Citation Nr: 21020702 Decision Date: 04/08/21 Archive Date: 04/08/21 DOCKET NO. 09-32 298 DATE: April 8, 2021 REMANDED Entitlement to an initial rating greater than 30 percent for dermatitis claimed as Sweet’s syndrome, to include on an extraschedular basis, is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1961 to October 1963. The history of this appeal is long. A Board of Veterans’ Appeals (Board) hearing was held in November 2011, before a Veterans Law Judge who is no longer employed by the Board. A transcript is of record. In a February 2021 letter, the Veteran declined a second hearing after being properly informed of his options. Most recently, in October 2018, pursuant to a Joint Motion for Remand (JMR), the Court of Appeals for Veterans Claims (Court) vacated and remanded the September 2017 Board decision that denied entitlement to an initial rating greater than 30 percent for dermatitis claimed as Sweet’s syndrome. In August 2019, the Board remanded the claim for further development consistent with the JMR. The appeal is now back before the Board. Also, the Board notes the Veteran was previously represented by a private attorney. However, in October 2019, prior to recertification of the appeal, the attorney withdrew his representation and notified the Veteran of the same. See 38 C.F.R. § 20.1305. Thus, prior power of attorney has been revoked and the Board will proceed with adjudication. The Board apologizes for the delay, but an addtional remand is required to ensure compliance with the prior remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). First, the August 2019 Board remand requested “an appropriate medical specialist…explain what Sweet’s syndrome is and [list] what symptoms are associated with it.” Then, it requested the medical specialist “consider the Veteran’s symptoms and provide an opinion as to whether it is at least as likely as not that any such symptoms are attributable to his Sweet’s syndrome.” This was not done. The Veteran’s service-connected condition is complex. First, the record reflects the Veteran’s rash was preliminarily diagnosed in 1961 as Sweet’s syndrome during service, which started on his scalp and then spread over his body. See July 2008 Dr. A.B. medical letter. In the 1980s, the rash was thought to be Lupus or Lupus-related. Id. In 2004, the Veteran suffered another flare-up; dermatologists and oncologists tested the Veteran and “a diagnosis of Sweet’s syndrome was made upon repeating a skin biopsy” and a CAT scan was conducted to “rule out lymphoproliferative disease.” Id. A diagnosis of Sweet’s syndrome was confirmed by Dr. A.B. Id. Since 2004, the Veteran has been treated aggressively off and on with various prescription medications in which “eye exams and lab work” were required “to monitor drug toxicity.” See July 2006 Dr. J.K. medical opinion. Despite this history and abundant treatment records, the subsequent September 2019 reviewing clinician stated “there is no current evidence of cutaneous Sweet’s and certainly not chronic or progressive Sweet’s. Sweet’s syndrome is often not a chronic condition unless there is an underlying malignancy; however, it is possible that the original diagnosis was in error and that the Veteran in fact had some sort of hypersensitivity reaction all along in which case he continues to get new lesions that are consistent with this.” The reviewing clinician, a nurse practitioner, neither explained Sweet’s syndrome nor listed the potential symptoms associated with it, as requested in the Board remand directives. She also did not consider the entire appeal period in her opinion, which spans back to 2006. Further, the reviewing clinician also did not state whether any of the Veteran’s claimed symptoms were at least as likely as not attributable to his Sweet’s syndrome. She merely noted the Veteran “continues to have “eye symptoms, chills and sweats, and anemia and low platelets” without any further discussion. Also, she noted an ophthalmologist should “determine whether or not…[the Veteran’s] eye symptoms are related to Sweet’s syndrome;” however, the AOJ never scheduled the Veteran for an eye examination. VA treatment records suggest the Veteran’s Sweet’s syndrome “may have caused iritis and secondary posterior synechiae,” of the right eye, along with various other contentions made by the Veteran that were not discussed. See March 2016 VA treatment records. As such, another remand is required to conduct an eye examination and obtain an adequate medical opinion that discusses all of the Veteran’s claimed symptoms in relation to his service-connected dermatitis claimed as Sweet’s syndrome. Additionally, after the August 2019 Board remand requested the AOJ obtain adequate opinions, it asked the Veteran’s claim be forwarded to the Director of Compensation Service for extraschedular consideration as the Veteran noted his symptoms are not fully contemplated under the schedular rating criteria for the skin, specifically Diagnostic Code 7806. As the September 2019 medical opinion did not properly address the Veteran’s claim or provide a complete picture of the Veteran’s symptoms, a new referral to the Director should also be completed after an adequate, comprehensive medical opinion is completed. The matters are REMANDED for the following action: 1. Obtain any updated relevant VA and/or private treatment records that have not already been obtained and associate the same with the claims file. 2. After the development of #1 above is complete, obtain an opinion from an appropriately qualified clinician to determine the nature and severity of the Veteran’s dermatitis claimed as Sweet’s syndrome. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the reviewing clinician. It is up to the discretion of the reviewing clinician whether a new examination is necessary to provide an adequate opinion. After a thorough review of the record, the reviewing clinician should answer the following: (a.) Explain what Sweet’s syndrome is and what symptoms are generally associated with the disease. (b.) Considering the entire appeal period, back to August 2006, identify all of the Veteran’s claimed symptoms regarding his Sweet’s syndrome, including but not limited to fever, aches, chronic malaise, fatigue, night sweats/chills, arthralgia and joint pain, weight gain, and lymphadenopathy. (c.) For each claimed symptom, provide an opinion with respect to whether it is at least as likely as not (a 50 percent probability or more) that the symptom is related to his service-connected dermatitis claimed as Sweet’s syndrome. The reviewing clinician is directed to review the following (i.) May 2017 JMR at page 5 has a non-exhaustive list of the Veteran’s claimed symptoms; (ii.) the September 2017 Appellate Brief pages 2-4 note the Veteran’s medication treatment during the appeal period; (iii.) May 2008 VA dermatology treatment records noting a description of the Veteran’s flare-ups with “flu-like symptoms” and “diffuse arthralgias, mild thrombocytopenia, and night sweats/fevers” in addition to a poor response to penicillin, Prednisone, Dapsone, and Plaquenil; (iv.) June 2005 VA treatment record noting “arthralgia- could be 2/2 to Sweet’s syndrome;” and, (v.) July 2008 letter from Comprehensive Cancer & Hematology Specialists discussing the Veteran’s history and noting “Dapsone has caused him to have numerous side effects, including severe painful joints and anemia.” In rendering these opinions, the examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran’s reports, he or she must provide an explanation for such rejection. The examiner is not to improperly discount the Veteran’s lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. A full and complete rationale for all opinions must be provided, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. After the development of #1-2 above is complete, obtain an opinion from an ophthalmologist or other appropriately qualified clinician to determine the nature and etiology of the Veteran’s reported eye symptoms related to his service-connected dermatitis claimed as Sweet’s syndrome. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the reviewing clinician. It is up to the discretion of the reviewing clinician whether an examination is necessary to provide an adequate opinion. After a thorough review of the record, the reviewing clinician should answer the following: For each of the Veteran’s claimed eye symptoms, including conjunctivitis and iritis, is it at least as likely as not (a 50 percent probability or more) that eye symptom is related to his service-connected dermatitis claimed as Sweet’s syndrome? The reviewing clinician is directed to (a.) September 2009 VA optometry examination consult where the optometrist opined the Veteran’s recurrent conjunctivitis was “more likely than not secondary to Sweet’s syndrome” after the Veteran noted his “chronic conjunctivitis” and skin flare-ups cause “blur, vision loss, flashes…as well as eye pain;” (b.) August 2009 Optometrist K.W. letter noting the Veteran’s “recent eye issues are due to his Sweet’s syndrome;” and, (c.) March 2016 VA optometry records noting the Veteran’s Sweet’s syndrome “may have caused iritis and secondary posterior synechiae OD.” A full and complete rationale for all opinions must be provided, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If the reviewing clinician cannot provide a requested opinion without resorting to mere speculation, it must be stated, and the reviewing clinician must provide the reasons why an opinion would require speculation. As such, the reviewing clinician must explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 4. After the development of #1-3 is complete, forward the Veteran’s claim to the Director of the Compensation Service for extra-schedular consideration of his service-connected dermatitis claimed as Sweet’s syndrome with consideration given to all of his symptoms that are not contemplated by the schedular rating criteria under Diagnostic Code 7806. 5. Thereafter, readjudicate the claim. If any benefit sought remains denied, provide the Veteran with a Supplemental Statement of the Case (SSOC) and return the case to the Board. DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Bona, 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.