[paul spychalski]

Thw PACT Act:

Subject: VA Approv. MG

Citation Nr: 1147153
Decision Date: 12/28/11 Archive Date: 01/09/12

DOCKET NO. 05-33 541 ) DATE
)
)

On appeal from the
Department of Veterans Affairs Regional Office in Waco, Texas

THE ISSUE

Entitlement to service connection for myasthenia gravis.

REPRESENTATION

Veteran represented by: Texas Veterans Commission

WITNESSES AT HEARING ON APPEAL

The Veteran and his spouse

ATTORNEY FOR THE BOARD

S. Dale, Associate Counsel

INTRODUCTION

The Veteran served on active duty from June 1966 to May 1968.

This matter comes before the Board of Veterans’ Appeals (BVA or Board) on appeal from an April 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, which denied the benefits sought on appeal. The Veteran appealed that decision to BVA, and the case was referred to the Board for appellate review.

The Veteran originally filed a claim of entitlement to service connection for myasthenia gravis in January 1992. That claim was denied by the RO in an unappealed February 1992 rating decision.

In October 2003, the Veteran filed a petition to reopen his previously denied claim of entitlement to service connection for myasthenia gravis. In the April 2004 rating decision, the RO denied this claim, determining that new and material evidence sufficient to reopen the claim had not been submitted. The Veteran expressed disagreement with that decision in June 2004 and subsequently perfected the present appeal.

A hearing was held on December 10, 2008, in Waco, Texas, before Kathleen K. Gallagher, a Veterans Law Judge (VLJ), who was designated by the Chairman to conduct the hearing pursuant to 38 U.S.C.A. § 7107(c), (e)(2) and who is rendering the determination in this case. A transcript of the hearing testimony is in the claims file.

After the December 2008 hearing, the Veteran submitted additional evidence to the Board which was accompanied by a waiver of local consideration. This waiver is contained in the Veteran’s VA claims file. See 38 C.F.R. §§ 19.9, 20.1304(c) (2011).

In March 2009, the Board reopened the Veteran’s previously-denied claim and remanded such for further evidentiary development. Specifically, the Board instructed that the RO or VA Appeals Management Center (AMC) should afford the Veteran a VA examination and obtain a medical opinion concerning the nature and etiology of the Veteran’s myasthenia gravis. After which, the Veteran’s claim was to be readjudicated in a supplemental statement of the case (SSOC) and returned to the Board. The requested VA examination was completed in May 2009, and the report of which has been associated with the Veteran’s VA claims file. However, in a November 2009 deferred rating decision, the RO in Seattle, Washington, assisting the VA AMC, advised that an addendum to the May 2009 VA examiner’s opinion was necessary. Accordingly, the Veteran’s VA claims file was returned to the May 2009 VA examiner, such an addendum was completed in December 2009 and the December 2009 addendum was associated with the Veteran’s VA claims file. The Veteran’s claim was readjudicated in a February 2010 SSOC and returned to the Board for further appellate adjudication.

In April 2010, the Board requested a medical advisory opinion from the VA Veterans Health Administration (VHA) concerning a medical issue raised by the Veteran’s appeal. See 38 U.S.C.A. § 7109 (West 2011); 38 C.F.R. § 20.901(a) (2011). A report dated in September 2010 containing a medical opinion by a VHA neurologist was received and has been associated with the Veteran’s VA claims file. The Veteran’s claim subsequently returned to the Board.

In January 2011, the Board remanded the Veteran’s claim for a second time because the Veteran submitted additional evidence in support of his claim and specifically stated that he did not waive his right to have the evidence initially reviewed by the RO. 38 C.F.R. §§ 19.31, 19.37 (2011). The Board instructed that the RO/AMC should review the additional evidence submitted by the Veteran in December 2010, and if not granted to the fullest extent, readjudicate such in an SSOC and return it to the Board. In an August 2011 SSOC, the AMC readjudicated the Veteran’s claim, and it was returned to the Board.

As the directives and instructions of the Board’s March 2009 and January 2011 Remands have been substantially complied with, the Board may proceed in adjudicating the Veteran’s claim. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board’s remand instructions were substantially complied with).

