Citation Nr: 21000665 Decision Date: 01/05/21 Archive Date: 01/05/21 DOCKET NO. 18-07 191 DATE: January 5, 2021 REMANDED Entitlement to service connection for porphyria cutanea tarda (PCT) is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1964 to February 1968. This matter comes on appeal before the Board of Veterans’ Appeals (Board) from a June 2017 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In May 2019, the Veteran testified before the undersigned Veterans Law Judge via videoconference hearing. A copy of the hearing transcript is of record and has been reviewed. Entitlement to service connection for porphyria cutanea tarda is remanded. The Board remanded this claim for further development in April 2020. Remand by the Board confers upon a claimant, as a matter of law, the right to compliance with the Board’s remand order. Stegall v. West, 11 Vet. App. 268, 271 (1998). Additionally, when VA undertakes to provide an examination or obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As an initial matter, the Veteran was diagnosed with PCT in a February 2017 VA Agent Orange examination. Porphyria cutanea tarda is a type of rare disorder that is characterized by photosensitivity that causes scarring bullae, hyperpigmentation, facial hypertrichosis, and sometimes sclerodermatous thickenings and alopecia. Urinary levels of uroporphyrin and coproporphyrin are increased and activity of uroporphyrinogen (UROD) is decreased. See DORLAND’S ILLUSTRATED MEDICAL DICTIONARY (32nd ed. 2012). Although it appears that the Veteran was afforded blood laboratory testing as a part of the February 2017 Agent Orange examination, the laboratory results did not indicate that his porphyria levels were tested. The RO determined that the February 2017 PCT diagnosis was not probative because the corresponding laboratory results were normal. See December 2017 SOC. As a result, the Board remanded the claim for a VA examination to determine whether the Veteran met the diagnostic criteria for PCT. The Veteran was afforded a VA examination in October 2020. The examiner, a physician, reported that the Veteran experienced a rash in service that resolved within one week but that left scars. The Veteran did not recall if biopsies were conducted. The examiner indicated the Veteran had PCT previously but that it had resolved. The examiner also found current scars were a residual of the PCT. See October 2020 VA examination reports for skin and scars. Despite these findings, the October 2020 VA examiner explained that PCT pathology includes excess porphyrin in the skin, resulting in photosensitivity. The examiner noted that individuals that are diagnosed with PCT present with increasingly fragile skin on the back of the hands and forearms. Other sun-exposed areas such as the face, scalp, neck, and arms may also be affected. The natural progression of PCT is that it is a chronic ongoing recurrent illness. Here, the Veteran was treated for a rash in 1965, diagnosed as acne, which ultimately resolved and did not reoccur. Additionally, the examiner indicated that analysis of blood, urine, and feces is required to analyze the porphyrin levels, which would be elevated if PCT was present. Specifically, the examiner noted that PCT is diagnosed with laboratory findings of elevated isocoproporphyrin in feces. The examiner was unable to find an evaluation of porphyrin levels in service or elevated porphyrin levels in the blood, urine, and feces in the Veteran’s current laboratory results. See October 2020 disabilities benefits questionnaire (DBQ) for skin and scars and October 2020 VA medical opinion. Of note, the October 2020 VA examiner also did not conduct this testing. In the April 2020 remand, the Board requested that a VA examination be scheduled to clarify whether the Veteran met, or had ever met, the diagnostic criteria for PCT or whether he had currently diagnosed PCT residuals during the appellate period. Although the explanation provided by the October 2020 VA examiner was thorough and well-explained, the examination findings and the examiner’s conclusions are contradictory. In addition, although the October 2020 VA examiner clearly states that PCT can only be diagnosed with laboratory testing for isocoproporphyrin in the feces and elevated porphyria in the urine and blood, no such testing was conducted. The examiner did not make findings as to whether this Veteran reported or exhibited photosensitivity, and no findings were made as to whether the Veteran exhibited or reported increasingly fragile skin on the back of his hands, forearms, or any other affected area. On remand, the Veteran should be scheduled for an additional VA examination and all necessary testing should be afforded to the Veteran to determine whether he meets, or has ever met, the diagnostic criteria for PCT or if he has currently diagnosed residuals of PCT. Next, the April 2020 Board remand directed that further development be obtained as to the Veteran’s service at Clark Air Force Base in the Philippines between 1965 and 1966. The Veteran asserts that he occasionally repaired the TACAN units in Operation Ranch Hand C-123 airplanes when they required repairs that could not wait until they returned to their home base. See, e.g., January 2019 VA Form 9 and May 2020 and October 2020 statements. The RO requested this information from DOD; however, the response from DOD only indicated that the Operation Ranch Hand C123s were not maintained outside of the 315th Carrier Group at Tan Son Nhut Air Base in the Republic of Vietnam. This response is incomplete as it only addressed where C-123s received routine maintenance, but it did not address whether any C-123s were repaired under other circumstances (such as urgent or emergency repairs) at Clark AFB between 1965 and 1966. See August 2020 e-mail. On remand, the RO should also request clarification if any C-123s used to spray herbicide agents were repaired at Clark AFB between 1965 and 1966. See November 2020 statement. The matters are REMANDED for the following action: 1. Obtain any outstanding pertinent VA treatment records and associate them with the claims file. 2. Furnish a detailed description of the Veteran’s claimed herbicide agent exposure at Clark Air Force Base in the Philippines between 1965 to 1966 to C&P service and request an additional review of DOD’s inventory of herbicide agent operations to determine whether any C-123s used for herbicide agent spraying were repaired at Clark AFB during that time. See, e.g., January 2019 VA Form 9 and May 2020 and October 2020 statements. 3. If a negative response is received from C&P service, submit a similar request to JSRRC, DRIS, or any other appropriate resource to attempt to verify exposure to herbicide agents at Clark Air Force Base in the Philippines between March 1965 and August 1966. See, e.g., January 2019 VA Form 9 and May 2020 and October 2020 statements. 4. Then, obtain an addendum VA opinion to address the following: a) Provide an opinion as to whether the Veteran currently meets the diagnostic criteria for porphyria cutanea tarda (PCT). Whether an additional physical examination is necessary is left to the discretion of the examiner; however, all necessary diagnostic laboratory testing should be conducted, to include blood, urine, or fecal matter testing. See October 2020 VA medical opinion. If the February 2017 PCT diagnosis was incorrect, a thorough rationale should be provided to explain this conclusion. b) If, and only if, the Veteran (1) has a current diagnosis of PCT or currently diagnosed residuals of PCT during the appellate period; and (2) if, and only if, the RO verifies and concedes herbicide agent exposure, then provide an opinion as to whether the Veteran had PCT that manifested to a degree of 10 percent or more within a year after the last date on which the Veteran was exposed to an herbicide agent during service. See July 2017 notice of disagreement and May 2019 hearing transcript. *In other words, if the Veteran either (1) does not meet the diagnostic criteria for a current diagnosis of PCT (or have currently diagnosed residuals from PCT) OR (2) if the Veteran’s herbicide agent exposure is not conceded, no VA medical opinion is required. *The RO should inform the examiner whether the Veteran’s herbicide agent exposure has been verified and conceded. c) If the Veteran’s scars are not residuals of PCT, provide an opinion as to whether the Veteran’s scars had onset during or are otherwise related to service, including the acne that was treated in service. (Continued on the next page)   5. Then readjudicate the claim on appeal. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Harper, Associate 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.