Here is the most through VA claim NEXUS letter from a Physician Toxicologist I have seen. The local VA, in Ohio, of course had to deny and make this veteran with a blood cancer appeal the the VBA in Washington DC, who finally granted service connection in 2025. Veteran medical support wins VBA for UDMH exposure for Multiple Myeloma
The attorney who helped in this matter, after local VA denial, was Heidi ( a big salute for her) at :
Lawyers for American Vets - Veterans Lawyers and Disability Appeals Help
September 23, 2021
Re: J W H (DOB 1964) - service connection of multiple myeloma
due to toxic contaminant exposure while enlisted in the military.
Disclosure: I am trained in Internal Medicine and have been practicing medicine since
2012. I also earned a PhD in Pharmacology in 2005, with training and experience in
toxicology and experimental therapeutics. I have published 23 peer reviewed articles in the
field of Physiology, Pharmacology and Experimental Therapeutics.
This report is free of any subjective bias of any kind and is based only on objective review
of the medical records provided, my medical training/experience, and review of current
literature.
My opinions are based on a standard of “a reasonable degree of medical certainty” or on
the standard of “at least as likely as not.” The opinions expressed do not constitute a
recommendation that specific claims or administrative action be made or enforced. I
declare under penalty of perjury that to the best of my knowledge the information contained
in this report is true and correct.
Records Reviewed:
1. Military records
2. Private Medical Records
3. Decision Report
Summary of Notable Medical Records:
1. 06/08/2021 Decision Report
a. Service connection for multiple myeloma
i. The DRO returned your claim for review of the file evidence and to
answer the question is it at least likely as not the Veteran current
diagnosis is related to or a manifestation of the exposure to multiple
chemicals during exposure of the Titan missile while performing
duties as medical support?
ii. Further examiner noted after review of evidence and current scientific
literature that the recent outcome of 2020 rating decision cannot be
changed based on scientific evidence that would support a statement
that there is a 50% or greater likelihood that claimants MM was
caused by his exposure on 4/18/1986 at Vandenberg AFB
iii. Favorable findings:
1. You have been diagnosed with a disability. Dr. Chandran dated
9/15/2020 reports a diagnosis of multiple myeloma
2. 5/4/2021 H & L Condition, including leukemia DBQ Donald Cohen MD
a. Diagnosis:
i. Multiple myeloma
b. History:
i. Progressed/worsened
c. Treatment:
i. Radiation therapy 4/2/2020
d. Anemia and thrombocytopenia
i. Platelet count above 50,000 and asymptomatic
ii. Plasmacytoma
e. Pertinent physical findings:
i. Peripheral neuropathy
f. Diagnostic testing:
i. Hemoglobin: 16.4, Hematocrit: 47.4, RBC 5.13, WBC 4.2
Discussion:
J W H (DOB /1964) served in the Air Force from 9/6/1983 to
8/31/1987. He is seeking service connection of multiple myeloma (MM) due to toxic
contaminant exposure while enlisted in the military. His MOS was an EMT and ambulance
driver, providing emergency response for potentially dangerous activities, which included
the Hot Flow Process. Mr. H states he is sure his health has been impacted from
chronic toxic exposure of rocket fuels, due to his MOS, and acute exposure from the Titan
34 D missile clean up. In my medical opinion, Mr. H has a valid claim, and his MM
is at least likely than not due to toxic contaminant exposure while enlisted in the military.
Multiple myeloma (MM) is a clonal plasma cell proliferative disorder characterized by the
abnormal increase of monoclonal paraprotein leading to evidence of specific end-organ
damage. It is part of the spectrum of monoclonal gammopathy. MM is a cancer that forms
in a type of white blood cell called a plasma cell. Plasma cells help you fight infections by
making antibodies that recognize and attack germs. Multiple myeloma causes cancer cells
to accumulate in the bone marrow, where they crowd out healthy blood cells. Rather than
produce helpful antibodies, the cancer cells produce abnormal proteins that can cause
complications. Multiple myeloma accounts for 1% of all cancers and approximately 10%
of all hematologic malignancies. Each year over 32,000 new cases are diagnosed in the
United States, and almost 13,000 patients die of the disease. The annual age-
adjusted incidence in the United States has remained stable for decades at approximately
four per 100,000. Multiple myeloma is slightly more common in men than in women and
is twice as common in African Americans compared with Caucasians. The median age of
patients at the time of diagnosis is about 65 years (2,3).
The exact etiology of MM is unknown. However, there is evidence that suggests genetic
abnormalities in oncogenes such as CMYC, NRAS, and KRAS may play a role in the
development of plasma cell proliferation. MM has also been associated with other factors
such as drinking alcohol, obesity, and environmental causes such as insecticides, organic
solvents, and radiation exposure (1). Risk Factors for MM include:
Increasing age. Your risk of multiple myeloma increases as you age, with most people
diagnosed in their mid-60s.
increasing or decreasing toxicity depending upon further metabolism of acetylhydrazine to
reactive species. Furthermore, cytochrome P450 isozymes (1A1, 1A2, 2B1 and 2E2) have
been shown to oxidize hydrazines to toxic intermediates that bind to cellular
macromolecules (17-22).
