Agent Orange Exposure and MGPosted by jodi-enders on October 17, 2022 at 7:30 am
Numerous individuals have written about receiving an MG diagnosis, wondering if it was caused by their previous exposure to agent orange while serving in the Vietnam War.
The exact cause of MG is unknown, but studies suggest people biologically have genes or other unknowns, which puts them at higher risk of showing MG symptoms. Something must trigger symptoms to begin appearing, but research indicates there are numerous triggers, not all known.
There is not enough investigation on the relationship between MG and agent orange. However, multiple conditions have been confirmed to possibly have been caused by the herbicide used to clear vegetation for military operations, including various cancers.
The number of people with MG and previous exposure to agent orange would appear to warrant research into this. Are you one of these individuals? What are your thoughts on this possible MG cause?
MemberOctober 18, 2022 at 3:06 am
Hi Ms. Jodi – So nice of you to think about us and asking the question.
I served in Viet Nam near the DMZ and Danang in 1970/71, and filed a VA Claim re: gMG due to Agent Orange exposure. It was denied.
I have done a bit of research on this topic and there does appear that there is not sufficient numbers reported to make gMG claimable.
I know a guy that has Parkinson’s and gMG. Because he was in Viet Nam and exposed to Agent Orange the VA presumed that the gMG was resultant and he receives disability moneys for both.
I would think if one had access to the VA health records, a sort could be made that might capture both Viet Nam service and gMG. Too simple. I wonder what a Significant Sample would produce.
The problem is, How can one prove?
I would guess that the vast majority of members of this forum that have a form of MG and served in Viet Nam are few.
I am being treated at DeBakey VA Hospital in Houston and get good care. In some ways better than many insurance companies provide.
The benefit, to me, having this disease being caused by Agent Orange would be an increase in Disability Rating and would result in a few extra dollars per month.
At the end of the day, that acknowledgement/designation/rating will not put the disease in remission.
MemberOctober 20, 2022 at 2:21 pm
I was recently diagnosed with Ocular myasthenia gravis. I served in Vietnam 1966-1968 in the central highland and was exposed to Agent Orange via spraying, and working in ranch-hand C123’s.
I have been complaining to my Ophthalmologist for more than 5 years about double vision, which would come and go, and of course never when I was at the office. He always said it was dry eye. Last summer it became so bad that I had to wear an eye patch to function. The Dr. said I needed special glasses, so after spending $$$ on glasses, which didn’t work because my eye kept changing, he finally sent me to a Neuro-Ophthalmologist (6 month wait for appointment) who thought it might be Acquired Brown Syndrome, but to be sure he had me do a blood test for MG. Sure enough it was MG. He put me on Pyridostigmine 4 times a day. After about 1 week I was able to stop wearing the patch and my eyes are functioning nearly normally. The brain is correcting for some of the shift (since it still isn’t perfect.
I submitted a disability claim to the VA and the response was “show us scientific evidence”!!!
Have found a few references to AO and other autoimmune diseases. But like so many other things the VA won’t admit that it is connected.
I am hoping I’m in the 15% that doesn’t progress to gMG.
Will fight it with VA Disability Lawyer once I get a formal denial.
MemberNovember 12, 2022 at 10:20 am
I am a Vietnam Vet with MG. I was lucky that my primary doc at the VA notice my eyes before I had a lot of problems, but it took several months for the final diagnosis. I made a big mistake by going to the VA for treatment (I was warned). In 2013 a memorandum was signed making VA hospitals an integral part of residency training for the nation’s physicians. All the resident doc’s (??? NG’s) rotate in and out ever few months leaving you with no continuity in service. To top that off the head of neology here is a gas-lighter. He has gone so far as to deny treatment. One of the times he said “I don’t want to waste a hundred thousand dollars.” Look up gas-lighting, medical gas-lighting and psychological warfare. It’s all the same.
The VA does counts MG as a disability if you were diagnose within ten year of getting out of service and can prove it.
The VA kind of ignores the words “Agent Orange”. They like to combine everything under “pesticide”. That includes herbicides and insecticides, plus????
Malaria pills (chloroquine) and insect repellent (DEET) may have been worse than AO. Several places in the Central highland of Vietnam are high in lithium if you were there. Diesel exhaust can cause immune system problems. I was in an armored unit.
