ÿþCitation Nr: 18107082

Decision Date: 06/01/18	Archive Date: 06/01/18



DOCKET NO. 15-11 805

DATE:	June 1, 2018

REMANDED ISSUES

1.   Entitlement to service connection for a low back condition is remanded.

2.   Entitlement to service connection for a pulmonary condition is remanded.

3.   Entitlement to service connection for a heart condition, to include pericarditis and chest pains, is remanded.

4.   Entitlement to service connection for a liver condition, to include hepatitis, is remanded.

5.   Entitlement to service connection for headaches is remanded.

6.   Entitlement to service connection for a dental condition, to include discolored teeth, as secondary to a liver condition is remanded.



REASONS FOR REMAND

The Veteran had active service from June 25, 1959 to March 28, 1961 and from October 26, 1961 to August 1, 1962.  He also served multiple periods of ACDUTRA, to include from March 11, 1973 to March 24, 1973.

This matter comes before the Board of Veterans Appeals (Board) on appeal from a July 2014 rating decision by the Department of Veterans  Affairs (VA) Regional Office (RO).

In an April 7, 2015 Substantive Appeal (VA Form 9), the Veteran requested a hearing before a Member of the Board in connection with his claim.  The Board remanded the claim March 2016 for a hearing.  In November 2016, the Veteran s representative submitted a statement that the Veteran s hearing request be withdrawn in this matter and requested a final determination as soon as possible.  There are no other hearing requests of record.  Accordingly, the Veteran s hearing request is deemed withdrawn.  See 38 C F R § 20.704(e).

The Board sincerely regrets the delay, but these claims must again be remanded for further development, as specified below.  Such development is necessary to aid the Board in making an informed decision, and will help ensure that the claims are afforded every consideration.

Heart, Liver and Dental Disorders

The Veteran asserts that he has heart and liver disorders that began after a severe influenza-type illness that he incurred during his period of ACDUTRA from March 11, 1973 to March 24, 1973.  He stated that at the end of his ACDUTRA period in Mayport, Florida, he began feeling ill.  He stated that he returned home on March 24 and his symptoms progressively increased until he went to the emergency room on April 1, 1973.  

At the time the Veteran was hospitalized at Sturdy Memorial on April 1, 1973, he stated that he had a febrile illness for the past three days.  The final diagnosis was a viral illness with pleural pericarditis and hepatitis.  

During the Veteran s hospitalization in April 1973, several EKGs were conducted.  Abnormal findings included sinus tachycardia and diffuse ST segment and T wave abnormalities consistent with pericarditis.

Thereafter, an August 1974 Report of Medical History (contained in the Veteran s service treatment records) noted the Veteran s history of hepatitis and jaundice with pericarditis in April 1973, with total recovery documented by blood work and electrocardiogram (EKG).  EKGs dated in 1980 and August 1982 showed nonspecific ST-T changes.  An EKG dated in July 1985 showed nonspecific ST-T changes and right ventricular conduction delay.  More recently, a May 2014 EKG showed sinus bradycardia with 1st degree AV block, possible left atrial enlargement, nonspecific T wave abnormality, and prolonged QT.

In September 2014, M. Justin Loew, M.D. stated that the Veteran suffers from chronic headaches, generalized intermittent chest pain and dyspnea.  He noted that the Veteran had a remote history of a severe viral infection complicated by pericarditis in 1973 that he may have contracted while on active military duty.  He stated that he had reviewed the Veteran s records and it was his opinion that the Veteran s current and ongoing symptoms may be related to this remote illness.

The Veteran reported on one of his annual service examinations that he was followed by a private physician for his pericarditis by annual examination and EKG.  See September 1980 Report of Medical History.  At a June 2014 VA examination, he reported having multiple negative stress tests over the years.   See Heart Condition DBQ.  These records should be obtained on remand.

Given the speculative wording of Dr. Loew s opinion, the Veteran should also be scheduled for appropriate VA examinations to determine the likelihood that his viral illness was incurred during his period of ACDUTRA from March 11, 1973 to March 24, 1973, and whether he has any current heart and/or liver disorders as a result of this illness.  

The claim for service connection for a dental disorder is deferred, as the Veteran claims that it is secondary to his liver disorder.  See 38 C.F.R. § 3.310; Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered).

