BVA9503209 DOCKET NO. 91-44 313 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUES 1. Entitlement to service connection for coccidioidomycosis. 2. Entitlement to an increased rating for varicose veins of the left leg, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Richard F. Williams, Counsel INTRODUCTION The veteran served on active duty from March 1957 to October 1977. This matter comes before the Board of Veterans' Appeals (Board) from decisions by the Department of Veterans Affairs (VA) St. Paul, Minnesota, Regional Office (RO). A June 1988 RO decision denied service connection for coccidioidomycosis. An RO decision in January 1989, in pertinent part, increased the rating for the veteran's varicose veins of the left leg from noncompensable to 10 percent. The veteran testified at a hearing conducted before a travel section of the Board in September 1991. The Board remanded the case to the RO in July 1992 and January 1994 for further development. The case was returned to the Board in November 1994. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that his coccidioidomycosis is the result of his active service. He notes that he engaged in military maneuvers in the desert while stationed in the southwestern United States, and he argues that he may have been infected with the fungus of coccidioidomycosis, even though the disease was first detected years after service. The veteran also contends that his service-connected varicose veins of the left leg are more disabling than currently evaluated. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims files. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the claim for service connection for coccidioidomycosis, and the evidence supports the claim for an increased rating to 20 percent for varicose veins of the left leg. FINDINGS OF FACT 1. Coccidioidomycosis was not present during service; it was first manifest many years after active duty and was not caused by any incident of service. 2. The veteran's service-connected varicose veins of the left leg are moderately severe. CONCLUSIONS OF LAW 1. Coccidioidomycosis was not incurred in or aggravated by active service, nor may it be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 1991); 38 C.F.R. §§ 3.303, 3.307, 3.309 (1993). 2. The criteria for a 20 percent rating for varicose veins of the left leg have been met. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.104, Code 7120. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background The 1957-1977 service medical records are negative for any finding attributed to coccidioidomycosis. The veteran was periodically treated throughout service for episodes of upper respiratory infections. The medical records from 1963 to 1965 indicate he was then stationed at Fort Irwin, California, although the records do not mention coccidioidomycosis exposure or symptoms. The veteran was treated for acute bronchitis in January and March 1970. At a general medical examination in October 1976, the veteran gave a history which included mild asthma with no medications; clinical examination of the lungs and a chest X-ray were normal. The veteran gave a similar history at his May 1977 retirement examination; the lungs again were clinically normal, as was a chest X-ray. Numerous other routine chest X-rays during service were normal. He was treated for varicose veins of the left leg while on active duty. He retired from service in October 1977. In November 1977 the veteran filed a claim for service connection for varicose veins and other conditions, but not for any lung condition. At a January 1978 VA compensation examination, the veteran had no respiratory complaints. The lungs were normal on clinical evaluation and X-ray. An RO decision in April 1978 granted service connection and assigned a noncompensable rating for postoperative varicose veins of the left leg. (The noncompensable rating remained in effect until the January 1989 RO decision on appeal, which assigned a 10 percent rating for the veteran's postoperative varicose veins of the left leg.) VA outpatient clinic records from June 1978 show the veteran was treated for a productive cough, questionable bronchitis. Medication was prescribed and, when seen for follow-up in two weeks, the chest was clear. Reports of VA general medical examinations and chest X-rays, performed in May 1981, February 1985, and April 1986, show normal lungs. On December 12, 1986, the veteran was treated at a VA outpatient clinic near his home in Minnesota, primarily for a right shoulder injury which he just sustained when falling down some stairs. He also noted that he had cold symptoms for a few days; a chest X- ray was normal, and the assessment was an upper respiratory infection. An outpatient clinic record dated December 22, 1986 (received by the RO in April 1994 pursuant to the Board's January 1994 remand), shows that the veteran was seen at the Phoenix, Arizona, VA Medical Center (VAMC) at that time (he was visiting the area) for a refill for medication for his hyperthyroidism. It was also reported that he had questionable laryngitis (he complained of hoarseness but the pharynx appeared normal) and was prescribed Ampicillin. When seen at a VA outpatient clinic on January 15, 1987, the veteran reported he had been sick for 4 or 5 days, with a sore throat, headaches, a cough, emesis, and fever as high as 103 degrees. He said he had self-treated the condition with Ampicillin and other medication. At an outpatient visit on February 6, 1987, the veteran said he had a tickle in his throat since December, worse in the past two weeks with coughing so bad that he had emesis. It was noted that a December 12, 1986, X-ray was normal and he was not coughing then. A current X-ray was ordered, which showed pneumonia, and the veteran was scheduled for hospital