MemberMay 24, 2023 at 2:55 pm
It is a symptom within 1 year of separation. I had prisms added to my glasses 3 months before discharge. Diagnosis 40 years later. Receiving VA Disability.
MemberOctober 7, 2023 at 11:32 am
Good luck lawyer and claim! I was diagnosed w/Ataxia by a neurologist but he never told me what it was or how to treat it. Then the VA looked at MG but their not sure the doctor told me there were spots on my Thymus but he said he didn’t think they were big enough to cause MG. Went on my own to a Neurologist, outside the VA, and he put me on Pyridostigmine 4x a day, and it’s working. I’m able to walk much better.
MemberNovember 11, 2023 at 2:30 pm
Hope it works for you brother!
MemberOctober 20, 2022 at 7:31 pm
Hi John –
After I got my formal letter of denial from the VA, I contacted an attorney that specializes in VA Health Claims and was told that there is nothing that they can do.
I would be most interested in the response that you get after you contact an attorney.
Good luck with your MG and hope, for you, it does not turn into gMG.
MemberNovember 2, 2022 at 9:45 pm
I have found a very interesting case that will probably interest our members.
Citation Nr: 1539119
Decision Date: 09/14/15 Archive Date: 09/24/15
DOCKET NO. 11-05 846 ) DATE
On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio.
This appeal is a case that answers how to get myasthenia gravis as service related. If you can’t find it, let me know and I will send a copy. I found it on the VA website. Contact with a VSO will probably also help.
The VA is no different that the military. Certain words or phrases must be used to establish your point. This is also true in legal proceedings. For the VA, these words are:
- A Veteran is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence.
- When a Veteran seeks benefits and the evidence is in relative equipoise, the Veteran prevails.
- that it was his opinion (Personal Doctor) that it was more than likely the Veteran’s myasthenia gravis was related to his military duty.
- As there is no medical evidence against the claim, and the competent medical evidence of record relates his myasthenia gravis to in service herbicide exposure.
However, these statements from the court record does not mean it would be an easy battle. Most veterans that served in the specified area are also probably eligible for other disability issues and also service-connected ratings.
I know a number of veterans that served with me or during my tour of duty, 67-68. Typical disability ratings are for PTSD, loss of hearing, wounds, high blood pressure, and several others. Check the assumed illnesses caused by Agent Orange since they have been recently updated. Working through all the disabilities you have attributed to the service and a few appeals; you can start getting some money from the VA.
I would steer clear of an attorney, especially the ones that advertise. Your best bet is a VSO, Veterans Service Officer. I don’t know about all states, but in Indian we have one in every county. Some of those are better than others and they can help you get started.
A second, and better choice, would be to use a VSO from one of the service organizations, like AmVets, VVA, or American Legion. These are free and they will take your case, and if needed, will also handle the appeals. There are the guys that know what they are doing and the VA knows it. If you are near a VA hospital you can find VSOs there too.
I think the most important thing to do is to start applying for disability and get some money coming in, if you haven’t done so already. Remember, if you win your appeal, the payments go all the way back to the date you first filed your claim. I am at 80% which qualifies me a permanently unemployable and qualifies me for 100% disability pay. There is no Agent Orange disability in my profile.
I also found many studies on herbicides like AO and their affect on gMG. Almost all studies that I read found some relationship between the studied herbicide and gMG patients.
Good luck and I hope you can get some help and some disability pay.
MemberNovember 3, 2022 at 12:23 am
Hi Lou –
Thanks so much for posting this document.
I will move forward using it as a template for my appeal.
MemberNovember 4, 2022 at 8:22 pm
Good luck, David. Remember the special words the VA is looking for. Read the docket if you can, quite interesting. Also be sure to get with a VSO from one of the veteran’s organizations. You will need someone to handle the appeal.
MemberNovember 4, 2022 at 8:28 pm
Hi Lou –
I have an appointment with a VSO on the 15th of this month. She will file all paperwork and will assure that the special words are applied.
My symptom profile is almost identical to the docket you referenced.
