April 5, 2014

Dr. Wendy Yong, MD11212 Monon StreetOoklond, CA 94605(4r 5) 238-4628

Ooklond Regionol Officeof ihe Veterons Administroiionl30l Cloy St., North TowerOoklond, CA 94612

This Stotement concerns Curtis C. Christy, 121-42-0474,VA File Number 29695006, concerning his VA Disobility Cloim

To the VA Disobility Roting Reviewers:

I om Curtis Christy's former wife ond I om o physicion speciolizing in pothology.During the ten yeors we were iogether (1992-2002) I boih leorned obout the illness

for which Curtis wos oworded service connected VA disobiliiy, ond directlyobserved o number of secondory conditions thot I believe more likely thon notstem from his pulmonory diseose. Curtis told me thot his illness begon qnd wosdiognosed while he wos serving in the Army of the militory hospiiol of SHAPE,

Belgium from 1977 lhrovgh 1979. Curtis hos indicoted to me thot he is currentlypetitioning io hove the secondory conditions [including onxiety, depression,foiigue, stominq issues, ond severol othersl odded to his service connecteddisobility, ond is osking to be re-roted on thoi bosis in order for him to be oble toreceive ongoing treotment for oll ospects of the physicol ond mentol heoltheffecis thot ore believed to stem from the sorcoidosis. I support his efforts ond I wish

to exploin why I do.

ln 1983 when Curtis wos first qworded service connected VA disobility, medicolreseorch of thot time wos generolly locking thot could hove linked (1) sorcoidosisto toxic exposure, ond (2) depression ond other secondory conditions tosorcoidosis. Thot is no longer the cose bosed on reseorch done over the post thirtyplus yeors. Curtis told me thot olthough he ottempted to get mentol heolth

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ossistonce when he first begon to become depressed in the Army, he found thotbecouse there wos no scientific reseorch proving the link, his concerns weredownployed or ignored. I do not believe thot would hove been the cose todoy.Furthermore, Curtis iold me thot when he otiempted to drow ottention to thelikelihood of toxic exposure in the Phormocy, thot concern wos olso ignored.Agoin, thot would not hoppen iodoy bosed on whot we know now. Mony thingshove chonged in the iniervening 33 yeors since his initiol disobility cloim wossubmitted--omong them being the foct thot formoldehyde hos been ploced onthe tist of corcinogens; ond thot becouse of their now known toxicity, the hondlingof the hozordous moteriols he worked with the phormocy [including boihformoldehyde ond cyiotoxic oncology drugsl now require technicions to useproteciive geor, to include breothing mosks ond gloves. However, Curtis told methot he wore neither type of proteciion while working with those ogents in Belgiumbock in the lote-l970's.

Since lwos his wife, ond not his doctor, I defer to whot Curtis' physicion of Koiser

Permonenie, Dr. Jerry Yong [no relotion to meJ, hos soid in his letter supportingCurtis'cloim. ln his letter Dr. Jerry Yong siotes thot in oddition io being followed forhis sorcoidosis, Curtis hos olso been "freofed for many conditions felf fo besecondory to this diognosis." Thot is o stotement thot probobly could not hovebeen sqid in 1982-3 (ot the time of the initiol cloim) becquse the reseorch on whichto bose such on ossertion hod not yet been performed. Furthermore, Dr. JerryYong stotes thot 'given the period of lhe onsef, the connecfion of the ongoingsecondory conditions fo the pvlmondry sorcoidosis cerfoinly cannot be ruled ouf."Dr. Jerry Yong goes so for os io stote thot "fhe origin [of his pulmonory sorcoidosisond his secondory medicol conditionsl more thon likely wos due fo fheenvironmenlal exposure to hormful chemicols ond vopors while in fhe UnitedSfofes Army." This is onother stotement thot probobly could not hove been modewith confidence in 1983. But the reseorch into the conneciions necessory to mokesuch ossertions hos increosed exponentiolly since those doys.

