# Williams v. Secretary of Health and Human Services

> United States Court of Federal Claims · January 23, 2026

URL: https://www.frixlaw.com/law-library/cases/11246071

## Case

- **Court:** United States Court of Federal Claims
- **Decided:** January 23, 2026
- **Precedential status:** Unpublished
- **Opinion:** Opinion
- **Judges:** Daniel T. Horner
- **Cited by:** 0 later opinions in the Frix Law Library

## Citator (automated)

- No negative treatment found by the automated citator. That is not the same as a confirmation that the case is good law; read the citing cases.
- Full citator and citing cases: https://www.frixlaw.com/law-library/cases/11246071

## How later opinions describe it (automated extraction)

- applying the six-part Loving test.

## Opinion text

In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
No. 19-1307V
Filed: December 18, 2025

Special Master Horner
TIMOTHY WILLIAMS,

Petitioner,
v.

SECRETARY OF HEALTH AND
HUMAN SERVICES,

Respondent.

Emily Beth Ashe, Anapol Weiss, Philadelphia, PA, for petitioner.
Meghan Murphy, U.S. Department of Justice, Washington, DC, for respondent.

DECISION1

On August 28, 2019, petitioner, Timothy Williams, filed a petition under the
National Childhood Vaccine Injury Act, 42 U.S.C. § 300aa-10, et seq. (2012),2 alleging
that he suffered myasthenia gravis (“MG”) and chronic inflammatory demyelinating
polyneuropathy (“CIDP”)3 caused-in-fact by an influenza (“flu”) vaccination that he
received on September 16, 2016. (ECF No. 1, p. 1.) On March 29, 2021, petitioner
filed an amended petition to additionally allege inflammatory polyradiculopathy. (ECF

1
Because this document contains a reasoned explanation for the action taken in this case, it must be
made publicly accessible and will be posted on the United States Court of Federal Claims' website, and/or
at https://www.govinfo.gov/app/collection/uscourts/national/cofc, in accordance with the E-Government
Act of 2002. 44 U.S.C. § 3501 note (2018) (Federal Management and Promotion of Electronic
Government Services). This means the document will be available to anyone with access to the
internet. In accordance with Vaccine Rule 18(b), Petitioner has 14 days to identify and move to redact
medical or other information, the disclosure of which would constitute an unwarranted invasion of privacy.
If, upon review, I agree that the identified material fits within this definition, I will redact such material from
public access.
2
Within this decision, all citation to § 300aa will be the relevant sections of the Vaccine Act at 42 U.S.C.
§ 300aa-10-34.
3
Although this decision consistently uses the acronym CIDP, in some instances varying terms were used
to refer to this condition. The petition refers to CIDP as being a polyneuritis and Dr. Steinman made
some references to “chronic inflammatory neuropathy” or “chronic demyelinating neuropathy” while Dr.
Price at one point referenced “chronic inflammatory demyelinating polyradiculoneuropathy.”

1
No. 44, p. 1.) For the reasons set forth below, I conclude that petitioner is not entitled to
an award of compensation.

I. Applicable Statutory Scheme

Under the National Vaccine Injury Compensation Program, compensation
awards are made to individuals who have suffered injuries after receiving vaccines. In
general, to gain an award, a petitioner must make a number of factual demonstrations,
including showing that an individual received a vaccination covered by the statute;
received it in the United States; suffered a serious, long-standing injury; and has
received no previous award or settlement on account of the injury. Finally – and the key
question in most cases under the Program – the petitioner must also establish a causal
link between the vaccination and the injury. In some cases, the petitioner may simply
demonstrate the occurrence of what has been called a “Table Injury.” That is, it may be
shown that the vaccine recipient suffered an injury of the type enumerated in the
“Vaccine Injury Table,” corresponding to the vaccination in question, within an
applicable time period following the vaccination also specified in the Table. If so, the
Table Injury is presumed to have been caused by the vaccination, and the petitioner is
automatically entitled to compensation, unless it is affirmatively shown that the injury
was caused by some factor other than the vaccination. § 300aa-13(a)(1); § 300 aa-
11(c)(1)(C)(i); § 300aa-14(a).

In many cases, however, the vaccine recipient may have suffered an injury not of
the type covered in the Vaccine Injury Table. In such instances, an alternative means
exists to demonstrate entitlement to a Program award. That is, the petitioner may gain
an award by showing that the recipient’s injury was “caused-in-fact” by the vaccination
in question. § 300aa-13(a)(1)(B); § 300aa-11(c)(1)(C)(ii). In such a situation, of course,
the presumptions available under the Vaccine Injury Table are inoperative. The burden
is on the petitioner to introduce evidence demonstrating that the vaccination actually
caused the injury in question. Althen v. Sec’y of Health & Human Servs., 418 F.3d
1274, 1278 (Fed. Cir. 2005); Hines ex rel. Sevier v. Sec’y of Health & Human Servs.,
940 F.2d 1518, 1525 (Fed. Cir. 1991).

The showing of “causation-in-fact” must satisfy the “preponderance of the
evidence” standard, the same standard ordinarily used in tort litigation.
§ 300aa-13(a)(1)(A); see also Althen, 418 F.3d at 1278-79; Hines, 940 F.2d at 1525.
Under that standard, petitioner must show that it is “more probable than not” that the
vaccination was the cause of the injury. Althen, 418 F.3d at 1279. He need not show
that the vaccination was the sole cause but must demonstrate that the vaccination was
at least a “substantial factor” in causing the condition at issue and was a “but for” cause.
Shyface v. Sec’y of Health & Human Servs., 165 F.3d 1344, 1352 (Fed. Cir. 1999).
Thus, petitioner must supply “proof of a logical sequence of cause and effect showing
that the vaccination was the reason for the injury[.]” Althen, 418 F.3d at 1278 (quoting
Grant v. Sec’y of Health & Human Servs., 956 F.2d 1144, 1148 (Fed. Cir. 1992)).
Ultimately, petitioner must satisfy what has come to be known as the Althen test, which
requires: (1) a medical theory causally connecting the vaccination and the injury; (2) a

2
logical sequence of cause and effect showing that the vaccination was the reason for
the injury; and (3) a showing of proximate temporal relationship between vaccination
and injury.4 Id.

Because the Vaccine Act requires a petitioner to present a claim for
compensation for a “vaccine-related injury or death,” § 300aa-11(c); § 300aa-
13(a)(1)(A); Stillwell v. Sec’y of Health & Human Servs., 118 Fed. Cl. 47, 56 (2014),
aff’d per curiam, 607 F. App’x 997 (Fed. Cir. 2015), a petitioner “must specify his
vaccine-related injury and shoulder the burden of proof on causation.” Broekelschen v.
Sec’y of Health & Human Servs., 618 F.3d 1339, 1346 (Fed. Cir. 2010). Accordingly,
where the identity and nature of the vaccine-related injury is in dispute, the Federal
Circuit has held that it is “appropriate for the special master to first determine what
injury, if any, [is] supported by the evidence presented in the record before applying the
Althen test to determine causation. Lombardi v. Sec’y of Health & Human Servs., 656
F.3d 1343, 1352-53 (Fed. Cir. 2011). However, “the function of a special master is not
to ‘diagnose’ vaccine-related injuries.” Andreu v. Sec’y of Health & Human Servs., 569
F.3d 1367, 1382 (Fed. Cir. 2009). Instead, special masters shall determine “based on
the record evidence as a whole and the totality of the case, whether it has been shown
by a preponderance of the evidence that a vaccine caused the [petitioner’s] injury.” Id.
(quoting Knudsen v. Sec’y of Health & Human Servs., 35 F.3d 543, 549 (Fed. Cir.
1994)).

Ultimately, a petitioner may not receive a Vaccine Program award based solely
on his or her assertions; rather, the petition must be supported by either medical
records or by the opinion of a competent physician. § 300aa-13(a)(1). Medical records
are generally viewed as particularly trustworthy evidence because they are created
contemporaneously with the treatment of the patient. Cucuras v. Sec’y of Health &
Human Servs., 993 F.2d 1525, 1528 (Fed. Cir. 1993). However, medical records and/or
statements of a treating physician’s views do not per se bind the special master to adopt
the conclusions of such an individual, even if they must be considered and carefully
evaluated. § 300aa-13(b)(1). A petitioner may rely upon circumstantial evidence. See
Althen, 418 F.3d at 1280. Moreover, the Althen court noted that a petitioner need not
necessarily supply evidence from medical literature supporting petitioner’s causation
contention, so long as the petitioner supplies the medical opinion of an expert. Id. at

4
The Vaccine Act also permits petitioners to recover damages for any vaccine-caused “significant
aggravation” of a pre-existing condition. The Act defines significant aggravation as “any change for the
worse in a preexisting condition which results in markedly greater disability, pain, or illness accompanied
by substantial deterioration of health.” § 300aa-33(4). Where a petitioner in an off-Table case is seeking
to prove that a vaccination aggravated a pre-existing injury, petitioners must establish three additional
factors. See Loving v. Sec’y of Health & Human Servs., 86 Fed. Cl. 135, 144 (2009) (combining the first
three Whitecotton factors for claims regarding aggravation of a Table Injury with the three Althen factors
for off-Table Injury claims to create a six-part test for off-Table significant aggravation claims); see also
W.C. v. Sec’y of Health & Human Servs., 704 F.3d 1352, 1357 (Fed. Cir. 2013) (applying the six-part
Loving test.). The additional Loving factors require petitioners to demonstrate significant aggravation by
showing: (1) the vaccinee’s condition prior to the administration of the vaccine, (2) the vaccinee’s current
condition, and (3) whether the vaccinee’s current condition constitutes a “significant aggravation” of the
condition prior to the vaccination. Loving, 86 Fed. Cl. at 144.

3
1279-80. While scientific certainty is not required, that expert’s opinion must be based
on “sound and reliable” medical or scientific explanation. Boatmon v. Sec’y of Health &
Human Servs., 941 F.3d 1351, 1359 (Fed. Cir. 2019).

Cases in the Vaccine Program are assigned to special masters who are
responsible for “conducting all proceedings, including taking such evidence as may be
appropriate, making the requisite findings of fact and conclusions of law, preparing a
decision, and determining the amount of compensation, if any, to be awarded.” Vaccine
Rule 3(b)(1). Special masters must ensure each party has had a “full and fair
opportunity” to develop the record but are empowered to determine the format for taking
evidence based on the circumstances of each case, including having the discretion to
decide cases without an evidentiary hearing. Vaccine Rule 3(b)(2); Vaccine Rule 8(a);
Vaccine Rule 8(d). Special masters are not bound by common law or statutory rules of
evidence but must consider all relevant and reliable evidence in keeping with
fundamental fairness to both parties. Vaccine Rule 8(b)(1). The special master is
required to consider “all . . . relevant medical and scientific evidence contained in the
record,” including “any diagnosis, conclusion, medical judgment, or autopsy or coroner’s
report which is contained in the record regarding the nature, causation, and aggravation
of the petitioner’s illness, disability, injury, condition, or death,” as well as the “results of
any diagnostic or evaluative test which are contained in the record and the summaries
and conclusions.” § 300aa-13(b)(1). The special master is required to consider the
entirety of the evidentiary record, draw plausible inferences, and articulate a rational
basis for the decision. Winkler v. Sec’y of Health & Human Servs., 88 F.4th 958, 963
(Fed. Cir. 2023) (citing Hines, 940 F.2d at 1528).

