Citation Nr: 21062894 Decision Date: 10/12/21 Archive Date: 10/12/21 DOCKET NO. 18-44 712 DATE: October 12, 2021 REMANDED Entitlement to service connection for hidradenitis suppurative is remanded. Entitlement to service connection for bilateral armpit scars and inflammation, including as due to hydradenitis suppurative, is remanded. Entitlement to service connection for bilateral foot inflammation, including as due to hydradenitis suppurative, is remanded. Entitlement to service connection for bilateral groin scrotal lymphedema, including as due to hydradenitis suppurative, is remanded. Entitlement to service connection for bilateral knee inflammation, including as due to hydradenitis suppurative, is remanded. Entitlement to service connection for a heart disability, to include an enlarged heart or irregular heartbeat, including as due to hydradenitis suppurative or medications prescribed to treat it, is remanded. Entitlement to service connection for hypertension, including as due to hydradenitis suppurative or medications prescribed to treat it, is remanded. Entitlement to service connection for tooth loss, including as due to medications prescribed to treat hydradenitis suppurative, is remanded. REASONS FOR REMAND The Veteran had active service in the U.S. Army from September 1986 to September 1988. He also had additional unverified U.S. Army Reserve and U.S. Army National Guard service. This appeal comes before the Board of Veterans' Appeals (Board) on appeal from a January 2017 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Sioux Falls, South Dakota, which denied all of the currently appealed claims. A virtual Board hearing was held in October 2020 before the undersigned Veterans Law Judge and a copy of the hearing transcript has been added to the record. Having reviewed the record evidence, to include the Veteran's hearing testimony, the Board finds that the issues on appeal should be characterized as stated above. 1. Entitlement to service connection for hidradenitis suppurative is remanded. The Veteran testified before the Board in October 2020 that the vaccinations which he received at service entrance via air gun injections caused or contributed to his current hidradenitis suppurative. The limited service treatment records currently associated with the claims file shows that he received multiple vaccinations contemporaneous to his service entrance in September 1986. He also testified that "years" of research he conducted into this issue had yielded medical treatise evidence supporting a potential etiological link between certain vaccinations and endocrine or autoimmune or immune system responses typically seen in persons who experience hidradenitis suppurative. The Board notes that air-jet (or air gun) injectors were used by the military extensively to vaccinate service members until a U.S. Department of Defense (DoD) Medical Quality Assurance System Device Alert on December 9, 1997, recommended that use of all jet injectors be discontinued. This action was taken in response to a letter from Ped-O-Jet International, the manufacturer of the jet injector. Because the jet injector breaks the barrier of the skin, there is a potential that biological material can be transferred from one user to the next. Some infectious viruses such as hepatitis B can be transmitted by less than one millionth of a milliliter. Although "hepatitis C" was not identified as a precise type of viral hepatitis for many years (it was called "non-A non-B hepatitis" in the 1970s), this kind of possible transmission would apply to what is now called Hepatitis C. The World Health Organization no longer recommends jet injectors for vaccination due to risks of disease transmission. This could occur due to "cross-contamination" between using the injector repeatedly, even with the best technique. This means that the vaccine itself is not "contaminated" but the way the vaccine is delivered to the service member could contain minute amounts of infected blood from another service member. The record evidence shows that the Veteran has complained of and been treated for hidradenitis suppurative in the decades since his service separation. He also submitted medical treatise evidence in November 2020 consisting of an article from a medical journal which discussed generally the potential for certain vaccinations to elicit autoimmune or immune system responses in persons administered vaccines. The Board notes that it is prohibited from exercising its own independent judgment to resolve medical questions such as the question of an etiological link between the Veteran's hidradenitis suppurative and active service. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Thus, the Board finds that, on remand, a medical opinion should be obtained which addresses this matter. 