Citation Nr: 21031443 Decision Date: 05/21/21 Archive Date: 05/21/21 DOCKET NO. 16-42 584 DATE: May 21, 2021 REMANDED Entitlement to service connection for a respiratory disability, to include sarcoidosis and lung nodules, to include as due to Gulf War illness, is remanded. REASONS FOR REMAND The Veteran had active service from September 1985 to March 1986 and from November 2004 to January 2006, to include service in the Southwest Asia theater of operations during the Persian Gulf War. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2012 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The case was remanded for further development in April 2019. That development has been completed, and the case has since been returned to the Board for appellate review. The February 2020 VA examiner diagnosed the Veteran with sarcoidosis with a date of onset of 2011. The examiner opined that his sarcoidosis was less likely than not related to service, including environmental exposures therein. The examiner explained that sarcoidosis was not noted to begin during active service, did not manifest within one year after separation from service, and was not noted during service with continuity of the same symptomatology since service. Rather, it was first noted on imaging in 2011, with normal imaging noted multiple years following service up until 2011. It may be presumed that the condition had its onset in 2011 at age 48, which is the normal age of onset for sarcoidosis. See February 2020 VA examination report. However, the examiner did not discuss the December 2005 post-deployment health assessment in which the Veteran reported symptoms including a chronic cough, chest pain/pressure, and difficulty breathing. In addition, the Veteran reported exposure to environmental hazards during Southwest Asia service, including smoke from oil well fires, smoke from burning trash or feces, vehicle or truck exhaust fumes, JP8 or other fuels, solvents, sand and dust. The examiner opined that the Veteran's sarcoidosis is less likely than not related to environmental exposures in-service because such exposure needs to be chronic for decades for the causal association to occur and it is only associated with specific chronic exposures known to cause granulomatous inflammation in the lungs. The examiner stated that due to the Veteran's brief active service dates, any limited exposures are not known to have a causal relationship with sarcoidosis. In support, the examiner referred to the literature review section of the report. See February 2020 VA examination report. However, the medical literature cited by the examiner does not necessarily support the negative nexus opinion. The research study relied upon by the examiner states that sarcoidosis is of unknown etiology and "remains mysterious"; however, there is accumulating evidence for both occupational and environmental causes of granulomatous inflammation. The study specifically mentioned that work environments that produce high levels of inorganic particulate matter emerge as places of higher risk for development of sarcoidosis, including exposures to wood stoves, fireplaces, talc, hard rock dust (silica), etc. Wood burning and firefighting were specifically mentioned as higher-risk activities. As set forth above, the Veteran has alleged exposure to environmental hazards including smoke from oil well fires and burn pits, and sand and dust. Nor does the study cited by the examiner state that exposure needs to be chronic for decades, as represented by the examiner. In fact, the article mentions major recent findings from the study of World Trade Center responders as supporting the probability that occupational, as well as environmental, exposures to inflammatory stimuli trigger sarcoidosis-like illness. Certainly, 9/11 first- responders were not exposed to inorganic particulates for "decades." Furthermore, the examiner characterizes the Veteran's exposure as "limited" and "brief," when the record documents service in Southwest Asia from January 2005 to December 2005, a period of almost one year. The Board agrees with the Veteran's representative that his active service in Iraq could not properly be considered "brief." See July 2020 post-remand appellate brief. For these reasons, the Board determines that an additional VA medical opinion is necessary to properly adjudicate the issue on appeal. The matter is REMANDED for the following action: 1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated him for his claimed disabilities, including from Beth Israel Hospital and Weill Cornell Medicine. After securing any necessary releases, the AOJ should request any relevant records identified. In addition, obtain updated VA treatment records. If any requested records are unavailable, the Veteran should be notified of such. 2. After completing the foregoing development, the Veteran should be afforded a VA examination to determine the nature and etiology of any respiratory disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and statements. The examiner should elicit a full history of the Veteran's relevant symptoms. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should address whether the Veteran has a current diagnosis associated with a respiratory disorder, including sarcoidosis. For each diagnosis identified, the examiner should opine as to whether it is at least as likely as not that the disorder manifested in service or is otherwise related to his military service, to include any symptomatology and environmental exposures therein. If the Veteran has any symptomatology that is not attributable to a known clinical diagnosis, the examiner should opine as to whether it is at least as likely as not that there are symptoms due to any undiagnosed illness, or a medically unexplained chronic multi-symptom illness resulting from service in Southwest Asia during the Gulf War. If so, the examiner should also comment on the severity of the symptomatology and report all signs and symptoms necessary for evaluating the illness under the rating criteria. The Veteran has reported environmental exposures during service in the Persian Gulf including smoke from oil well fires, burn pits, vehicle exhaust fumes, and sand/dust. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. M. Donohue Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D.S. Chilcote, 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.