II. Procedural History

As noted above, the initial petition alleged either MG or CIDP caused-in-fact by
petitioner’s vaccination. (ECF No. 1.) In September of 2019, petitioner filed initial
medical records and an affidavit in support of his claim. (ECF Nos. 7-8; Exs. P1-P9.)
Throughout the rest of 2019 and the beginning of 2020, petitioner filed additional
medical records and a statement of completion. (ECF Nos. 10, 12, 14, 16-17, 19-21;
Exs. P10-P18.)

Respondent filed a Rule 4(c) Report on August 7, 2020. (ECF No. 26.)
Respondent contended that petitioner failed to support his allegation of vaccine injury
with preponderant evidence, stressing that petitioner had not submitted an expert
report, petitioner’s symptoms preceded vaccination by between six months to five years,
and the lack of reliable evidence showing a causal association between the flu vaccine
and MG and/or CIDP in the existing medical literature. (Id. at 9-10.) Thereafter,
petitioner filed additional medical records and another statement of completion by the
end of 2020. (ECF Nos. 35-36; Exs. P19-P20.)

In March of 2021, petitioner filed additional medical records and another
statement of completion. (ECF Nos. 41-42; Exs. P21-P23.) Petitioner filed an expert
report by neurologist and neuroimmunologist Lawrence Steinman, M.D., with supporting

4
medical literature, on March 29, 2021. (ECF Nos. 43; Ex. P24.) Dr. Steinman opined
that petitioner’s condition represented an inflammatory polyradiculopathy, rather than
either CIDP or MG. (Ex. P24, p. 6.) Thereafter, petitioner filed an amended petition,
alleging inflammatory polyradiculopathy in addition to the previously alleged MG and
CIDP. (ECF No. 44.)

Respondent then filed responsive expert reports by neurologist Raymond S.
Price, M.D., and immunologist John T. Bates, Ph.D., along with supporting medical
literature. (ECF Nos. 47-48; Exs. A-D.) Dr. Price opined that petitioner suffered MG,
but not CIDP or inflammatory polyradiculopathy. (Ex. A, pp. 9-13.) Dr. Bates’s opinion
contested Dr. Steinman’s theory of vaccine causation vis-à-vis inflammatory
polyradiculopathy. (Ex. C.) The parties then exchanged further reports by their experts.
(ECF Nos. 50, 52, 54-55; Exs.P25-P26; Exs. E-F.)

An entitlement hearing was scheduled to commence on July 23, 2024. (ECF No.
59.) Before the hearing, petitioner filed additional medical records and medical
literature. (ECF Nos. 60, 62-64; Exs. P27-P36.) In a joint pre-hearing submission, the
parties agreed that petitioner did not suffer CIDP, narrowing the diagnostic dispute to
MG versus inflammatory polyradiculopathy. (ECF No. 69.)

The two-day entitlement hearing commenced on July 23, 2024. (See Transcript
of Proceedings (“Tr.”), at ECF Nos. 80-81.) At the close of the hearing, the parties
confirmed that the evidentiary record was complete. (ECF No. 76.) However, I advised
the parties that, although petitioner had initially pleaded a vaccine-caused MG, I felt that
petitioner had effectively abandoned any prosecution of such a claim. (Tr. 333-34.) I
instructed petitioner to explain in post-hearing briefing what basis, if any, he had for
continuing to assert a claim for vaccine-caused MG. (Id. at 334-35.) Thereafter, on July
26, 2024, petitioner filed a status report indicating that he was “releasing his claim” that
his flu vaccine caused MG. (ECF No. 77.)

Petitioner filed his post-hearing brief on October 7, 2024 (ECF No. 83);
respondent filed his responsive post-hearing brief on November 2, 2024 (ECF No. 84);
and petitioner filed his reply on November 18, 2024 (ECF No. 85). Accordingly, this
case is now ripe for resolution of entitlement.

Petitioner argues that he has met his burden of proof with respect to a vaccine-
caused inflammatory polyradiculopathy regardless of whether he additionally suffered
MG. (ECF Nos. 83, 85.) Respondent argues, however, that petitioner only ever
suffered MG and not inflammatory polyradiculopathy. (ECF No. 84, pp. 15-18.)
Because I agree with respondent, and because petitioner did not pursue any claim that
his vaccine caused or aggravated MG, it is not necessary to reach any Althen or Loving
analysis in this case.

5
III. Factual History

a. Medical Records

Before receiving the vaccine at issue in this case, petitioner had a medical history
significant for sinus problems, coronary artery disease, and hypertension. (E.g., Ex. P2,
p. 158; Ex. P13, p. 11.) Additionally, he suffered from chronic low back pain with
radiculopathy and was treated with Depo-Medrol injections. (E.g., Ex. P2, p. 165; Ex.
P11, pp. 311-23.) On December 8, 2014, petitioner reported that, despite conservative
treatment with pain and anti-inflammatory medication, his back pain was so severe that
he was unable to walk more than 100 feet before having to stop. (Ex. P8, pp. 250-52.)
He additionally reported numbness in his right thigh that caused his leg to give way,
interfering with his ability to work. (Id. at 252.) Petitioner was treated with Depo-Medrol
injections and NSAIDs for hip and back pain up until the vaccination at issue in this
case. (Ex. P8, pp. 186-93, 201, 205-08, 211-13, 228-30.) Petitioner also received
annual flu vaccinations in 2013, 2014, and 2015. (Ex. P2, pp. 94, 172.)

On September 16, 2016, petitioner followed up with his primary care physician,
William Pickard, M.D., for back pain and sinus problems. (Ex. P2, pp. 93-96.) Dr.
Pickard noted that petitioner’s back pain, which was associated with his lumbar
radiculopathy, was improved and stable at that time. (Id. at 93.) However, during this
appointment, petitioner reported back and joint pain, as well as sinus pressure. (Id. at
95.) His physical exam was positive for low back pain, as well as sinus congestion pain
and pharyngitis. (Id. at 95-96.) Petitioner received the flu vaccination at issue at this
appointment. (Id. at 94; Ex. P1, p. 1.)

On September 20, 2016, petitioner returned to Dr. Pickard with reports of
excessive fatigue, which he suspected could be due to Lyme disease as he had
recently spent time in the woods. (Ex. P2, p. 90.) However, he denied a rash and
subsequent Lyme disease testing was negative. (Id. at 90, 182.) His physical exam
continued to show pharyngitis and low back pain but was otherwise normal. (Id. at 92-
93.)

The next day, September 21, 2016, petitioner presented to neurologist
Mohammad Sadeghi, M.D. (Ex. P3, pp. 1-8.) On his intake form, petitioner indicated
that he presented for evaluation of possible multiple sclerosis symptoms. (Id. at 25.)
He reported a five-year history of intermittent, aching pain that “starts in my arm and
wrist on left side, then goes to the left hip with a burning sensation and then from calf
down to foot on left side.” (Id. at 25-26.) His pain intensified when sitting but improved
when walking. (Id. at 26.) Petitioner also reported back pain, numbness and weakness
in his arm and leg, tingling in hands and feet, limping, facial weakness and tremors,
difficulties with speech and swallowing, cough, extreme fatigue, decreased
concentration, double or blurry vision, and lightheadedness. (Id. at 27-29.) He noted
that he experiences his back pain “[q]uite a bit.” (Id. at 28.) Petitioner described his leg
numbness, weakness, and pain as moderate, while noting that his arm weakness was
moderate with only minimal pain and numbness. (Id.)

6
At his appointment with Dr. Sadeghi, petitioner reported a history of insomnia
with worsening fatigue over the past four years. (Ex. P3, pp. 5, 7.) Petitioner indicated
that he was started on testosterone injections to address his fatigue, which helped for a
time, but he noticed worsening fatigue about six months prior, followed by new onset of
blurry vision. (Id.) He described one “major” episode at night, as well as frequent
episodes while watching television. (Id.) He also reported intermittent numbness of the
left side of his face, arm, and leg; increased phonation; difficulty swallowing; and slurred
speech. (Id.) On physical exam, petitioner’s speech was “somewhat slurred” and nasal
but coherent, and his sensory exam, coordination, and gait were normal. (Id. at 6, 8.)
Petitioner’s strength was normal and intact in his bilateral upper and lower extremities,
with the exception of some mild fatigability in petitioner’s right upper extremity. (Id.) Dr.
Sadeghi ordered testing for myasthenia gravis (“MG”) and prescribed Mestinon. (Id.)

Petitioner underwent an MRI of his brain on September 28, 2016. (Ex. P4, p.
14.) The study showed no acute intracranial abnormality and mild nonspecific white
matter changes most commonly secondary to chronic small vessel ischemia. (Id.) On
October 6, 2016, petitioner presented to Dr. Sadeghi for a review of his MRI and follow
up for possible MG. (Ex. P3, p. 46.) He reported improvement in his symptoms since
he began taking Mestinon. (Id.) Specifically, he reported that he did not feel as fatigued
and denied further episodes of diplopia and ptosis. (Id.) However, petitioner did note
that he “takes up to 3 or 4 tablets” of Mestinon when working the night shift as his
symptoms recur at the end of the day. (Id.) On physical exam, petitioner had diplopia
and fatigability upon sustained upward gaze. (Id. at 47.) However, strength in his
bilateral upper and lower extremities was normal with no appreciable fatigability. (Id.)
Petitioner’s sensory examination, gait, and coordination were normal. (Id.)

Petitioner had a follow up appointment with his primary care provider on October
14, 2016. (Ex. P2, p. 87.) Dr. Pickard noted that petitioner had recently been
diagnosed with MG but was doing much better after starting Mestinon. (Id. at 89.)
Petitioner reported joint and back pain, as well as sinus problems. (Id.) Petitioner’s low
back pain, sinus congestion pain, and pharyngitis were confirmed on physical exam.
(Id. at 90.) However, his exam was otherwise unremarkable. (Id.)

On October 27, 2016, petitioner presented to gastroenterologist Dr. Nezar
Shobassy. (Ex. P5, p. 2.) Petitioner reported his MG diagnosis and explained that he
was having indigestion and difficulty swallowing. (Id.) His physical examination was
normal. (Id.) Dr. Shobassy scheduled petitioner for an abdominal ultrasound, an
esophagogastroduodenoscopy (“EGD”), and a colonoscopy. (Id.) Petitioner’s EGD was
suggestive of Barrett’s esophagus; however, a biopsy was performed which was
negative for Barrett’s esophagus with no evidence of dysplasia or malignancy. (Ex. P5,
pp. 1, 3-4, 6.)