As the one person who observed ond poid ottention to Curtis'depression, onxiety,fotigue ond stomino issues during the ten yeors we were together, I hove beeninterested to understond the connections between his pulmonory illness ond other,non-pulmonory conditions. Alihough the clinicol presentotion of both sorcoidosisond depression ore not my oreos of clinicol expertlse, I did toke speciol interest inreoding the medicol literoture ovoiloble thot correlotes (l ) the origin of sorcoidosis(ot leost in some coses) with exposure to hormful ogents, ond (2) non-pulmonorysecondory conditions ossocioted with sorcoidosis. lt seems oppropriote for me tosubsioniiote this comment wiih severol key citotions:

Y of/ot/ry

Fotigue in potients with sorcoidosis is well known, even for potients in remission fromsorcoidosis (Korenromp(1) , 2A1l ). Chronic fotigue is most common omongpotients of Stoge lll, which wos Curtis siiuotion when he wos diognosed, ond whenhe first begon io struggle with fotigue (Korenromp(2),201 1). Depression is knownto be very common (obout iwo-thirds, Clevelond Clinic{2),2014) in potients withsorcoidosis (Hinz, 2012; Gorocci,2008). A prominent sorcoidosis reseorcher coinedthe phrose 'posfsorcoidosis fotigue" to describe the fotigue thot continues to beexperienced by potients even ofter the pulmonory ospecis of their sorcoidosishove gone inio remission (Shormo, 20.l2). Medicol reseorchers hove concludedthot potients whose sorcoidosis hos gone into remission moy continue toexperience depression (Korenromp(1),201 1), ond psychologicot interventionshove been suggested (Trombini & Trombini , 2012). Of course depression ondfotigue feed off eoch other, ond couse cyclic bouts of both for the people whoexperience them (Kerr, M., 201 2; De Kleiin, 2013). lt hos been known since os eorlyos 1980 thoi potients thoughi to be in remission from sorcoidosis con monifest thesymptoms of depression (Gilmore, 1980; Stiller, ZAn), so this is noi o new concept,but roiher one thot hos become beiter undersiood ond more well-known in recentyeors.

When Curtis wos first diognosed with sorcoidosis, he hos indicoted thot hecomploined to his doctors obout the depression ond fotigue, but thot he keptbeing told thqt it would poss, ond thot it wos simply o noturol response to beingtold thot he wos ill. Curtis totd me thot even when ihe pulmonory symptomsbegon to remit once he left the phormocy in Belgium, he could not get o mentolheolih referrol for the continuing depression. Flnolly, when he went oround thesystem ond directly to on Army Psychioirist in ltoly, he wos immediotely gronted ocompossionote reossignment bock to the Stotes.

Curtis hod olwoys been puzzled thot while his pulmonory symptoms were cleoringup, his oiher concurrent ond opporently ossocioied non-pulmonory symptomsincluding onxiety, depression, fotigue ond stqminq issues did not improve. lt is wellknown in medicine thot some effects of toxins leod to only tronsient clinicolconditions which will relieve when the toxins ore removed from the environment;while other effects of toxins con leod to permonent body domoge, either resultingin immediote permonent clinicol conditions (i.e., olcohol with ossocioted olcoholneuropothy, etc.) or eventuolly in deloyed medicol condiiions {i.e., the relotionshipbetween osbestos ond mesotheliomo mony yeors loter, eic.) I believe thot it is

more likely thon not thof the toxic chemicols thot Curtis hod been exposed io inthe Phormocy in Belgium hove hod permonent detrimentol effects on his bodythot hove led to his other persistent non-sorcoidosis symptoms even ofter he wos

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not exposed to the toxins. I think thoi his clinicol history is consistent with thereseorch findings referred to ond demonstroted in mony other medicoljournolorticles on reloted topics. lt is olso known thot sorcoidosis con recur (Boughmonond Judson, 20,I4) ond flore-ups con occur. ln foct, for potients who undewentcorticosteroid theropy (os Curtis did in the eorly months of his illness), relopsesoccurred in 36.6% of coses (Rizzoto, G., et ol., 1998).

