Citation Nr: A21005249 Decision Date: 03/09/21 Archive Date: 03/09/21 DOCKET NO. 200701-94691 DATE: March 9, 2021 ORDER Service connection for a skin disability, to include eczema dermatitis, xerosis cutis, melanocytic nevi, rosacea, and hypovitaminosis D, claimed as due to in-service chemical exposure, is granted. Service connection for anemia, claimed as due to in-service chemical exposure, is granted. Service connection for an ulcer, claimed as due to in-service chemical exposure, is granted. FINDINGS OF FACT 1. The Veteran was exposed to harmful chemicals during service, has a diagnosis of a skin disability, and the evidence is in equipoise as to whether the Veteran’s skin disability is related to her in-service chemical exposure. 2. The Veteran was exposed to harmful chemicals during service, has a diagnosis of anemia, and the evidence is in equipoise as to whether the Veteran’s anemia is related to her in-service chemical exposure. 3. The Veteran was exposed to harmful chemicals during service, has a diagnosis of a gastric ulcer, and the evidence is in equipoise as to whether the Veteran’s gastric ulcer is related to her in-service chemical exposure. CONCLUSIONS OF LAW 1. The criteria for service connection for a skin disability have been met.  38 U.S.C. §§ 1110, 1131, 5107 (b); 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for anemia have been met.  38 U.S.C. §§ 1110, 1131, 5107 (b); 38 C.F.R. §§ 3.102, 3.303.  3. The criteria for service connection for an ulcer have been met.  38 U.S.C. §§ 1110, 1131, 5107 (b); 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from November 1981 to July 1992. The Board of Veterans’ Appeals (Board) notes that by rating decision in November 2019, the claims were denied. In December 2019, the Veteran submitted a VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), and requested review of the November 2019 rating decision. In April 2020, the agency of original jurisdiction (AOJ) issued the HLR decision on appeal, which considered the evidence of record at the time of the initial rating decision. In the July 2020 VA Form 10182, Decision Review Request: Board Appeal, the Veteran elected the Hearing docket. Therefore, the Board may only consider the evidence of record at the time of the initial AOJ decision on appeal, (in November 2019), as well as any evidence submitted by the Veteran at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). Contentions The Veteran contends that service connection for a skin disability, anemia, and an ulcer is warranted. Specifically, she contends that while serving as an Aviation Structural Mechanic during her military service, she was exposed to several chemicals, to include solvents, jet fuel/fumes, aircraft paint/thinners, aircraft hydraulic fluids, and aircraft cleaners and that such exposure has resulted in her current skin disabilities, anemia, and ulcer. In support of her claim, she submitted medical treatise evidence relating certain in-service chemical exposures to subsequent health problems. Significantly, in an article entitled “Health Hazards of Chemicals Commonly Used on Military Bases,” it is noted that exposure to solvents such as trichloroethylene (TCE), which is commonly used to clean mechanical equipment on airbases, either through inhalation or skin exposure, can damage the skin and then move through the body, to include the gastrointestinal tract. It was also noted that many veterans who worked with equipment or did maintenance on aircraft or vehicles used TCE as a solvent, paint remover, and for other purposes. Furthermore, the article noted that military bases have been found to leak benzene, a chemical found in fuel, and that benzene exposure has been linked to abnormal blood cell profiles like anemia. The Veteran also submitted an article entitled “Potential Exposure at Fort McClellan” noting the use of harmful chemicals at Fort McClellan. The Veteran’s service personnel records (SPRs) confirm that the Veteran served as an AMS (Navy Aviation Structural Mechanic) during her military service, with primary duties of inspecting and maintaining aircraft fuselages, wings, fixed and movable surfaces, airfoils, empennages, seats, wheels, tires, controls, and mechanisms. Significantly, the Veteran’s SPRs include a list of “hazardous chemicals used in corrosion control” which, presumably, were used by the Veteran in connection with her duties. Also, the Veteran’s SPRs show that she was stationed at Fort McClellan in Alabama from May to July 1987. Legal Criteria Service connection requires evidence of three elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the current disability and the disease or injury incurred or aggravated during active service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004).  