Initially, the Board notes that, in the April 2004 rating decision, the RO denied the Veteran’s claims of (1) entitlement to service connection for basal and squamous cell carcinomas of the head, hands and arms, and (2) entitlement to service connection for ureterolithiasis (kidney stones). The Veteran’s June 2004 notice of disagreement failed to express dissatisfaction with the RO’s denial of those issues. As such, those issues are not in appellate jurisdiction and will be discussed no further. See Archbold v. Brown, 9 Vet. App. 124, 130 (1996) (pursuant to 38 U.S.C.A. § 7105(a), the filing of a notice of disagreement initiates appellate review in the VA administrative adjudication process, and the request for appellate review is completed by the claimant’s filing of a substantive appeal after a statement of the case is issued by VA).

Please note this appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900(c) (2011). 38 U.S.C.A. § 7107(a)(2) (West 2002).

FINDING OF FACT

Resolving all reasonable doubt in favor of the Veteran, the Veteran has continuously had the symptoms of myasthenia gravis since service.

CONCLUSION OF LAW

Entitlement to service connection for myasthenia gravis is warranted. 38 U.S.C.A. 38 U.S.C.A. §§ 1101, 1110, 1154 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2011).

REASONS AND BASES FOR FINDING AND CONCLUSION

Because the claim of entitlement to service connection for myasthenia gravis is being granted, there is no need to review whether VA’s statutory duties to notify and assist are fully satisfied as any error would be non-prejudicial. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2011); see also 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2011).

Service Connection

Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).

In relevant part, 38 U.S.C. § 1154(a) requires that the VA give “due consideration” to “all pertinent medical and lay evidence” in evaluating a claim to disability benefits. Generally, in order to establish direct service connection for a disorder, there must be (1) medical evidence of the current disability; (2) medical, or in certain circumstances, lay evidence of the in-service incurrence of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). However, medical evidence of a current disability and nexus is not always required to establish service connection. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (footnote omitted).

Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It would also include statements contained in authoritative writings such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2).

In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) (“Although interest may affect the credibility of testimony, it does not affect competency to testify.”).

Additionally, service connection for certain chronic diseases, including myasthenia gravis, may be established on a presumptive basis by showing that the disease manifested itself to a degree of 10 percent or more within the initial post-service year. See 38 C.F.R. §§3.307(a)(3), 3.309(a) (2011). In such cases, the Board must reconcile the evidence of record with the rating criteria for the specific injury or disease as set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4.
Further, in the case of any Veteran who has engaged in combat with the enemy in active service during a period of war, satisfactory lay or other evidence that an injury or disease was incurred or aggravated in combat will be accepted as sufficient proof of service connection if the evidence is consistent with the circumstances, condition or hardships of such service, even though there is no official record of such incurrence or aggravation. Every reasonable doubt shall be resolved in favor of the Veteran. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). “Satisfactory evidence” is credible evidence. Collette v. Brown, 82 F.3d 389, 392 (1996). Such credible, consistent evidence may be rebutted only by clear and convincing evidence to the contrary. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d).

Discussion

For the reasons noted below, the Board concludes that the evidence in this case is in equipoise as to whether the Veteran has experienced continuous symptoms of myasthenia gravis since his time in active service. Therefore, the Board concludes that reasonable doubt must be resolved in favor of the Veteran, and service connection for myasthenia gravis must be granted.

In the present case, the Veteran contends that the manifestations of current myasthenia gravis were initially documented during the initial post-service year (November-December 1968) and that this period of symptoms was the result of in-service treatment for malaria. See the Veteran’s statements dated in December 1991, June 2004, July 2006, March 2010, December 2010 and September 2011 as well as the December 2008 hearing transcript at page 13. Service connection for certain chronic diseases, including myasthenia gravis, may be established on a presumptive basis by showing that the disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In such cases, the chronic disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). It is not required that the disease be diagnosed in the presumptive period, but only that there be then shown by acceptable medical or lay evidence characteristic manifestations of the disease to the required degree, followed without unreasonable time lapse by definite diagnosis. 38 C.F.R. § 3.307(c).

