, and the side effects of the Hepatitis B, typhoid and anthrax vaccines. The Board finds these opinions conclusory, generalized, internally inconsistent, and inadequate. Nieves Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007).

The February 2024 VA examiner concluded that the Veteran's splenomegaly clearly and unmistakably existed prior to service and was clearly and unmistakably not aggravated beyond its natural progression by service. In his rationale, he said that while the Veteran's splenomegaly clearly and unmistakably pre-existed the Veteran's second period of service, it was at least as likely as not aggravated by subsequent periods of service and that a nexus had been established. He did not explain his conclusions further. A clarification of this opinion was sought, and in September 2024, the VA examiner provided the same rationale. In October 2024, in response to another clarification request, the examiner wrote that the Veteran's splenomegaly condition clearly and unmistakably pre-existed service and was less likely as not aggravated by subsequent service periods, explaining that the Veteran's claims file lacked objective evidence of splenomegaly aggravation during service. The examiner did not explain or account for his February and September 2024 opinions that reached the opposite conclusion, and the Board therefore finds these three opinions inadequate as they lack an adequate rationale. Nieves Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008).

In December 2024, another VA examiner, a physician's assistant, provided multiple negative nexus opinions. He concluded it was less likely than not that the Veteran's myelofibrosis was incurred in or caused by service. He based this on the lack of complaints, diagnosis or treatment related to myelofibrosis or its early manifestations in the STRs. He further explained that it was at least as likely as not that the Veteran's splenomegaly was a manifestation of myelofibrosis as anemia and splenomegaly are recognized clinical features of myelofibrosis, but their appearance years after the Veteran's first period of service and the long gap between the anemia and splenomegaly diagnosis and 2014 myelofibrosis diagnosis diminished the likelihood of a direct service connection. Elsewhere in the document, he concluded that myelofibrosis did not clearly and unmistakably pre-exist the Veteran's military service, based on the absence of medical records between 1983 and 2005.

With regard to splenomegaly, the VA examiner concluded that it was less likely than not directly related to service as it clearly and unmistakably pre-existed the Veteran's second period of active service. He also concluded that this pre-existing condition was clearly and unmistakably not aggravated beyond its natural progression by service. He explained that the medical records did not show aggravation of splenomegaly during either the Veteran's second or third periods of service, and while the Veteran's reported reaction to the 2005 vaccines was noted, there was no evidence, medical or otherwise, of a causal relationship between vaccines and the progression of splenomegaly or pre-existing myeloproliferative conditions.

In a May 2025 written statement, the Veteran stated that he had pre-existing anemia and splenomegaly.

Anemia

The Board finds that the persuasive weight of the evidence shows that the Veteran's anemia pre-existed his second period of active service. The Veteran himself has consistently reported that he was first diagnosed and treated for anemia in the 1990s. STRs from August 2005 document his military treatment providers' review of these civilian treatment records which are not associated with the file, showing that the Veteran had been treated for anemia since 1997. This evidence is uncontradicted - the Veteran has not claimed that his anemia began during his first period of active service between 1978 and 1983.

STRs show medical evidence an increase of the Veteran's anemia during service. In July 2005 during service, the Veteran sought emergency treatment for symptoms of severe fatigue and inability to run that had begun a few days prior after he received several vaccinations. His hematocrit was measured at 22 percent, and he required iron supplements. These same records document that prior to July 2005, the Veteran's hematocrit had ranged from 38 percent in 1998 to 32 percent in February 2005.

The evidence of record does not contain a positive finding that the Veteran's increase in disability was due to the natural progression of the disease. While the claims file contains various opinions regarding the likelihood that the July 2005 anemic episode was related to his in-service vaccinations, the Board need not resolve this disagreement as these opinions are not pertinent to rebut the presumption of aggravation. Therefore, as the presumption of aggravation has not been rebutted, service connection is warranted.

Splenomegaly

The Veteran contends that he is entitled to service connection for splenomegaly. He has been diagnosed with splenomegaly, satisfying the requirement of a current disability.

The Board finds that the persuasive weight of the evidence establishes that the Veteran's splenomegaly pre-existed his second period of active service. The Veteran himself conceded this in his May 2025 statement. In addition, he has consistently and competently reported that his splenomegaly was first observed when he was diagnosed with anemia, and the August 2005 STRs document treatment providers review of a 2000 CT scan documenting splenomegaly. This evidence is uncontradicted - the Veteran does not claim that his splenomegaly is related to his first period of military service, nor does the evidence support such a conclusion.