Certain chronic diseases, including primary anemia and peptic ulcers (gastric or duodenal), will be presumed related to service if they were noted as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if continuity of the same symptomatology has existed since service, with no intervening cause.  38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant.  38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990).  1. Service connection for a skin disability, to include eczema dermatitis, xerosis cutis, melanocytic nevi, rosacea, and hypovitaminosis D, claimed as due to in-service chemical exposure, is granted. The Veteran’s service treatment records (STRs) are negative for skin problems. Significantly, the Veteran’s May 1992 separation examination shows normal skin and, in a May 1992 report of medical history, the Veteran specifically denied “skin diseases.” Similarly, a February 1997 National Guard enlistment examination shows normal skin and, in a February 1997 report of medical history, the Veteran specifically denied “skin diseases.” Post-service records show skin complaints as early as July 2004. Specifically, a July 2004 show complaints of a rash on face for one year with a diagnosis of perioral dermatitis, a March 2013 private treatment record shows diagnoses of eczema dermatitis and hypovitaminosis D, and an August 2017 private treatment record shows diagnoses of rosacea, melanocytic nevi, and xerosis cutis. The Veteran submitted an initial claim for service connection for a skin disability in February 2018. In connection with this claim, she was afforded a VA skin examination in August 2018. This examination report shows a diagnosis of eczema dermatitis, noting an onset in May 2013. However, upon review of the record, the examiner opined that the Veteran’s eczema dermatitis was less likely as not related to her active duty. As rationale for this opinion, the examiner noted that the STRs are negative for complaints, treatment or diagnosis of skin conditions during active duty and the separation exam is negative for the diagnosis of skin conditions. The initial diagnosis of skin conditions (dermatitis) was in 2004, about 12 years following separation from active duty. Therefore, per objective medical evidence and time frame, it is reasonable to conclude that the Veteran’s current skin condition (eczema dermatitis) is less likely than not incurred in or caused by potential hazardous materials during service. In connection with the Veteran’s September 2019 supplemental claim, she submitted a May 2019 medical opinion from Dr. C.N.B. Significantly, Dr. C.N.B. noted that the Veteran currently had a diagnosis of psoriasis and opined that, considering every possible sound medical etiology/principle, to at least the 90 percent level of probability that her current psoriasis is due to her military service because: (1) the Veteran entered service without any doctor-diagnosed illnesses, (2) she had exposure to TCE in service as supported by an EPA (Environmental Protection Agency) report regarding her assigned military bases, (3) the Veteran’s post-service diagnosis of seborrhic dermatitis in April 2005 was her first sign of psoriasis as these two are often confused, (4) the Veteran has psoriasis and medical literature supports a link between TCE and psoriasis, (5) the Veteran’s psoriasis was caused by her exposure to TCE in service, (6) her other skin problems include rosacea/xerosis cutis, (7) her symptoms show continuance and chronicity, (8) her records do not support another more plausible etiology for her current psoriasis pathology or other risk factors (in or out of service) to explain her problems other than her service time experiences with TCE, (9) the time lag between TCE exposure in service and current psoriasis pathology is consistent with known medical principles and the natural history of this disease, (10) no other physician has made a controverting opinion, (11) this opinion is consistent with the Veteran’s subjective lay statements, the objective findings/imaging tests/diagnoses, and (12) this illness is permanent in nature and thus is not expected to improve with time. The Veteran was afforded another VA skin examination in October 2019. This examination report shows diagnoses of rosacea and melanocytic nevi with an onset in 2004. Significantly, the examiner opined that the Veteran’s skin disabilities were less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. As rationale for this opinion, the examiner noted that, after reviewing medical records dated in May 1992, February 1997, June 2009, March 2013, July 2018, February 2019, and May 2019 and performing physical examination, it was less likely as not that the Veteran’s rosacea and melanocytic nevi are related to her military service as there are no medical records showing diagnosis, treatment for the skin condition or any related rosacea and melanocytic nevi condition while the Veteran was still in service. There was also no medical literature showing that exposure to TCE leads to skin conditions of rosacea and melanocytic nevi. Upon review of the evidence, the Board finds that the evidence of record is in relative equipoise and, affording the Veteran the benefit of the doubt, service connection for a skin disability is warranted.  