BVA9504209 DOCKET NO. 93-08 284 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for pulmonary sarcoidosis. 2. Entitlement to an increased rating for seborrheic dermatitis of the scalp with tinea versicolor and a history of neurodermatitis, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD Martin F. Dunne, Counsel INTRODUCTION The veteran served on active duty from April 1977 until April 1980. This matter comes before the Board of Veterans' Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Columbia, South Carolina, Regional Office (RO). In January 1982, the veteran filed an application for entitlement to service connection for swollen glands and for sarcoidosis. The RO, in a rating decision dated in July 1982, granted service connection for bilateral parotid gland enlargement which was assigned a non-compensable disability rating. The VA notification letter sent to the veteran in July 1982 did not mention anything about sarcoidosis. In June 1991, the veteran requested that she be reevaluated for sarcoidosis. In this decision, the Board will address, on the merits, only the issue of entitlement to service connection for sarcoidosis. The issue of entitlement to an increased rating for the veteran's skin disability is being remanded to the RO for further development and readjudication. CONTENTIONS OF APPELLANT ON APPEAL Essentially, the veteran contends that sarcoidosis was first manifest while she was on active duty service. In support of her contention, she notes that her service medical records show that she developed the signs and symptoms of sarcoidosis while on active duty. She also notes that the military physicians suspected sarcoidosis but that she had no idea what this meant at the time. She further contends that when she was examined by the VA shortly after her separation from active duty service, the VA physician also suspected sarcoidosis even though the condition was not confirmed by diagnosis until 1986. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims files. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the evidence is in favor of the claim for service connection for sarcoidosis. FINDINGS OF FACT 1. While on active duty service, the veteran was treated for symptomatology suspected as sarcoidosis. 2. Shortly after the veteran's separation from active duty service, she was treated for symptomatology suspected as sarcoidosis. 3. Sarcoidosis was confirmed by VA diagnosis in 1986. CONCLUSION OF LAW The veteran's sarcoidosis was incurred while she was on active duty service. 38 U.S.C.A. §§ 1131, 5107 (West 1991); 38 C.F.R. § 3.303 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSION Initially, the Board finds that the veteran has presented a well grounded claim for service connection for sarcoidosis; that is, one which is plausible. The Board also finds that the VA has adequately fulfilled its responsibility to assist her in the development of her claim. 38 U.S.C.A. § 5107(a) (West 1991). Factual Background The veteran's service medical records show that she developed swollen parotid glands in February 1978. In May 1978, she was still experiencing swelling of the glands and it was thought that she had the contracted the mumps. At the time, she informed her treating physician that she had had the mumps as a youngster. In August 1978, she was treated for complaints of acute respiratory disease symptoms. On examination, her nodes were swollen under both ears. Her chest was clear. For treatment, she was confined to quarters for twenty-four hours. In December 1978, she had lost her voice and was treated for whooping cough and a cold. By January 1979, she was experiencing earaches, bilateral swelling of the parotid glands, and sore throat. In July 1979, an X-ray taken of her chest showed no infiltrate or plural effusion in her lungs; however, the examiner's impression was possible sarcoidosis and recommended that a biopsy be taken. A biopsy was taken in July 1979 of the minor labial salivary gland because of the enlargement of the parotid glands. The preoperative diagnosis is listed on the report as sarcoid. The post-operative diagnosis is also listed as sarcoid, although the biopsy findings found no evidence that sarcoid was present. In October 1979, she was scheduled to undergo another biopsy but her dental records note that she canceled her appointment claiming that she could not go through another biopsy and she did not want to reschedule her appointment. In November 1979, she was again seen for complaints of swollen glands. In January 1980, she was treated for excessive fatigue. On examination, she had no shortness of breath or fever but her glands were swollen. She was given a provisional diagnosis of sarcoidosis and was again scheduled for a biopsy to rule out sarcoidosis. Her service medical records do not contain another biopsy report and there is no indication that she underwent another biopsy. In February 1980, the veteran signed a waiver declaring the she did not desire a separation from active duty medical examination and none was done. The veteran's post-service medical records show that she was treated at a VA medical facility in June 1980 and February 1981 for complaints of swelling glands and a phlegm producing cough. The report of a VA examination conducted in May 1982 notes that the veteran gave a history of swollen parotid glands. Examination findings revealed swollen parotid glands but no abnormal palpation or percussion of her chest. Her lungs fields were clear to auscultation. but an X-ray revealed that the depth of inspiration was slightly shallow. The diagnoses included asymptomatic bilateral parotid gland enlargement. The examiner requested a biopsy but the record contains no biopsy report pursuant to this examination. In April 1986, the veteran's VA outpatient treatment reports reflect findings of defuse coarse infiltrations in both of her lungs. The diagnosis was pulmonary sarcoidosis. In May 1986, her VA outpatient report notes probable sarcoid and a definitive diagnosis of sarcoidosis was made pursuant to her VA hospitalization in a VA medical facility in June 1986. At the time, she had been admitted to the hospital with a dry, nonproductive paroxysmal cough without a history of asthma, cigarette smoking, hemoptysis, shortness of breath, or tuberculosis exposure. During hospitalization, a biopsy was performed which was positive for sarcoidosis. The veteran's subsequent medical records, both VA and non-VA, reflect continuing treatment for sarcoidosis, to include prescribed steroids. In