Citation Nr: 21042676 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 16-49 541 DATE: July 13, 2021 ORDER Entitlement to service connection for fibromyalgia is granted. Entitlement to service connection for irritable bowel syndrome (IBS) is granted. Entitlement to service connection for sarcoidosis is granted. REMANDED Entitlement to service connection for a skin condition, other than folliculitis barbae, is remanded. FINDINGS OF FACT 1. The Veteran served in Southwest Asia from June 1991 to May 1991. 2. The Veteran has a current diagnosis of fibromyalgia that has manifested to a compensable degree during a six-month period since service in Southwest Asia. 3. The Veteran has a current diagnosis of IBS that has manifested to a compensable degree during a six-month period since service in Southwest Asia. 4. The evidence is in equipoise regarding whether the Veteran's sarcoidosis is related to exposure to environmental hazards during Gulf War service CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for fibromyalgia are met. 38 U.S.C. §§ 1110, 1117, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 2. The criteria for establishing entitlement to service connection for IBS are met. 38 U.S.C. §§ 1110, 1117, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 3. The criteria for establishing entitlement to service connection for sarcoidosis are met. 38 U.S.C. §§ 1110, 1117, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1988 to July 1991. These matters come before the Board of Veterans' Appeals (Board) on appeal from an April 2012 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO), which, in pertinent part, denied entitlement to service connection for fibromyalgia, IBS, a respiratory condition, and a skin condition. The Veteran timely perfected an appeal. See September 2012 Notice of Disagreement; September 2016 Statement of the Case; October 2016 VA Form 9. In February 2019, the Board remanded this matter for additional development. Service Connection Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F. 3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table); 38 C.F.R. § § 3.303. Service connection may also be granted for any disease diagnosed after the military discharge, when all the evidence, including that pertinent to the period of military service, establishes that the disease was incurred during the active military service. 38 U.S.C. § § 1113 (b); 38 C.F.R. § § 3.303 (d). Service connection may be established on a presumptive basis for a Persian Gulf Veteran who exhibits objective indications of chronic disability resulting from undiagnosed illness that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a) (1). In claims based on undiagnosed illness, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Notably, laypersons are competent to report objective signs of illness. Id. The term "Persian Gulf Veteran" means a Veteran who served on active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317(e) (1). A "qualifying chronic disability" for purposes of 38 U.S.C. § 1117 is a chronic disability resulting from (A) an undiagnosed illness, (B) a medically unexplained chronic multisymptom illness (such as chronic fatigue syndrome, fibromyalgia, or a functional gastrointestinal disorder) that is defined by a cluster of signs or symptoms, or (C) any diagnosed illness that the Secretary determines in regulation prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i)(B). Fibromyalgia and irritable bowel syndrome are qualifying chronic disabilities for purposes of 38 U.S.C. § 1117. See 38 C.F.R. § 3.317 (a)(2)(i)(B). For purposes of considering service-connection of gastrointestinal disorders as a qualifying chronic disability in Persian Gulf War veterans, functional gastrointestinal disorders are a group of conditions characterized by chronic or recurrent symptoms that are unexplained by any structural, endoscopic, laboratory, or other objective signs of injury or disease and may be related to any part of the gastrointestinal tract. Specific functional gastrointestinal disorders include, but are not limited to, irritable bowel syndrome, functional dyspepsia, functional vomiting, functional constipation, functional bloating, functional abdominal pain syndrome, and functional dysphagia. These disorders are commonly characterized by symptoms including abdominal pain, substernal burning or pain, nausea, vomiting, altered bowel habits (including diarrhea, constipation), indigestion, bloating, postprandial fullness, and painful or difficult swallowing. Diagnosis of specific functional gastrointestinal disorders is made in accordance with established medical principles, which generally require symptom onset at least 6 months prior to diagnosis and the presence of symptoms sufficient to diagnose the specific disorder at least 3 months prior to diagnosis. 38 C.F.R. § 3.317(a) (2) (i) (B) (3), Note. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the Veteran. A. Fibromyalgia and IBS In the present case, the Veteran served in the Southwest Asia Theater of Operations during the Gulf War as shown by service personnel records. Thus, the Board finds that the Veteran is a "Persian Gulf Veteran" for the purposes of 38 C.F.R. § 3.317. See 38 C.F.R. § 3.317(e)(1). During the Veteran's June 1991 separation examination, he reported stomach problems, leg cramps, and back pain. The Veteran was afforded a VA Gulf War examination in July 2011. The Veteran reported muscle and joint pain in his shoulders, hands, and knees. The examiner indicated that the Veteran did not have fibromyalgia and that his joint pains were explained by post-service injuries to his knee, right knee, and left hand. The Veteran reported constipation every two weeks, but he denied diarrhea. The examiner indicated that the Veteran did not have IBS. A May 2013 private treatment record shows a diagnosis of IBS. In December 2015, the Veteran submitted an independent medical evaluation prepared by Dr. L.H., who indicated that she reviewed the Veteran's claims file and medical records and that she examined the Veteran. Dr. L.H. diagnosed the Veteran with IBS and fibromyalgia. Regarding IBS, the examiner noted that the Veteran's abdominal exam showed tenderness and that he had been diagnosed with IBS based on digestive issues and unexplained abdominal pain. She also noted that since the Veteran returned from Saudi Arabia, he had undergone endoscopy, colonoscopy, and biopsies and been prescribed various medications, none of which helped his symptoms except for a medication specifically for IBS. The examiner opined that the Veteran's IBS had been of moderate severity since at least 2002 based on evidence showing frequent episodes of bowel disturbance with abdominal distress. Regarding fibromyalgia, the examiner disagreed with the July 2011 VA examiner that the Veteran did not have tender points. She noted that the Veteran had positive tender points during her examination. The examiner indicated that "it is clear that he has fibromyalgia" based on the medications that he takes and the "consistent symptoms that he has complained of for many years support that fact that he truly does have fibromyalgia." The Veteran was afforded a VA fibromyalgia examination in June 2016. He reported regular pain in his neck, back, shoulders, hands, and knees. On examination, the Veteran had tenderness to his wrists, shoulders, cervical and lumbar spine, and knees. The examiner opined that the Veteran did not meet the diagnostic criteria for fibromyalgia because "[t]here are many causes of aches and pains of joints or muscles to include vigorous exercise, alcohol, sprains or strains, and vitamin deficiency." The examiner noted that the Veteran's post-service medical record contains evidence of degenerative arthritis of the cervical spine, lumbar spine, and knees, as well as evidence of "multiple hand fractures." The examiner concluded that it was less likely as not that the Veteran's claimed joint pains were incurred in or caused by service. The Veteran was afforded a VA intestinal conditions examination in June 2016. He reported frequent bowel movements, twice-weekly diarrhea, soft stool, constipation, and frequent abdominal cramping. The examiner opined that the Veteran did not meet the diagnostic criteria for IBS because of evidence "in his post service medical record of rectal polyps; disease with clear and specific etiology and diagnosis." The examiner also indicated that risk factors for colorectal polyps include obesity, cigarette smoking, diet high in fat, red meat, low-fiber diet. The examiner opined that it was less likely as not that the Veteran's bowel symptoms were related to a specific exposure event experience during service in Southwest Asia because "[m]edical literature does not support a causational link." The examiner also opined that it was less likely as not that the Veteran's bowel condition was incurred in or caused by service because available service records are "silent for polyps or a chronic bowel condition." A December 2018 VA treatment record shows a diagnosis of irritable bowel syndrome. The Veteran was afforded a VA fibromyalgia examination in July 2019. The examiner opined that the Veteran did not meet the diagnostic criteria for fibromyalgia and that the Veteran had arthritis and arthralgia due to sarcoidosis. The Veteran was afforded a VA intestinal conditions examination in July 2019. The examiner indicated that the Veteran's intestinal condition was a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology. The examiner also opined that the Veteran did not have IBS because his diagnosis of IBS in medical records was "self-reported." The examiner indicated that there were no GI records that confirm the Veteran's history of IBS. The Veteran was afforded a VA fibromyalgia examination in July 2020. The examiner indicated that the Veteran did not have any signs or symptoms of fibromyalgia. The examiner opined that the Veteran did not have a diagnosis of fibromyalgia. The Veteran was afforded a VA intestinal conditions examination in July 2020. The examiner did not diagnose IBS and opined that colon polyps were less likely as not related to service. In April 2021, the Veteran submitted an independent medical evaluation prepared by Dr. M.L.C., who indicated that he reviewed the Veteran's claims file and interviewed the Veteran. After an extensive and thorough summary of the Veteran's medical history, Dr. M.L.C. indicated that "there is no question that [the Veteran] had extensive toxic exposures during his active duty service in Southwest Asia in 1991." He also indicated that the Veteran thereafter "developed a plethora of medical problems, the vast majority without clear explanation." He further indicated that the Veteran meets that diagnostic criteria for fibromyalgia and a functional gastrointestinal disorder. Regarding fibromyalgia, Dr. M.L.C. noted that the Veteran had been diagnosed with fibromyalgia and that his discussion with the Veteran "unequivocally supported the diagnosis." Dr. M.L.C. noted that multiple physical examinations show "the classic signs and symptoms of this