Death occurred on August 16, 1962. Autopsy confirmed the diagnosis of acute mal myelogenous leukemia with generalized leukemic infiltration of parenchy organs. There was an acute hemorrhagic bronchopneumonia as the primary cause of death, The bone marrow showed complete replacement by immature ee Oe - CASE NO. 11 particularly the tibia cells of the granulocytic series. The left lower extremity, ve chronic presumpti t subsequen and previously involved with trauma examined. not was itis osteomyel Type of Injury: Acute Myelogenous Leukemia. diagnostic The question raised by this case was whether the exposure to for an existed (which state tory inflamma and infection X-ray and the chronic BVA’s Decision: Denia! Affirmed. role in the eventual! acute leukemia. Date of Decision: 1971. Appellant's Allegation: That the veteran's service-connected chronic infection of his left leg and/or treatment for such disability was the cause of his leukemia. [t is suggested that, since the role of radiation cannot be excluded, a reasonable doubt exists and should be resolved:in favor of the appellant. Facts: The veteran was born in September 1919 and had active service from March 1942 to June 1946. He was in apparent good health at age 22 when he entered the service. Service medical records disclosed that the veteran sustained a compound comminuted fracture of the left tibia when hit by flak during combat in September 1943. Despite appropriate therapy, non-union of the left tibial fracture occurred, with granulating skin wourfd; seven months following the injury a successful skin graft to the area of the fracture site was applied without evidence of subsequent skin infection. During this period the patient developed serum hepatitis secondary to transfusions, which remitted spontaneously. Seventeen months after the injury, the patient continued to have leg pain and X-rays showed presistent non-union. Because of suspected osteomyelitis, penicillin therapy was given. significant etiologic indeterminate period of time following the injury) played a and Medical Evidence: One medical doctor stated that chronic infection veteran's the d”if “wondere and dyscrasia blood some exposure to X-ray cause medical teukemia had been related to his service-connected infection. Another and infection “chronic veteran’s the doctor expressed the opinion that ing factor repeated X-ray exposure very definitely could have been a contribut toward the development of an acute leukemia”. The records were then submitted to a medical officer of the Veterans the Administration for an opinion regarding the relationship of the leukemia to his of because subjected been had radiation exposure to which the veteran the that opinion officer's medical the was It es. disabiliti service-connected the radiation exposure “would be only a speculative possibility as a cause of veteran’s leukemia”. the Board that The veteran’s family physician stated in a letter submitted to there might be a connection between the veteran’s repeated X-ray exposure chronic and final development of leukemia and that it was possible that the the entof developm the in factor ing osteomyelitis could have been a contribut _ leukemia, The records were forwarded to a leading medical school for the opinion of The an independent specialist, not employed by the Veterans Administration. opinion furnished is, in pertinent part, as follows: The veteran was discharged from military service on June 14, 1946. After Studies of atomic bomb survivors’, American radiologists”, British radiologists’, patients with ankylosing spondylitis® > treated with X-ray extremity were done over a fourteen year period. Clinica) and radiologic all indicated that sufficient dosage of irradiation given to hematopoietic bone marrow is associated with an increase in the incidence of discharge, the veteran was followed in Veterans Administration Hospitals where three additional X-ray diagnostic studies of the involved left lower evaluation of the left leg in 1960 indicated no evidence ofactive osteomyelitis but marked osteosclerosis at the previous fracture site. There was shortening of the left lower extremity with secondary residual weakness and loss of muscle bulk, associated with dysesthesias. On April 9, 1962, he was admitted to the hospital with severe anemia. In February of 1962 he had pneumonia treated with Declomycin and Achromycin. After that time he had had repeated bouts of pharyngitis and sinusitis and noted increasing fatigability., A review of a bone marrow aspiration done at the time of this admission by a consultant confirmed the diagnosis of acute myeloblastic leukemia. The patient was subsequently treated with whole blood transfusions and (presumptively) intravenous chemotherapy (although not clear from the record). On August 14, 1962, the patient was again admitted to the hospital acutely ill with weakness, high fever, dyspnea. 44 and patients treated with radium ['?', thorotrast and phosphorus 32°", myeloproliferative disorders, including acute leukemias in these individuals. In the Japanese bombcasualties, the incidence of leukemia was increased ten fold, whereas in American and British radiologists prior to 1963, acute leukemia occurred with twice the frequency seen in & non-radiologist physicians. Commontoall of these cases, however, Was of excess in time, of period variable a over given on irradiati of dose high of 100 R (total body radiation), and permitting the exposure either n radiatio ionizing to marrow bone ietic proliferating hematopo and external or internal. A study of the relation of diagnostic ma lympho and leukemia of e incidenc therapeutic X-rays to the only in published in 1962, showed that radiogenic leukemia occurred years ten within taken abdomen association with X-rays to the chest or 45