On November 2, 2016, petitioner had a follow up appointment with his primary
care physician for his lumbar radiculopathy. (Ex. P2, p. 84.) While physical exam
continued to show joint and back pain, Dr. Pickard noted that petitioner’s back pain was

7
somewhat improved. (Id. at 86-87.) At this appointment, petitioner requested a
neurology referral for a second opinion. (Id. at 84, 87.) Additionally, Dr. Pickard
ordered MG antibody panels after documenting that petitioner’s neurologist “lost” his
prior laboratory results. (Id. at 87.) During a follow up encounter on November 18,
2016, Dr. Pickard noted that petitioner was still undergoing a neurology workup. (Id. at
81.) That same day, petitioner’s lab results, including an MG panel and testing for
acetylcholine receptor binding antibodies and muscle-specific kinase (“MuSK”)
antibodies, returned negative. (Id. at 178-81.) However, it is noted in the record that a
negative result does not conclusively rule out MG. (Id. at 179.)

On November 28, 2016, petitioner presented for further evaluation by
neurologist, Robert Glenn Smith, M.D. (Ex. P6, p. 3.) Dr. Smith noted petitioner’s MG
diagnosis and description of “2 different types of problems” involving weakness. (Id. at
4.) Petitioner reported “many years” of severe fatigue “when he has overworked
himself,” with a recovery period of hours to overnight before returning to his baseline.
(Id.) This problem was compounded by his chronic low back pain and history of
radicular pain, and he noted an increase in the severity of his symptoms over the past
two years. (Id.) However, petitioner’s “more recent severe activity dependent fatigue”
appeared to be a separate issue. (Id.) He documented an episode of weakness and
difficulty breathing, requiring up to two days of sleep before he felt normal. (Id.)
Petitioner reported that his arms and legs “feel like lead” and become very fatigued with
activity. (Id.) He described another episode, during which petitioner experienced leg
cramps from climbing stairs or ladders and low back pain without radicular pain. (Id.)
He also reported bilateral ptosis with episodic muscle twitching, and worsening choking
on foods and liquids, especially when fatigued. (Id.) Petitioner reported further
weakness in his shoulders and neck. (Id.) Although petitioner reported diplopia, Dr.
Smith opined that this could be related to petitioner’s cataracts, rather than actual
binocular diplopia. (Id.) Petitioner reported improvement in his ptosis, diplopia, and
fatigue with Mestinon, as well as a reduction in pain with Celebrex. (Id.) While Dr.
Smith did not have petitioner’s lab results to review, he recorded that, according to
petitioner, the initial and repeat MG panels were both negative. (Id.) Dr. Smith further
recorded that petitioner “has a history of sciatica, possibly most affecting dermatome L5,
and S1,” as well as “a history of singultus, associated with his increase in episodic
choking.” (Id.)

Physical exam revealed mild, bilateral ptosis affecting the right more than the left;
mild atrophy of the tongue; and minimally reduced strength in petitioner’s left hip flexor,
knee extensor, and ankle evertor. (Ex. P6, pp. 6-7.) His reflexes were normal and
intact, with the exception of reduced reflexes in petitioner’s knees bilaterally. (Id. at 7-
8.) Petitioner’s sensory exam, coordination, and gait were all normal. (Id. at 8.)
Petitioner’s differential diagnosis was MG, though Dr. Smith observed that additional
testing was necessary to verify the diagnosis. (Id. at 9.) He therefore ordered an EMG,
CT of the chest with contrast, and basic metabolic panel. (Id.)

Petitioner underwent an EMG/nerve conduction study on December 7, 2016.
(Ex. P19, p. 2.) There was no evidence of decrement on repetitive nerve stimulation.

8
(Ex. P19, p. 8.) The EMG revealed evidence of “inactive, mild to moderate severity
denervation with partial reinnervation of muscles normally in functional contact with
motor neurons at multiple lumbar levels, consistent with an inactive polyradiculopathy.”
(Ex. P19, p. 8.) The upper extremity muscles tested were “much less affected
electrically, with denervation changes noted mostly in C7 and possible C8 innervated
muscles.” (Id.) The nerve conduction study revealed normal distal latencies and
conduction velocities in the tested upper and lower extremity motor nerves with the
exception of right ulnar distal latency and mild slowing of the left median motor velocity.
(Id.) F-wave latencies were essentially normal. (Id.) Dr. Smith’s impression of
petitioner’s EMG/nerve conduction study findings was

[w]idespread inactive motor denervation with partial reinnervation in the
tested lower extremity, with significantly less denervation reinnervation
changes observed in the tested upper extremity. Likewise, reduction in
recruitment was observed in both upper and lower extremities tested.
Inactive denervation changes were observed in the thoracic paraspinal
muscles and in the genioglossus muscles.

Relatively normal nerve conduction studies, though early demyelination
changes possibly may be observed in right median and ulnar nerve
responses.

(Id. at 10.) These findings suggested the presence of a “longstanding, progressive,
relatively inactive, polyradiculopathy” without significant neuropathy. (Id.) Although the
differential diagnosis was broad and included inflammatory, infectious, paraneoplastic,
POEMS, MUGAS, vascular, metabolic, or genetic etiologies, it was noted that many of
these etiologies had been excluded and that petitioner’s upper motor neuron findings
were not consistent or present in most of these diseases. (Id.) Additionally, petitioner’s
chest CT showed “[a] couple of lung nodules bilaterally likely post inflammatory.” (Ex.
P23, p. 1.)

On January 17, 2017, petitioner followed up with Dr. Smith to review his test
results. (Ex. P6, pp. 22-23.) Dr. Smith recorded that petitioner presented with a
symptom complex suggestive of a neuromuscular junction disorder with improvement of
ptosis and weakness with Mestinon. (Id. at 23.) In documenting petitioner’s history, Dr.
Smith recorded:

Since last seen, he [has] undergone EMG, which did not confirm decrement
on repetitive stimulation, but noted the presence of a polyradiculopathy.
While no obvious neuropathic findings were observed, the patient did have
significant side-to-side variation in his left versus right median nerve, with
slight slowing in conduction velocity noted on the tested left side. Similar
observation was noted in comparing the left and right sensory median
results. Other than prolonged motor distal latency of the ulnar nerve on the
left, without sensory latency abnormality, no other significant abnormalities
were noted on nerve conduction studies.

9
(Id.) Petitioner reported that he was able to stay off Mestinon for 36 hours prior to his
EMG study. (Id. at 23-24.) However, his weakness and fatigue had worsened since his
last visit. (Id. at 23.) Although his symptoms improved with Mestinon, Dr. Smith
documented that petitioner was unable to completely control his activity dependent
weakness. (Id.)

Petitioner’s physical examination again showed mild, bilateral ptosis affecting the
right more than the left, mild tongue atrophy, minimally reduced strength in the left lower
extremity, as well as mild tenderness over the cervical spine without reduced range of
motion or muscle spasm and tenderness over the lumbosacral spine with mildly
reduced range of motion. (Ex. P6, pp. 26-27.) His sensory exam, coordination, and gait
were all again normal, and his reflexes were normal and intact with the exception of
reduced reflexes in his knees, bilaterally. (Id. at 28.) X-ray of the thoracic and cervical
spine both showed degenerative changes. (Ex. P23, pp. 2-3.) Dr. Smith documented
that the x-ray of petitioner’s cervical spine revealed “C6/C7 degenerative/spondylitic
changes” with minimal changes observed in the thoracic spine. (Ex. P6, p. 29.) Dr.
Smith’s assessment was MG with exacerbation, CIDP, bilateral lumbar radiculopathy,
chronic bilateral low back pain without sciatica, polyradiculopathy, and a possible
cervical radiculopathy at C7/C8. (Id. at 29-31.) In addition to continuing with Mestinon,
petitioner was started on prednisone and CellCept, and further testing was ordered. (Id.
at 25, 29-31.)

On January 25, 2017, petitioner underwent a successful lumbar puncture, which
revealed no abnormalities. (Ex. P23, p. 4; Ex. P29, p. 389.) Given that there was no
evidence of any significant brachial blood brain barrier or CSF inflammation, Dr. Smith
opined that most of the differential diagnoses for polyradiculopathy could be excluded
on the basis of the lumbar puncture results. (Ex. P6, p. 31.)

Petitioner’s next follow up appointment with Dr. Smith was on March 30, 2017.
(Ex. P6, pp. 44, 47-48.) Since his last visit, petitioner reported improvement in his
generalized weakness, fatigue, ptosis, double vision, and beathing. (Id.) His response
to Mestinon was described as “variable.” (Id.) Dr. Smith noted that petitioner called the
office in January of 2017 to report persistent muscle weakness that continued to
progress. (Id.) At that time, petitioner’s work was significantly limited by weakness and
associated shortness of breath. (Id.) However, petitioner reported “significant
improvement” after introducing prednisone and CellCept. (Id.) Petitioner also reported
continued episodic difficulty swallowing and “choking spells,” though it was noted that
“symptom onset predates the onset of other myasthenic symptoms.” (Id.) He described
his fatigue and weakness as constant. (Id.) Although he experienced an erratic sleep
pattern due to his shift work, he reported “feeling excessively fatigued even after full
night/day sleep.” (Id.) He also reported occasional transient double vision at the end of
his workday. (Id.) However, he denied shortness of breath after day-to-day activities,
focal weakness in arms and legs, or a limitation of his activity at work or at home due to
weakness. (Id.)

10
Petitioner’s physical exam showed mild ptosis, affecting the right more than the
left; mildly reduced range of motion in his lumbar spine; slightly reduced strength in his
left deltoid, bicep, hip flexor, and knee extensor; and reduced strength in the left ankle
evertor. (Ex. P6, pp. 51-52.) Petitioner’s reflexes were normal with the exception of
reduced reflexes in his triceps, bilaterally. (Id. at 52.) Petitioner’s sensory examination,
coordination, and gait were all normal. (Id. at 53.)

Dr. Smith continued to list MG as a diagnosis. (Ex. P6, p. 55.) However, CIDP
was removed from petitioner’s problem list. (Id. at 44.) Dr. Smith noted that, although
petitioner’s EMG showed no evidence of decrement on repetitive nerve stimulation and
his antibody testing was negative, petitioner has had “significant response” to his
treatment regimen. (Id. at 55.) Dr. Smith suggested a reevalution for MG antibodies.
(Id.) Additionally, Dr. Smith noted petitioner’s long shifts that alternated between day
and night shifts, highlighting that petitioner had finished his night shift early that morning
but had not yet slept by the time he presented for his afternoon appointment, and that
petitioner reported significant fatigue, despite normal strength testing that was stable
when compared to his prior testing. (Id.) Dr. Smith prescribed modafinil on a trial basis
for “shift work sleep disorder.” (Id.) He also documented concern for undiagnosed
obstructive sleep apnea and advised petitioner to undergo a sleep study. (Id.)