As an initial matter, the Board notes that the Veteran’s SPRs show that she was likely exposed to harmful chemicals during her military service and medical records show diagnoses of several skin disabilities during the appeal period.  The only matter still in question is whether there is a medical link between the Veteran’s skin disabilities and her military service.  In this case, the record contains both positive and negative nexus opinions.  While both the August 2018 and October 2019 VA examiners opined that the Veteran’s skin disabilities are not related to her claimed in-service chemical exposure, these opinions mistakenly found that medical literature does not show a link between exposure to TCE and skin disabilities. As above, medical treatise evidence submitted by the Veteran shows that TCE, which is commonly used to clean mechanical equipment on airbases, either through inhalation or skin exposure, can damage the skin and then move through the body, to include the gastrointestinal tract. While the May 2019 medical opinion from Dr. C.N.B. relates the Veteran’s skin disabilities to her claimed in-service chemical exposure, this opinion is premised on in-service TCE exposure and, while the Veteran’s SPRs do show exposure to several harmful chemicals, they do not show specific exposure to TCE. At this time, the Board declines to remand for an additional opinion as such would resemble a fishing expedition for negative evidence, which, in view of the available medical evidence, is not necessary.  Indeed, obtaining such additional evidentiary development in this instance would only result in additional delay with no benefit to the Veteran.  Sabonis v. Brown, 6 Vet. App. 426 (1994); VAOPGCPREC 5-04, 69 Fed. Reg. 59,989 (2004).  As such, the Board will resolve reasonable doubt in favor of the Veteran and find that the Veteran’s skin disabilities are related to her in-service exposure to harmful chemicals.  Therefore, service connection for a skin disability is warranted.  2. Service connection for anemia, claimed as due to in-service chemical exposure, is granted. The Veteran’s STRs are negative for anemia. Significantly, the Veteran’s May 1992 separation examination shows a normal lymphatic system and, in a May 1992 report of medical history, the Veteran specifically denied symptoms of anemia including “dizziness or fainting spells,” “cramps in your legs,” and “frequent trouble sleeping.” Similarly, a February 1997 National Guard enlistment examination shows a normal lymphatic system and, in a February 1997 report of medical history, the Veteran specifically denied symptoms of anemia. Post-service records show anemia as early as August 1999. Specifically, an August 1999 private treatment record shows an evaluation for iron deficiency anemia and subsequent records show a confirmed diagnosis of anemia. The Veteran submitted an initial claim for service connection for anemia in February 2018. In connection with this claim, she was afforded a VA hematologic examination in August 2018. This examination report shows a diagnosis of anemia, noting an onset in 1999. However, upon review of the record, the examiner opined that the Veteran’s anemia was less likely as not related to her active duty. As rationale for this opinion, the examiner noted that the STRs are negative for complaints, treatment or diagnosis of anemia. The initial diagnosis of anemia was in 1999, about 8 years following separation from active duty. Per objective medical evidence, a diagnosis of anemia was made following dysfunction uterine bleeding and duodenal ulcers. Therefore, per objective medical evidence and time frame, it is reasonable to conclude that the Veteran’s current anemia is less likely than not incurred in or caused by potential hazardous materials during service. In connection with the Veteran’s September 2019 supplemental claim, she submitted a May 2019 medical opinion from Dr. C.N.B. Significantly, Dr. C.N.B. opined that, considering every possible sound medical etiology/principle, to at least the 90 percent level of probability that her current anemia is due to her military service because: (1) the Veteran entered service without any doctor-diagnosed illnesses, (2) she had exposure to TCE in service as supported by an