Citation Nr: 21025540 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 16-07 422 DATE: April 28, 2021 REMANDED Entitlement to service connection for multiple myeloma is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1965 to July 1969 and from December 1969 to October 1971, with additional periods of reserve and national guard service. This case was previously before the Board in September 2018, when the claim listed above was remanded for additional development. A February 2021 supplemental statement of the case was most recently issued, and the claim is once again before the Board. 1. Entitlement to service connection for multiple myeloma. The Veteran contends he was exposed to lead-based paint, asbestos, solvents, chemicals, and herbicide agents while working as an aircraft mechanic and while serving on an aircraft carrier, which may have caused his multiple myeloma. See VA Form 21-4138, received April 30, 2020. Alternatively, he contends that his multiple myeloma began in serivce but was not properly diagnosed until after separation from service. See VA Form 9. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for multiple myeloma because the Veteran has never been afforded a VA examination to determine etiology and, given the medical literature cited in the January 2021 VA examination report, no VA examiner has opined whether the condition began in or was aggravated during service, including as secondary to the Veteran’s service-connected non-specific urethritis. In the cited article entitled “Multiple Myeloma: A Review of the Epidemiologic Literature,” it was noted that the established risk factors for multiple myeloma are male gender, increasing age, African American ethnicity, positive family history of lymphatohematopoietic cancer, and monoclonal gammopathy of undertermined significance (MGUS). MGUS, a condition of excessive plasma cell growth, is related to and greatly increases the risk of progression to multiple myeloma. Multiple myeloma is a malignancy of plasma cells that results in an overproduction of certain monoclonal immunoglobulins, resulting in M-protien secreted in the serum and/or urine. The condition usually presents with bone destruction, hypercalcemia, anemia, renal damage or increased susceptibility to infection. See https://onlinelibrary.wiley.com/doi/epdf/10.1002/ijc.22718. Service treatment records during both active duty periods indicate a potentially compromised immunity with a history of inflammatory conditions of unspecified etiology, including epididymitis, scattered calcific densities in all lung fields compatible with chronic granulomatous disease, dilated bronchiole in the left lung field, slight hilar adenopathy, chronic urethritis, chronic prostatitis, and epithelial cells in the urine. Military physicians noted that renal tuberculosis was a possibility given a prior histoplasmosis diagnosis and chest x-ray showing scattered calcific lesions. There was also a reference to a culture showing hormondendrum species, which the physcian categorized as a contaminant or a persistent fungal infection. After reviewing what military physicians decribed as the Veteran’s “interesting but tough problem,” a private physician found no serious pronounced infection but suspected a “further and perhaps larger cause.” VA treatment records from August 1969 to October 1969 show the Veteran was hospitalized for “suspicion of miliary tuberculosis” one month after his first discharge. Bone marrow aspiration findings were compatible with an inflammatory process, although no granulomatous lesions or lymphocyte nests were found. A bone marrow culture was negative for tuberculosis and fungi, but the Veteran received prophylactic tuberculosis treatment. Numerous sputum and urine smears and cultures were negative for fungus and acid-fast bacilli, but for one isolated positive result for histoplasmosis capsulatum. Serum tests were positive for histoplasmosis. The sicklemia trait was also noted. The Veteran was diagnosed with acute pulmonary histoplasmosis secondary to fungal exposure while gardening. The diagnosis was made with the caveat that there was an outstanding report of hemoglobin electrophoresis (which could have revealed the presence of M-protiens, multiple myeloma, anemia, sickle cell disease, and other hemoglobin disorders). Additionally, laboratory results remained outstanding for garden samples submitted for a confirmatory fungus culture. Because the medical opinions and prior decisions only considered the Veteran’s claim in light of his theory that his multiple myeloma was related to in-service herbicide or chemical exposure, the direct and secondary causal implications raised by the record and medical literature have not been addressed. Specifically, the Board is unable to determine whether the Veteran’s multiple myeloma was an underlying previously undiagnosed condition that began in or is otherwise related to service, to include whether it is proximately due to or aggravated by his service-connected non-specified urethritis. The Board is required to consider all theories of entitlement to VA benefits that are either raised by the claimant or reasonably raised by the record. Schroeder v. West, 212 F.3d 1265, 1271 (Fed. Cir. 2000). The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the Veteran’s multiple myeloma. 2. Provide the clinician a complete copy of the Board remand. After review of the Board remand and the claims file and completion of the examination, the clinician should provide an opinion responsive to the following: a) Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s presently diagnosed multiple myeloma began in or is otherwise etiologically related to service, considering the inflammatory conditions or immunodeficiencies noted in service and notwithstanding any delayed diagnosis? b) Whether the Veteran’s presently diagnosed multiple myeloma is at least as likely as not (i.e., a 50 percent or greater probability) proximately due to or aggravated by a service-connected disability, including non-specific urethritis. Aggravation means “any incremental increase in disability—any additional impairment of earning capacity—in non-service-connected disabilities resulting from service-connected conditions…regardless of its permanence.” Provide a complete rationale to support the requested opinion. In providing a rationale, the clinician must consider the Veteran’s competent lay statements. (Continued on the next page)   If the examiner feels that the requested opinions cannot be rendered without resorting to speculation, he or she must explain why this is so. C. CRAWFORD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Jones, Catherine J. 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.