Unfortunately, not much has been studied on the effects of hydrazine on MM, however,
there is enough convincing evidence to show hydrazine has carcinogenic effects on the
hematological system and is a putative carcinogen (6-22). In my medical opinion, exposure
time and dose of hydrazine in the Veteran had never been elucidated. Especially since he
had both chronic exposure from his MOS, and acute exposure from the Titan 34D missile
explosion at the Vandenberg base. There is too much ambiguity in the amount of hydrazine
exposure. This was the basis for denial by the previous examiner. This is incorrect. A lack
of evidence for the amount of exposure and length of exposure is a burden which the VA
examiner must provide with definitive parameters to refute the claim, as this is an argument
of at least likely than not.
It is clear from literature that Mr. H’s diagnosis of MM indeed was influenced from
his exposure to hydrazine while enlisted in the military. There are numerous unexplained
variables present here, including dose of rocket fuel exposed, length, and route of exposure.
A stable constant dose over years of hydrazine increases your risk of getting the
malignancy. Indeed, Mr. H may have had other risk factors for MM which led to his
diagnosis, however, this does not negate the fact hydrazine at least as likely as not
contributed to the development of MM. Mr. H’s claim that MM 1s at least as likely as
not due to military enlistment activities, is consistent with my medical opinion without any
reservations.
The Veteran’s entire file provided was reviewed to reconcile with his claim. It is in my best
ability with sound consciousness to state, all medical opinions given in this document are
according to the Veteran’s claims and medical chart review. I reserve the right to change
my medical opinion if discrepancies are noted otherwise.
Signed,
Syed B WP/PAP
Syed R. B M.D., PhD.
Internal Medicine/Pharmacology & Toxicology
References:
1. Dhodapkar MV. MGUS to myeloma: a mysterious gammopathy of underexplored
significance. Blood. 2016 Dec 08;128(23):2599-2606.
Male sex. Men are more likely to develop the disease than are women.
Black race. Black people are about twice as likely to develop multiple myeloma as are
white people.
Family history of multiple myeloma. If a brother, sister or parent has multiple myeloma,
you have an increased risk of the disease.
Personal history of a monoclonal gammopathy of undetermined significance
(MGUS). Every year | percent of the people with MGUS in the United States develop
multiple myeloma.
Obesity. Being overweight or obese increases a person’s risk of developing myeloma.
Toxic and organic solvent exposure (4,5).
Indeed, there is abundant literature finding showing a causal/nexus amongst toxic exposure
of rocket fuel and malignancies. Rocket fuel consists of an inherent chemical, hydrazine,
which is a putative disease-causing agent. The primary route of potential human exposure
is through a complex molecule of hydrazine, 1,1-dimethylhydrazine (1,1-DMTH). The
chemical is exposed through inhalation, ingestion, and dermal contact. The potential for
1,1-DMTH may be higher for people who live near military installations where the
chemical is used as an aerospace propellant or for people who live near hazardous waste
sites contaminated with hydrazine (6-8). Previous mortality studies show associations
between hydrazine exposure and death from cancers of the hemato- and lymphopoietic
system, bladder and kidney, and pancreas (9). Acute exposure to hydrazine produces
severe central nervous system effects, such as coma and convulsions sometimes resulting
in death. Studies emphasize the importance of acute ammonia intoxication as a major
component of the metabolic effects of hydrazine (10). There are chronic and acute effects
discussed in the literature on organ systems due to hydrazine exposure.
Of importance is the recognition of how hydrazine has toxic effects on the hemato- and
lymphopoietic system. Epidemiologic studies have suggested that occupational toxic
exposure may be a leading risk factor MM. Multiple meta-analyses of case-control studies
show the association between occupational exposure to organic solvents and the risk of
MM (11-16). It has been suggested that metabolic activation of hydrazines leads to their
toxicity, and various non-enzymatic and enzymatic systems have been identified.
Hydrazines undergo acetylation by N-acetyl transferase, in which an acetyl group is
transferred from acetyl coenzyme A; the rate of acetylation of hydrazines can be fast or
slow depending upon the concentrations of the enzyme and an individual’s phenotype.
People who are fast acetylators rapidly convert hydrazine to its acetyl form, thus either
. International Myeloma Working Group Updated Criteria for diagnosis of MM.
Lancet Oncol. 2014
A Cancer statistics, 2020. CA Cancer J Clinic 2020; 70; 7-30
. https://www.mayoclinic.org/diseases-conditions/multiple-myeloma/symptoms-
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Up-to-Date, Rajkumar, S., Pathobiology of Multiple Myeloma, April 2014
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on Hydrazine/hydrazine Sulfate. Washington, DC: National Center for
Environmental Assessment, Office of Research and Development; 1999.
9. Ritz B, Morgenstern H, Froines J, et al. Chemical exposures of rocket-engine test-
stand personnel and cancer mortality in a cohort of aerospace workers. J Occup
Environ Med. 1999;41:903-910.
10. Floyd WN Jr. The importance of ammonia in the metabolic effects of hydrazine.
Aviat Space Environ Med. 1980 Sep;51(9 Pt 1):899-901. PMID: 7417161.
11. Morris PD, Koepsell TD, Dalling JR, et al. Toxic substance exposure and multiple
myeloma: a case-control study. J Natl Cancer Inst, 1986; 76: 987-994.
12. Linet MS, Harlow SD, McLaughlin JK. A case-control study of multiple myeloma
in whites: chronic antigenic stimulation, occupation, and drug use. Cancer Res,
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13. Flodin U, Fredriksson M, Persson B. Multiple myeloma and engine exhausts, fresh
wood, and creosote: a case-control study. Am J Ind Med, 1987; 12: 519-529.
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Aw
Un
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