Cutis hos told me thot he hod no clinicol history of ony pulmonory disorder prior tothe diognosis of sorcoidosis ofter he storled working in the Army Phormocy.Although Curtis' sorcoidosis wos considered in remission soon ofter he left theArmy, he did hove multiple episodes of coughing ond wheezing thoi led io odiognosis of osthmo of Koiser. lt is known thot "ln sorcoidosrs, symptom resolutionfends fo be femporory os evidence by fhe epidemiologicolreseorch" (The

Morsholl Protocol, 2014l.. Symptomotic remission doesn't meon thot the diseose iscompleiely gone since with respect to sorcoidosis "Remission meons fhe diseoseisn'l oclive, but it con return" (NlH, 20,l3 ; Mono, 2003). Although sorcoidosis is odiognosis of "Exclusion"-which meons thot oll oiher couses other thon sorcoidosishove to be excluded-it is highly likely thot his recurrent pulmonory sympioms wererepresentotive of recurrence or flore-ups of sorcoidosis bosed on his known history

of sorcoidosis.

There is on obundont scieniific [iteroture to support the connection of his

sorcoidosis io duties performed in Curtis' Army workploce (nomely the Phormocy otSHAPE, Belgium). Although it is not yet cleor the specific ogents thot cousesorcoidosis, evidence from omple reseorch supports thot it is coused by onimmune reoction to some trigger (colled on ontigen) which moy be from one'senvironment including chemicols or infectious ogents, etc. The solient exomplesinclude the finding thot on unexpeciedly high proporiion of soldiers who served inthe Gulf Wor ond who become ill from iheir exposure to toxins in their field ofoperotions, hove been diognosed with pulmonory sorcoidosis--l5 times greoterfrequency in one study (lnstituie of Medicine, 1996lr. Also, o higher thon expectedproportion of the first responders (including firemen) ond those involved in thecleon-up operotions of the collopsed Towers ofter 9-l l, become ill ond developedsorcoidosis from breothing the toxic chemicols in thot environment (Jordon, 2001;

lzbicki, 2007l,. There ore mony websites ovoiloble to veierons with heolth problemsincluding sqrcoidosis. Although sorcoidosis hos long been referred to os o 'diseose

of unknown etiology," there is o big difference between knowing the diseosepoihophysiology but not knowing the specific cousotive ogents, versus notknowing the diseose pothophysiology of oll. The current reseorch supports thotsorcoidosis is most tikely coused by ogents in the environment fond opporently by4 ,l offrry/f

a voriety of suspecied ogenfs, bio/ogical and chemicol (Cleveland Clinic, 2013;Boughmon & Culver,20l l/J. ln ihe most elementory terms, in o publicoiion wriitenfor the public, the NIH-through the Notionol Heort, Lung ond Blood lnstitute-soys," More thon one f octor moy ploy a role in cousing fhe diseose. Some reseorchersthink fhof sorcoidosis deve/ops if your immune sysfem responds to a trigger, such osbocterio, viruses, dust, or chemico/s" (NlH, 2013). As indicoted obove, evidencesupporting the link to environmentol exposure hos been observed.

Recent studies now point to toxic exposure to such things os herbicides ondpesticides cousing depression (Weisskopf, 2013). Another use of formoldehyde is oson herbicide ond pesticide. Concerning ihe chemicols Curtis wos exposed towhile in the Army in porticulor, formoldehyde is o volotile orgonic compound thotis used in loborotory histology, in ihe wood industry, ond in in ihe funerol industry,where in eoch situotion it hos been linked to o number of heolth problems (CDPH,

2011: CDC,2008); omong ihe symptoms coused by these hozordous moteriolsinclude depression (Sporks, 1991; Stollones & Beseler,20A2: Brown, 20A4. Along withsuch hozordous moteriols os benzene, tuolene, styrene, ond trichloroethylene,formoldehyde is olso clossified os o volotile corbohydron.

So well ore the dongers of formoldehyde known now, thot OSHA hos octivelysought to prevent toxic exposure in very minutely defined occupotions. For

exomple, in controst to ihe situoiion bock in 1977-1979, the government is nowconcerned obout the risks presented by formoldehyde in noil polish ond noilhordeners (OSHA(l ). 201 4), ond in hoir stroightening products (OSHA (2l', 2011 ). lt is

well understood thot these indusiriol ogents like formoldehyde [ond Curtis lold methat he hod to use industrial strength formoldehyde on his iobj ore neurotoxic ondthot different people con be offected in vostly different woys from the some levelond durotion of exposure (Berger, 1990).