EPA report, (3) the Veteran has anemia and medical literature supports a link between TCE and anemia, (4) the Veteran’s anemia was caused, in significant part, by her exposure to TCE in service, (5) she also had dysfunctional menstrual bleeding in service which is also a significant cause of her anemia, (6) her symptoms show continuance and chronicity, (7) her records do not support another more plausible etiology for her current anemia pathology or other risk factors (in or out of service) to explain her problems other than her service time experiences with TCE and dysfunctional menstrual bleeding, (8) the time lag between TCE exposure in service and current anemia pathology is consistent with known medical principles and the natural history of this disease, (9) no other physician has made a controverting opinion, (10) this opinion is consistent with the Veteran’s subjective lay statements, the objective findings/imaging tests/diagnoses, and (11) this illness is permanent in nature and thus is not expected to improve with time. The Veteran was afforded another VA hematologic examination in October 2019. This examination report also shows a diagnosis of anemia but notes an onset in 1995 rather than 1999. Significantly, the examiner opined that the Veteran’s anemia was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. As rationale for this opinion, the examiner noted that, after reviewing medical records dated in May 1992, February 1997, June 2009, March 2013, July 2018, February 2019, and May 2019 and performing physical examination, it was less likely as not that the Veteran’s anemia is related to her military service as there are no medical records showing diagnosis, treatment for the hematological condition or any related anemia condition while the Veteran was still in service. There was also no medical literature showing that exposure to TCE leads to the hematological condition of anemia. Upon review of the evidence, the Board finds that the evidence of record is in relative equipoise and, affording the Veteran the benefit of the doubt, service connection for anemia is warranted.  As an initial matter, the Board notes that the Veteran’s SPRs show that she was likely exposed to harmful chemicals during her military service and medical records show a diagnosis of anemia during the appeal period.  The only matter still in question is whether there is a medical link between the Veteran’s anemia and her military service.  In this case, the record contains both positive and negative nexus opinions.  While both the August 2018 and October 2019 VA examiners opined that the Veteran’s anemia is not related to her claimed in-service chemical exposure, these opinions mistakenly found that medical literature does not show a link between exposure to TCE and anemia. As above, medical treatise evidence submitted by the Veteran shows that benzene exposure has been linked to abnormal blood cell profiles like anemia. While the May 2019 medical opinion from Dr. C.N.B. relates the Veteran’s anemia to her claimed in-service chemical exposure, this opinion is premised on in-service TCE exposure and, while the Veteran’s SPRs do show exposure to several harmful chemicals, they do not show specific exposure to TCE. At this time, the Board declines to remand for an additional opinion as such would resemble a fishing expedition for negative evidence, which, in view of the available medical evidence, is not necessary.  Indeed, obtaining such additional evidentiary development in this instance would only result in additional delay with no benefit to the Veteran.  Sabonis; VAOPGCPREC 5-04, 69 Fed. Reg. 59,989 (2004).  As such, the Board will resolve reasonable doubt in favor of the Veteran and find that the Veteran’s anemia is related to her in-service exposure to harmful chemicals.  Therefore, service connection for anemia is warranted. 3. Service connection for an ulcer, claimed as due to in-service chemical exposure, is granted. The Veteran’s STRs are negative for ulcers. Significantly, the Veteran’s May 1992 separation examination shows a normal G-U (gastrointestinal-urinary) system and, in a May 1992 report of medical history, the Veteran specifically denied “stomach, liver, and intestinal trouble.” Similarly, a February 1997 National Guard enlistment examination shows a normal G-U system and, in a February 1997 report of medical history, the Veteran specifically denied “stomach, liver, and intestinal trouble.” Post-service private treatment records show ulcer symptoms as early as February 1999. Specifically, an October 1999 private treatment record shows ulcer and reflux symptoms beginning February 1999 and subsequent treatment records show a duodenal ulcer which became perforated in July 2014 and was treated with partial