Citation Nr: 21012891 Decision Date: 03/05/21 Archive Date: 03/05/21 DOCKET NO. 17-09 668 DATE: March 5, 2021 REMANDED Entitlement to service connection for pleurisy, claimed as due to exposure to environmental hazards, including oil fires, vaccinations, and gas from chemical weapons is remanded. Entitlement to service connection for pericarditis, claimed as due to exposure to environmental hazards, including oil fires, vaccinations, pills and gas from chemical weapons is remanded. Entitlement to service connection for irritable bowel syndrome (IBS), claimed as due to environmental hazards, including oil fires, vaccinations, pills and gas from chemical weapons is remanded. Entitlement to service connection for dermatitis, claimed as due to exposure to environmental hazards, including oil fires, vaccinations, pills and gas from chemical weapons is remanded. Entitlement to service connection for undifferentiated connective tissue, claimed as due to exposure to environmental hazards, including oil fires, vaccinations, pills or gas from chemical weapons is remanded. Entitlement to service connection for joint pain, claimed as due to exposure to environmental hazards, including oil fires, vaccinations, pills or gas from chemical weapons is remanded. Entitlement to service connection for chronic muscle fatigue, claimed as due to exposure to environmental hazards, including oil fires, vaccinations, pills or gas from chemical weapons is remanded. Entitlement to service connection for chronic fatigue, claimed as due to environmental hazards, including oil fires, vaccinations, pills or gas from chemical weapon is remanded. REASONS FOR REMAND The Veteran served on active duty from December 2,1990 to May 15, 1991, to include service in the Southwest Asia Theater of operations during the Persian Gulf War. These matters come before the Board of Veterans' Appeals (Board) on appeal from a January 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. In February 2020, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. Following the hearing, the Veteran submitted additional evidence along with a waiver of initial RO consideration. 1. Entitlement to service connection for pleurisy, claimed as due to exposure to environmental hazards, including oil fires, vaccinations, and gas from chemical weapons is remanded. 2. Entitlement to service connection for pericarditis, claimed as due to exposure to environmental hazards, including oil fires, vaccinations, pills and gas from chemical weapons is remanded. 3. Entitlement to service connection for chronic muscle fatigue, claimed as due to exposure to environmental hazards, including oil fires, vaccinations, pills or gas from chemical weapons is remanded. 4. Entitlement to service connection for dermatitis, claimed as due to exposure to environmental hazards, including oil fires, vaccinations, pills and gas from chemical weapons is remanded. 5. Entitlement to service connection for joint pain, claimed as due to exposure to environmental hazards, including oil fires, vaccinations, pills or gas from chemical weapons is remanded. The Veteran maintains that he is seeking service connection under the presumptions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 because he has multiple symptoms with really no known etiology and no diagnosis. The Veteran contends that his claimed disabilities are related to exposure to environmental hazards, including oil fires and gas from chemical weapons. At his personal hearing in February 2020, the Veteran testified that he witnessed chemicals being used while in Bagdad. The Veteran also reported that they were exposed to a lot of smoke; he noted that the smoke was so thick that you could hardly see. The Veteran related that he was also given Anthrax vaccine and other vaccines before going to the Persian Gulf, several of which were experimental. The Veteran was afforded a VA/Gulf War examination in January 2011. Following the examination, the examiner indicated that the pertinent diagnoses included chronic diarrhea secondary to medication, recurrent pericarditis secondary to autoimmune disorder, recurrent pleurisy secondary to autoimmune disorder, chronic muscle fatigue secondary to steroidal use and joint pain secondary to autoimmune disorder. The examiner stated that the Veteran had a diagnosable multi-symptom illness with a partially explained etiology; however, he stated that Veteran’s conditions were less likely than not related to a specific exposure event in Southwest Asia. The examiner stated that the Veteran’s service treatment records (STRs) are silent for his present complaints, and they did not begin until 2007 which was 13 years after military service; and many of his complaints are side effects of his medications. The examiner provided no further rationale. Submitted in support of the Veteran’s claim was a Gulf War Related Illness questionnaire completed by the Veteran’s private physician, Dr. T.D., dated in January 2020, wherein he noted that the Veteran currently experienced joint pain, chronic fatigue, chronic muscle fatigue, pleurisy, pericarditis, joint pain, bowel problems, and dermatitis. The physician indicated that the conditions claimed by the Veteran do not have a known etiology, and they are consistent with symptoms experienced by Gulf War Veterans that served in Southwest Asia. However, no rationale was provided for this opinion. A similar questionnaire was completed by Dr. M.B. in July 2017 also