Of course the smoller the populotion of workers directly involved withformoldehyde, the less likely thot populoiion-specific reseorch con be found onihe precise group. Curtis told me thot his former Phormocy Officers of SHAPE hoveboth indicoied in stotements they provided to him thot the SHAPE Phormocy wosthe only Army phormocy of which either mon found formoldehyde to be siored orphormocy technicions to be responsible for mixing it into formolin solution for oLob. lt wos qn onomoly thot formoldehyde wos even in thot phormocy, occordingto Curtis; o proctice thot only hoppened of thot specific Army Phormocy. Thotunusuol situqtion, he believes, ond the stoff members' unfomiliority withformoldehyde, moy occouni for why no one knew to hove the technicions useprotective geor when mixing it. The literqture never shows thot formoldehyde in on

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"occupotionol hazard" for phormocy technicions becouse it wosn't doneonywhere else ond, he remembers thot it wosn't iought of the Acodemy of HeolthSciences (where Phormocy Technicions ore troined). ln thot cose, if would be ospeciol situotion, unique to the SHAPE Hospitol, Lob ond Phormocy, ond os such itwos ond o very risky, dongerous ond hozordous duty for Curtis ond for other stoffwho hod to perform thot duty.

Although formoldehyde hos been known for decodes io couse o long list of heolthproblems, it wos only recently thot it wos finolly closslfied os o corcinogenic. Curtistold me thot his successor in the Army Phormocy (o femole phormocy technicionwho wos pregnont when she took over those duties) loter died of concer. Hodformoldehyde been known os o corcinogenic ogent in the .l960's,

it might hoveprevented the prociice of storing ond mixing formoldehyde in ihe SHAPE

Phormocy, ond perhops Curtis would noi hove become ill, ond his successor in thePhormocy might not hove gotten concer ond subsequently died of it. Curtis toldme thot his concerns obout formoldehyde toxicity hod not been token seriously byhis Army doctors in 1977 through 1979. Otherwise, perhops on inspection or oninvestigotion of the formoldehyde in the SHAPE Phormocy might hove tokenploce, ond his colleogue might hove been spored ever hoving to do thot risky,

toxic job when Curtis wos reossigned to ltoly.

The oncology drugs thot Curtis worked with in the l.V. preporotions room of theSHAPE Phormocy were cytotoxic by definition fthof is, chemotheropy drugs oredesigned to killcel/s]. Whereos todoy sterile product or l.V. technicions qre requiredto employ both gloves ond protective breothing opporotus, Curtis told me thoithose kinds of preventive ond precoutionory tools were not ovoiloble for use by thephormocy technicions of SHAPE. More thon thot, Curtis olso told me thot the fumehood used by the phormocy wos moil-ordered ond ossembled by ihe phormocyiechnicions. lt wos noi correctly ventiloied, nor wos the tiny room it wos ploced in.

The hood often over-heoted ond hod to be shut down, leoding to toxic voporsbeing recycled bock inio the work oreo, exposing the technicions to increosedrisk.

Curtis exploined to me thot his work with both formoldehyde ond oncology drugswqs done doily ond weekly over q three yeor period without the benefit offocemqsks or gloves. Therefore it con be sofely soid ihot his work in thephormocy of SHAPE connot be ruled out os the origin of both the sorcoidosis ondthe secondory conditions thot orose of the some time.

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Bosed on the clinicol reseorch findings over the post ihirty plus yeors (ofter Curtis

left the Army), one does not hove to be o physicion to recognize the connectionsond come to the conclusion, os Dr. Jerry Yong of Koiser did, thoi more likely thqnnot Curiis' illness not only begon while he wos working in the SHAPE Phormocy(which everyone ogrees wiih), but thot it olso wos more likely thon not coused bythe toxic chemicols thot he wos exposed to while working in the environment ofthot Army Phormocy.