disease process, including pain and tenderness in the hands, shoulders, knees, cervical and lumbar regions." Regarding IBS, Dr. M.L.C. noted that the Veteran developed diarrhea, constipation, flatulence, cramps, and tenesmus, which are consistent with a functional gastrointestinal disorder. After review of the forgoing evidence, the Board finds that the record is in relative equipoise regarding whether the Veteran has current diagnoses of fibromyalgia and IBS. As noted above, although the VA examiners failed to diagnose these conditions, two private examiners, one of whom examined the Veteran, diagnosed both fibromyalgia and IBS. Moreover, post-service private and VA treatment records reflect a diagnosis of IBS. The Board also finds that the Veteran's fibromyalgia and irritable bowel syndrome have both manifested to a compensable level. The Board has analyzed the Veteran's reported symptoms of irritable bowel syndrome under Diagnostic Code 7319 (Irritable Colon Syndrome). 38 C.F.R. § 4.114. Diagnostic Code 7319 provides a 10 percent rating for moderate irritable colon syndrome symptoms with frequent episodes of bowel disturbance with abdominal distress. Here, the evidence reflects frequent episodes of bowel disturbance with abdominal distress, and the December 2015 and April 2021 private examiners both opined that the Veteran's IBS was at least moderate in severity. The Board finds that this evidence shows that the Veteran meets the criteria for a compensable rating under Diagnostic Code 7319. Under the schedular rating criteria for fibromyalgia, a 10 percent rating is warranted for widespread musculoskeletal pain that required continuous medication for control. 38 C.F.R. § 4.71a, Diagnostic Code 5025. In this case, the medical evidence reflects that the Veteran has widespread musculoskeletal pain and requires continuous medication for control of his ongoing symptoms. The Board therefore concludes that his fibromyalgia has become manifest to a degree of 10 percent. Accordingly, after resolving any reasonable doubt in favor of the Veteran, the Board finds that the Veteran's currently diagnosed fibromyalgia and irritable bowel syndrome have been present to a disabling (at least 10 percent) degree within the applicable period following his Persian Gulf War service in the Southwest Asia theater, so as to warrant service connection for medically unexplained chronic multisymptom illnesses. 38 C.F.R. § 3.317. B. Sarcoidosis As an initial matter, the record shows that the Veteran has been diagnosed with sarcoidosis. See July 2016 VA Examination Report; July 2020 VA Examination Report; VA Treatment Records. As such, the Board finds the current disability element is established. Shedden v. Principi, 381 F.3d 1163, 1167. Additionally, the Veteran has competently and credibly described his environmental exposures during service in Southwest Asia. As such, there is evidence of an event, injury, or disease in service. Accordingly, the issue turns upon whether there is evidence of a nexus between the in-service injuries and the present disability. Id. In December 2015, the Veteran submitted an independent medical evaluation prepared by Dr. L.H., who indicated that she reviewed the Veteran's claims file and medical records and that she examined the Veteran. Dr. L.H. noted that the Veteran "was clearly exposed to pyridostigmine bromine which has [been] shown to have an over activation of the parasympathetic nervous system." The examiner opined that the Veteran's sarcoidosis was "at least as likely as not related to his exposure to pyridostigmine bromine, as well as the fact that his respiratory was taxed by the exposure to burning oil." The Veteran was afforded a VA respiratory conditions examination in June 2016. The examiner noted a post-service diagnosis of sarcoidosis. The examiner indicated that the "[c]urrent hypothesis regarding the etiology of sarcoidosis is that in genetically susceptible individuals it is caused through alteration of the immune response after exposure to an environmental, occupational, or infectious agent." The examiner also indicated that "[o]nly beryllium and its salts have been shown to produce granulomata that are similar to that seen in sarcoidosis" and that "studies have largely failed to identify an external agent or agents responsible for sarcoidosis." The examiner opined that it was less likely as not that the Veteran's respiratory problems were related to a specific exposure event experience during service in Southwest Asia because "[m]edical literature does not support a causational link." The examiner also opined that it was less likely as not that the Veteran's respiratory problems were incurred in or caused by service because "there is no evidence of chronic lung pathology in service." The Veteran was afforded a VA respiratory conditions examination in July 2019. The examiner noted a diagnosis of sarcoidosis and opined that it was a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology. However, the examiner opined that the Veteran's sarcoidosis was less likely as not related to a specific exposure event experienced by the Veteran during service in Southwest Asia because "[t]here presently is no medical literature to support a correlation between [s]arcoidosis and Gulf War exposures." In April 2021, the Veteran submitted an independent medical evaluation prepared by Dr. M.L.C., who indicated that he reviewed the Veteran's claims file and interviewed the Veteran. After an extensive and thorough summary of the Veteran's medical history, Dr. M.L.C. indicated that "there is no question that [the Veteran] had extensive toxic exposures during his active duty service in Southwest Asia in 1991." Regarding sarcoidosis, Dr. M.L.C. opined that it was more likely than not related to the Veteran's environmental exposures in Southwest Asia based on medical literature, which he cited, showing an increased rate of sarcoidosis in Gulf War veterans who reported exposure to inhalational hazards that included desert dust particulate matter, burn pits, and oil well fire smoke. After review, the Board finds no adequate reason to favor the negative opinions over the positive opinions that are favorable to the Veteran's claim. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (in evaluating the evidence and rendering a decision on the merits, the Board is required to assess the credibility and probative value of proffered evidence in the context of the record as a whole); Evans v. West, 12 Vet. App. 22, 26 (1998). Accordingly, the Board finds that the positive and the negative opinions put the evidence in relative equipoise as to whether the Veteran's sarcoidosis is related to service. When the evidence for and against the claim is in relative equipoise, by law, the Board must resolve all reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Based on the foregoing and resolving all doubt in the Veteran's favor, the Board finds that entitlement to service connection for sarcoidosis is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND The Veteran claims he experienced a skin rash on his legs and thighs while serving in Operation Desert Storm/Shield and that he has continued to experience skin rashes throughout his body on a periodic basis. Although the Veteran has consistently reported skin rashes to his treating VA and private medical providers they have rarely been observed on physical examination within the appellate period. Historically, the Veteran was diagnosed with hives, urticaria, and cellulitis in 2008 and tinea cruris in 2004. More recently, in August 2014 and August 2016, the Veteran was diagnosed with cellulitis, although these diagnoses were linked to specific events and do not appear to be related to the claim before the Board. At the July 2011, June 2016, July 2019, and July 2020 VA examinations, the Veteran did not exhibit any skin rashes rendering it extremely difficult for the VA examiners to assess the nature of his claimed skin rash and provide a fully-informed medical nexus opinion. However, the Board notes that the Veteran recently submitted private dermatology records showing treatment for skin conditions in February 2020. It does not appear that the July 2020 VA examiner considered this evidence in rendering a negative skin diagnosis. Accordingly, on remand, an addendum medical opinion should be obtained. See Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return an inadequate examination report "if further evidence or clarification of the evidence...is essential for a proper appellate decision"); 38 C.F.R. § 4.2 (noting that if the examination report does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes). The matters are REMANDED for the following action: 1. Obtain and associate with the Veteran's claims file all outstanding VA treatment records documenting treatment for the issue on appeal. The Veteran should also be provided an opportunity to identify and/or submit any relevant private treatment records. 2. After all available records have been associated with the claims file, obtain an addendum opinion regarding the etiology of the Veteran's skin condition, other than folliculitis barbae. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. The claims file and a copy of this Remand must be made available to the reviewing examiner, and the examiner shall indicate in the addendum report that the claims file was reviewed. After reviewing the record and, if necessary, examining the Veteran, the examiner should identify all skin conditions diagnosed during the pendency of this appeal, i.e. since 2010, other than folliculitis barbae. For EACH skin condition diagnosed during the pendency of this appeal, the examiner should render an opinion as to whether it is at least as likely as not (i.e., 50 percent probability or greater) incurred in, caused by, or is otherwise related to, the Veteran's military service, to include his service in the Southwest Asia Theater of Operations. The examiner must specifically discuss and comment on the Veteran's complete post-service treatment records (VA and private), as well as the April 2021 private opinion of Dr. M.L.C. regarding the etiology of the Veteran's skin conditions. If necessary, and to the extent possible, the examiner must reconcile his or her findings with these records. The examiner's report must reflect consideration of the Veteran's entire documented medical history and assertions and all lay evidence. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. The examiner must provide a thorough rationale for each opinion given. (Continued on the next page) 3. Following the completion of the foregoing, and any other development deemed necessary, the AOJ should readjudicate the Veteran's claim. If the claim is denied, supply the Veteran and her representative with a supplemental statement of the case and allow an appropriate period of time for response. Thereafter, the claims folder should be returned to the Board for further appellate review, if otherwise in order. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Kipper, 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.