2. Entitlement to service connection for bilateral armpit scars and inflammation, bilateral foot inflammation, bilateral groin scrotal lymphedema, and bilateral knee inflammation, each including as due to hidradenitis suppurative, is remanded. The Veteran also testified at his October 2020 virtual Board hearing that he incurred bilateral armpit scars and inflammation, a bilateral foot inflammation, bilateral groin scrotal lymphedema, and bilateral knee inflammation as a result of his hidradenitis suppurative. Adjudication of the service connection claim for hidradenitis suppurative being remanded in this decision (as discussed above) likely will impact adjudication of the secondary service connection claims for each of these claimed disabilities. The Board finds all of these claims are inextricably intertwined and adjudication of the secondary service connection claims for bilateral armpit scars and inflammation, bilateral foot inflammation, bilateral groin scrotal lymphedema, and for bilateral knee inflammation must be deferred. See Henderson v. West, 12 Vet. App. 11, 20 (1998), citing Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that two issues are inextricably intertwined when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). 3. Entitlement to service connection for hypertension, a heart disability, to include an enlarged heart or irregular heartbeat, and for tooth loss, each including as due to hidradenitis suppurative or the medications prescribed to treat it, is remanded. The Veteran finally testified at his October 2020 virtual Board hearing that he incurred hypertension, a heart disability (which he characterized as both an enlarged heart and an irregular heartbeat), and tooth loss as due to hidradenitis suppurative. He also testified that he incurred each of these claimed disabilities as a result of the medications prescribed to treat his hidradenitis suppurative. The Board finds all of these claims are inextricably intertwined and adjudication of the secondary service connection claims for hypertension, a heart disability, and for tooth loss also must be deferred. Id. Finally, it is not clear to the Board whether all of the Veteran's available service treatment records and post-service VA and private treatment records are associated with the claims file. There are only limited service treatment records currently associated with the claims file. And the VA outpatient treatment records currently associated with the claims file only are dated through 2016. He testified that he continued to seek ongoing treatment for his claimed disabilities from a variety of private providers, the Indian Health Service, and VA at his October 2020 virtual Board hearing. The Board notes in this regard that the United States Court of Appeals for Veterans Claims (Court) has held that VA is on constructive notice of all documents generated by VA, even if the documents have not been made part of the record in a claim for benefits. See Bell v. Derwinski, 2 Vet. App. 611 (1992). The Veteran also testified that he is receiving Social Security disability benefits at his October 2020 virtual Board hearing. It does not appear that the RO attempted to obtain these records. The Board notes that VA has a duty to obtain SSA records when it has actual notice that the Veteran is receiving SSA benefits. Murincsak v. Derwinski, 2 Vet. App. 363 (1992). Thus, on remand, the Veteran's updated treatment records and his complete SSA records, including any administrative decision(s) on his application for SSA disability benefits and all underlying medical records, should be obtained. The matters are REMANDED for the following action: 1. Conduct any appropriate development to obtain the Veteran's updated treatment records, to include contacting the appropriate Federal records repository and requesting his complete Indian Health Service medical records and service treatment records from all periods of active service. A copy of any request(s) for records, and any reply, to include any records provided, should be associated with the claims file. 2. Contact the Social Security Administration (SSA) and request the Veteran's complete SSA records, including any administrative decision(s) on his application for SSA disability benefits and all underlying medical records. A copy of any request(s) for records, and any reply, to include any records provided, should be associated with the claims file. 3. Thereafter, forward the claims file and a copy of this REMAND to an appropriate clinician for an opinion concerning the nature and etiology of the Veteran's hidradenitis suppurative. The decision on whether the Veteran should report for examination is left to the discretion of the clinician asked to provide the requested opinion(s). Based on a review of the claims file and the results of the Veteran's examination (if held), the clinician is asked to state whether it is at least as likely as not (i.e., a 50 percent or greater probability) that hidradenitis suppurative is related to active service or any incident of service, to include in-service vaccinations provided at his entry on to active service in September 1986. A rationale must be provided for any opinion(s) expressed. If any requested opinion(s) cannot be provided without resorting to speculation, then the clinician must explain why this is so. The clinician is asked to address the clinical significance, if any, of medical treatise evidence submitted by the Veteran in November 2020 which appears to suggest that certain vaccinations may trigger an autoimmune or immune system response in persons administered the vaccinations. The clinician is advised that the lack of contemporaneous records documenting complaints of or treatment for a hidradenitis suppurative, alone, is insufficient rationale for a medical nexus opinion. 4. Readjudicate the appeal. R. FEINBERG Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Michael T. Osborne, 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.