STRs do not show evidence of an increase in the Veteran's splenomegaly during service. Military physicians characterized the Veteran's splenome
-existed his second period of active service. The Veteran himself conceded this in his May 2025 statement. In addition, he has consistently and competently reported that his splenomegaly was first observed when he was diagnosed with anemia, and the August 2005 STRs document treatment providers review of a 2000 CT scan documenting splenomegaly. This evidence is uncontradicted - the Veteran does not claim that his splenomegaly is related to his first period of military service, nor does the evidence support such a conclusion.

STRs do not show evidence of an increase in the Veteran's splenomegaly during service. Military physicians characterized the Veteran's splenomegaly as chronic and significantly asymptomatic and noted that it had decreased in size. While the Veteran reported low appetite and early satiety, the Veteran also said that he had been at the low end of the weight requirements shortly prior to his second period of service. STRs document no specific treatment for the Veteran's splenomegaly, and he did not complain of symptoms. A May 2009 CT scan showed that the Veteran's spleen size had remained the same since 2007. Similarly, there is no indication that the Veteran's splenomegaly worsened during his third period of service. In his retirement report of medical history, splenomegaly was noted and the Veteran was instructed to follow up with hematology and oncology. No current symptoms or concerns were documented, and the Veteran has repeatedly denied experiencing significant symptoms of splenomegaly. Therefore, the presumption of aggravation does not apply. 38 C.F.R. § 3.306

The Board acknowledges that complete STRs from the Veteran's second and third periods of service are not in the claims file. However, the Veteran has consistently, competently and credibly described his splenomegaly symptoms as stable, which is consistent with the other medical evidence of record, especially his private oncology records. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011).

The Board finds the December 2024 examination adequate. The opinion is well reasoned, detailed, and includes consideration of the Veteran's relevant medical history. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). While the examiner applied an incorrect legal standard of clear and unmistakable evidence that the Veteran's splenomegaly was not aggravated beyond its natural progression by service, this is a higher standard than required in this case, because there is no evidence of inservice increase in splenomegaly, and the presumption of aggravation, which requires clear and unmistakable evidence to rebut, has not attached. The application of this higher evidentiary standard necessarily satisfies the lesser standard of at least as likely as not. As explained by the examiner, the evidence of record does not show aggravation of the Veteran's pre-existing splenomegaly during his second or third periods of service. Accordingly, the Board gives this opinion some weight.

An opinion regarding the effects of the Veteran's in-service toxic exposures on his splenomegaly is not required in light of the finding that the Veteran's splenomegaly pre-existed his service, and therefore his in-service toxic exposures. 38 U.S.C. § 1168. The evidence does not show, and the Veteran does not contend that the Veteran's subsequent toxic exposures worsened this condition.

The persuasive weight of the evidence is that the Veteran's splenomegaly was not incurred in or otherwise related to the Veteran's first period of active duty service and pre-existed his second period of active duty service. The persuasive evidence, especially the Veteran's own statements describing the course of his splenomegaly, likewise does not show in-service increase of his pre-existing splenomegaly. Therefore, service connection of splenomegaly is not warranted. In reaching this conclusion, the Board has considered its heightened obligation to consider carefully the benefit of the doubt doctrine; the weight of the evidence is persuasively against the Veteran's claim, and the doctrine is not applicable. 38 U.S.C. § 5107(b); O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991).

Myelofibrosis

The Veteran contends that his myelofibrosis is the result of his July 2005 in-service vaccinations. He argues that during his second period of service, he underwent an intensive oncological work up
-existing splenomegaly. Therefore, service connection of splenomegaly is not warranted. In reaching this conclusion, the Board has considered its heightened obligation to consider carefully the benefit of the doubt doctrine; the weight of the evidence is persuasively against the Veteran's claim, and the doctrine is not applicable. 38 U.S.C. § 5107(b); O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991).

Myelofibrosis

The Veteran contends that his myelofibrosis is the result of his July 2005 in-service vaccinations. He argues that during his second period of service, he underwent an intensive oncological work up that confirmed splenomegaly but did not mention myelofibrosis. The Veteran was diagnosed with myelofibrosis in 2014, satisfying the requirement of a current disability.

The Veteran's statement that the July 2005 vaccinations caused his later-diagnosed myelofibrosis is not probative. The Veteran did not submit or identify any medical literature identify such a causal connection, and he is not competent to identify a causal connection, as he lacks the specialized medical training or knowledge to do so. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). It is true that the Veteran underwent testing in service to look for cancer. While that testing did not detect the Veteran's myelofibrosis, no bone marrow biopsy was performed. As it was ultimately the bone marrow biopsy that diagnosed the Veteran's myelofibrosis, and such was not done during service, the testing done during service did not rule out myelofibrosis at that time.