To evaluate for a clinical diagnosis of vertebrobasilar insufficiency, Dr. Smith
recommended that petitioner undergo an MRA of the head and neck. (Ex. P6, p. 55.)
Petitioner’s subsequent MRA on April 7, 2017, was unremarkable. (Ex. P23, pp. 5-6.)
Petitioner followed up with his primary care physician on April 26, 2017, and May 26,
2017. (Ex. P2, pp. 62-68.) At both encounters, petitioner reported low back pain. (Id.
at 65, 68.) Additionally, his primary care provider noted that petitioner’s energy levels
were improving on his current medication regimen and that his insomnia was also
better. (Id. at 68.)

On June 14, 2017, petitioner had a follow up appointment with Dr. Smith. (Ex.
P6, p. 67.) Although petitioner reported experiencing both good and bad days, he
described fewer episodes of swallowing problems. (Id. at 70.) He also could not recall
when he last experienced double vision, but continued to report occasional blurred
vision when fatigued. (Id.) Petitioner continued to take CellCept, Mestinon, and
prednisone. (Id.) He denied fluctuating weakness, despite taking prednisone on
alternating days. (Id.) Additionally, petitioner reported experiencing significant
improvement in function when taking modafinil to address his shift work sleep disorder.
(Id. at 67, 77.) Dr. Smith documented that petitioner’s symptoms of double vision,
ptosis, and shortness of breath had largely resolved. (Id. at 77.) Additionally, he
recorded that petitioner was negative for the acetylcholine receptor and the MuSK
antibodies and without evidence of decrement on repetitive nerve stimulation. (Id.)
However, Dr. Smith noted that petitioner had a polyradiculopathy on needle exam and
that the possibility of a distal inflammatory motor polyneuropathy producing symptoms
similar to MG could not be ruled out. (Id.) Dr. Smith assessed petitioner with MG,
cervical radiculopathy at C7, polyradiculopathy, and bilateral lumbar radiculopathy, as

11
well as insomnia and shift work sleep disorder. (Id.) Petitioner continued to follow up
with his primary care physician throughout the rest of the year. (Ex. P2, pp. 44-62.)

Petitioner’s next follow up appointment with Dr. Smith was on December 20,
2017. (Ex. P6, p. 90.) Petitioner reported that “he continues to have more good days
than bad with function continuing to improve, though in a more limited fashion.” (Id.)
He described difficulty with endurance, despite apparently normal immediate strength,
and increased fatigue when walking or standing for extended periods. (Id.) Specifically,
petitioner was only able to walk about 50 yards and could stand for no more than 5
minutes before needing to rest. (Id.) Dr. Smith documented that petitioner had
“previously been noted to have a polyradiculopathy superimposed upon his myasthenia
gravis, with clinical findings suggestive of the C7 and/or C6 radiculopathy affecting the
upper extremities (C7/C8 by EMG).” (Id.) He also noted that “[s]econdary to
[petitioner’s] polyradiculopathy and proximal weakness, our concern about CIDP as a
component of his overall process (with additional involvement of the neuromuscular
junction) is increasing.” (Id. at 97.)

On physical exam, petitioner had minimal ptosis in the right side only, mildly
reduced range of motion in his lumbar spine, and normal strength in his extremities with
the exception of 4+/5 strength in his left ankle evertor. (Ex. P6, pp. 94-95.) Petitioner’s
reflexes were normal and intact with the exception of reduced reflexes in his triceps,
bilaterally. (Id. at 95.) His sensory examination, coordination, and gait were normal.
(Id.) Dr. Smith assessed petitioner with CIDP, MG with exacerbation, bulbar MG,
chronic bilateral low back pain without sciatica, cervical radiculopathy at C7, and
vertebrobasilar TIAs. (Id. at 97.)

Dr. Smith ordered a repeat EMG, which petitioner underwent on January 17,
2018. (Ex. P6, p. 97; Ex. P20, p. 1.) The repeat EMG revealed:

Inactive, chronic polyradiculopathy, affecting all tested extremities on
needle exam. The patient’s denervation disease does not appear to have
progressed significantly since last visit; there may be some mild evidence
of improvement proximally in the upper extremities and thoracic paraspinal
muscles.

Nerve conduction studies no longer document evidence of demyelination,
with improvement in previously noted slowing of several motor distal
latencies and/or conduction velocities.

(Ex. P20, p. 7.) Dr. Smith remarked that these findings were consistent with an
“inactive, demyelinating motor polyradiculopathy,” and that the possible etiologies
remained “broad.” (Id. at 8.)

Petitioner continued to see his primary care physician throughout 2018. (Ex. P2,
pp. 6-44; Ex. P8, pp. 82-95.) On June 14, 2018, petitioner had a follow up appointment
with Dr. Smith for fatigable weakness and MG. (Ex. P6, p. 131.) Dr. Smith explained

12
that petitioner’s “neuromuscular junction abnormality has been complicated by the
presence of an additional polyradiculopathy, a component of which appears not to have
a structural basis.” (Id.) Since his last encounter, petitioner’s insurance had denied
treatment of his MG with either IVIG or rituximab. (Id.) While petitioner noted that his
weakness was better controlled after increasing his prednisone dosage, he reported
that he continued to experience intermittent weakness, shortness of breath, and
paroxysmal nocturnal dyspnea-like episodes. (Id.) Additionally, petitioner noted fatigue
at the end of the day with episodes of tremulousness in his legs after showering and
hand tremors. (Id.) Despite evidence that treatment with steroids and Mestinon was
“aiding his level of function,” petitioner reported that he did not believe CellCept was
offering any symptomatic relief for his MG and requested a different medication. (Id.)
Petitioner’s physical exam was consistent with prior exams except for a 6 Hz tremor that
was previously described as an essential tremor. (Id. at 136.) Dr. Smith recommended
reassessing petitioner’s acetylcholine receptor and MuSK antibody titers. (Id. at 131.)
Petitioner was assessed in pertinent part with acetylcholine receptor antibody double
negative bulbar MG, lumbosacral radiculitis, CIDP, cervical radiculopathy at C7, bilateral
lumbar radiculopathy, and shift work sleep disorder. (Id. at 140.) Dr. Smith noted that a
significant portion of the appointment was spent discussing whether petitioner’s
polyradiculopathy was playing a role in his fatigable weakness. (Id.)

Petitioner continued to see his primary care provider throughout 2019. (Ex. P8,
pp. 45-82; Ex. P11, pp. 150-170.) Additionally, petitioner underwent physical therapy
from January 2019 to February 2019 and from June 2019 to August 2019 to improve his
generalized weakness. (See Ex. P7.)

Petitioner’s next follow up appointment with Dr. Smith was on March 20, 2019.
(Ex. P29, p. 374.) In documenting petitioner’s history, Dr. Smith noted that petitioner
was previously diagnosed with acetylcholine receptor and MuSK antibody negative MG,
although petitioner’s clinical symptoms were more typical for acetylcholine receptor
antibody positive disease. (Id.) He also noted that petitioner had “evidence on EMG of
a superimposed neuropathic process, initially recognized as a demyelinating
polyradiculoneuropathy.” (Id.) Based on repeat EMG findings, Dr. Smith explained that
petitioner’s polyradiculoneuropathy had been stable on Mestinon, CellCept, and
prednisone. (Id.) However, petitioner’s fatigable weakness worsened, and he was
started on methotrexate to help stabilize his motor function. (Id.) At the time of the
encounter, petitioner reported that he was still experiencing significant problems with
fatigable weakness, noting that he typically was unable to function after a day of work,
as well as episodes of blurred vision and shortness of breath. (Id.) Petitioner’s
shortness of breath primarily occurred at night when he was lying flat and resolved after
several minutes of standing. (Id.) That said, Dr. Smith also noted that petitioner
experienced shortness of breath almost exclusively on days that he does not take
prednisone, suggesting that he may be experiencing diaphragmatic weakness when his
medication wears off. (Id.) Additionally, petitioner’s visual blurring would be present
when he woke up in the morning prior to taking his first dose of medication. (Id.) Dr.
Smith noted that petitioner’s undiagnosed sleep apnea was superimposed on these two
issues. (Id.) Petitioner also reported experiencing radicular and allodynic pain affecting

13
his shoulders and neck, as well as occasional difficulty maintaining a grip on objects.
(Id.) Dr. Smith documented that petitioner was suffering from distal peripheral
neuropathy and noted that his severe allodynic pain occurred mainly at night limiting
petitioner’s sleep. (Id.) Finally, Dr. Smith noted that petitioner was also suffering from
“shiftwork disorder with mental clouding” and experienced incomplete improvement with
medication. (Id.)

Based on these findings, Dr. Smith concluded that (1) petitioner still had
substantial problems with his MG, and that the condition was not yet adequately
controlled on the days that he takes prednisone; (2) that petitioner’s radiculopathy and
distal, painful neuropathy were both negatively impacting his life and affecting his ability
to complete activities of daily living; and (3) that petitioner’s shift work sleep disorder,
presumably superimposed on his other problems, was making it more difficult for
petitioner to function throughout the day. (Ex. P29, p. 374.) On physical exam,
petitioner had minimal ptosis on the right side only, a 6 Hz tremor, slightly decreased
strength in the hip flexors and left ankle evertor, and reduced reflexes in the triceps,
knees, and ankles. (Id. at 379-80.) Petitioner’s sensory examination was abnormal with
decreased pinprick sensation in the bilateral upper and lower extremities and decreased
vibration sensation in the bilateral lower extremities. (Id. at 381.) Additionally, petitioner
had a positive Baylor and lateral Adson’s tests, bilaterally. (Id. at 380.) Although his
request for IVIG treatment for petitioner was denied the year prior, Dr. Smith planned to
request IVIG again. (Id. at 375, 384.) Petitioner began his IVIG treatment in June of
2019. (See Ex. P18.)

Petitioner began seeing pulmonologist Sujatha Goli, M.D., on August 15, 2019,
for evaluation of symptoms related to his MG, including shortness of breath and
choking, as well as treatment for sleep apnea. (Ex. P15, p. 1.) Dr. Goli ordered a
pulmonary function test, arterial blood gas test, a chest x-ray, and a swallow study. (Id.
at 2.) Petitioner’s labs and chest x-ray were largely unremarkable, and the swallow
study did not reveal any evidence of aspirations. (Id. at 4.) However, a home sleep
study showed severe sleep apnea. (Id. at 4, 12.)