admission. The veteran was hospitalized at a VAMC in North Dakota from February 10 to 25, 1987, for treatment of left lower lobe pneumonia. He gave a history of having a cough with increasing sputum for the past month. It was noted that a February 6, 1987, outpatient chest X-ray showed a left basal infiltrate with a questionable mass, and this was compared to a chest X-ray performed on December 12, 1986, when the lung fields were both clear. At the time of hospital discharge in February 1987, the pneumonia was still clearing, and follow-up studies, including repeat chest X-rays, were planned. When seen as an outpatient in March 1987, the veteran still had symptoms from clearing pneumonia, with a left lung infiltrate shown on X-ray. Additional outpatient studies in April 1987, including chest X- rays and a CT scan, showed a persistent left lung infiltrate, and a diagnostic bronchoscopy was scheduled. The veteran was admitted to a VA hospital from April 30, 1987, to May 1, 1987, and underwent a bronchoscopy. History provided at that time included traveling to Texas in 1957, 1962, and 1964; being in Arizona in December 1986, and then receiving treatment at a VA hospital for a cough; and, since January 1987, feeling as if he had an upper respiratory infection, weakness and a small amount of hemoptysis. It was noted that he had undergone hospital and outpatient treatment and diagnostic studies since February 1987, relating to pneumonia and a left lung lesion, and that these included tests for a possible fungal infection, coccidioidomycosis. The final hospital diagnosis was a left lung infiltrate of unclear etiology. A May 1987 outpatient record notes that bronchoscopy results had been reviewed, and these showed no malignancy. It was noted that the left lung infiltrate was of unclear etiology and probably represented scar tissue; further chest X-rays were planned to monitor the condition. At a VA compensation examination later in May 1987, the veteran reported he developed a lung infection in January 1987, which just cleared up except for some scarring. A current chest X-ray showed a nodular density in the left chest, which the radiologist noted could be a neoplasm or fungus. The veteran was referred for further evaluation of the pulmonary nodule. VA treatment records from 1987 show the left lung mass was noted and evaluated on a number of occasions, including during multiple hospitalizations in late 1987 when diagnostic procedures, such as a bronchoscopy and needle biopsy, rendered inconclusive results. The veteran was subsequently hospitalized in January 1988 and underwent a left thoracotomy and left lower lobe lobectomy because of the lesion. A biopsy of the lesion showed granuloma consistent with coccidioidomycosis. The pertinent hospital discharge diagnosis in February 1988 was nodular pulmonary coccidioidomycosis. Numerous later medical records, dated into the 1990's, describe the postoperative lung condition, and the records note that the coccidioidomycosis lesion was completely removed by the surgery. VA outpatient clinic records show that the veteran was seen on several occasions in 1988 and 1989 for follow-up for varicose veins of the left leg. It was reported in May 1988 that he did well with support stockings, but tired after walking one block, with a numbing sensation, which was relieved with rest. Physical examination at that time revealed multiple bilateral varicosities, superficial in nature, in the posterior calves, with saphenous and lesser saphenous involvement. A 1.2 by 3.3 centimeter venous varicosity was specifically noted in the left popliteal fossa. The assessment was saphenous vein varicosities. Doppler studies in June 1988 showed incompetency of superficial and deep veins. The veteran was told that he was not a surgical candidate; treatment included support stockings. The veteran complained of inability to walk or stand for a prolonged period of time upon VA general medical examination in June 1989. He also indicated that his left leg felt heavy and sensitive to pressure. A history of vein stripping surgery during service was noted. The clinical evaluation revealed a moderate to severe varicosity of the left saphenous vein. A June 1989 examination for diabetes noted lower extremity symptoms, including peripheral neuropathy, related to that disease; bilateral varicosities were also noted. A venous reflux test in October 1989 revealed findings suggestive of but not diagnostic of deep venous insufficiency of the left leg. The veteran testified before the Board in September 1991 that his varicose veins of the left leg had caused considerable trouble. He noted that he experienced recurrent numbness, swelling and coldness of the left lower extremity, which affected his ability to perform many activities including any prolonged walking or standing. He noted that he wore Jobst support stockings. The veteran further testified that he believed his coccidioidomycosis was causally related to his active duty in the southwestern part of the United States. He said that during part of his service he was stationed in Texas, and that he was also stationed at Fort Irwin, California, for about 16 months from 1963 to 1965, and during a portion of that time he engaged in desert maneuvers in the area of California, Nevada, and Arizona. He attributed his lung disease to the desert maneuvers he participated in. He said that, since he had lived in Minnesota before and after his service, the only explanation for his lung disease was his exposure to the causative fungus while on active duty in the southwestern part of the country where the disease was endemic. The veteran said he had not otherwise traveled to the southwest. He related that in recent years there had been four other people operated on for the condition at Fargo, North Dakota, where he had his surgery. He also claimed that chest X-rays in service revealed some small or minor abnormalities, but he could not remember when those X-rays were taken. His service representative pointed to the note under 38 C.F.R. § 4.97, Diagnostic Code 6821, pertaining to the delayed onset of San Joaquin Valley Fever or coccidioidomycosis and the relevance of service in the southwestern part of the United States, in support of the claim that the veteran's lung disability began in service. The veteran underwent a VA vascular examination in November 1992. A history of surgery for left leg varicose veins during service was noted. The veteran stated that his left leg got ice cold and hurt all the time. He also said he had protrusion of the veins of the left leg most of the time and that the veins were very tender. He added that he had to avoid sitting with any weight on the left side and had to wear support hose for both legs. Physical examination revealed tenderness to the entire left leg. The skin of both feet was cool to touch. Varices were noted predominantly in the left calf region. The varices were light blue in color, and some of them were tortuous and protruding. Spider varices were also noted on the anterior aspect of the left leg and in the left ankle region. One of the larger varices extended approximately 12 centimeters proximal to the medial aspect of the left knee. Sharp versus dull sensation was not detectable on the left foot, but it was detectable on the left leg to the left ankle. Additional findings included loss of hair from the midthigh region distally and numbness of the left foot. Venous incompetence studies suggested incompetency of the superficial veins on the left; equivocal incompetency, but probable competency, of the deep veins. The examiner's diagnosis was postoperative varicose veins of the left leg. Pursuant to the Board's January 1994 remand, a May 1994 statement was submitted by the veteran. He listed the geographic areas that he had visited since retiring from service, including Chula Vista, California; Litchfield Park, Arizona; Phoenix, Arizona; and the Grand Canyon, Arizona, all during a trip to the southwestern United States which lasted from December 20 to December 31, 1986. Other areas visited since service included Germany, the Black Hills of South Dakota, and various midwestern and eastern states. II. Analysis The Board initially finds that the veteran has presented well- grounded claims within the meaning of 38 U.S.C.A. § 5107(a). That is, he has presented claims which are not inherently implausible. Following the Board remands, the relevant evidence has been obtained by the RO, and there is no further duty to assist the veteran in developing facts pertinent to his claims. Id. A. Service Connection for Coccidioidomycosis Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Where coccidioidomycosis becomes manifest to a degree of 10 percent within one year from date of termination of service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. The presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. The veteran served on active duty from 1957 to 1977. During part of this time, 1963 to 1965, he was stationed at Fort Irwin, California, and he says that while there he engaged in desert maneuvers in the southwestern United States. The service medical records are negative for any complaints or findings attributed to coccidioidomycosis. Significantly, numerous chest X-rays during service were normal, and the lungs were normal on clinical and X- ray study at the 1977 retirement examination. In reviewing the post-service evidence of record, the Board finds no indication of coccidioidomycosis for many years following service. Chest X-rays for many years after service were normal. On December 12, 1986, the veteran was seen as a VA outpatient near his home in Minnesota, primarily for evaluation and treatment of a shoulder injury which he just sustained in a fall. He also complained of cold symptoms at that time, and a chest X- ray was normal. The veteran reports he went on a trip to the southwestern United States (Arizona and California) from December 20 to December 31, 1986. During that trip, on December 22, 1986, he had hyperthyroid medication refilled at the VAMC in Phoenix, and he was also prescribed medication for questionable laryngitis. After returning to Minnesota, the veteran was seen at a VA outpatient clinic on January 15, 1987, reporting that for 4 or 5 days he had been sick with such symptoms as a sore throat, headaches, cough, emesis and fever. At a clinic visit on February 6, 1987, the veteran continued to have respiratory symptoms, and a chest X-ray showed a left lung infiltrate assessed as pneumonia. Reportedly that chest X-ray also first detected the left lung lesion which would eventually be diagnosed as coccidioidomycosis. The veteran was thereafter hospitalized in February 1987 for treatment of the pneumonia, which gradually cleared, although a suspicious left lung lesion remained. That lesion was the subject of numerous inconclusive diagnostic studies for the remainder of 1987. In January 1988 the veteran underwent a thoracotomy and lower lobe lobectomy of the left lung, and pathology studies showed the lesion was from a fungal disease, coccidioidomycosis. The veteran maintains that he may have contracted the left lung fungus infection, coccidioidomycosis, while performing desert maneuvers in the southwestern United States, during the time he was stationed at Fort Irwin, California (1963-1965). His service representative cites a note following 38 C.F.R. § 4.97, Diagnostic Code 6821 (coccidioidomycosis), which reads as follows: "This disease, San Joaquin Valley Fever, has an incubation period up to 21 days, and the disseminated phase is ordinarily manifest within 6 months of the acute