Citation Nr: 20002435 Decision Date: 01/10/20 Archive Date: 01/10/20 DOCKET NO. 18-25 082 DATE: January 10, 2020 REMANDED Entitlement to service connection for scleroderma is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1984 to July 1984, from December 1988 to December 1992 and from August 2005 to June 2006. He was awarded the Combat Action Badge and served in Iraq from September 2005 to May 2006. The Board remanded this claim in June 2019. Service Connection – Scleroderma Upon review, the Board finds that remand is required to afford the Veteran a new VA examination and to obtain various opinions. The Veteran filed a claim in May 2015 for entitlement to service connection for “Systemic Scleroderma due to Gulf War Illnesses.” The Board notes that systemic scleroderma is also called systemic sclerosis. See Dorland’s Illustrated Medical Dictionary 1679-80 (32nd ed. 2012). Various medical evidence of record noted a diagnosis of the claimed disability. See, e.g., February 2015 Rheumatology Associates Record (noting an impression from Dr. J.M. of progressive systemic scleroderma). The Veteran was afforded a VA examination in August 2015 and a Skin Diseases Disability Benefits Questionnaire (DBQ) was completed. A diagnosis was noted of scleroderma, with a date of diagnosis noted of 2008. The examiner provided a negative direct service connection opinion that “[t]he claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness.” The provided rationale stated in full that “[t]he patient was near burn pits while in the gulf war. I have no evidence of an acute illness during the period of 8/2/90-12/1/92. He was diagnosed with scleroderma in 2008. It is less likely than not that the scleroderma was related to the gulf war absent any acute illness.” Upon review of this opinion, the Board finds that such did not sufficiently address the various medical contentions raised by the Veteran as to multiple theories of service connection. As the Board is not competent to address the medical contentions raised, the Board finds that remand is required to afford the Veteran a new VA examination and to obtain various opinions that address the Veteran’s contentions and the evidence of record. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). The Board will outline the Veteran’s contentions below, in order to explain the various opinions being requested on remand. First, the Veteran has raised the theory of direct service connection. He has presented multiple contentions as to this theory of service connection. Initially, he has contended that, essentially, scleroderma had its onset during his active service, as he had symptoms during such service that were manifestations of scleroderma that was diagnosed after separation from active service. See November 5, 2015 Veteran Statement (stating that in Iraq “I was seen for a severe skin irritation that worsened when I showered. This is actually a sy[m]ptom that occurs with scler[o]derma…This incident in hindsight is the first time that I had sy[m]ptoms of scleroderma…I feel this was actually the first time my sy[m]ptoms appeared”); March 2019 Veteran Statement (“my severe itching began while [in] Iraq in 2005…I reported it to the medic tent…I since learned that the itching is a hallmark of the onset of scleroderma”). The Board notes that while no service treatment records (STRs) are of record documenting the reported treatment, the only STRs of record from this period of service were submitted by the Veteran in February 2011 (and are limited) and the agency of original jurisdiction (AOJ) stated in a February 2013 letter that all of the Veteran’s STRs could not be located. Also with respect to direct service connection, the Veteran has contended that, essentially, scleroderma is due to his exposure to various environmental hazards during his active service. In this regard, he has contended that scleroderma is due to environmental exposure during his service in Iraq from 2005 to 2006. See October 2015 Notice of Disagreement (NOD) (referencing exposure to “dust, debris, smoke, fuel” and stating “I was exposed to most if not all of the enviro[n]mental conditions and haz[]ards found in Iraq and believe thi[s] to be the cause of my condition”); November 30, 2015 Veteran Statement (stating “scleroderma can be connected [to] particulate exposure in Iraq” and referencing exposure to silica dust, dust storms and burn pit particulate exposure; the statement also referenced a National Institute of Health (NIH) report as indicating “[c]rystalline silica exposure contributes to development of…systemic scleroderma”). The Veteran has also contended that scleroderma is due to environmental exposure during his earlier period of service from 1988 to 1992, specifically by way of exposure to solvents. See November 30, 2015 Veteran Statement (referencing an NIH report as indicating that “solvent exposure contributes to the development of [systemic scleroderma]” and reporting his solvent exposure while working as a plumber at Robbins Air Force Base from 1988 to 1992); see also October 1992 Occupational Health History STR (noting work from 1988 to 1992 as a plumber and exposure to, among other things, solvents). In light of the Veteran’s contentions and the evidence of record, an opinion as to direct service connection will be requested on remand. Second, the Veteran has raised the theory of service connection based on presumptive service connection related to Persian Gulf War veterans and he has specifically contended that his scleroderma warrants service connection as a medically unexplained chronic multisymptom illness (MUCMI) under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. See e.g., October 21, 2015 Veteran Statement (referencing 38 C.F.R. § 3.317(a)(2)(ii) and stating that scleroderma “has no known cause (etiology) only hypotheses exist, but not even partial etiology is known”); November 9, 2015 Veteran Statement (stating “[c]ause of scler[o]derma are unknown,” with reference to various medical sources); May 2018 VA Form 9 (referencing 38 C.F.R. § 3.317(a)(2)(ii) and that scleroderma “pathophysiology and etiology unknown or at best inconclusive,” with reference to various medical sources). 