On September 22, 2019, petitioner was admitted to the hospital after presenting
to the emergency department with reports of a sudden onset of palpitations, which he
described as feeling like his heart was racing, and associated shortness of breath. (Ex.
P12, pp. 6, 8.) What was likely a new onset of atrial fibrillation was detected, and
petitioner was treated with a Cardizem drip. (Id.) He was discharged on September 24,
2019. (Id. at 6.)

Petitioner followed up with Dr. Smith on May 28, 2020. (Ex. P28, p. 438.) Dr.
Smith summarized petitioner’s history as “acetylcholine receptor antibody negative,
[M]u[SK] antibody negative, LR P4 antibody? [MG] (with clinical symptoms more typical
for acetylcholine receptor antibody positive disease) and evidence o[n] EMG of a
superimposed neuropathic process, initially recognized as a demyelinating
polyradiculoneuropathy.” (Id.) He noted that petitioner was responding well to IVIG and
had experienced an improvement in overall motor function; however, despite petitioner’s

14
improvement with IVIG therapy, Dr. Smith documented that petitioner continued to take
Mestinon, methotrexate, and steroids, in combination with IVIG. (Id.) Additionally, Dr.
Smith explained that petitioner had developed acute lower back pain on January 27,
2020, and had participated in aquatic therapy through March of 2020. (Id.) At the time
of the visit, petitioner reported that his “back pain is still relatively severe and continues
to be a problem,” as well as some residual balance problems. (Id.)

At this encounter, Dr. Smith assessed petitioner with MG and CIDP, among other
conditions, such as lumbosacral radiculitis, bilateral lumbar radiculopathy, chronic
bilateral low back pain, cervical radiculopathy at C7, and shift work sleep disorder. (Ex.
P28, p. 450.) He documented that petitioner “has multiple problems, caused by
different diseases.” (Id.) Dr. Smith noted that petitioner’s MG was finally improving with
IVIG therapy but indicated that petitioner needed to increase the frequency of his
treatments to maintain better control. (Id.) Additionally, Dr. Smith remarked that while
treatment with steroids had helped petitioner control his neuromuscular disorder
symptoms, his distal symmetric polyneuropathy had worsened with steroid use. (Id.)
Further, Dr. Smith documented that “[t]he fact that his previous neuropathic findings in
ulnar and median nerve is actually improved on immunomodulatory therapy has
suggested that his EMG quantitated and clinically identified motor neuropathic findings
[that] are likely inflammatory in nature.” (Id.) However, he noted that a marker antibody
to explain petitioner’s myasthenic signs and symptoms had not yet been detected. (Id.)
Dr. Smith instructed petitioner to determine if his insurance would cover testing for
LRP4 antibodies and indicated that petitioner may still need a cell-based assay for
acetylcholine receptor antibody testing. (Id.)

To address petitioner’s low back pain, Dr. Smith ordered an MRI of the
lumbosacral spine. (Ex. P28, pp. 450-51.) He also noted that petitioner had not
experienced further episodes of left neck pain. (Id. at 451.) Petitioner was instructed to
consider restarting aquatic therapy and advised on back exercises for older individuals
with radiculopathies that he could do at home. (Id.) Petitioner began physical therapy
in September of 2020 and continued to pursue treatment until September 2023. (Ex.
P27; Ex. P31.) During some of these visits, petitioner reported being diagnosed with
Guillain-Barré Syndrome (“GBS”). (Ex. P31.)

On November 9, 2020, petitioner underwent an MRI of the lumbar spine, which
revealed “no acute osseous lesion,” normal spinal contents and paraspinal structures,
“[m]oderate compromise of the spinal canal at L3-4 [that] is secondary to ligamentous
hypertrophy and spondylotic change without disc herniation or compromise of the neural
foramina,” and “[m]oderately severe compromise of the spinal canal at L4-5 . . . due to
ligamentous hypertrophy, spondylotic change and a central, 7 mm disc herniation which
compresses the thecal sac and does not affect the neural foramina.” (Ex. P28, pp. 453-
54.) Petitioner had another follow up appointment with Dr. Smith on November 19,
2020. (Id. at 423.) Dr. Smith reviewed petitioner’s MRI and explained that petitioner’s
“newest clinical symptoms are suggestive of lumbosacral stenosis with neurogenic
claudication.” (Id.) Petitioner continued to report back pain and fatigable weakness
upon walking and standing. (Id.) Dr. Smith suggested that, “[g]iven that his aquatic

15
therapy only provided transient benefits, and that his white count [when] most recently
checked was elevated with mild left shift, assessment by his [primary care physician]
would be appropriate to verify lack of an infectious process coincident with his current
low back symptoms.” (Id.) Additionally, Dr. Smith noted that surgical intervention was
likely necessary, given the severity of his lumbosacral canal stenosis. (Id. at 423, 436-
37.) While petitioner could undergo a repeat EMG, Dr. Smith advised that petitioner’s
canal stenosis would be affecting multiple roots, and thus the EMG would basically just
reveal worsening of his polyradiculopathy. (Id. at 437.) With respect to petitioner’s MG,
Dr. Smith documented that petitioner’s condition was well-controlled after increasing the
frequency of his IVIG treatments and expressed his intent to pursue LRP4 antibody
testing if covered by petitioner’s insurance. (Id. at 427, 436.)

Petitioner’s next follow up appointment was on April 1, 2021. (Ex. P28, p. 708.)
Dr. Smith reported that petitioner had “symptoms of CIDP, but additional fatigable
weakness complaints previously diagnosed as acetylcholine receptor antibody negative,
[M]u[SK] negative, LRP4 [antibody]? [MG].” (Id.) He explained that petitioner continued
to be treated with steroids, methotrexate, Mestinon, and IVIG. (Id.) Dr. Smith continued
to stress that petitioner needed to undergo LRP4 antibody testing, if possible. (Id. at
721.) He also indicated that petitioner would need to continue with his current therapy
for treatment of CIDP. (Id.)

On September 13, 2021, petitioner returned to Dr. Smith. (Ex. P28, p. 832.)
Petitioner reported experiencing significant life stressors since his last visit, including his
wife being ill and his daughter unexpectedly passing away. (Id.) He indicated that he
had to take a few days off in early June after experiencing a flare of dyspnea,
weakness, and fatigue. (Id.) Additionally, petitioner reported that he resumed aquatic
therapy in mid-June, but that he had to end at least one session early due to weakness,
and that his physical therapy evaluation confirmed significant leg weakness. (Id.)
Petitioner’s diltiazem dose was reduced, which helped with the dyspnea but did not
improve his weakness. (Id.) However, at the time of the encounter, petitioner reported
that he was feeling stronger. (Id. at 833.) Dr. Smith documented that petitioner’s “[l]ast
EMG actually suggested stabilization of the disease and possible slight improvement at
least in demyelinating features. However, if he fails to improve, we will need to
readdress at least markers that are potentially involved in this process.” (Id. at 832.)
He noted that LRP4 antibody testing should be more affordable as it was now available
through multiple laboratories. (Id.) No diagnosis was listed for this appointment;
however, it was noted that petitioner would be reevaluated in March of 2022. (Id. at
846.)

Petitioner saw Dr. Smith again on March 14, 2022. (Ex. P28, p. 1012.) Dr. Smith
documented that petitioner had

fatiguable weakness associated with radicular pain and other problems
suggestive of overwork, previously followed by Dr. Sadeghi for myasthenia
gravis, which she diagnosed in 2016. On [Mestinon], the patient has noted
improvement in fatigable weakness and diplopia. However, he has been

16
negative for any markers of myasthenia gravis. Further, EMG-tested in
2016-showed no evidence of decrement on repetitive stimulation. In fact,
there was no evidence of neuropathy, although there was a
polyradiculopathy noted on testing. Subsequent studies in 2017 [and] 2018
did not show any significant progression in neuro changes, again only
documenting evidence of a polyradiculopathy.

(Id.) With respect to petitioner’s underlying disease, Dr. Smith explained that petitioner
“does not meet criteria” for either MG or CIDP, but noted that petitioner has “a
polyradiculopathy and fatigable weakness that appears to respond to IVIG.” (Id.) He
noted that petitioner had not experienced any significant worsening in his strength
except in the most proximal muscles. (Id. at 1026.) While possibly indicative of a
progression of petitioner’s underlying disease, Dr. Smith documented that petitioner
experienced a worsening in clinical symptoms around the time he became due for his
next IVIG treatment, which suggested that any progression was likely due to the
treatment wearing off. (Id. at 1012, 1026.) However, petitioner declined to increase the
frequency of his IVIG treatments and indicated his preference to increase his Mestinon
dose as needed in the event of worsening fatigue. (Id. at 1012.) Dr. Smith listed MG,
CIDP, neurogenic claudication due to lumbar spinal stenosis, bilateral lumbar
radiculopathy, cervical radiculopathy at C7, and shift work sleep diagnoses among the
diagnoses for the encounter. (Id. at 1026.)

On October 31, 2022, petitioner had his next follow up appointment with Dr.
Smith for “CIDP MG overlap,” as well as fatigable weakness associated with radicular
pain and other problems suggestive of overwork. (Ex. P29, p. 126.) Petitioner reported
occasionally feeling weak before his IVIG infusion, but his symptoms were otherwise
essentially stable and controlled on Mestinon, methotrexate, and IVIG. (Id. at 126-27,
141.) Petitioner also reported that he occasionally experiences “right hand tingling and
‘shock’ like pain from the wrist down.” (Id. at 127.) Dr. Smith noted that these
symptoms were consistent with a right median neuropathy, specifically carpal tunnel
syndrome. (Id. at 126, 141.) Petitioner’s positive right Phalen’s sign and prior EMG
also supported a finding of carpal tunnel syndrome. (Id.) Given the mildness of his
symptoms, petitioner was advised to treat conservatively with acetaminophen and a
splint. (Id.) MG and CIDP were listed as petitioner’s diagnoses for the encounter. (Id.
at 141.)

Petitioner’s next appointment with Dr. Smith was on March 27, 2023, for fatigable
weakness and CIDP MG overlap. (Ex. P28, p. 1479.) In recording petitioner’s history,
Dr. Smtih continued to stress that, despite his prior MG diagnosis and improvement on
Mestinon, petitioner had tested negative for antibody markers for MG and his EMG
showed no evidence of decrement on repetitive stimulation. (Id.) However, Dr. Smith
noted that petitioner’s Mestinon “may not have been completely ‘out of his system’ with
his ingestion of the medication within 24 hours of his [EMG] testing.” (Id.) He also
documented that petitioner’s polyradiculopathy and evidence of demyelination revealed
by his initial EMG had somewhat improved by the time of his most recent needle exam
assessment in early 2018. (Id.) Petitioner continued to report experiencing weakness

17
prior to his next IVIG therapy session. (Id.) Accordingly, Dr. Smith concluded that, “[a]t
present, his polyradiculopathy with fatigable weakness is therefore adequately but
incompletely controlled by current IVIG treatments.” (Id.) Additionally, Dr. Smith noted
that once petitioner started therapy, petitioner’s “demyelinating polyneuropathy
‘resolved’ with normalization of the previously demyelinating neuropathic features,
indicating improvement on therapy.” (Id.) Petitioner again refused to increase the
frequency of his IVIG therapy. (Id.) CIDP, MG, bilateral lumbar radiculopathy,
neurogenic claudication due to lumbar spinal stenosis, sensory polyneuropathy, and
shift work sleep disorder were listed among petitioner’s diagnoses for the encounter.
(Id. at 1493.)

