BVA9506505 DOCKET NO. 89-26 411 ) DATE ) RECONSIDERATION ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for pulmonary sarcoidosis. REPRESENTATION Appellant represented by: Florida Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Nancy S. Kettelle, Counsel INTRODUCTION The veteran served on active duty from November 1976 to June 1980. This matter came to the Board of Veterans' Appeals (Board) on appeal from a March 1989 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In a December 5, 1989, decision, the Board denied service connection for residuals of viral syndrome, residuals of upper respiratory infections, and pulmonary sarcoidosis. The veteran requested reconsideration of the Board's decision, and in March 1990 the Board docketed the case for reconsideration by an expanded Reconsideration Section of the Board. This decision replaces the Board decision of December 5, 1989. As was noted in the Reconsideration Section's October 1993 remand, at an October 1992 hearing before a travel section of the Board at the RO, the veteran stated that it is her contention that the viral syndromes and upper respiratory infections she experienced in service were the beginning of her pulmonary sarcoidosis and that she is not seeking service connection for those disabilities per se. The Board, therefore, considers the issues of service connection for viral syndromes and upper respiratory infections to have been withdrawn and will consider only the issue of entitlement to service connection for pulmonary sarcoidosis. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that during service she was periodically treated for cold and flu symptoms but was never seen by a doctor or given a chest X-ray in response to her upper respiratory complaints. She states that after service she continued to have respiratory problems. She contends that her inservice upper respiratory problems were in fact the beginning of her pulmonary sarcoidosis which was first diagnosed in 1981. 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 file. 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 of entitlement to service connection for pulmonary sarcoidosis. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained to the extent possible. 2. Pulmonary sarcoidosis was not present within a year of service, and is not shown to be related to service. CONCLUSION OF LAW Pulmonary sarcoidosis 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, 1112, 1131, 1137, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.307, 3.309 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSION Initially, the Board notes that the veteran's claim of entitlement to service connection for pulmonary sarcoidosis is well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). That is, the claim is at least plausible. Further, the Board is satisfied that relevant facts sufficient to reach an equitable decision have been properly developed to the extent possible. Specifically, the Board has twice remanded the case in an attempt to obtain copies of treatment records dating from 1981 from the veteran's private physician John R. Parnell, M.D., and, in addition, in the second remand attempted to obtain other early postservice examination and X-ray reports to which the veteran has referred, particularly those from the Volusia County Health Department, Daytona Beach Community College, and Gayfers Department Store. Further, the Board has attempted via its second remand to locate the veteran's service medical records and have them reassociated with the claims file. Unfortunately, the service medical records have not been found, and the veteran did not respond to the RO's request for authorization for release of information from Dr. Parnell and other sources she had identified, nor did she provide any additional evidence in support of her claim. As has been pointed out by the United States Court of Veterans Appeals in Wood v. Derwinski 1 Vet.App. 190, 193 (1991), the duty to assist is not always a one-way street, and the Board finds that in the absence of cooperation from the veteran, no more can be done to obtain evidence relevant to her claim. Under the circumstances, no further assistance to the veteran is required to comply with 38 U.S.C.A. § 5107(a). Generally, entitlement to service connection requires that it be shown that a disease or injury was present in service and has resulted in continuing or residual disability. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. In addition, service connection for sarcoidosis may be established on a presumptive basis if it is demonstrated that the disease was manifested to a compensable degree within one year following service. 38 U.S.C.A. §§ 1101, 1112, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. In this case, the veteran's service medical records are, unfortunately, not available. At the veteran's October 1992 hearing, she testified that she was in good health when she entered service and her entrance physical examination included X-rays, as well as blood and urine testing. She was not informed of any indication of disability at that time. She testified that in 1978 she began having almost continuous cold symptoms and fevers. She testified that her temperature would usually be about 100 to 101 degrees but sometimes rose to 102 degrees. She testified that she sought treatment at a dispensary and was usually given Actifed and put on light duty for 24 hours. She was not seen by a physician, nor was she given a chest X-ray. She testified that in 1978 she was sent to