March 1992, she was hospitalized in a VA medical facility for treatment of sarcoidosis. The medical report notes, by history, that she first began to be short of breath from her sarcoidosis while serving in the military and that, upon military discharge, her symptoms worsened. Also on file are transcripts of the veteran's personal hearings held at both the RO and at the Board. At these hearings, the veteran testified about the symptoms she experienced both while on active duty and subsequent thereto. Analysis Service connection connotes many factors but basically it means that the facts, shown by evidence, establish that a particular injury or disease, resulting in disability, was incurred coincident with service in the Armed Forces or, if preexisting such service, was aggravated therein. This may be accomplished by affirmatively showing inception or aggravation during service or through the application of statutory presumptions. When a chronic disease is shown in service so as to permit a finding of service connection, subsequent manifestations of the same chromic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. Determinations as to service connection will be based on review of the entire evidence of record, with due consideratio to the policy of the VA to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C.A. § 1131 (West 1991); 38 C.F.R. § 3.303(a) (1994). Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. Presumptive periods are not intended to limit service connection. The presumptive provisions of the statute and VA regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. 38 C.F.R. § 3.303(d) (1994). In the veteran's case, she was treated for cough, fatigue, shortness of breath, and swollen parotid glands both in service and shortly after her separation from active duty service. The military physicians suspected sarcoidosis and requested that biopsies be performed. However, only one was done and that one came back negative for sarcoidosis. During the veteran's VA examination of May 1982, the examiner also suspected sarcoidosis and requested that she undergo a biopsy. It appears from the record that this biopsy too was not done. However, the examiner did note that the veteran's bilateral parotid glands were swollen. It was not until 1986 that a definitive diagnosis of sarcoidosis was made based on a biopsy performed at that time. Also, upon admission to a VA medical facility in March 1992 with symptoms consistent with bronchitis with hemoptysis, the hospitalization summary notes that the veteran first began to be short of breath from her sarcoidosis while in the military and that, upon military discharge, her symptoms continued to worsen. Under the circumstances, the evidence shows that the symptomatology manifested while the veteran while was on active duty service and shortly thereafter plus the documented medical suspicions, both in service and post service, that the veteran had every indication of sarcoidosis, the signs and symptomatology of sarcoidosis are, therefore, found to have been present while the veteran was on active duty service. In fact, the bilateral parotid gland enlargement for which service connection was granted by the RO in 1982 was a symptom of sarcoidosis for which the Board is now granting service connection. ORDER Entitlement to service connection for pulmonary sarcoidosis is granted. REMAND The veteran contends that her skin disability, seborrheic dermatitis of the scalp with tinea versicolor and a history of neurodermatitis, is such that more than the current 10 percent disability rating is warranted. At her personal hearings, she testified that the skin condition was covering ever-greater areas of her body and was now spreading all over her back. There are also indications in the medical records that she may have developed an urticarial rash, hives, which could be associated with steroid treatment. Inasmuch as the Board has granted service connection for sarcoidosis, the possibility of a worsening of her skin condition secondary to treatment for sarcoidosis should be explored. Lastly, it has been many years since the veteran has undergone a dermatology examination specifically for evaluation purposes. Pursuant to the VA's duty to assist the veteran in development of facts pertinent to her claim under 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103(a) (1994), a final decision is being deferred on the issue of an increased rating for the veteran's skin disability pending a REMAND for the following action: 1. The RO is to obtain copies of the veteran's VA medical records subsequent to July 1993 and have them incorporated in her claims file. 2. The RO is to obtain copies of the veteran's non-VA treating physicians' medical records and have them incorporated in her claims file. 3. After the above-mentioned records are obtained, the RO is to schedule the veteran for a dermatology examination at a VA medical facility. The examiner is to follow the VA's Physician's Guide for Disability Evaluation Examinations and the veteran's claims file is to be made available to the examiner for review in this case. The examiner is to report detailed findings, both positive and negative. The examiner is to distinguish between the veteran's service-connected seborrheic dermatitis of the scalp with tinea versicolor and a history of neurodermatitis and any other skin condition found and to express an opinion whether there is an etiological relationship between any other skin condition noted and either the veteran's service-connected skin condition or to her service-connected sarcoidosis secondary to treatment or otherwise. The examination report and examiner's opinions are to be associated with the veteran's claims file. 4. When the above-mentioned action is completed, the RO is to review the veteran's claim for an increased rating for her skin condition, to include consideration of 38 C.F.R. § 3.321(a) (1994), and possible secondary effects due to medical treatment for her service-connected sarcoidosis. If the rating decision pertaining to the veteran's skin disability remains unfavorable to her, she and her representative are to be provided with a supplemental statement of the case and afforded the appropriate period of time in which to respond. Thereafter, in accordance with current appellate procedures, the claims files, to include the requested additional evidence, are to be returned to the Board for further appellate consideration. BRUCE KANNEE Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1994).