92 Decision Citation: BVA 92-17970 Y92 BOARD OF VETERANS' APPEALS WASHINGTON, D.C. 20420 DOCKET NO. 90-27 136 ) DATE ) ) ) THE ISSUES 1. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for arthritis. 2. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for a skin disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The appellant ATTORNEY FOR THE BOARD William W. Berg, Associate Counsel INTRODUCTION The veteran had active military service from January 1967 to August 1972. This matter came before the Board on appeal from a rating decision of July 1989 from the Montgomery, Alabama, Regional Office (hereinafter RO). The notice of disagreement was received on March 28, 1990. The statement of the case was issued on April 18, 1990. A hearing was held before a hearing officer at the RO in May 1990, and the veteran's appearance at the hearing was accepted in lieu of a substantive appeal (VA Form 1-9). In December 1990, the Board remanded this case for further medical evaluation. Following a Department of Veterans Affairs (VA) examination, completed in May 1991, supplemental statements of the case were issued on July 17, 1991, and September 5, 1991. The appeal was received at the Board on January 7, 1992, and docketed on January 9, 1992. The veteran has been represented throughout his appeal by the Disabled American Veterans, to which the file was referred on January 9, 1992. That organization submitted additional written argument to the Board on February 5, 1992, and the case is now ready for appellate review. In January 1988, the Board denied the veteran's claims of entitlement to service connection for arthritis and for dermatitis. At that time, the Board found that neither arthritis nor a chronic skin disease was present in service or for many years thereafter; that the veteran did not have a chronic skin disorder secondary to Tagamet or Zantac; and that there was no etiological relationship between Tagamet and Zantac and arthritis of the hands, which was first shown long after service. The Board concluded that neither arthritis nor dermatitis was incurred in or aggravated by service, and that neither arthritis nor dermatitis was proximately due to or the result of a service-connected disability. The veteran requested to reopen his claim for these benefits, most recently in June 1989, and additional evidence was associated with the claims file in support thereof. REMAND The veteran contends, in essence, that the RO committed error in denying his claim of entitlement to service connection for arthritis and for a chronic skin disorder. He maintains that he has arthritis and a chronic skin disorder as the result of Tagamet and Zantac prescribed for treatment of his service-connected duodenal ulcer disease. He claims that he did not have polyarthritis, polyarthralgias, or acne lesions prior to being treated with Tagamet and Zantac. He claims that both medications are known to cause such symptoms and that he continues to be treated for these disabilities. He also claims that he now has tenosynovitis and hammertoe deformities as a result of the systemic arthritis involving new joints. Of record is a May 1990 statement from George R. McWhorter, M.D., who states that since 1985, the veteran has had a seronegative arthritis, and dermatitis involving the face associated with cysts or nodules; that the onset of the symptoms was related to taking Tagamet; that the symptoms have persisted despite discontinuance of Tagamet; and that a bone scan earlier in the year was negative. It was his opinion that the veteran's symptoms are related to Tagamet. He enclosed a copy of a December 1980 article from The Lancet which reported that inflammatory arthritis could be a side effect of the use of histamine H2 blockade with cimetidine. A subsequent VA examination, completed in May 1991, found no evidence of inflammatory arthritis at that time and concluded that there was no way to rule out or rule in the role of cimetidine (Tagamet) in the veteran's claimed disabilities. X-ray films were interpreted as showing the lumbosacral spine, sacroiliac joints and the feet as "okay." However, in a statement received in July 1991, the veteran indicated that the rheumatology examiner for the VA had found generalized tenderness of the metatarsophalangeal joints and shoulder discomfort. The veteran also said that he had received an injection of steroid and anesthetic on February 5, 1991, that he was on Motrin at that time, and that these factors would explain why the range of motion of his joints was full when examined by the rheumatologist in April 1991. He cited the findings of Dr. Runas Powers in 1987 to the effect that he had an inflammatory response in which Tagamet triggered a latent immunological problem that helped result in arthritic symptoms. The veteran also noted that he had positive antinuclear antibody findings by two different physicians, including a VA physician, that suggested he had the residuals of "Tagamet toxicity." He veteran maintained that the results of his recent VA examination were inconclusive and did not refute the evidence favoring a grant of the benefits sought. Regarding his VA dermatology examination in 1991, he stated that a diagnosis of Grade II acne was entered but that it was important to note that he was on medication (Cleocin, Retin-A, and Sulfacet-R) in order to maintain a Grade II condition. He asserted that without medication, he experiences full-blown acne disease with continued disfigurement and scarring and that he has permanent scarring as residuals of acne. In effect, the veteran has challenged the adequacy of the VA examinations regarding his claimed disabilities. The VA has a duty to assist the veteran in the development of facts pertinent to his claim. 38 U.S.C. § 5107(a) (1992); 38 C.F.R. § 3.103(a) (1991). Under the circumstances of this case, we are of the opinion that further assistance is required regarding the residuals of Tagamet and Zantac treatment. Moreover, we note that the veteran served a year in Vietnam. In a statement received in November 1991, he claimed entitlement to service connection for the residuals of exposure to Agent Orange, including arthritis and a chronic skin disorder. The Agent Orange claim is closely related to the claims currently on appeal, and claims so closely related must be adjudicated together. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (copy attached). We are of the opinion that further development is also necessary with respect to the Agent Orange claim. Accordingly, the case is REMANDED to the RO for the following: 1. The veteran should be afforded a VA rheumatology examination by a board of two VA physicians to determine the current nature and extent of his claimed arthritic disorder. He should also be afforded a VA dermatological examination to determine the current nature and extent of his skin disorder. The examiners are requested to comment on whether the veteran has the claimed disorders as a result of treatment of his service-connected duodenal ulcer disease with Tagamet and Zantac. In the circumstances of this case, the claims folder should be made available to the examiners for their review prior to examination. 2. The veteran's claim for service connection for the residuals of exposure to Agent Orange, including arthritis and a chronic skin disorder, should be referred to a rating board for adjudication, if feasible. Consideration should be given to the recently promulgated provisions of 38 C.F.R. § 3.311a (1991). If the action remains adverse to the veteran, he and his representative should be provided with an appropriate supplemental statement of the case, which should include regulations governing claims for service connection for the residuals of exposure to Agent Orange, and the case should be returned to the Board for further appellate consideration. BOARD OF VETERANS' APPEALS WASHINGTON, D.C. 20420 ANTHONY FAVA CHARLES E. EDWARDS, M.D. * (MEMBER TEMPORARILY ABSENT) *38 U.S.C. § 7102(a)(2)(A) (1992) permits a Board of Veterans' Appeals Section, upon direction of the Chairman of the Board, to proceed with the transaction of business without awaiting assignment of an additional Member to the Section when the Section is composed of fewer than three Members due to absence of a Member, vacancy on the Board or inability of the Member assigned to the Section to serve on the panel. The Chairman has directed that the Section proceed with the transaction of business, including the issuance of decisions, without awaiting the assignment of a third Member. Under 38 U.S.C. § 7252 (1992), 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.