Korea and noticed an increase in severity and frequency of her upper respiratory problems. She said she was constantly in the infirmary complaining about cold-like symptoms and not being able to breathe, even in the summertime. She testified that throughout the time she was stationed in Korea, she saw only a corpsman, never saw a physician, and did not have a chest X-ray. The veteran also testified that she was not given a separation examination when she left service. At the October 1992 hearing, the veteran also testified that during the first year after service she continued to have the same sort of problems and sought treatment from Dr. Parnell. She said that when she kept complaining of colds and coming in with the same symptoms, the doctor ordered a chest X-ray. She also stated that the chest X-ray was not taken within the first year after she got out of service. She testified that after Dr. Parnell received the X-ray results, she was diagnosed as having sarcoidosis. The veteran also testified that the first and subsequent chest X-rays were taken at the Volusia County Health Department at Dr. Parnell's request. She testified that she continued to receive treatment for her sarcoidosis only from Dr. Parnell until 1989, when she had to be hospitalized for treatment because of breathing problems and fever. The veteran also testified that after service she went to school at Daytona Beach Community College beginning in September 1980 and had to take a physical exam. She stated she had problems with sarcoidosis while she was attending the college. Additionally, she testified that after service she worked as a sales clerk at May Cohens Department Store (which later became Gayfers Department Store). She said that at her employment physical examination, which was done at the Volusia County Medical Clinic, and "right before school" she had to explain why she was tuberculin positive, and Dr. Parnell wrote and told the store she had sarcoidosis. Evidence of record shows that the veteran received VA educational benefits for attendance at Daytona Beach Community College beginning in September 1980. The record also shows that in a statement dated in February 1982, the veteran reported that illness had forced her to withdraw from classes; later records show that she resumed classes in May 1982 but in November 1982 reported that she had reduced attendance to 3/4 time because she had a flare-up of her sarcoid disease and was too ill to attend classes. In a January 1985 letter, the Nursing Counselor at Daytona Beach Community College stated that the veteran had received an Associate of Arts degree in the Health-Medical area in December 1982 and had completed a Licensed Practical Nurse program in January 1984. In the absence of her service medical records, the Board accepts as true all factual statements made under oath by the veteran concerning her physical complaints and treatment she received in service, because she is competent to testify as to her physical symptoms, the treatment she received and whether or not she received chest X-rays and a service separation examination. Although the record shows that the veteran has some medical training, the Board does not give great weight to the veteran's argument that the symptoms she experienced in service evidenced the beginning of her pulmonary sarcoidosis. In the Board's view, the veteran's opinion is outweighed by the remaining evidence of record as to the onset of the disease. The record includes a January 1989 letter from Dr. Parnell, stating the veteran had been confirmed as having pulmonary active sarcoidosis since 1981. In a February 1989 letter, Dr. Parnell listed specific dates, ranging from August 5, 1981, to December 30, 1988, and stated that the reported dates were those that related to monitoring or treatment of the veteran's sarcoidosis. In an October 1992 letter, Dr. Parnell stated that the veteran had had X-ray-confirmed systemic sarcoidosis since December 1981, with gradual progression of her disease so that she was now totally disabled. The Board must infer from Dr. Parnell's statements that the earliest date he was able to diagnose the veteran as having pulmonary sarcoidosis was in August 1981, and that it was not until December 1981 that the clinical diagnosis was confirmed by an X-ray study. Other than the veteran's hearing testimony, no evidence in the record supports a date earlier than August 1981 for manifestation of the sarcoidosis. For example, on a VA Form 21-2545, dated in February 1989, the veteran gave a history of having worked in sales at May Cohens from 1981 to 1983, but did not specify the month in which she started working. Also on the same form she reported that she had been treated for sarcoidosis by Dr. Parnell since 1981, but again did not specify the month in which treatment began. At the February 1989 VA examination, the physician reported that the veteran gave a history of having increased frequency of upper and lower respiratory infections "since 1981" and as a result had been seen and evaluated by Dr. Parnell who diagnosed her as having pulmonary sarcoidosis. Records from Halifax Hospital Medical Center show that the veteran was hospitalized in December 1988 after a week-long history of shortness of breath, progressive congestion in the chest and head, runny nose and fevers to 102 degrees. On the hospital discharge summary it was stated that the veteran had a long history of pulmonary sarcoidosis and had been on and off Prednisone therapy with relatively good control of her sarcoid until