gastrectomy. The Veteran submitted an initial claim for service connection for an ulcer in February 2018. Subsequently, she submitted a May 2019 medical opinion from Dr. C.N.B. Dr. C.N.B. noted that the Veteran developed a gastric ulcer/gastritis in 1994 and was treated with a partial gastrectomy for a perforated gastric ulcer in 2014. Significantly, Dr. C.N.B. opined that, considering every possible sound medical etiology/principle, to at least the 90 percent level of probability that her current GI (gastrointestinal) and ulcer problems are due to her military service because: (1) the Veteran entered service without any doctor-diagnosed illnesses, (2) she had exposure to TCE in service as supported by an EPA report, (3) the Veteran has GI ulcer problems and medical literature supports a link between TCE and GI ulcer problems, (4) the Veteran’s GI gastric ulcers/gastritis problems were caused by her exposure to TCE in service, (5) her symptoms show continuance and chronicity, (6) her records do not support another more plausible etiology for her current GI ulcer problems pathology or other risk factors (in or out of service) to explain her GI problems other than her service time experiences with TCE, (7) the time lag between TCE exposure in service and current GI ulcer problems pathology is consistent with known medical principles and the natural history of this disease, (8) no other physician has made a controverting opinion, (9) this opinion is consistent with the Veteran’s subjective lay statements, the objective findings/imaging tests/diagnoses, and (10) this illness is permanent in nature and thus is not expected to improve with time. The Veteran was then afforded a VA stomach examination in October 2019. This examination report shows a diagnosis of gastric ulcer, noting an onset in 1995. Significantly, the examiner opined that the Veteran’s gastric was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. As rationale for this opinion, the examiner noted that, after reviewing medical records dated in May 1992, February 1997, June 2009, March 2013, July 2018, February 2019, and May 2019 and performing physical examination, it was less likely as not that the Veteran’s gastric ulcer is related to her military service as there are no medical records showing diagnosis, treatment for the stomach condition or any related gastric ulcer condition while the Veteran was still in service. There was also no medical literature showing that exposure to TCE leads to stomach condition of gastric ulcer. Upon review of the evidence, the Board finds that the evidence of record is in relative equipoise and, affording the Veteran the benefit of the doubt, service connection for an ulcer is warranted.  As an initial matter, the Board notes that the Veteran’s SPRs show that she was likely exposed to harmful chemicals during her military service and medical records show a diagnosis of a gastric ulcer during the appeal period.  The only matter still in question is whether there is a medical link between the Veteran’s gastric ulcer and her military service.  In this case, the record contains both positive and negative nexus opinions.  While the October 2019 VA examiner opined that the Veteran’s gastric ulcer is not related to her claimed in-service chemical exposure, this opinion mistakenly found that medical literature does not show a link between exposure to TCE and gastrointestinal disability. As above, medical treatise evidence submitted by the Veteran shows that TCE, which is commonly used to clean mechanical equipment on airbases, either through inhalation or skin exposure, can damage the skin and then move through the body, to include the gastrointestinal tract. While the May 2019 medical opinion from Dr. C.N.B. relates the Veteran’s gastric ulcer to her claimed in-service chemical exposure, this opinion is premised on in-service TCE exposure and, while the Veteran’s SPRs do show exposure to several harmful chemicals, they do not show specific exposure to TCE. At this time, the Board declines to remand for an additional opinion as such would resemble a fishing expedition for negative evidence, which, in view of the available medical evidence, is not necessary.  Indeed, obtaining such additional evidentiary development in this instance would only result in additional delay with no benefit to the Veteran.  Sabonis; VAOPGCPREC 5-04, 69 Fed. Reg. 59,989 (2004).  As such, the Board will resolve reasonable doubt in favor of the Veteran and find that the Veteran’s ulcer is related to her in-service exposure to harmful chemicals.  Therefore, service connection for an ulcer is warranted. Bethany L. Buck Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board April Maddox, 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.