In April of 2023, petitioner presented for chiropractic care, with major complaints
of cervical, thoracic, and lumbo pelvic pain, which petitioner indicated first occurred after
his flu vaccination in 2016. (Ex. P32, p. 3.) Petitioner reported that he was
subsequently diagnosed with GBS, MG, and CIDP. (Id.) He explained that he
experiences periodic flares of varying intensity that last anywhere from a day to a week.
(Id.) Petitioner described his discomfort as an ache in the cervical, thoracic, and lumbo
pelvic areas with tingling in his left hand and a burning sensation in his thighs, as well
as weakness in his left arm and thigh. (Id.) The chiropractic provider described
petitioner’s gait as abnormal, noting that he tended to drag his left foot, and observed
that he had difficulty breathing. (Id.) Petitioner reported that his pain is aggravated by
standing for more than hour and is less bothersome when he is seated or laying down.
(Id.) On physical exam, petitioner’s left ilium appeared higher than his right, and his
right shoulder was higher than his left. (Id.) Additionally, he had reduced cervical range
of motion with discomfort during testing, as well as reduced thoraco-lumbar range of
motion with discomfort along the entire spine on flexion and pain in the lumbo pelvic,
lower thoracic, and scapular areas on lateral flexion. (Id.) Petitioner was diagnosed
with “[c]hronic severe cervical sprain and strain with associated cervical subluxation
complex, accompanied by moderate to severe myalgia and cervicalgia,” “[c]hronic
severe thoracic sprain and strain with associated thoracic subluxation complex,
accompanied by moderate to severe thoracic and costal myalgia and pain;” “[c]hronic
severe lumbo pelvic sprain and strain with associated lumbo pelvic subluxation
complex, accompanied by severe myalgia and lumbo pelvic pain;” and “[c]hronic mild to
moderate sprain/strain in left shoulder and arm with associated upper extremity
subluxation complex accompanied by weakness and tingling.” (Id. at 3-4.) After
petitioner initiated regular chiropractic care in November of 2023, he was able to
maintain “an overall decrease in his pain levels.” (Id. at 4.) Petitioner continued
chiropractic treatment through June of 2024. (Ex. P32.)

Based on the records submitted in this case, petitioner continued to receive IVIG
through April of 2024. (Ex. P30.)

b. Testimony

Petitioner filed a sworn affidavit and provided testimony during the entitlement
hearing. (Ex. P9; Tr. 7-34.) Petitioner avers that, prior to the subject vaccination, he

18
“had no history of neurological disorders.” (Ex. P9, ¶ 3.) He maintains that he received
the flu vaccine at issue in this case on September 16, 2016. (Id. ¶ 4; Tr. 13.)

During the hearing, petitioner provided testimony regarding the nature of his
employment at an oil refinery. (Tr. 8-12, 31.) He describes the intense physical
demands of his job, explaining, for example, that some tasks involved climbing towers in
excess of 200 feet via ladder and noting that he was sometimes required to “work
endless days of 12-hour shifts.” (Id. at 9-12, 31.) Petitioner admits that, prior to
receiving the flu vaccination at issue, he suffered from low back pain. (Id. at 13-14, 29-
34.) He recalls receiving some injections for his low back pain and concedes that he
followed up with his primary care provider, Dr. Pickard, for continuing low back pain.
(Id. at 14, 29-31.) However, petitioner states that he was able to work through it and
avers that his low back pain did not prevent him from doing his job or any of his
hobbies. (Id. at 14, 32-34.)

Petitioner summarizes his medical course as contained in his medical records.
(Ex. 9, ¶¶10-28; Tr. 16-28.) He maintains that he started experiencing fatigue and
weakness approximately three days after receiving his flu vaccine. (Tr. 14-16.)
Petitioner states that he followed up with Dr. Pickard the next day and requested to be
tested for Lyme disease as he had spent the prior weekend at his lake house. (Id. at
16-17; Ex. 9, ¶ 10.) He recalls his neurology appointment with Dr. Sadeghi on
September 21, 2016, stating that he remembers experiencing fatigue, weakness,
blurred vision, trouble swallowing, slurred speech, tingling from his head to his foot, and
left sided pain at the time of that encounter. (Tr. 18; Ex. 9, ¶ 11.) Petitioner avers that
prior to receiving his flu vaccine on September 16, 2016, he had never experienced
blurred or double vision, difficulty speaking or swallowing, or tingling from his face down
to his foot. (Tr. 18-19, 21-22.) Dr. Sadeghi prescribed Mestinon and ordered blood
tests for myasthenia gravis (“MG”), which came back negative. (Id. at 23.) After
becoming frustrated with Dr. Sadeghi’s office, petitioner explains that he sought a
second opinion from Dr. Smith in November of 2016. (Id. at 24.) Petitioner avers that
Dr. Smith eventually diagnosed him with polyradiculopathy. (Id. at 24-26.) However, he
also states that Dr. Smith thought petitioner had MG, kept him on the treatment, and
tested him for MG again, which came back negative. (Id. at 25.) Throughout the course
of his care, Dr. Smith continued to prescribe petitioner Mestinon and started him on
prednisone, CellCept, physical therapy, and eventually IVIG treatment. (Ex. 9, ¶¶ 19,
22; Tr. 26.) As of the date of the hearing, he was still taking Mestinon and prednisone,
undergoing IVIG therapy, and attending physical therapy. (Tr. 26-28.) He avers that
prior to his flu vaccine, he had not taken prednisone or any other steroids and had never
undergone IVIG treatment. (Id. at 27-28.)

Petitioner describes how he continues to suffer from constant and severe pain,
fatigue, weakness, and numbness. (Ex. 9, ¶ 29.) These symptoms have limited his
ability to walk, work, perform many activities of daily living, and participate in many
activities he previously enjoyed, such as fishing and hunting. (Id. ¶¶ 29-30.)

19
IV. Expert Opinions and Qualifications5

a. Petitioner’s Expert, Lawrence Steinman, M.D.6

Dr. Steinman submitted three expert reports and testified during the entitlement
hearing. (Exs. P24-P26; Tr. 35-122, 321-33.) He was proffered, without objection, as
an expert in neurology and neuroimmunology. (Tr. 6-7, 38.)

According to Dr. Steinman, the three most likely diagnoses considered by
petitioner’s treating physicians’ included MG, CIDP, and inflammatory
polyradiculopathy. (Ex. P24, p. 6.) However, Dr. Steinman notes that he and Dr. Price
agree that petitioner does not suffer from CIDP. (Ex. P24, p. 6; Ex. P26, p. 2; Tr. 102.)
Therefore, the two competing diagnoses in this case are MG and inflammatory
polyradiculopathy. (Tr. 44-45.) Dr. Steinman states that it is possible for inflammatory
polyradiculopathy and MG to exist as comorbid diagnoses in rare cases. (Ex. P24, pp.
1, 6 (citing Saskia Bolz et al., CIDP, Myasthenia Gravis, and Membranous
Glomerulonephritis – Three Autoimmune Disorders in One Patient: A Case Report, 18
BMC NEUROLOGY 1 (2018) (Ex. P24, Tab 4)); see also Tr. 119-20.) However, he
maintains that in this case, it is more likely than not that petitioner suffers from one or
the other, rather than both conditions. (Tr. 119-20.) While he concedes that a
diagnosis of MG cannot be definitively ruled out and notes that this is a complex case,
Dr. Steinman opines that inflammatory polyradiculopathy is more likely than not the
correct diagnosis in this case. (Tr. 44-45; Ex. P24, pp. 1, 6; Ex. P26, p. 2.)

Dr. Steinman contends that petitioner does not suffer from MG. (Tr. 46; Ex. P24,
p. 1.) To support his opinion, he points to petitioner’s antibody and electrodiagnostic
testing results. (Tr. 45, 100.) He stresses that petitioner tested negative for the
acetylcholine receptor and muscle-specific kinases (“MuSK”) antibodies, which he
maintains are “rarely” negative “in people who actually still have myasthenia gravis.”
(Id. at 45.) Additionally, Dr. Steinman emphasizes that petitioner’s treating neurologist,
Dr. Smith, conducted comprehensive EMG studies which revealed no evidence of
decrement on repetitive nerve stimulation. (Id. at 54, 100; Ex. P24, p. 6.) While he

5
Because I have concluded, for the reasons discussed below, that the diagnostic issue presented by the
parties is dispositive, summaries of the experts’ opinions are limited to their views regarding diagnosis
and do not address their opinions relative to whether the flu vaccine at issue in this case can or did cause
an inflammatory polyradiculopathy.
6
Dr. Lawrence Steinman received his medical degree from Harvard University. (Ex. P24, Tab 1, p. 1.)
He completed a surgery internship and two residencies, one in pediatrics and one in pediatric and adult
neurology, at Stanford University Hospital. (Id.; Tr. 36.) He also completed fellowships at the Weizmann
Institute of Science, the Aharon Katzir-Katchalsky Center, and the National Institutes of Health. (Ex. P24,
Tab 1, p. 1.) He currently works at Stanford University as a professor of Neurology and Neurological
Sciences, Pediatrics, and Genetics. (Id.) He is board certified in psychiatry and neurology. (Id. at 2.) Dr.
Steinman was elected to the Institute of Medicine of the National Academy of Sciences in 2009. (Ex.
P24, pp. 2-3; Tr. 40-41.) He has cared for hundreds of patients with neuroinflammatory diseases,
including inflammatory polyradiculoneuropathy and MG, and he has written several papers on MG. (Ex.
P24, pp. 1-2; Tr. 36.) He has published roughly 600 journal articles. (Ex. P24, Tab 1, pp. 5-49.)

20
concedes that it is possible for an individual to suffer from “double antibody negative,
EMG negative” MG, he opines that he puts “[v]ery low weight” on that possibility in
petitioner’s case. (Tr. 100.)