MemberNovember 6, 2022 at 4:37 pm
My father served along the DMZ during the Vietnam war, where Agent Orange was also used in abundance. His exposures were confirmed by the VA prior to his death, which was 2 years before my MG diagnosis. I have seen research linking AO to changes in DNA as well as a strong link to autoimmune disorders, certain cancers, and cardiac birth defects in the offspring of AO veterans. Unfortunately, the VA does not recognize any conditions other than Spina Bifida in the offspring of male veterans.
When I spoke with a VA rep about the 2015/2016 Toxic Exposures Act, he recommended that those of us (children of AO veterans who have medical issues) all reach out to our congresspersons to get the VA to move forward with recognizing more conditions.
MemberNovember 7, 2022 at 2:18 pm
For those who may be interested in getting a Veteran Service Officer to help file a VA claim, or appeal, here is some information to get you started. Amvets are not the only service group to offer assistance and will work much like this article. There services are free.
MemberNovember 6, 2022 at 9:50 pm
Try talking to a Veteran’s Service Officer as noted in my previous message.
MemberNovember 15, 2022 at 9:12 pm
Update – Met with my VSO today.
We will Appeal – and provide:
1. 38CFR.309 – “Disease subject to presumptive connection”. MG is listed in this document.
2. Supplying a copy of the NIH document that links Chemical Exposure like AO to MG.
3. 3 – “Citations that show evidence that the VA has acknowledged that MG, more likely than not, was caused by exposure to toxic Chemicals/Agent orange and paid Disability compensation. MG disability is rated at a minimum of 30%. A C&P Examination will determine level of disability after the Appeal has been won. This is a separate meeting. (That is my understanding)
MemberMay 23, 2023 at 9:34 pm
MemberDecember 1, 2022 at 12:13 am
I just received a 30% disability rating for my Ocular MG. I submitted initial application in June 2022, and additional info August 2022), numerous technical papers showing the relationship between Dioxin/AO and Autoimmune disease and MG is an autoimmune disease. Also submitted Citation Nr: 1539119 shown above. I did all this without any outside help. I’m seeing a neuropathologist and asked him to write a nexus letter, but they approved before his letter would have been submitted. I’m out of the country and couldn’t follow up with him. (of all places I’m in Saigon for the next 6 months).
So it is possible to get the rating!!!!
Still waiting on AO disability for my peripheral neuropathy.
MemberDecember 1, 2022 at 1:08 am
Hi John –
Glad to hear that you got your rating.
I believe what has changed is that the doc. 38 CFR 3.309, Revised in Nov. 2022 now shows MG as linked as a chronic disease.
§ 3.309 Disease subject to presumptive service connection.
“(a) Chronic diseases. The following diseases shall be granted service connection although not otherwise
established as incurred in or aggravated by service if manifested to a compensable degree within the
applicable time limits under § 3.307 following service in a period of war or following peacetime service on
or after January 1, 1947, provided the rebuttable presumption provisions of § 3.307 are also satisfied.”
I mailed of my document set this morning and am hoping for a 100% Rating – we shall see.
MemberDecember 3, 2022 at 5:01 pm
MemberDecember 5, 2022 at 2:17 pm
Thanks so much for your post. Without it I would not be this far along.
MemberDecember 5, 2022 at 2:18 pm
Someone recently shared that HR 3518 is seeking to expand benefits to those affected by AO, including the offspring of male servicemembers like me. Here’s the link: https://www.govtrack.us/congress/bills/117/hr3518/summary.
Here’s an excerpt, “HHS must (1) make grants to public health organizations and Vietnamese American organizations to conduct a broad health assessment of Vietnamese Americans who may have been exposed to Agent Orange and their descendants; and (2) establish centers in U.S. locations where large populations of Vietnamese Americans reside to provide assessment, counseling, and treatment for conditions related to Agent Orange exposure.”
My guess is that most on this thread are veterans, but I hope this information proves helpful to you and your families.
Under the bill, certain benefits will be made available to the children of male Vietnam veterans who are affected by certain birth defects. Currently, these benefits are only available to the children of women Vietnam veterans. The VA shall require any health care provider with whom the VA enters into a contract for the provision of health care to such children to provide the VA access to their medical records for research into the intergenerational effects of Agent Orange exposure.”