In this case, myasthenia gravis was not diagnosed in service or in the one-year presumptive period thereafter. However, the Veteran was hospitalized for several days at a VA hospital in November to December 1968. The service treatment records show that the Veteran was treated for malaria in service in 1967, and the VA Hospital Summary and other clinical records from the period of hospitalization in 1968 show that, because of the history of malaria, he was examined for a recurrence of that disease but that none was found. Consequently, no diagnosis of any condition was made during this period of hospitalization within one year from service discharge.

Specifically, the records of this hospitalization show that on November 29, 1968, the Veteran presented at the Emergency Room of a VA Medical Center (VAMC) with complaints of malaise, lethargy, vomiting, deep muscle pains and aching of the upper-right quadrant. The admitting physician noted the Veteran’s in-service diagnosis of and treatment for malaria, to include the completion of the Veteran’s prophylactic drug therapy after his in-service hospitalization. After the Veteran was admitted, blood smears reflected no atypical lymphocytes, eosinophilic response or trophozooites in the Veteran’s red blood cells and a stool test for ova and parasites was negative. The Veteran’s symptoms improved with bedrest and “good diet”, and he was discharged on December 4, 1968, with a notation that he could return to work “immediately.” No diagnosis was rendered in connection with this hospitalization, but a notation on the discharge report reflected that no “recurrent tropical diseases” (malaria) were found. See VA hospitalization records dated from November 29, 1968, to December 4, 1968.

Consideration of service connection for myasthenia gravis on a presumptive basis is problematic because the rating criteria in the VA Schedule for Rating Disabilities for the disease provide a minimum rating of 30 percent and do not clearly define or depict manifestations of the disease to a degree of 10 percent so that the Board might compare the manifestations shown on the 1968 VA hospital records with those that constitute a 10 percent degree of disability, a requirement for service connection on a presumptive basis. 38 C.F.R. §§ 3.307(a)(3), 3.309(a), 4.124a, Diagnostic Code 8025. Nevertheless, the Board notes that, with regard to a theory of direct service connection, the Veteran’s alleges that his treatment of malaria with quinine in service either exposed or worsened the symptoms of mysthenia gravis, resulting in his hospitalization in the year following service. He contends that he continued to experience mild to moderate symptoms of the disease over the years but that diagnosis was elusive for many years until myasthenia gravis was first diagnosed in 1980.

In support of this theory of entitlement he has submitted his own lay statements and sworn testimony describing his continuous symptoms over the years since service until 1980 when medical reports in the file show he was diagnosed with myasthenia gravis; medical treatise evidence showing that quinine worsens the symptoms of mysthenia gravis; and the opinion of A.W.M., M.D., whose December 2008 letter provides, in pertinent part, as follows:

[The Veteran] has been under my care with autoimmune myasthenia gravis for many years. He dates the onset of his symptoms back to at least 1968 with weakness, difficulty chewing and swallowing, and ocular symptoms. He has records from evaluations at the VA where they described weakness in his extremities. He continued to have symptoms of fluctuating weakness, dysphagia, and weight loss, and had multiple medical evaluations, but was not diagnosed completely until 1980. . . . He continues to have some objective evidence of weakness, bulbar dysfunction, and ocular musle weakness that has been present for many years and correlates with his symptoms which he has described dating back to 1968.

Based on his history, the description from his workup, and my long experience of managing his chronic neuromuscular disease, I think it is more likely than not that his myasthenia gravis has been present and symptomatic since at least 1968.

The credibility of the Veteran’s lay statements that he experienced symptoms since service that he now realizes were the manifestations of mysthenia gravis is undermined somewhat by history from him recorded on early private treatment records in the file contemporaneous with the time of diagnosis which show a six-month, rather than twelve-year, history of symptoms. For example, private records, dated in April 1981 and May 1981 from G.M.C., M.D., and F.D.W., M.D., respectively, reflect a six-month history of fatigue and an initial diagnosis of myasthenia gravis in 1981. The Veteran’s symptoms worsened, and in 1982, his myasthenia gravis manifested in ptosis, diplopia, drooling, bulbar weakness, difficulty chewing and proximal weakness in his upper and lower extremities. The Veteran had a thymectomy in 1982 which was positive for thymoma upon pathological testing. Acetylcholine receptor antibodies were positive upon testing. The Veteran has been treated for myasthenia gravis since that time and has been prescribed prednisone, Imuran, cyclosporine and Mestinon as well as undergoing plasma exchange and intravenous immunoglobulin. When immunosupression drugs were decreased, the Veteran relapsed. See e.g. a November 1990 private treatment record from A.W.M., M.D., and an April 1982 private treatment record from R.S.A.T., M.D.

