Citation Nr: 1328671 Decision Date: 09/09/13 Archive Date: 09/17/13 DOCKET NO. 11-07 672 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUE Entitlement to service connection for idiopathic thrombocytopenia purpura (ITP), to include as due to in-service herbicide exposure. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his wife ATTORNEY FOR THE BOARD M. Zawadzki, Counsel INTRODUCTION The Veteran served on active duty from August 1963 to July 1967, to include service in Vietnam from July 1966 to July 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from December 2009 and February 2010 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio and Pittsburgh, Pennsylvania, respectively, in which the RO denied service connection for ITP. The case was certified to the Board by the Pittsburgh RO. The Veteran was previously represented by Veterans of Foreign Wars of the United States (as reflected in a July 2009 VA Form 21-22, Appointment of Veterans Service Organization as Claimant's Representative). In September 2010, the Veteran filed a VA Form 21-22 appointing Disabled American Veterans as his representative. In July 2011, the Veteran testified before the undersigned Veterans Law Judge via videoconference; a transcript of the hearing is of record. The Veteran's paper claims file and Virtual VA e-folder have been reviewed as part of his appeal. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND Remand is required to obtain outstanding VA and private treatment records, Social Security Administration (SSA) records, and to afford the Veteran a VA examination to obtain a medical opinion regarding the etiology of his ITP. Accordingly, the case is REMANDED for the following action: 1. Request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for ITP. After acquiring this information and obtaining any necessary authorization, obtain and associate any outstanding pertinent records with the claims file or Virtual VA e-folder. The AMC/RO should ensure that all pieces of evidence relied on in the September 2012 rating decision included in the Virtual VA e-folder are available for the Board's review in either the e-folder or the paper claims file. This evidence includes: * The Veteran's January 2011 VA Form 21-4138; * The Veteran's October 2011 VA Form 21-4138; * An October 2011 VA diabetes mellitus examination report; * Private medical records from Allegheny General Hospital Electrophysiology, Dr. C.B., dated from March 2004 to October 2011; * December 2011 VA heart conditions and male reproductive system conditions Disability Benefits Questionnaires; * Private medical records from Dr. M.M.T., dated from May 2010 to March 2012; * Private medical records from Dr. T.J.L., dated from May 2007 to March 2012; * Private medical records from Dr. K.A.R., dated from April 2011 to March 2012; * VA treatment records from the Butler VA Medical Center (VAMC), dated from November 2003 to June 2011; and * VA treatment records from the Pittsburgh VA Healthcare System, dated from May 2011 to June 2011. A specific request should also be made for: * Any treatment records from the Butler VAMC dated prior to November 2003, to specifically include the report of a June 2001 VA Agent Orange examination; * Any more recent treatment records from the Butler VAMC and the Pittsburgh VA Healthcare System, dated since June 2011; * Any additional treatment records from Dr. F.W., dated since May 2005 (as identified in a November 2003 VA Form 21-4142); and * All records regarding hospitalization in July 1999 from United Community Hospital and/or Garden City Hospital. If any identified records are not obtainable (or none exist), the Veteran and his representative should be notified and the record clearly documented. 2. Obtain from the Social Security Administration (SSA) a copy of any decision regarding the Veteran's claim for disability benefits pertinent to the claim on appeal, as well as copies of all medical records underlying those determinations. 3. After all available records have been associated with the claims file and/or Virtual VA e-folder, afford the Veteran a VA examination to determine the etiology of his ITP. The claims folder must be made available to the examiner for review of the case. A notation to the effect that this record review took place should be included in the report of the examiner. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. The examiner must provide an opinion as to whether the Veteran's current ITP began during active service or is related to any incident of service, to include in-service exposure to herbicides. As indicated above, the examiner should review the record in conjunction with rendering the requested opinion; however, his or her attention is drawn to the following: * The Veteran asserts that his ITP is related to in-service exposure to Agent Orange. * The Veteran served in Vietnam from July 1966 to July 1967 and is presumed to have been exposed to herbicides, to include Agent Orange. * Service treatment records are negative for complaints regarding or findings of ITP. * Post-service private treatment records reflect diagnoses of and treatment for ITP, as early