38 C.F.R. § 3.317(a)(2)(ii) states that a MUCMI “means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities.” The United States Court of Appeals for Veterans Claims (Court) stated in Stewart v. Wilkie, 30 Vet. App. 383, 389 (2018) regarding this provision that “a multisymptom illness is a MUCMI if either the etiology or the pathophysiology of the illness is inconclusive” (emphasis in original). The Court also stated in Stewart that “a determination of whether a condition is a MUCMI must be based on an individual veteran’s circumstances.” In this case, competent evidence is currently not of record that addresses whether the Veteran’s scleroderma is a MUCMI, specifically as to the issue of whether the etiology or pathophysiology of such is inconclusive. In light of the Veteran’s contentions and the evidence of record, an opinion as to this issue will be requested on remand. Third, the Veteran has raised the theory of service connection based on the chronic disease presumption. See 38 C.F.R. § 3.309(a) (listing scleroderma as a chronic disease). He has contended that, essentially, he had manifestations of scleroderma within one year of his separation from active service. See October 21, 2015 Veteran Statement (stating that “even though I was not diagnosed until 2008, my symptoms begin in 2007. In April of 2007 my hands swelled so bad that two guys had to help me cut my wedding band off. I also developed what I thought was frostbite; I now know that it was [R]aynaud[’]s disease. I also suffered joint pain. All these are symptoms of Systemic scleroderma, that I was subsequently diagnosed with”); see also October 2015 Buddy Statement from J.D. (describing in April 2007 having “to cut [the Veteran’s] wedding band off because he had severe swelling of his hands…He also developed what looked to be frostbite on his fingertips to the point that the skin was peeling off in little layers…His hands would turn blue and he complained of being stiff”). In light of the Veteran’s contentions and the evidence of record, an opinion will be requested on remand as to whether the Veteran’s symptoms reported as occurring within one year of separation from active service (hand swelling, suspected frost bite and joint pain) were manifestations of the later diagnosed scleroderma. The matters are REMANDED for the following action: Afford the Veteran a VA examination with respect to his scleroderma claim. The examiner must provide an opinion addressing the following: (a.) Whether it is at least as likely as not (i.e., probability of 50 percent or greater) that scleroderma had its onset during active service or is caused or aggravated by any in-service disease, event, or injury. The examiner’s attention is invited to the Veteran’s various contentions that were outlined in the body of the remand, to include: i. That scleroderma had its onset during his active service, as he had symptoms (specifically a severe skin irritation and severe itching) during such service that were manifestations of the scleroderma that was diagnosed after separation from active service. See November 5, 2015 Veteran Statement; March 2019 Veteran Statement. ii. That scleroderma is due to various environmental exposure during his service in Iraq from 2005 to 2006. See October 2015 NOD; November 30, 2015 Veteran Statement. iii. That scleroderma is due to environmental exposure (specifically solvents) during his period of service from 1988 to 1992. See November 30, 2015 Veteran Statement; October 1992 Occupational Health History STR. (b.) Whether, based on the Veteran’s individual circumstances, his scleroderma has: i. Inconclusive pathophysiology. ii. Inconclusive etiology. The examiner’s attention is invited to the Veteran’s contention that his scleroderma is a MUCMI because the etiology and pathophysiology of such are unknown or inconclusive and additional attention is invited to the medical sources referenced in support of such contentions. See e.g., October 21, 2015 Veteran Statement; November 9, 2015 Veteran Statement; May 2018 VA Form 9. (c.) Whether the Veteran’s symptoms reported as occurring within one year of separation from active service (hand swelling, suspected frost bite and joint pain) were manifestations of the later diagnosed scleroderma. The examiner’s attention is invited to the Veteran’s October 21, 2015 statement and the October 2015 buddy statement from J.D., which were quoted in the body of the remand. For all opinions provided, the examiner must include the underlying reasons for any conclusions reached. C. TRUEBA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Hoopengardner, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.