While he notes that petitioner does not satisfy the antibody or electrodiagnostic
tests to support a diagnosis of MG, Dr. Steinman opines that petitioner “was treated with
the appropriate drugs.” (Ex. P25, p. 12.) Dr. Steinman acknowledges that petitioner
was started on Mestinon, an effective and approved treatment for MG. (Tr. 45.)
Although he concedes that Mestinon is not a medication prescribed to treat
inflammatory polyradiculopathy, Dr. Steinman emphasizes that Dr. Smith “escalated”
petitioner’s therapy by prescribing steroids and CellCept to suppress inflammation,
which he suggests favors a diagnosis of inflammatory polyradiculopathy. (Id. at 45-46.)
However, Dr. Steinman acknowledges that medications, such as prednisone and
CellCept, would also benefit patients suffering from MG. (Id. at 46, 53.) Dr. Steinman
argues that the fact that Dr. Smith added four “highly impactful” medications to
petitioner’s regimen over the course of his treatment indicates that petitioner was not
responding well to Mestinon, which cuts against a finding that MG is the most
appropriate diagnosis. (Id. at 323-24.)

Moreover, Dr. Steinman stresses that Dr. Smith, an expert on neuromuscular
disease, “weighed all of the evidence and cast aside a diagnosis of myasthenia gravis in
favor of inflammatory polyradiculopathy.” (Tr. 45.) He places high value on the opinion
of Dr. Smith as the treating physician and agrees with Dr. Smith that inflammatory
polyradiculopathy, rather than MG, is the correct diagnosis. (Id. at 46, 99.) Specifically,
Dr. Steinman opines that “abandoning the diagnosis of myasthenia gravis is the best
course of action” in this case. (Id. at 53.) While he acknowledges that he cannot point
to a record where Dr. Smith explicitly used the word “inflammatory” when diagnosing
petitioner with a polyradiculopathy, Dr. Steinman contends that based on the context,
particularly his decision to treat petitioner with potent anti-inflammatory medications,
such as prednisone and CellCept, Dr. Smith thinks petitioner has an inflammatory
polyradiculopathy. (Id. at 104-05, 117.) He concedes that Dr. Smith continued to list
MG as a diagnosis in the record for petitioner’s most recent neurology encounter;
however, Dr. Steinman states that he thinks it is very clear that Dr. Smith does not
believe petitioner suffers from MG and argues that just because MG is listed as a
diagnosis within an electronic medical record does not mean that Dr. Smith endorses
MG as an appropriate diagnosis. (Id. at 101.)

In addition, Dr. Steinman opines that petitioner does not suffer from CIDP. (Ex.
P24, p. 6; Ex. P25, p. 13; Tr. 90, 102, 105, 108.) He explains that petitioner does not
have evidence of a demyelinating neuropathy. (Ex. P24, p. 6; Tr. 103.) Specifically, Dr.
Steinman stated that petitioner’s electrodiagnostic studies did not reveal evidence of
demyelination, which would be expected for an individual suffering from CIDP. (Tr. 102,
112.) Again, while he acknowledges that Dr. Smith continues to list CIDP as a
diagnosis in petitioner’s most recent medical records, Dr. Steinman indicates it is very
clear that Dr. Smith does not think petitioner has CIDP. (Id. at 56, 101-02, 108.)

21
According to Dr. Steinman, inflammatory polyradiculopathy has been described
with an autoimmune response to a paranodal protein called contactin-1. (Ex. P24, p. 6
(citing Kathrin Doppler et al., Destruction of Paranodal Architecture in Inflammatory
Neuropathy with Anti-Contactin-1 Autoantibodies, 86 J. NEUROLOGY NEUROSURGERY &
PSYCHIATRY 720 (2015) (Ex. P24, Tab 6)); Ex. P26, p. 2.) Additionally, he notes that
antibodies to another paranodal protein, neurofascin, have been reported in patients
with inflammatory polyradiculopathy. (Ex. P25, pp. 12-13 (citing Atay Vural et al.,
Autoantibodies Against the Node of Ranvier in Seropositive Chronic Inflammatory
Demyelinating Polyneuropathy: Diagnostic, Pathogenic, and Therapeutic Relevance, 9
FRONTIERS IMMUNOLOGY 1 (2018) (Ex. P25, Tab 5); Masato Kadoya et al., IgG4 Anti-
Neurofascin155 Antibodies in Chronic Inflammatory Demyelinating
Polyradiculoneuropathy: Clinical Significance and Diagnostic Utility of a Conventional
Assay, 301 J. NEUROIMMUNOLOGY 16 (2016) (Ex. P25, Tab 6)); Ex. P26, p. 2.)

Relying on a study by Doppler et al., he explains that contactin-1, an antigen at
the node of Ranvier, is targeted in inflammatory polyradiculopathy. (Tr. 62, 66
(discussing Doppler et al., supra, at Ex. P24, Tab 6).) He states that inflammatory
polyradiculopathy does not involve demyelination because contactin-1 is at the node of
Ranvier, not in the myelin. (Id. at 103 (discussing Doppler et al., supra, at Ex. P24, Tab
6).) Dr. Steinman explains that inflammatory polyradiculopathy involves axonal damage
and potentially axonal loss. (Id. at 108.) Because contactin-1 is not limited to nerve
roots and is found in the central and peripheral nervous systems, Dr. Steinman opines
that it is difficult to determine whether inflammatory polyradiculopathy involves a
generalized process affecting the whole spine or discrete lesions at various points on
the spine. (Id. at 116-17.)

In Doppler et al., high reactivity to contactin-1 by enzyme-linked immunosorbent
assay (“ELISA”) was observed in four patients with chronic inflammatory demyelinating
polyradiculopathy and in none of the patients with GBS. (Ex. P24, p. 6 (citing Doppler
et al., supra, at Ex. P24, Tab 6).) Dr. Steinman notes that the four patients in Doppler et
al. presented with a typical clinical picture, namely acute onset of disease and severe
motor symptoms, and three patients developed an action tremor. (Id. (citing Doppler et
al., supra, at Ex. P24, Tab 6).) In these four patients, disruption of paranodal
architecture was observed via immunofluorescence-labelling of paranodal proteins of
dermal myelinated fibers, and histology testing revealed axonal damage with no
classical signs of demyelination. (Id. (citing Doppler et al., supra, at Ex. P24, Tab 6).)
Therefore, the authors of the Doppler et al. study concluded that “anti-contactin-1-
related neuropathy constitutes a presumably autoantibody-mediated form of
inflammatory neuropathy with distinct clinical symptoms and disruption of paranodal
architecture as a pathological correlate. Anti-contactin-1-associated neuropathy does
not meet morphological criteria of demyelinating neuropathy and therefore, might rather
be termed a ‘paranodopathy’ rather than a subtype of demyelinating inflammatory
neuropathy.” (Id. at 7 (citing Doppler et al., supra, at Ex. P24, Tab 6).)

Dr. Steinman opines that the clinical picture of the four patients examined in
Doppler et al. is closest to petitioner’s clinical picture. (Ex. P24, p. 6; Tr. 116 (citing

22
Doppler et al., supra, at Ex. P24, Tab 6).) He states that the four patients examined in
Doppler et al. were found to have a non-demyelinating inflammatory polyradiculopathy.
(Tr. 66, 103-05.) Dr. Steinman opines that petitioner did not suffer from demyelination
and agrees underlying pathophysiology at petitioner’s nerve root is not demyelinating.
(Id. at 103, 111-13.) Therefore, Dr. Steinman contends the diagnosis in Doppler et al.
supports his opinion that inflammatory polyradiculopathy is the diagnosis that fits best in
this case. (Ex. P24, p. 6, Tr. 104-05, 116 (citing Doppler et al., supra, at Ex. P24, Tab
6).)

Specifically, Dr. Steinman opines that petitioner suffered from a significant
aggravation of an inflammatory polyradiculopathy on the weekend he received the flu
vaccine. (Ex. P24, p. 6; Tr. 39, 114-15.) He argues that petitioner’s symptoms following
vaccination, specifically the symptoms in his face, numbness and tingling, and his
difficulty swallowing and speaking, are more likely than not a manifestation of a new
radiculopathy that developed after he received the flu vaccination at issue. (Tr. 50.) Dr.
Steinman explains that petitioner’s preexisting radiculopathy seemed amplified post-
vaccination with new areas of the nervous system, specifically cervical and bulbar nerve
roots, being implicated. (Id. at 43-44, 50.)

Although Dr. Steinman concedes that he would expect an individual suffering
from inflammatory polyradiculopathy to have elevated cerebrospinal fluid (“CSF”)
protein, he explains that petitioner was on anti-inflammatories at the time the CSF
testing was completed which could have kept his CSF albumin levels within normal
range. (Tr. 117-18.) He argues that all of the symptoms that petitioner presented with
post-vaccination can be explained by inflammatory polyradiculopathy. (Id. at 118.)
Furthermore, Dr. Steinman opines that the EMG and nerve conduction study results and
the antibody testing results reinforce his preferred diagnosis of inflammatory
polyradiculopathy because these tests are negative for CIDP and MG. (Id. at 111-12,
118-19.) Accordingly, he agrees that the diagnosis of inflammatory polyradiculopathy is
arrived at in this case by process of elimination. (Id. at 118.) Additionally, Dr. Steinman
agrees that inflammatory polyradiculopathy is an umbrella term for a variety of different
conditions, such as CIDP and GBS, as opposed to a specific clinical entity with strict
diagnostic criteria. (Id. at 115-16.)

While the medical records indicate that petitioner suffered from lumbar
radiculopathy prior to receiving the flu vaccine at issue, Dr. Steinman emphasizes that
there is no reference to any cervical radiculopathy in the pre-vaccination records. (Tr.
42-43.) He places the onset of petitioner’s nerve pain and dysfunction in his cervical
spine after the flu vaccination at issue. (Id. at 43.) Dr. Steinman distinguishes
petitioner’s preexisting lumbar radiculopathy from his post-vaccination clinical
presentation, stating that the anatomy of petitioner’s preexisting radiculopathy was
confined to the lumbar area and extended, at most, into the thoracic area with no
evidence of cervical or bulbar involvement. (Id. at 43-44, 49-50.) He notes that
petitioner’s lumbar radiculopathy primarily manifested as back pain, and that petitioner’s
pre-vaccination records do not reference many of the symptoms that petitioner
complained of after vaccination, including tingling in his face and double vision. (Id. at

23
44.) While acknowledging that petitioner had fatigue prior to vaccination, Dr. Steinman
contends that petitioner complained of fatigue “much more vigorously” post-vaccination.
(Id. at 43-44.)