stating that the Veteran had many conditions that did not have a known etiology and were consistent with symptoms experienced by Gulf War veterans. However, no rationale was provided for this opinion. Finally, the Veteran submitted a February 2020 medical record from Dr. A.O. indicating that he had been diagnosed with pleurisy and pericarditis that is related to his service in the Gulf war. To the extent that the February 2020 statement is an etiology opinion, no rationale was provided. The Board notes that the January 2011 VA examination and July 2017 and January 2020 private Gulf War questionnaires are inadequate to allow the Board to render a decision. Specifically, while the January 2011 VA examiner explained why presumptive service connection is not warranted for the diagnosed conditions, the examiner’s rationale based on direct service connection is incomplete. Notably, the examiner relied exclusively on the lack of treatment in the Veteran's service treatment records. The examiner also failed to provide any rationale as to why exposure to environmental hazards in Southwest Asia was not the cause of the claimed disabilities. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (a medical opinion is inadequate where the examiner fails to properly account for competent lay evidence). The July 2017 and January 2020 private examiners failed to provide a clear rationale for the positive nexus opinions and the conclusions reached. Based on the inadequacies of the above cited opinions, the Board finds that an additional VA examination is warranted to attempt to reconcile the conflicting evidence as to whether the Veteran’s claimed disabilities may be attributed to his time in service, to include exposure to environmental hazards while serving in the Gulf War. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). 5. Entitlement to service connection for undifferentiated connective tissue, claimed as due to exposure to environmental hazards, including oil fires, vaccinations, pills or gas from chemical weapons is remanded. 6. Entitlement to service connection for IBS, claimed as due to environmental hazards, including oil fires, vaccinations, pills and gas from chemical weapons is remanded. 7. Entitlement to service connection for chronic fatigue, claimed as due to environmental hazards, including oil fires, vaccinations, pills or gas from chemical weapon is remanded. The Veteran is seeking to establish service connection for connective tissue disorder, IBS and chronic fatigue, all claimed as due to exposure to environmental hazards, including oil and gas from chemical weapons while serving in the Persian Gulf. Following a VA/Gulf War examination in January 2011, the examiner indicated that no chronic fatigue syndrome and no IBS were found. The examiner also noted that the Veteran complained of connective tissue disease, however the lab tests were negative for connective tissue disease. The Board notes that, since the January 2011 examination, private treatment records added to the record indicate that the Veteran received treatment for a gastrointestinal disorder (GI) variously diagnosed. During a routine clinical visit in March 2013, it was noted that the Veteran had an 11-year history of mixed connective tissue disease and he was having worsening shortness of breath; it was noted that aggressive treatment for gastroesophageal reflex disease (GERD) did not improve his dyspnea. The assessment was shortness of breath, restrictive lung disease, GERD, and scleroderma with pulmonary involvement. Among the records is the report of a diagnostic EGD performed April 18, 2013 which revealed findings of mild gastritis and hiatal hernia. These records should be addressed upon remand. Submitted in support of the Veteran’s claim was a Gulf War Related Illness questionnaire completed by the Veteran’s private physician, Dr. T.D., dated in January 2020, wherein he noted that the Veteran currently experienced joint pain, chronic fatigue, chronic muscle fatigue, pleurisy, pericarditis, joint pain, bowel problems, and dermatitis. The examiner indicated that the conditions claimed by the Veteran do not have a known etiology, and they are consistent with symptoms experienced by Gulf War Veterans that served in Southwest Asia. However, no rationale for this opinion was provided. A similar questionnaire was completed by Dr. M.B. in July 2017 also stating that the Veteran had many conditions that did not have a known etiology and were consistent with symptoms experienced by Gulf War veterans. However, no rationale was provided for this opinion. Private treatment reports, dated from October 2019 through February 2020, show that the Veteran received ongoing clinical attention and treatment for various conditions. In October 2019, the Veteran was diagnosed with recurrent pericarditis, joint pain in multiple sites, and fibromyalgia. A treatment report, dated in December 2019, reflect diagnoses of systemic involvement of connective tissue and chronic pain syndrome. The Board notes that since the January 2011 examination, private treatment records added to the record indicate that the Veteran is receiving treatment for a GI variously diagnosed; they reflect current diagnoses of connective tissue disease and chronic fatigue. These records should be addressed upon remand. The Board further notes that while the private Gulf War questionnaires in July 2017 and January 2020 suggest that the claimed conditions are related to Veteran’s service in the Gulf War, the examiners did not provide any rationale for the conclusion reached. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). While these opinions are not sufficient to grant service connection for the claimed connective tissue disorder, GI disorder, or chronic fatigue, the Board finds it is sufficient to remand the claims for a new VA examination and opinion. The matters are REMANDED for the following actions: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claims on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in her possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. The Veteran should be afforded an appropriate VA examination by a rheumatologist or neurologist in order to determine the current nature and etiology of his claimed connective tissue disorder, chronic fatigue syndrome, chronic muscle fatigue and joint pain. The claims file, to include a copy of this Remand, must be made available to and be reviewed by the examiner. Any indicated evaluations, studies, and tests should be conducted. The need for further in-person examination is left to the discretion of the examiner. The examiner is to address the following questions: (a) The examiner should specifically state whether the Veteran's muscle and/or joint aches or pain and chronic fatigue syndrome are attributed to a known clinical diagnosis. (b) If any symptoms of chronic fatigue syndrome and/or joint and muscle aches and pains have not been determined to be associated with a known clinical diagnosis, the examiner should indicate whether the Veteran has objective indications of a chronic disability resulting from an undiagnosed illness, as established by history, physical examination, and laboratory tests, that has either (1) existed for 6 months or more, or (2) exhibited intermittent episodes of improvement and worsening over a 6-month period. (c) If any symptoms of chronic fatigue syndrome and/or joint and muscle aches and pains have been determined to be associated with a known clinical diagnosis, is it at least as likely as not (i.e., there is a 50 percent or greater probability) that such disorder is related to the Veteran's service, to include any vaccines received, and/or exposure to environmental or chemical hazards during his service in the Persian Gulf? A complete rationale should be provided for any opinion provided. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). 3. Following the receipt of outstanding records, schedule the Veteran for a VA examination to determine the nature and etiology of the claimed pericarditis and pleurisy. The claims file, and a copy of this remand, will be available to the examiner, who must acknowledge receipt and review of these materials in any report generated as a result of this remand. The need for further in-person examination is left to the discretion of the examiner. The examiner is to address the following questions: (a) Identify all cardiovascular or pulmonary disorders that are currently present, if any, to include pleurisy and pericarditis. If the examiner disagrees with any diagnoses already established in the medical records, he or she should so state and explain why. (b) Is it at least as likely as not (50 percent or greater probability) that any cardiovascular or pulmonary disorders found, including pericarditis and pleurisy, had its onset during active service, or is otherwise related to it, including exposure to environmental or chemical hazards during his service in the Persian Gulf? A complete rationale should be provided for any opinion provided. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). 4. Following the receipt of outstanding records, schedule the Veteran for a VA examination by an examiner with sufficient expertise to determine the nature and etiology of the Veteran's dermatitis. The examiner should review the claims file and indicate that review in the report. Any indicated studies should be performed. The need for further in-person examination is left to the discretion of the examiner. The examiner is should respond to the following: Is it at least as likely as not (50 percent or greater probability) that dermatitis is etiologically related to service, to include environmental hazard exposure during his service in the Persian Gulf? A complete rationale should be provided for any opinion provided. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). 4. Following the receipt of outstanding records, schedule the Veteran for a VA examination to determine the nature and etiology of the claimed gastrointestinal disability, to include IBS and GERD. The claims file, and a copy of this remand, will be available to the examiner, who must acknowledge receipt and review of these materials in any report generated as a result of this remand. The need for further in-person examination is left to the discretion of the examiner. The examiner is to address the following question: Is it least as likely as not (50 percent or greater probability) that the Veteran’s gastrointestinal disorder had its onset during active service or is otherwise related to it, including exposure to environmental or chemical hazards during his service in the Persian Gulf? A complete rationale should be provided for any opinion provided. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). KRISTY L. ZADORA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Suzie S. Gaston, 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.