as in July 1999. A July 1997 record from Dr. F.W. includes an assessment of thrombocytopenia and records from this physician also indicate that the Veteran was diagnosed with thrombocytopenia in September 1995. * In July 1999, the Veteran presented to United Community Hospital with complaints of bruising for several weeks; however, this treatment record later states that he had had bruising for several days prior to admission. A complete blood count (CBC) done prior to admission showed platelet count to be below 50. He was admitted for unknown thrombocytopenia. * An October 1999 treatment record from the Mayo Clinic notes that the Veteran was in his usual state of health until early July when he presented with extensive bruising on his arms, legs, and stomach. He was found to be severely thrombocytopenic and was hospitalized. He underwent splenectomy later that month. The Mayo Clinic hematologist noted that, with regards to precipitating or etiologic factors, at the time the Veteran developed immune thrombocytopenia he was working on his deck and noted that the treated wood had an unusual odor and he developed a pruritic rash on his shoulders and extremities. The only medications he was taking at the time the thrombocytopenia occurred were Hydrochlorothiazide and Prednisone. Prior to July, he had no history of abnormal blood counts or anemia. He had no history of autoimmune disease and denied any prior episodes of venous thrombosis or symptoms of a connective tissue disorder. The impression was immune thrombocytopenia, apparently refractory to therapy with Prednisone and splenectomy. The hematologist stated that possible etiologic associations included exposure to some form of chemical in the wood treating solution. However, she added that the Veteran was on and continued to be on Hydrochlorothiazide. Other etiologic factors were an underlying lymphoproliferative disorder, autoimmune disorder, or viral infection. She ordered additional studies. * The Veteran returned for follow-up the next day and the hematologist stated that investigations appeared consistent with ITP. The etiology was "still uncertain"; however, the physician noted that possibilities included toxic exposure to wood treatment solution which apparently contained quinine and cyanide and possibly also a drug effect related to the Veteran's Hydrochlorothiazide use. The physician commented that Hydrochlorothiazide was an unlikely cause given the fact that the Veteran had been taking it for several years prior to the onset of his acute thrombocytopenia; however, this did not exclude it from being causative. It was noted that the Veteran had discontinued Hydrochlorothiazide a day earlier. The diagnosis was immune thrombocytopenic purpura. * In a December 2010 letter, the Veteran's private physician, Dr. T.J.L., wrote that the Veteran was currently a patient under his care and had "a clear diagnosis" of idiopathic thrombocytopenic purpura (ITP). Dr. T.J.L. stated, "It is likely that his diagnosis of ITP could be linked to his military service." * Also in December 2010, the Veteran's private hematologist, Dr. M.M.T., wrote that the Veteran had been under her care for refractory idiopathic thrombocytopenia purpura. She stated that the question had been raised regarding his prior exposure to herbicides while serving in Vietnam. Dr. M.M.T. stated, "There certainly has been documented relationship between exposure of substances to hematologic and malignant disorders. I feel that further consideration in [the Veteran's] case is certainly warranted." * During the July 2011 hearing, the Veteran testified that he was originally diagnosed with ITP in June of 1999 and did not really have symptoms of ITP earlier than that time. He stated that he had been building a deck and experienced extreme bruising, so he went to the hospital where he was diagnosed with ITP. * During the July 2011 hearing, the Veteran's wife testified that ITP comes from pesticides, like cyanide, to which the Veteran was exposed. The Veteran clarified that when he was first diagnosed with ITP, it was thought that it might be related to treated wood he had been handling, which had cyanide in it. However, he stated that his doctors had since told him that, if he was working on a deck one day, he would not start showing symptoms the next day, which is what happened. Rather, it was coincidental that he happened to be working with this wood when the problem occurred. In rendering the requested opinion, the examiner must consider and address the December 2010 opinions from Drs. T.J.L. and M.M.T. All examination findings, along with a complete explanation for all opinions expressed, should be set forth in the examination report. 4. Conduct any other appropriate development deemed necessary. Thereafter, readjudicate the claim, considering all evidence of record. If the benefit sought remains denied the Veteran and his representative should be provided an SSOC. An appropriate period of time should be allowed for a response. The appellant has the right to submit additional evidence and argument on the matter that the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).