this illness. On the report of History and Physical Examination, it was reported that the veteran had had sarcoidosis for a period of approximately 5 or 6 years and had been relatively asymptomatic until this illness when she began to experience severe shortness of breath with laryngitis. It was noted that a chest X-ray taken in the emergency room suggested probable superimposed pneumonitis in addition to a long-standing sarcoid disease. On the discharge summary it was noted that during hospitalization the veteran underwent a bronchoscopy with pulmonary biopsy. The final diagnoses reported on the discharge summary were active pulmonary sarcoidosis (progressive) and chronic interstitial bronchitis. On a December 1988 X-ray report it was noted that December 1988 chest films were compared with previous X-ray studies of December 1985 and September 1986. It was noted that according to the history on the previous X-ray reports, the veteran had a diagnosis of sarcoid, and it was indicated that comparison with the old films suggested the veteran was experiencing an exacerbation of known sarcoid. A December 1988 consultation report for an eye examination included the comment that the veteran had been carrying a diagnosis of sarcoidosis for eight years, had had pulmonary problems, had been on steroids, but as far as she knew had not had any renal, joint, skin or eye manifestations of the disease. The histories reported in the various reports associated with the veteran's December 1988 hospitalization do not provide definitive information regarding the onset of the veteran's pulmonary sarcoidosis in that they include statements that she had a "long history of pulmonary sarcoidosis," that she had had sarcoidosis for approximately 5 or 6 years and that she had been carrying a diagnosis of sarcoidosis for eight years. Because none of the times reported is corroborated by other evidence of record and they are also inconsistent with one another, the Board can only regard the times reported as approximate and of almost no probative value in a determination as to the onset of the veteran's pulmonary sarcoidosis. At a June 1994 VA examination, the veteran gave a history of repeated bouts of upper respiratory infections in service but said that no chest X-rays were made during those episodes and that none was made at discharge from service. She reported that about six months after discharge from service she applied for a job and a chest X-ray was made because her tuberculosis skin test had been positive. At the time she was told she had an abnormal X-ray and her local physician referred her to a pulmonary specialist. She reported that she had a skin biopsy that was negative for sarcoid, but a node from a supraclavicular area was positive. Following this she was started on Prednisone for about six months, and then the dose was reduced and eventually stopped. She did well for a year and a half when occasional bouts of night sweats, fever, and shortness of breath occurred. When this developed, the steroids were restarted. After examination, including chest X-ray, CT chest scan and laboratory studies, the diagnoses at the June 1994 VA examination included sarcoidosis, manifested by abnormal chest X-ray and liver function studies. The examining VA physician noted that the veteran claimed that her family physician wrote a letter to VA indicating that he had seen her and treated her within six months after discharge from the service. The VA physician stated that he had been unable to find this letter in reviewing the veteran's claims file. The physician also commented that on the basis of information in the veteran's claims file there appeared to be no evidence that the veteran suffered from sarcoidosis while on active duty, but noted that no previous X-rays had been made available for comparison with current films. The physician further commented that it appeared that the case could be resolved if the veteran's private physician could provide evidence of a definitive diagnosis made within the six month period after the veteran was discharged as she alleged. The Board notes that, as outlined above, the record does include a February 1989 letter from Dr. Parnell, in which he stated that as accurately as was reflected by his office files, he was reporting dates related to the veteran's sarcoidosis, either as flare-ups of symptoms, office visits for monitoring of progress or dates medications were prescribed. The dates listed in Dr. Parnell's letter ranged from August 5, 1981, to December 30, 1988. The veteran's DD 214, Certificate of Release or Discharge from Active Duty, shows June 13, 1980, as her service separation date. As the VA physician who reviewed the claims file did not equate the inservice and early postservice upper respiratory symptoms, reported by the veteran in sworn testimony at her hearing, to manifestations of pulmonary sarcoidosis, and because the earliest date of clinical documentation of pulmonary sarcoidosis reported by the veteran's own physician is more than a year after separation from service, it is the Board's decision that the preponderance of the evidence is against the service connection claim. The Board concludes, therefore, that service connection for pulmonary sarcoidosis may not be granted on either a direct or presumptive basis. ORDER Service connection for pulmonary sarcoidosis is denied. J. J. SCHULE F. JUDGE FLOWERS SHANE A. DURKIN (CONTINUED ON NEXT PAGE) GORDON H. SHUFELT EILEEN M. KRENZER JANE E. SHARP 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.