MemberJune 24, 2023 at 11:04 am
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
Entitlement to service connection for myasthenia gravis.
Veteran represented by: Texas Veterans Commission
WITNESSES AT HEARING ON APPEAL
The Veteran and his spouse
ATTORNEY FOR THE BOARD
S. Dale, Associate Counsel
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 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).
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).
Entitlement to service connection for myasthenia gravis is granted.
MemberJuly 19, 2023 at 6:20 pm
Thank you Paul- I had hoped that the PACT Act would extend coverage to the offspring of AO-affected service members, like me. Unfortunately it does not. There is hope under the Toxic Exposures Act of 2015 and 2016. But, we need lawmakers to update it to specifically include us.
I developed MG (MuSK variant) 8 years ago, 2 after AO took my dad. It would have killed him to imagine that his service to the country caused me to develop MG.
MemberJuly 20, 2023 at 9:38 am
That is on every Vietnam Service members mind, they unleashed the Devil on us for a War That our President OUIT! I hope I’m not around to see that.
I was in Nam 1967, I didn’t have Health insurance until 1973. When I did I was found to have blood in my Urin. Test after test, Cystascope after Cystascope, nothing found until in 1980, when I had 2 lumps removed on my back and a Urologist told my wife that I had Bladder Cancer. I had injections and I thought that was that. Today blood is showing up again.
“I was just a Defoiliant”!
MemberJuly 20, 2023 at 9:39 am
” IT ” sorry.
MemberDecember 23, 2022 at 6:15 pm
I have my C&P Exam set for Jan 3rd, 2023.
MemberDecember 23, 2022 at 7:18 pm
That’s great! Good Luck.
MemberJanuary 3, 2023 at 6:20 pm
Had my exam today.
We shall see what happens.
MemberJanuary 13, 2023 at 1:52 am
Got notification today that I have another C&P exam appt. on Jan 20th. This one is with a Psychologist.
MemberJanuary 20, 2023 at 6:49 pm
Had my C&P Mental Health Exam today.
Evidently my first C&P examiner listed some mental stuff in his report so had my 2nd today.
Exam went well.
We shall see.
MemberJanuary 20, 2023 at 10:54 pm
Another step done and probably another check mark on the disability list.
MemberMarch 18, 2023 at 10:36 am
Got my 2nd Denial Letter yesterday.
My VSO said that it was denied because I do not have a letter from a Medical Doctor saying that ” it was more likely that not” that I got this disease due to my Vietnam exposure to herbicides.
It is interesting that the VA shows that MG is on the presumptive list but still requires a doctor’s letter. I did supply documents from NIH that states that herbicide exposure does cause neurological disorders but to no avail. I do not understand. Neither does the VSO but says that a letter is required.
My VSO said I should sign up for the Agent Orange Registry. They might provide the letter. More tests and exams. ARGH
I have contacted my local VA Environmental Health Coordinator, who controls the Agent Orange Registry to find out what I need to do next.
I also contacted my VA Neuro and he is not sure whether or not he can write such a letter. I meet with him next week during my monthly IVIG and will try to get clarification from him.
I have also contacted the VFW asking for help/guidance in this matter.
In the meantime I’m discouraged and depressed but am continuing to move along. Such a hassle.
How can anyone say: “More likely than not”? How does one find a Dr. that might pen such a letter?
My next step may be to contact an attorney that specializes in VA Disability Claims for assistance.
MemberMarch 18, 2023 at 9:39 pm
MG is not on the presumptive list for Agent Orange. It is presumptive only if it manifest within 1 year of separation.
Certain chronic diseases, such as Myasthenia Gravis (an organic disease of the nervous system, are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a).
MemberMarch 18, 2023 at 10:08 pm
Hi John –
Thanks for your input –
I read that section as well.
I hope with a Nexus letter, and numerous VA precedents that have acknowledged service connection, will prevail.
I’m sure I don’t know. We shall see what the Lawyers say.
MemberMarch 24, 2023 at 3:02 pm
I’m in pretty much in the same boat. I’m at 80% (PTSD & hearing) Filed for MG was denied. I had a Kaiser doctor agree that it’s as probable as not it is AO related but not sure if he will do a nexus letter. Please keep posting with updates.I’ll do the same.
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