Headaches

The Veteran asserts that he developed a headache disorder as a result of his viral illness in April 1973.  

At the time the Veteran was hospitalized in April 1973, as noted in his past history, he gave a history of frequent headaches that occurred late at the end of the day, relieved by Aspirin, not severe.  

The Veteran s service treatment records contain Annual Reports of Medical History showing that he denied experiencing headaches in August 1974, September 1975, October 1976, August 1978, September 1979, September 1980, September 1981, August 1982, September 1983, October 1984, July 1985, September 1986, September 1987 and August 1988.  Clinical evaluation at the time of all of these annual examinations contained no findings of a headache disorder.

The Veteran underwent an MRI and CT of his head in January 1996 due to complaints of headaches.  The CT showed a small area of decreased attenuation in the right parieto-occipital region.  The findings on MRI were highly suggestive of the presence of MS.

As noted above, in September 2014 M. Justin Loew, M.D. stated that the Veteran s current and ongoing symptoms, which included chronic headaches, may be related to his viral illness in 1973.

In February 2016, Megan Callahan, M.D. stated that she had ordered the MRI of the Veteran s head in 1996, although her consultation notes were no longer available.  She stated that it was her impression that the findings related to a remote viral infection causing acute disseminated encephalomyelitis (ADEM). She noted that the Veteran had suffered from a severe systemic viral infection in 1973, shortly after returning from 2 weeks of active duty military service in Florida.  She stated that the illness included fever, hepatitis, pericarditis and headache.  She noted that the Veteran made a gradual recovery from that illness but continued with intermittent headaches and other complaints.  She stated that,  Residual neurological problems can be a long-term sequelae of ADEM. . . It is my opinion that his ongoing headaches may be a result of this remote viral illness.   

In October 2017, Edward Zech. M.D. noted that the Veteran was admitted to the hospital within a very few days after a period of ACDUTRA in Florida in April 1973.  He stated that even though the record reflects that the Veteran was well when he left Florida, the incubation time for almost any virus is such that he believed that the Veteran was becoming ill before he left for home. He stated that the record reflects that the Veteran had been ill for several days before he was admitted.  Dr. Zech reviewed the Veteran s treatment records from 1973 and the February 2016 opinion from Dr. Callahan.  He stated that he found the Veteran s headaches compellingly linked to his acute illness in 1973 and that it was at least as likely as not that his headaches were related to his time in service.

As Dr. Loew s opinion is speculative, and as Drs. Callahan and Zech did not acknowledge the Veteran s history of frequent headaches reported upon his hospitalization in 1973 or his subsequent denial of experiencing headaches on annual examinations from 1974 to 1988, the Veteran should be scheduled for an appropriate VA examination to determine the etiology of any current headache disorder.

Pulmonary Disorder

The Veteran asserts that he has a current pulmonary disorder as a result of his in-service duties as a welder and firefighter.  More specifically, he stated that while fighting a fire in August 1960 some oil rags caught fire and filled the compartment with smoke, leaving him with a chronic cough.  He also asserts that his pulmonary problems worsened after his viral illness in April 1973.  

The Veteran s service treatment records from his first period of active duty from June 1959 to March 1961 are negative for any complaints or findings pertaining to a pulmonary disorder.  A December 1960 chest x-ray was normal.  The March 1961 separation shows that clinical evaluation of his lungs and chest was normal.  A March 1961 chest x-ray was also normal. 

On entrance examination for his second period of active in September 1961, the Veteran complained of chronic or frequent colds and a chronic cough.  The examiner noted that the Veteran had a cold three to four times a year, with no disability, and a cough with smoking.  No pulmonary disorder was noted.  During his period of active duty, the Veteran was treated for a cough and cold in January 1962, for a head cold in February 1962, and for a cold on June 5 and 12, 1962.  On separation examination in July 1962, clinical evaluation of his lungs and chest was normal.  A July 1962 chest x-ray was also normal. 

Thereafter, Annual Reports of Medical History show that the Veteran reported a chronic cough in June 1964 and June 1965 and chronic or frequent colds in August 1963 and August 1965.  December 1964 and August 1965 chests x-ray were normal.  Subsequently, the Veteran denied experiencing any pulmonary problems in July 1967, August 1968, November 1969, August 1974, September 1975, October 1976, August 1978, September 1979, September 1980, September 1981, August 1982, September 1983, October 1984, July 1985, September 1986, September 1987 and August 1988.  Clinical evaluation of his lungs and chest was normal on all annual examinations from 1964 to 1988.  Chest x-rays dated in March 1969, November 1976 and January 1984 were normal.  

