Citation Nr: 0925539 Decision Date: 07/08/09 Archive Date: 07/21/09 DOCKET NO. 04-13 846 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUES 1. Entitlement to service connection for nonspecific inflammatory polyarthritis and/or psoriatic arthritis (claimed as a joint condition or an arthritic condition of multiple joints) as due to an undiagnosed illness or a medically unexplained chronic multisymptom illness as a result of Persian Gulf War service. 2. Entitlement to service connection for psoriasis/eczema (claimed as a skin rash) as due to an undiagnosed illness or a medically unexplained chronic multisymptom illness as a result of Persian Gulf War service. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD S. Heneks, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1984 to February 1992. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from a September 2003 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. In a July 2005 decision, the Board reopened the claims on appeal and remanded both for further development. As the Board is granting the claims for entitlement to service connection for nonspecific inflammatory polyarthritis and psoriasis/eczema, a discussion of whether the directives of the July 2005 Board remand were fully complied with is not necessary, as no prejudice will result to the Veteran. FINDINGS OF FACT 1. After resolving all reasonable doubt in the Veteran's favor, nonspecific inflammatory polyarthritis and/or psoriatic arthritis has been shown to be causally or etiologically related to the Veteran's military service during the Persian Gulf War. 2. After resolving all reasonable doubt in the Veteran's favor, psoriasis/eczema has been shown to be causally or etiologically related to the Veteran's military service during the Persian Gulf War. CONCLUSIONS OF LAW 1. The criteria for service connection for nonspecific inflammatory polyarthritis and/or psoriatic arthritis have been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2008); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2008). 2. The criteria for service connection for psoriasis/eczema have been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2008); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2008). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Because the claims for entitlement to service connection on appeal are 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. 2008); see also 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2008). LAW AND ANALYSIS 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 injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). In sum, 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)). Under the provisions of specific legislation enacted to assist veterans of the Persian Gulf War, service connection may be established for a qualifying chronic disability which became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2011. 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317(a)(1)(i). The term "qualifying chronic disability" means a chronic disability resulting from an undiagnosed illness; a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined as a cluster of signs or symptoms; or, any diagnosed illness that VA determines in regulations warrants a presumption of service connection. 38 U.S.C.A. § 1117(a)(2). Signs or symptoms that may be a manifestation of an undiagnosed illness or a chronic multisymptom illness include: (1) fatigue, (2) unexplained rashes or other dermatological signs or symptoms, (3) headache, (4) muscle pain, (5) joint pain, (6) neurological signs and symptoms, (7) neuropsychological signs or symptoms, (8) signs or symptoms involving the upper or lower respiratory system, (9) sleep disturbances, (10) gastrointestinal signs or symptoms, (11) cardiovascular signs or symptoms, (12) abnormal weight loss, and (13) menstrual disorders. 38 U.S.C.A. § 1117(g). Among the requirements for service connection for a disability due to an undiagnosed illness is that such disability, by history, physical examination, and laboratory tests, cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a)(1)(ii). There must be no affirmative evidence that relates the undiagnosed illness to a cause other than being in the Southwest Asia theater of operations during the Persian Gulf War. See 38 C.F.R. § 3.317(c). If signs or symptoms have been attributed to a known clinical diagnosis in the particular veteran's case being considered, service connection may not be provided under the specific provisions pertaining to Persian Gulf veterans. See VAOPGCPREC 8-98 at paras. 4-5 (Aug. 3, 1998). The Board notes that, in rendering a decision on appeal, it must analyze the credibility and probative value of the evidence, account for the evidence which 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). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert, 1 Vet. App. at 54. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is entitled to service connection for non-specific chronic polyarticular inflammatory arthritis and psoriasis/eczema. The Veteran asserts that his skin rash and arthritis are the result of exposure to chemicals and contaminants during his service in the Persian Gulf. In particular, he contends that his skin condition began as a rash shortly after his return from the Persian Gulf and later developed into arthritis. The Veteran's DD Form 214 reflected that he served in the Southwest Asia theater of operations during the Persian Gulf War and that he received the Southwest Asia Service Medal and Kuwaiti Liberation Service Medal, which the Board finds is sufficient to establish the requisite service in this case. 38 C.F.R. § 3.317(d)(1); (2). As an initial matter, the Board notes that the Veteran has diagnoses of non-specific chronic polyarticular inflammatory arthritis and psoriasis/eczema, therefore rendering the provisions of 38 C.F.R. § 3.317 inapplicable. Notwithstanding the foregoing, regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). In this regard, although the evidence is somewhat unclear, it appears that the Veteran initially developed a skin rash following his service in the Persian Gulf that developed into a non-specific form of arthritis. In December 2002, Dr. E.R.S., who was the Veteran's rheumatologist since 2000, noted that the Veteran's symptoms began shortly after he returned from Desert Storm. His symptoms began with a rash and dryness and after two years, he began having joint pain and stiffness involving his hands and feet. He was initially diagnosed with eczema and then following multiple skin biopsies, he was diagnosed with psoriasaform dermatitis. He was later diagnosed with psoriatic arthritis that was based on inflammatory polyarthritis in the context of a skin rash. Both the skin rash and arthritis responded well initially to the medication Methotrexate. During a May 2003 VA Gulf War examination, the Veteran stated that he served in Saudi Arabia, Kuwait, and Iraq from August 1990 to April 1991. He reported that he first noticed a rash on his hands in approximately 1993, two months after returning from the Persian Gulf. Following examination, diagnoses of nonspecific inflammatory polyarthritis; history of skin condition involving hands, unable to make a specific diagnosis; and skin condition involving elbows by history suggestive of psoriasis or xerosis were given. The examiner commented that since the Veteran did not appear to have a definite diagnosis, it was difficult to determine whether his skin condition was due to his military service. The examiner added that she could not exclude this possibility. Most recently during an April 2007 VA rheumatology examination, after reviewing the claims file, the examiners again diagnosed non-specific polyarticular inflammatory arthritis. The examiners stated that the cause of inflammatory arthritis is unknown but it is believed that genetic factors determine the susceptibility and environmental triggers are believed to be important. The examiners added that most researchers believe that the immune system is somehow mistakenly triggered and that documented service related exposures raise suspicion as a contributing factor. The examiners concluded that it was their joint opinion that the Veteran's non-specific chronic polyarticular inflammatory arthritis was most likely caused by or the result of his exposure to multiple contaminants while serving in the Persian Gulf. Further, they noted that his non- specific chronic polyarticular inflammatory arthritis was a medically unexplained chronic multisymptom illness that was without pathophysiology or etiology. Therefore, based on the April 2007 VA examination, the Board will grant service connection for non-specific chronic polyarticular inflammatory arthritis. Turing to the claim for a skin rash, the March 2007 VA dermatology examiner noted that the Veteran first developed excessive dryness of the hands after his discharge in 1992 and 1993. It was also stated that after the dryness of his hands cleared up, he developed poly-arthritis, and that he has found that when he misses his Methotrexate that he takes for arthritis, he gets a re-institution of the dryness of his hands. The diagnosis was mild hand eczema. The examiner concluded that based on a review of the claims file and the Veteran's history, his skin disorder started after his discharge in 1992. The examiner also stated that the Veteran could not correlate his skin disorder with any particular event or occurrence during his military service. The examiner indicated that psoriasis was unclear as to its complete etiology and could be associated with other symptoms, such as fatigue, pain, etc. and that the only specific diagnostic test was a skin biopsy. The examiner concluded that since his symptoms presented after his discharge from service, it could not be said that this is a service related condition. However, the Board notes that contrary to the examiner's assertion that the Veteran could not correlate his skin condition with any particular event during the military, the Veteran has contended that it is related to his exposure to various containments he was exposed to while in the Persian Gulf. Additionally, as referenced above, Dr. E.R.S., the May 2003 VA examiner, April 2007 VA rheumatology examiner, as well as the March 2007 VA dermatology examiner all indicated that the Veteran's symptoms first manifested as a skin rash that developed into a non-specific type of inflammatory arthritis. This conclusion is further supported by the medical evidence which tends to show that both his skin rash and arthritis improves when taking Methotrexate. Additionally, both the May 2003 and March 2007 VA examiners indicated that the etiology of the Veteran's skin rash was unclear. Thus, after considering the medical evidence a whole and resolving all reasonable doubt in favor of the Veteran, the Board will grant service connection for non- specific chronic polyarticular inflammatory arthritis and psoriasis/eczema. ORDER Entitlement to service connection for nonspecific inflammatory polyarthritis and/or psoriatic arthritis is granted. Entitlement to service connection for psoriasis/eczema is granted. ______________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs