Citation Nr: 21073966 Decision Date: 12/13/21 Archive Date: 12/13/21 DOCKET NO. 16-34 923 DATE: December 13, 2021 REMANDED Entitlement to service connection for an infectious disease, to include as due to herbicide agent exposure is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from October 1967 to August 1969, to include service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2014 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In February 2017, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge. The Board remanded the appeal for further development in November 2018, March 2020, and November 2020. Pursuant to the November 2020 remand, an addendum opinion regarding the etiology of the Veteran's infectious disease was obtained in February 2021. The February 2021 examiner opined that it was less likely than not that the Veteran's infectious disease was caused by service or walking through swamps. The examiner related the Veteran's actinomycosis to his dental infection and opined that the infection was not caused by environmental exposures. In providing a negative opinion, the examiner noted that the Veteran did not complain of either condition during service. The Board finds the February 2021 examiner's supporting rationale inadequate for adjudicative purposes. Notably, the November 2020 remand determined that the April 2020 examiner's finding that the Veteran's infection was attributed to a dental condition unpersuasive in light of the fact that the infection has persisted since the Veteran's teeth were extracted in 2007. Although the February 2021 examiner explained that "Actinomycosis is a rare chronic disease caused by Actinomyces spp., anaerobic Gram-positive bacteria that normally colonize the human mouth and digestive and genital tracts," the examiner did not address the fact that the infection has persisted since the extraction in 2007. Additionally, the examiner did not address the September 2020 Appellate Brief, which noted that animal studies have shown an influence of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) on the development of the gut microbiome in mice and that previous Veterans and Agent Orange (VAO) reports have concluded that there is inadequate or insufficient evidence to determine whether there is an association between exposure to the Chemicals of Interest and gastrointestinal and digestive diseases. Finally, the February 2021 examiner opined that zoster is common in people with weakened immune systems. In response, the Veteran's representative highlighted that the Veteran's service-connected heart and prostate disabilities would cause a compromised immune system. Based on the Veteran's assertions, the Board finds that it is appropriate to expand the scope of the Veteran's claim to include entitlement to service connection on a secondary basis to afford the Veteran every possible consideration. For these reasons, another remand is necessary to obtain an adequate etiology opinion. The matter is REMANDED for the following action: Obtain an addendum opinion from an examiner, preferably an infectious disease specialist, to determine the etiology of the Veteran's infectious disease. The claims file, to include a copy of this remand, must be made available to the examiner for review, and the examination report must reflect that such a review was accomplished. No additional examination of the Veteran is necessary, unless the examiner determines otherwise. a.) For any infectious disease present since January 2014, to include but not limited to diagnosed thoracoabdominal actinomycosis (see October 2019 VA examination), left supraorbital zoster infection (see September 2014 VA treatment records), helicobacter pylori (H. pylori) (see February 2014 VA treatment record); and neutropenia (see February 2016 VA treatment record) the examiner should opine as to each of the following: 1.) whether it is at least as likely as not (50 percent or greater probability) that such disability had its onset in service or is otherwise related to service; or 2.) is due to or caused by walking through field and swamp areas in Vietnam; or 3.) is due to or caused by coming into contact with wet soil in Vietnam; or 4.) is due to or caused by conceded herbicide agent exposure in Vietnam. In addressing (a)(1-4), the examiner must specifically address (1) the September 2020 Appellate Brief, which noted that animal studies have shown an influence of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) on the development of the gut microbiome in mice; (2) that previous VAO reports have concluded that there is inadequate or insufficient evidence to determine whether there is an association between exposure to the Chemicals of Interest and gastrointestinal and digestive diseases; and (3) the fact that the Veteran's infection has persisted since the Veteran's teeth were extracted in 2007. In addressing these questions, the examiner is advised that the fact that a given disability is not one for which service connection can be presumptively awarded cannot be used as the sole basis for a negative opinion. b.) Please opine as to whether it is at least as likely as not that any diagnosed infectious disease is (1) proximately due to or (2) aggravated (worsened) by service-connected coronary artery disease and prostate cancer. In addressing this question, the examiner must address the February 2021 VA examiner's opinion that "zoster is common in people with weakened immune systems" and the Veteran's representative's assertion that the Veteran's service-connected disabilities would cause a compromised immune system. See September 2021 Appellate Brief. In addressing secondary service connection, please note that the service-connected disability need not be diagnosed or service-connected at the time the infectious disease is incurred to establish secondary service connection, and reliance on this fact will render any secondary opinion inadequate. c.) If an infectious disease identified in part (a) above is related to service or another service-connected disability but another such disease identified in part (a) is not, please opine as to whether it is at least as likely as not that any infectious disease unrelated to service or a service-connected disability is (1) proximately due to or (2) aggravated (worsened) by the service-related infectious disease, to include based on medications used to treat the same. A complete rationale must be provided for each opinion expressed. In the event the examiner is unable to provide a medical opinion, he or she must provide a statement as to whether there is any additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. S. BUSH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Forde, 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.