During the Veteran s hospitalization at Sturdy Memorial in April 1973, he developed pleural effusions, which resolved.

As noted above, in September 2014 M. Justin Loew, M.D. stated that the Veteran s current and ongoing symptoms, which included dyspnea, may be related to his viral illness in 1973.

Given the speculative wording of Dr. Loew s opinion, the Veteran should be scheduled for an appropriate VA examination to determine the etiology of any current pulmonary disorder.

Low Back Disorder

The Veteran asserts that he has a low back disorder from lifting heavy loads during service.  See VA Form 21-526b, dated January 15, 2013.  He reported that he injured his back in 1961 while unloading naval gun shells onto a barge.  

The Veteran s service treatment records show that during active service from June 1959 to March 1961 and from October 1961 to August 1962, there were no complaints or findings pertaining to his lumbar spine.  Both the March 1961 and July 1962 separation examinations reveal that clinical evaluation of his spine was normal.  Thereafter, Annual Reports of Medical History dated in July 1967, August 1968, and November 1969 show that the Veteran denied experiencing back pain.

At the time the Veteran was hospitalized for a viral illness in April 1973, he stated that he had been seen by Dr. Rodgers about one year ago and was told that he had a degenerated disc.

Subsequently, Annual Reports of Medical History show that the Veteran did report experiencing recurrent back pain in August 1974, September 1975, October 1976, August 1978, September 1979, September 1980, September 1981, August 1982, September 1983, October 1984, July 1985, September 1986, September 1987 and August 1988.  In September 1979, it was described as occasional back pain in the morning.  In October 1984, there was mild back pain with heavy effort.  In July 1985, it was noted that he had a history of L5 disc disease.  

On remand, the Veteran s complete treatment records from Dr. Rodgers should be obtained.  He should also be scheduled for an appropriate VA examination to determine the etiology of his current low back disorder.

Finally, with respect to all of the Veteran s claims, he has reported being treated at the Providence VA Medical Center.  See VA Form 21-526b, dated January 15, 2013.  His VA treatment records must be obtained.

The matters are REMANDED for the following action:

1. Make arrangements to obtain the Veteran s complete treatment records from the Providence VA Medical Center.

2. Ask the Veteran to identify the private medical care providers that followed him for pericarditis by annual examinations and EKGs after his illness in April 1973 and that conducted his stress tests over the years.  Then, make arrangements to obtain all records that he adequately identifies.  

3. Make arrangements to obtain the Veteran s complete treatment records from Medical Associates of Attleboro on Hayward Street, dated from 1970 forward; from Dr. Rodgers, dated from 1970 forward; and from M. Justin Loew, M.D. of Attleboro Medical Associates on Sturdy Street, dated from 2004 forward.

4. After the above records have been obtained, schedule the Veteran for appropriate VA examinations to obtain the following medical opinions. The Veteran s electronic file must be made available to the examiners for review.  All indicated tests and studies are to be performed.  A complete rationale should be provided for all opinions given.

Viral/Infectious Diseases

Is it at least as likely as not (50% or greater probability) that the Veteran was exposed a virus during his period of ACDUTRA from March 11, 1973 to March 24, 1973, that subsequently resulted in his viral illness with pleural pericarditis and hepatitis treated in April 1973?  

In providing this opinion, the examiner must consider the Veteran s statement that at the end of his ACDUTRA period in Mayport, Florida, he began feeling ill.  He stated that he returned home on March 24 and his symptoms progressively increased until he went to the emergency room on April 1, 1973.  Further, at the time the Veteran was hospitalized at Sturdy Memorial on April 1, 1973, he stated that he had a febrile illness for the past three days.  

The examiner should also consider the October 2017 letter from Edward Zech. M.D.  stating that the incubation time for almost any virus is such that he believed that the Veteran was becoming ill before he left for home on March 24, 1973. 

Heart Disorder

(a) The examiner should identify all current heart disorders found to be present.  In so doing, the examiner should acknowledge the May 2014 EKG that showed sinus bradycardia with 1st degree AV block, possible left atrial enlargement, nonspecific T wave abnormality, and prolonged QT.  

(b) Is it at least as likely as not (50% or greater probability) that any current heart disorder is related to the Veteran s viral illness with pleural pericarditis and hepatitis treated in April 1973?  

In providing this opinion, the examiner must consider the EKGs dated in 1980 and August 1982 showing nonspecific ST-T changes, the EKG dated in July 1985 showing nonspecific ST-T changes and right ventricular conduction delay, and well as any additional treatment records (to include any additional EKGs and stress tests) obtained as a result of this remand.  

Liver Disorder

(a)  The examiner should identify all current liver disorders found to be present.  

(b) Is it at least as likely as not (50% or greater probability) that any current liver disorder is related to the Veteran s viral illness with pleural pericarditis and hepatitis treated in April 1973?  

Pulmonary Disorder

(a) The examiner should identify all current pulmonary disorders found to be present. 

(b)  Is it at least as likely as not (50% or greater probability) that any current pulmonary disorder is related to the Veteran s viral illness with pleural pericarditis and hepatitis treated in April 1973?   

In providing this opinion, the examiner must consider that during the Veteran s hospitalization in April 1973 he developed pleural effusions.  

(c)  Is it at least as likely as not (50% or greater probability) that any current pulmonary disorder is related to any incident of service, to include environmental exposures (i.e., smoke, welding fumes, etc.) associated with the Veteran s in-service duties as a welder and firefighter?

In providing this opinion, the examiner must consider the Veteran s statement that while fighting a fire in August 1960 some oil rags caught fire and filled the compartment with smoke, leaving him with a chronic cough; negative chest x-rays dated in December 1960 and March 1961; service treatment records showing that the Veteran was treated for a cough and cold in January 1962, for a head cold in February 1962, and for a cold on June 5 and 12, 1962; and negative chest x-rays in March 1969, November 1976 and January 1984.  

Headache Disorder

(a) The examiner should identify all current headache disorders found to be present. 

(b) Is it at least as likely as not (50% or greater probability) that any current headache disorder is related to the Veteran s viral illness with pleural pericarditis and hepatitis treated in April 1973?   

In providing this opinion, the examiner must consider the following:

" 	At the time the Veteran was hospitalized in April 1, 1973, as noted in his past history, he gave a history of frequent headaches that occurred late at the end of the day, not severe;  

" 	On Annual Reports of Medical History dated from 1974 to 1988, the Veteran denied experiencing headaches;

" 	The MRI and CT of the head conducted in January 1996 due to the Veteran s complaints of headaches.  The CT showed a small area of decreased attenuation in the right parieto-occipital region.  The findings on MRI were highly suggestive of the presence of MS;

" 	The February 2016 letter from Megan Callahan, M.D. stating that the January 1996 MRI findings related to a remote viral infection causing acute disseminated encephalomyelitis (ADEM), that residual neurological problems can be a long-term sequelae of ADEM, and that the Veteran s ongoing headaches may be a result of viral illness; and  

" 	The October 2017 letter from Edward Zech. M.D. stating that he found the Veteran s headaches compellingly linked to his acute illness in 1973 and that it was at least as likely as not that his headaches were related to his time in service.

Low Back Disorder

(a)  The examiner should identify all current low back disorders found to be present. 

(b) Is it at least as likely as not (50% or greater probability) that any current low back disorder is related to any incident of service, to include the Veteran s in-service duties which required lifting heavy loads?

In providing this opinion, the examiner must consider the following:

" 	The Veteran s statement that he injured his back in 1961 while unloading naval gun shells onto a barge;   

" 	The Veteran s service treatment records dated from 1961 to 1969 showing no complaints or finding of a low back disorder;

" 	During hospitalization in April 1973, the Veteran stated that he had been diagnosed as having a degenerated disc about one year ago; and

(Continued on the next page)

 

" 	The Veteran reported experiencing recurrent back pain on Annual Reports of Medical History from 1974 to 1988.  In September 1979, it was described as occasional back pain in the morning.  In October 1984, there was mild back pain with heavy effort.  In July 1985, it was noted that he had a history of L5 disc disease.





 

P.M. DILORENZO

Veterans Law Judge

Board of Veterans  Appeals

ATTORNEY FOR THE BOARD	C. Edwards, Associate Counsel




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