As one who observed Curtis' physicol ond mentol heolth issues on o doily bosis forien yeors, ond who felt the undermining of ihe quoliiy of life for him ond for his

fomily os o resuli of those conditions, I concur with Curtis' physicion Dr. Jerry Yong.Therefore, I belleve thot the scientific evidence supports the conclusion thot theconditions listed in Curtis'cloim should be considered secondory to the PulmonoryDiseose for which he hos olreody been roted for VA service connecied disobiliiy. I

believe thot the obundont scientific evidence now ovoiloble in the medicolliteroiure support such o conclusion.

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List of cifsfions, offoched.

of/"6frfWendy Yong, M.D.

Journol orticles. reseorch popers, scieniific obstrocls o,!rd websilqs cited:

Boughmon, R.P. & Culver, D. A concise review of pulmonory sorcoidosis. AmericonJournol of Respirotory ond Criticol Core Medicine; 201.l Mor l; ,l83(5):

573-81 .

doi: 10.11641rccm.201006-0865C1. Epub 2010 Oct 29.

Boughmon, R.P. & Judson, M.A. Relopses of sorcoidosis: whot ore they ond conwe predict who will get them? (Editoriol). lnterstitiol ond Orphon Lung Diseose.Europeon Respirotory Journol: 2014:43:337-339 | DOI:0. I 1 83/0903 1 936.001 389 I 3

Berger, A.R., ef ol. Humon Toxic Neuropothy Due to lndustriol Agenls (chopter). lnldentificotion of Toxic Periphergl Neuropothies, 1990.h tt p : / /www. n e u ro o o i h v. orq /si te / D o cS erv e r/Toxi n -

lnduced Neuropothies.pdf ?doclD= I 603

Brown, J.S. Environmentol ond Chemicol Toxins ond Psvchiotric lllness. AmericonPsyc hiotric Publishing, 2002.

CDC (Centers for Diseose Control). Formoldehyde: Public Heolth Stotement. ToxicSubstonces Poriol of the Agency for Toxic Subsionces ond DiseoseRegistry. Division of Toxicology ond Environmentol Medicine. CAS # 50-00-0;2008.

CDPH (Colifornio Deportmeni of Public Heolth). Formoldehyde. OccupotionolHeolth Bronch, Hozord Evoluotion System ond lnformotion Service.20l 1 Feb.(rev).hitp ://www.cdph.co.qov/orogroms/hesis/Documents/formoldehvde.pdf

Clevelond Clinic (1). Sorcoidosis. Center for Continuing Educotion, DiseoseMonogement Projecl; 201 4.Website:http://www.clevelo ndclinicmeded.com/medicolpubs/diseosemo noqement/pulmonory/sorcoidosis/

Clevelond Clinic {2). Sorcoidosis ond your orgons. 2014. Website:http://my.clevelondclinic.org/disorders/sorcoidosis/hic sorcoidosis ond your orqons.ospx

De Kleijn, W.P., et ol. Noture of fotigue moderotes depressive sympioms ondonxlety in sorcoidosis. Brifish Journol of Heolth Psychology. 2013 Moy; 1812):439-52. doi: l0.l I 111j.2044-8287 .2412.02094.x. Epub 2012 Sep 18.

Gilmore, K. et ol. Psychiotric monifestotions of sorcoidosis. Conodion Journol ofPsychiotry; I 980 Jun;25(4):329-31 .

Gorocci, A., et ol. Quolity of life, onxieiy ond depression in Sorcoidosis {OriginolReseorch Article). Generol Hospifol Psychiatry {o peer-reviewed reseorch

1 of Pr/tr

journol published bimonthly by Elsevier Science), 2008, Sep-Oct, 30(5), pp. 441-445.

Hinz, A., et al. Anxiety ond depression in sorcoidosis: the influence of oge, gender,offected orgons, concomiiont diseoses ond dyspneo. Sorcoidosis Vosculitis ondDiffuse Lvng Diseoses. 2012; 29; 139-1 46

lnstitute of Medicine. Heolth Consequences of Service during the Persion Gulf Wor:Recommendotion for Reseorch ond Informqtion Systems. Notionol AcodemyPress: Woshington D.C.; 1995

lzbicki, G., et ol. World Trode Center "sorcoid-like" gronulomotous pulmonorydiseose in New York City Fire Deportment rescue workers. Chesf; 2007 , Moy,l3l (5):1414-23. Epub 2OA7 Mor 30.