As to the elements for service connection other than nexus, the Board notes that, concerning medical evidence of the current disability, it is uncontroverted that the Veteran has been diagnosed with myasthenia gravis. See e.g., an April 1981 private treatment record from G.M.C., M.D., a May 1981 private treatment record from F.D.W., M.D. and an April 1982 private treatment record from R.S.A.T., M.D., as well as the May 2009 VA examination report. Therefore, Hickson element (1) has been demonstrated.

Regarding Hickson element (2), medical, or in certain circumstances, lay evidence of the in-service incurrence of a disease or injury, the Veteran’s service treatment records, as noted above, are devoid any instance of complaints of or treatment for symptomatology associated with myasthenia gravis. Indeed, the Veteran has not asserted that he suffered from such during his service; rather, alleging that antimalarial medications prescribed during his service caused the initial manifestations of myasthenia gravis in November 1968 (within the initial post-service year). The Veteran’s service treatment records reflect an in-service diagnosis of malaria in September 1967, for which he was hospitalized for 12 days. The Veteran was treated for this condition with primaquine and dapsone which were continued after his release from the hospital. The Veteran’s April 1968 separation examination reflects the September 1967 diagnosis and further notes that there were no recurrences of malaria after the initial manifestation of the disease from September 1967 to October 1967. The Veteran separated from service in May 1968. To the extent that the Veteran was prescribed antimalarial medications during his service, Hickson element (2) has been demonstrated.

Concerning Hickson element (3), medical evidence of a nexus between the claimed in-service disease or injury and the current disability, the Board notes that, unlike the opinion of Dr. M., the private physician, the VA nexus opinions of record are unfavorable to the Veteran’s claim. Specifically, the May 2009 VA examiner and September 2010 VHA examiners opined that the Veteran’s myasthenia gravis less likely than not had its onset during the Veteran’s service and is less likely than not otherwise causally-related to his service. See the May 2009 VA examination report, the December 2009 addendum to the May 2009 VA examination report and the September 2010 VHA opinion.

However, the Board notes that lack of a medical nexus opinion is not fatal to the Veteran’s claim. As noted above, service connection may be granted for a condition by showing continuity of symptomatology after service under the provisions of 3.303(b). Indeed, the crux of the Veteran’s claim is that the symptomatology which led to his hospitalization from November 1968 to December 1968 was an early manifestation of his current myasthenia gravis. See the Veteran’s statements dated in December 1991, June 2004, July 2006, March 2010, December 2010 and September 2011.

The Board has the authority to “discount the weight and probity of evidence in the light of its own inherent characteristics and its relationship to other items of evidence.” See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). However, the Board may not reject medical opinions based on its own medical judgment. See Obert v. Brown, 5 Vet. App. 30 (1993).

In evaluating the probative value of medical evidence, the Court has stated in pertinent part:

“The probative value of medical opinion evidence is based on the medical expert’s personal examination of the patient, the physician’s knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the adjudicator…”

See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). The Board has reviewed the evidence of record and notes certain strengths and weaknesses with each of the opinions. See Evans v. West, 12 Vet. App. 22, 30 (1998) (the Board must account for the evidence it finds persuasive or unpersuasive, and provide reasons for rejecting material evidence favorable to the claim).