Rather, the persuasive weight of the competent and probative evidence shows that the Veteran's myelofibrosis pre-existed his second period of service. Medical professionals agree that anemia and splenomegaly are recognized clinical features of myelofibrosis. Specifically, the Veteran's private oncologist, Dr. MP, in his November 2015 letter, stated that vaccine effects are poorly studied in patients with myelofibrosis in his rationale regarding the July 2005 vaccines as the cause of the Veteran's in-service anemic exacerbation, implicitly acknowledging that the Veteran had myelofibrosis well in advance of his eventual diagnosis, and at the time of his July 2005 vaccinations. In April 2017, the Veteran's VA oncologist wrote that he suspected that the Veteran's myelofibrosis was long standing, based on his long history of anemia and splenomegaly. These conclusions are consistent with the other evidence of record, including the medical literature cited by VA examiners, that anemia and splenomegaly are recognized clinical features of myelofibrosis.

The December 2024 VA negative nexus opinions are not persuasive, and the Board does not rely on them. The evidence of record does not show that the Veteran was examined prior to his entry into active duty in 2005, therefore, there is no presumption that he was without disease or defect at entry into his second period of service, and clear and unmistakable evidence is not required to establish pre-existence, and the examiner's conclusion is not pertinent to the question before the Board. 38 C.F.R. § 3.304(b); Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). Moreover, his conclusion rested on the unavailability of medical records from 1983 to 2005. Some medical records from this time period are associated with the file, such as records from the Veteran's time with the U.S. Naval Reserves, and other records were viewed and summarized by the Veteran's treatment provides, including military providers in 2005, and his private oncologist. These records are sufficient to determine that the Veteran's myelofibrosis pre-existed his second period of service. In addition, the examiner's rationale does not account for his own statement that anemia and splenomegaly are recognized clinical features of myelofibrosis and that such pre-existed the Veteran's second period of service.

Notwithstanding the post-service formal diagnosis of myelofibrosis, the competent, probative, persuasive and uncontradicted evidence establishes that the Veteran's myelofibrosis pre-existed service.

The evidence of record does not show that the Veteran's pre-existing myelofibrosis increased during service. The only pre-existing disease that increased was the Veteran's anemia, which underwent a short but severe exacerbation in July 2005 and then recovered. The Veteran's splenomegaly did not increase during service. The evidence of record, including the STRs, the Veteran's statements to treatment providers both in service and after service, and the assessment of his private oncologist, establishes that the Veteran's in-service anemic exacerbation was temporary and not the result of an increase in his underlying myelofibrosis. The Veteran's private oncologist and VA primary care physician have repeatedly characterized the Veteran's myelofibrosis as clinically stable even without treatment for such. This finding is consistent with the Veteran's May 2025 statement in which he contended that he did not have myelofibrosis during service. While the Veteran lacks the specialized medical training or knowledge to make such a diagnosis, his statement indicates that he was not experiencing symptoms of myelofibrosis, a statement that he is competent to make. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Therefore, the Board finds the evidence establishes that there was no in-service increase in the Veteran's myelofibrosis, and the presumption of aggravation does not apply. 38 C.F.R. § 3.306.

The Veteran is not entitled to service connection for myelofibrosis on a presumptive basis. Although the Veteran is presumed to have certain toxic exposures from his service in Kuwait, Qatar, and Afghanistan and myelofibrosis is a listed condition that is presumptively caused by those exposures, there is affirmative evidence that the Veteran's myelofibrosis was not incurred or aggravated during his military service, namely that his myelofibrosis pre-existed these exposures, which occurred during his second period of service. 38 C.F.R. §§ 3.320, 3.320b. For the same reasons, an opinion regarding the effects of the Veteran's in-service toxic exposures on his myelofibrosis is not required. 38 U.S.C. § 1168. The evidence does not show, and the Veteran does not contend, that his subsequent toxic exposures worsened this condition.

The persuasive weight of the evidence is that the Veteran's myelofibrosis did not have its onset during the Veteran's first period of active duty service and pre-existed his second period of active duty service. The persuasive evidence, especially the Veteran's own statements and the STRs, likewise do not show in-service increase of his pre-existing myelofibrosis. Therefore, service connection of myelofibrosis is not warranted. In reaching this conclusion, the Board has considered its heightened obligation to consider carefully the benefit of the doubt doctrine; the weight of the evidence is persuasively against the Veteran's claim, and the doctrine is not applicable. 38 U.S.C. § 5107(b); O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991).

WILLIAM H. DONNELLY

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Viccellio, MB

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.

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