phase. However, there are instances of delayed onset of the disseminated phase, up to many years, after the initial infection which may have been unrecognized. Accordingly, when service connection is under consideration in the absence of record or any other evidence of the disease in service, service in southwestern United States where the disease is endemic and absence of prolonged residence in this locality before or after service will be the deciding factor." While this note provides guidance when reviewing service connection cases, it does not provide a lifetime presumption of service connection for veterans who had service in the southwestern United States. By federal law and regulation, the presumptive period for coccidioidomycosis is clearly limited to one year after service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Of course, service connection might still be possible for coccidioidomycosis first diagnosed after service, and beyond the presumptive period, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). However, the evidence makes it unlikely that the veteran's pulmonary coccidioidomycosis is due to service. The fungus infection was first manifest in early 1987, and first diagnosed in early 1988. This is more than 20 years after the period when the veteran served on active duty in the southwestern United States (1963-1965) and about 10 years after his 1977 discharge from service. The intervening service and post-service records, with normal chest X-rays and no clinical findings attributed to the disease, provide highly probative evidence that the veteran did not have coccidioidomycosis, in either a dormant or active phase, until many years after service. Exactly when and how the veteran contracted the fungus infection cannot be known with certainty, although it appears improbable that the veteran was infected in service years before the disease became manifest. At his hearing the veteran noted that several other individuals had been diagnosed with the disease in recent years where he received his treatment in North Dakota. Although at his hearing the veteran said he had not left the Minnesota area since service, subsequently received evidence indicates he was on vacation in the southwestern United States (Arizona and California) during the latter part of December 1986. Soon thereafter, in January 1987, he developed an acute illness, with respiratory and other symptoms, and the lung lesion appeared on X-ray study in February 1987. With reference to the note following Code 6821, this fact pattern is suggestive of infection during his recent trip. In any event, the evidence makes it more likely than not the fungus infection occurred years after service discharge. The preponderance of the evidence indicates that the veteran's pulmonary coccidioidomycosis began years after service and was not caused by any incident of service. The disorder was neither incurred in nor aggravated by service. As the preponderance of the evidence is against the veteran's claim, the benefit of the doubt doctrine is inapplicable, and service connection must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet.App. 49 (1990). B. A Rating in Excess of 10 percent for Varicose Veins of the Left Leg Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Varicose veins which are moderate, with varicosities of superficial veins below the knee and with symptoms of pain or cramping on exertion, warrant a 10 percent rating. Unilateral varicose veins which are moderately severe, involving superficial veins above and below the knee, with varicosities of the long saphenous ranging in size from 1 to 2 centimeters in diameter, with symptoms of pain or cramping on exertion, and with no involvement of the deep circulation, warrant a 20 percent rating. Severe varicosities below the knee, with ulceration scarring, or discoloration and painful symptoms also will be rated moderately severe (i.e., 20 percent for a unilateral condition). Unilateral varicose veins which are severe, involving superficial veins above and below the knee and with involvement of the long saphenous vein, ranging over 2 centimeters in diameter, with marked distortion and sacculation, and with edema and episodes of ulceration, and no involvement of the deep circulation, warrant a 40 percent rating. 38 C.F.R. § 4.104, Code 7120. In reviewing the clinical evidence of record and the veteran's testimony at his Board hearing, it is apparent that his service- connected varicose veins of the left leg remain symptomatic and productive of some functional limitation. He complains of painful varicosities, particularly on prolonged use of the left leg, and he must wear support stockings. The VA treatment record since 1988, and the 1992 compensation examination, indicate the varicose veins are located below the knee. The 1992 examination indicates, however, that these varicose veins are tender and discolored, and some of the veins are tortuous and protruding. Testing for deep venous competency was equivocal, although it was thought the deep venous system was competent; the evidence does not establish involvement of deep circulation. The veteran's left leg varicose veins most closely approximate the criteria for a 20 percent rating; specifically, severe below- the-knee involvement which is to be rated as moderately severe. 38 C.F.R. § 4.7. The medical and other evidence does not, however, show severe varicose veins both above and below the knee, as described in Code 7120, and thus a 40 percent rating is not warranted. For those reasons, an increased rating, to 20 percent, for left leg varicose veins is granted. ORDER Service connection for coccidioidomycosis is denied. An increased rating, to 20 percent, for varicose veins of the left leg is granted. L. W. Tobin Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.