Jordon, H.T., et ol. Sorcoidosis diognosed ofter September I 1, 2001, omong odultsexposed to the World Trode Center disoster. Journol of Occupotionol ondEnvironmentol Medicine; 201 1 Sep; 53(91:9 66-7 4.doi: 0.1097 / JOM.ObO'l 3e3l 822o3596.

Kerr, M. Depression ond Fotigue: A Vicious Cycle. HeolthLine [Medicolly Reviewedby George Krucik, MDl, Published on Morch 29,2012.

Korenromp, l.H.E., et ol. (l ). Chorocterizotion of Chronic Fotigue in Potlents withSorcoidosis in Remission. Chesf (Diffuse Lung Diseose), 2011; 14012), pp. 441-447.

Korenromp, l.H.E., et ol. (2). Reduced Th2 cytokine production by sorcoidosispotients in clinicol remission with chronic fotigue. Broin, Behovior ond lmmunity.201 1 Oct;25{'7):1498-502. doi:

,l0.101 6/j.bbi.201

.l.06.004. Epub 20ll Jun

,l3.

Mono, J. et ol. Recurrent sorcoidosis: A study of 17 potients with 24 episodes ofrecurrence. Sorcoidosis, Vosculitis, ond Diffuse Lunq Diseoses, Cfficiol Journol ofthe World Associotion of Sorcoidosis ond other Gronulomoious Disorders; 2003Oct; 20(3):212-21.

Morsholl Protocol Knowledge Bose, The, Autoimmunity Reseorch Foundotion.Sorcoidosis: Sponioneous Remission. 201 3http://m pkb.oro/home/diseqseslsorcoidosis

NtH (Notionol lnstitutes of Heolth, Notionol Heort, Lung ond Blood lnsiituie. Whot is

Sorcoidosis? 20,I 3. http://www.nhlbi.nih.gov/heolth/heolth-topics/tooics/sorc/printoll-index.html

OSHA (1) (U.S. Deportment of Lobor, Occupotionol Sofety ond HeolihAdministrotion). Heqlth Hozords in Noil Solons; 2014.h tt ps : / /www. os h o . g ov/S LTC / n o ilso I o n s/c h e m ico I h ozord s. h t m I

"Y / "ll ty

OSHA (2) (U.S. Deporiment of Lobor, Occupotionol Sofety ond HeolthAdministroiion). Hoir Smoothing Products Thot Could Releose Formoldehyde;2A1 1 . hiips://www.osho.q ovlSLTC/formoldehyde/hozord olert.html

Rizzoto, G., et ol. The lote follow-up of chronic sorcoid poiients previously treotedwith corticosteroids. Sorcoidosis, Vosculitis gnd Diffuse Lung Diseose; l99B Mor;15{l):52-8.

Shormo, O.P. Fotigue in sorcoidosrs; incompletely understood, inadequotelyfreoted. Current Opinion in Pulmonory Medicine. 2012 Sep;18(5):a70-l . doi:1 0. I 097lMCP.0b0'l 3e328354 1 232.

Sporks P.J., et ol. Depression ond ponic ottocks reloied to phenol-formoldehydecomposite moteriol exposure in on oerospoce monufocturing plont. AllergyProceedings, 1991, Nov-Dec;1216| : 389-93.

Stollones, L. & Beseler, M. Pesticide Poisoning ond Depressive Sympioms omongForm Residents. Annols of Epidemiology {2002]r, 12'.6, pp 389-394.

Stiller, J., et ol. Neurosorcoidosis presenting os mojor Depression fietter] . Journal ofNeuro/ogy, Neurosurgery ond Psychiotry, Moy 23, 2412, pp. '1050-l.

Trombini, G & Trombini, E. Sorcoidosis: Psychotheropy ond Long-Term Outcome-ACose Report. Cose Reports in Medicine. Hindowi Publishing Corporotion, 2012;orticle 232491.

Weisskopf, Morc G. Pesticide Exposure ond Depression Among AgriculturolWorkers in Frqnce American Journalof Epidemiology. (2013) 178 (7): l05l-1058first published online July 12, 201 3 doi:10.1 093/oje/kvrt089

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