In favor of the Veteran’s claim is the December 2008 statement from A.W.M., M.D., which asserts that “[The Veteran] dates the onset of his symptoms to at least 1968,” but notes that myasthenia gravis “was not completely diagnosed until 1980.” A.W.M., M.D., opined, “Based on [the Veteran’s] history, the description from his workup, and my long experience of managing his chronic neuromuscular disease, I think it is more likely than not that his myasthenia gravis has been present and symptomatic since at least 1968.” See the December 2008 statement from A.W.M., M.D. The Board observes that A.W.M., M.D.’s December 2008 statement is largely based upon a history provided by the Veteran and was made without the benefit of review of the Veteran’s VA claims file except perhaps for certain “VA evaluations” which may have included some of the records from the 1968 hospitalization.
Regarding the fact that the Veteran’s VA claims file appear not to have been reviewed in its entirety by A.W.M., M.D., prior to his December 2008 statement, in many instances, the Court has held that a failure to review the claims file renders a VA examination inadequate for rating purposes. See, e.g., Proscelle v. Derwinski, 2 Vet. App. 629, 932 (1992) (“The [VA] examiner should have the Veteran’s full claims file available for review.”), but see Snuffer v. Gober, 10 Vet. App. 400, 403-04 (1997) (review of claims file not required where it would not change the objective and dispositive findings made during a medical examination). See also 38 C.F.R. §§ 4.1, 4.2 (2011). However, the Court held in Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008), that when VA undertakes to provide a medical examination or obtain a medical opinion, the relevant inquiry is whether “the examiner providing the report or opinion is fully cognizant of the claimant’s past medical history.” Despite the absence of the claims folder, the evidence shows that A.W.M., M.D., obtained a medical history from the Veteran, reviewed the Veteran’s medical history, recorded his current complaints, and conducted appropriate physical examinations before rendering this opinion. As such, the December 2008 statement from A.W.M., M.D., is adequate despite the fact that the Veteran’s VA claims file was not reviewed.

Weighing against the Veteran’s claim are the opinions from the May 2009 VA examiner and the September 2010 VHA examiner. These clinicians have opined that the Veteran’s myasthenia gravis did not have its onset until 1981, and the Veteran’s November 1968 VA hospitalization was unrelated to symptomatology attributable to myasthenia gravis. See the May 2009 VA examination, the December 2009 addendum to the May 2009 VA examination and the September 2010 VHA opinion. More specifically, the September 2010 VHA examiner noted that there was no evidence of “unmasking of symptoms consistent with myasthenia gravis” while the Veteran was on antimalarial drugs and the symptoms that occurred in 1968 were not suggestive of myasthenia gravis. The September 2010 VHA examiner concluded that, due to the presence of a thymoma and acetylcholine receptors in 1982, the Veteran’s myasthenia gravis is a paraneoplastic disorder which was first treated in 1980 and diagnosed in 1981; 12 and 13 years after the Veteran’s separation from service. See the September 2010 VHA opinion.

However, the Board observes that the September 2010 VHA examiner noted that myasthenia gravis is an autoimmune disorder whose precise origin is unknown. Moreover, the September 2010 VHA examiner acknowledged that antimalarial drugs have been reported as provoking myasthenia-like symptoms or causing an exacerbation in patients with known myasthenia gravis, although the precise mechanism for the links between antimalarials and myasthenia is not well understood. In such cases, symptoms of myasthenia gravis start while patients are on these medications and resolve when discontinued. See the September 2010 VHA opinion. Indeed, the VA hospitalization records dated from November 1968 to December 1968 reflect that, prior to his admission, the Veteran had recently completed prophylactic drug therapy in connection with his in-service treatment for malaria. See VA hospitalization records dated from November 29, 1968 to December 4, 1968.

While the Board acknowledges that there is no evidence, medical or otherwise, concerning the Veteran’s myasthenia gravis between his discharge from the VAMC in December 1968 and the private treatment records dated in April 1981 (a period of more than 12 years), the Court has held that the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). Indeed, as discussed above, the Board finds the Veteran’s assertions to be both competent and credible, despite some variation in the history recorded in the early private treatment records regarding the onset of the timing of the symptoms. See Layno, Rucker and Cartwright, all supra. In this regard, the Veteran has stated that he experienced mild to moderate symptoms over the years which worsened to severe in the months before his diagnosis. Therefore, the change in the severity of the continuous symptoms may account for the Veteran having provided doctors with only a six-month history of symptoms prior to diagnosis.

In sum, the Board concludes that the evidence of record regarding whether the Veteran continuously suffered from myasthenia gravis since his separation from service is at least in equipoise. Accordingly, the Board will resolve the benefit of the doubt in favor of the Veteran in this case as the law requires and grant service connection for myasthenia gravis. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2011).

ORDER

Entitlement to service connection for myasthenia gravis is granted.

paul