Dr. Steinman disagrees with Dr. Price’s opinion that the evidence of chronic
polyradiculopathies observed on petitioner’s first EMG indicates that petitioner
sustained a nerve root axonal injury prior to receiving the flu vaccination at issue, with
some of the lumbar radiculopathies being secondary to his preexisting low back pain
experienced in late 2014. (Ex. P25, pp. 12-13; Tr. 47-51.) He fails to understand how
Dr. Price can assert that petitioner’s EMG could pinpoint pathology back to two years
prior. (Ex. P25, p. 13; Tr. 51.) Dr. Steinman explains that an EMG captures one point
in time. (Tr. 49.) Accordingly, there is no way to substantiate Dr. Price’s theory that,
had petitioner undergone an EMG in late 2014 or early 2015, it would have
demonstrated chronic polyradiculopathies with axon loss. (Id.) Dr. Steinman stresses
petitioner’s complaints following vaccination go above the lumbar and thoracic areas,
while his complaints pre-vaccination never went above his low back. (Id. at 49, 52.)
Specifically, he states that post-vaccination, petitioner had complaints of new
symptoms, including blurry vision, double vision, difficulty swallowing, and numbness
and tingling in the face and arm, and contends that these symptoms could not be
attributed to a lumbar radiculopathy. (Id. at 52; Ex. P25, p. 13; Ex. P26, p. 1.)

b. Respondent’s Expert, Raymond S. Price, M.D.7

Dr. Price submitted two expert reports and provided testimony during the
entitlement hearing in this case. (Exs. A, E; Tr. 123-273.) He was proffered as an
expert in neurology without objection. (Tr. 6-7.)

Dr. Price provided an extensive review of petitioner’s medical course. (Ex. A, pp.
2-9.) He notes that petitioner’s pre-vaccination medical history was significant for
chronic low back pain with a lumbar radiculopathy. (Ex. A, p. 2; Tr. 140-41, 249-50.)
Specifically, Dr. Price stresses petitioner’s encounter with his primary care doctor in
December of 2014, at which time petitioner reported that his back pain had not
improved with pain medication and anti-inflammatories, complained of numbness in his
right thigh causing his leg to give out, and noted that he could not walk for more than
100 feet without stopping and was thus not able to work. (Tr. 140-41 (discussing Ex. 8,
p. 252).) He opines that petitioner’s reported history and complaints are certainly
7
Dr. Raymond S. Price received his medical degree from the University of Pennsylvania in 2004, before
going on to complete an internship in internal medicine, a residency in neurology, and a fellowship in
clinical neurophysiology with a neuromuscular focus at the University of Pennsylvania. (Ex. B, p. 1.) He
is board certified in psychiatry and neurology, electrodiagnostic medicine, and neuromuscular medicine,
and he maintains an active medical license in Pennsylvania. (Id. at 2.) He currently works as an
associate professor in Clinical Neurology at the University of Pennsylvania School of Medicine, and as
both the Neurology Residency Director and the Neurohospitalist Division Co-Director in the Department of
Neurology at the University of Pennsylvania. (Id. at 1.) He has published 16 peer-reviewed research
articles and reviews; 41 editorials, reviews, and chapters; and one book. (Id. at 11-15.) Additionally, he
has cared for hundreds of patients with radiculopathies, neuropathies, and neuromuscular junction
diseases, including patients with both CIDP and MG. (Ex. A, p. 1.)

24
suggestive of underlying lumbar spine disease. (Id. at 140.) Given the intense and
physically demanding nature of petitioner’s job and his reported symptomology, Dr.
Price opines “[i]t’s more likely than not by 99.9 percent that” petitioner’s chronic back
pain, leg numbness, and difficulty walking were “secondary to spine degenerative
changes as opposed to some latent inflammatory polyradiculopathy.” (Id. at 140-41.)
Additionally, Dr. Price emphasizes that later records indicate that petitioner’s chronic
back pain with radicular pain improved with physical therapy and chiropractic
maneuvers, which are treatments very commonly used to treat degenerative spine
disease but are not treatments for a preexisting inflammatory polyradiculopathy. (Id. at
153, 155-56 (discussing Ex. P2, p. 192).)

Like Dr. Steinman, Dr. Price addresses the three diagnoses potentially at issue:
MG, CIDP, and inflammatory polyradiculopathy. (Ex. A, pp. 9-13.) However, he opines
that only MG is implicated in this case. (Id.) He explains that autoimmune MG8 is a
disease affecting the neuromuscular junction. (Ex. A, p. 9; Tr. 127.) Dr. Price explains
that MG can be classified based on the presenting clinical symptoms, noting that ocular
MG symptoms are localized to the eye whereas generalized MG can impact the eye, as
well as other muscular components in the body, such as the throat and extremities. (Tr.
127-28.) Additionally, MG can be subdivided based on the presence or absence of
certain antibodies. (Id. at 128; see also Ex. A, p. 9.) Most patients affected by MG have
antibodies against the acetylcholine receptor or the muscle-specific tyrosine kinase
(“MuSK”); however, some individuals have seronegative MG, meaning they test
negative for both known antibodies. (Ex. A, p. 9 (citing Emma Ciafaloni, Myasthenia
Gravis and Congenital Myasthenic Syndromes, 25 CONTINUUM: MUSCLE &
NEUROMUSCULAR DISORDERS 1767 (2019) (Ex. A, Tab 1)); Tr. 128-29, 132-33.)
Therefore, the fact that an individual may test negative for a “known” MG antibody does
not rule out the possibility of autoimmune MG. (Tr. 129.)

Ptosis, frequently asymmetric, and binocular diplopia are the most common
presenting symptoms of MG. (Ex. A, p. 9 (citing Ciafaloni, supra, at Ex. A, Tab 1); see
also Tr. 130.) Other classic symptoms of generalized MG include blurred vision;
dysphagia; jaw closure weakness; facial weakness; speech that is slurred, nasal, or of
reduced volume; and weakness of big muscles. (Ex. A, p. 9 (citing Ciafaloni, supra, at
Ex. A, Tab 1); Tr. 130-31.) Dr. Price emphasizes that MG typically does not involve
weakness in distal muscles, such as muscles in the hands, fingers, toes, and feet. (Tr.
131.) Rather, MG typically involves weakness in proximal muscles and tends to be
localized to the shoulder and pelvic area. (Id.) Limb weakness often results in difficulty
performing tasks, such as getting up from a seated position, walking prolonged
distances, climbing stairs, and tasks that involve raising the arms above the head. (Ex.
A, p. 9 (citing Ciafalonia, supra, at Ex. A, Tab 1); Tr. 131.)

8
Dr. Price explained that in addition to autoimmune myasthenia gravis, there is also a genetic myasthenia
referred to as congenital myasthenic syndrome, which is not associated with antibodies. (Tr. 128-29.)
However, congenital myasthenic syndrome is not at issue in this case. (Tr. 127.) Therefore, all
references to myasthenia gravis (“MG”) in this decision refer to autoimmune MG.

25
Fluctuating and fatigable weakness of muscle groups that worsens with activity
and improves with rest is the core clinical feature of MG. (Ex. A, p. 9 (citing Ciafaloni,
supra, at Ex. A, Tab 1); Tr. 135-36.) Therefore, it is very common for individuals with
MG to describe their symptoms getting worse at the end of the day. (Tr. 135.)
Additionally, similar to individuals with other neurologic conditions such as CIDP,
patients with MG can have a “relapsing-remitting course,” meaning they can experience
flare ups where their symptoms are worse or severe and periods where they experience
low to no symptomology. (Id. at 136.)

Dr. Price explains that there are various approaches to diagnosing an individual
with MG. (Tr. 131-35.) One method involves placing patients on an
acetylcholinesterase inhibitor, such as Mestinon,9 which is a medication that blocks the
breakdown of acetylcholine in the neuromuscular junction. (Id. at 131-32.)
Improvement on an acetylcholinesterase inhibitor is highly suggestive of a
neuromuscular disease, such as MG. (Id. at 132.) Another method is serologic testing,
which involves testing patients for known antibodies. (Id.) Approximately 70-80% of
individuals with generalized MG will test positive for an acetylcholine receptor antibody.
(Id.) Of the population of patients with generalized MG who are negative for the
acetylcholine receptor antibody, around 5-10% are positive for the MuSK antibody. (Id.)
However, approximately 15-20% of individuals with generalized MG test negative for
both known antibodies, and are found to have seronegative MG. (Id. at 129, 133.) In
the case of seronegative MG, Dr. Price notes that some physicians hypothesize that
those cases involve different antibodies, such as the low-density lipoprotein c-receptor
related protein 4 (“LRP4”). (Ex. A, p. 9; Tr. 133.) Providers can also try to diagnose
generalized MG electrophysiologically via repetitive nerve stimulation. (Tr. 133.) If a
reduction in the amplitude (“decrement”) is observed when you repetitively stimulate the
nerve within one second, that is suggestive of a neuromuscular disease, such as MG.
(Id.) However, Dr. Price emphasizes that a decrement on repetitive nerve stimulation is
only observed in approximately 60-70% of patients with MG. (Id. at 133-34, 168.)
Lastly, providers can perform a single-fiber EMG of a weak muscle, which is the most
sensitive diagnostic tool used to confirm the diagnosis of MG and is positive in
approximately 97% of affected patients. (Ex. A, p. 9 (citing Ciafalonia, supra, at Ex. A,
Tab 1)); Tr. 134, 222.) If a single-fiber EMG is normal in a clinically affected muscle, the
diagnosis of MG is excluded. (Ex. A, p. 9 (citing Ciafalonia, supra, at Ex. A, Tab 1)); Tr.
134.) Dr. Price stresses that in his practice, it is not uncommon for him to see patients
who are seronegative with no evidence of decrement on EMG and are only found to
have MG based on a single-fiber EMG. (Tr. 134-35.)

In this case, Dr. Price opines that petitioner was correctly diagnosed with MG.
(Ex. A, p. 9-11.) He emphasizes that when petitioner presented for his first neurology
encounter on September 21, 2016, he reported symptoms consistent with generalized
9
Mestinon is brand name preparation of pyridostigmine bromide, which acts by inhibiting destruction of
acetylcholine to facilitate transmission of impulses across the neuromuscular junction and is used for
symptomatic treatment of myasthenia gravis. Mestinon, DORLAND’S MEDICAL DICTIONARY ONLINE,
https://www.dorlandsonline.com/dorland/definition?id=30704 (last visited Dec. 10, 2025); Pyridostigmine
bromide, DORLAND’S MEDICAL DICTIONARY ONLINE,
https://www.dorlandsonline.com/dorland/definition?id=42398 (last visited Dec. 10, 2025).

26
MG, including fatigue, difficulty with swallowing and speech, and episodic blurred vision
that is associated with fatigue and happens at night. (Tr. 141-44; Ex. A, pp. 9-10
(discussing Ex. P3, p. 5).) Additionally, Dr. Price stresses that petitioner’s physical
examination revealed nasal, slurred speech and mild fatigability of the right upper
extremity with repetitive effort despite normal strength, which are findings also
consistent with generalized MG. (Tr. 144-45; Ex. A, pp. 9-10 (discussing Ex. P3, p. 6).)
At that encounter, Dr. Sadeghi noted that petitioner reported that “[h]e was started on
testosterone injections which did help with fatigue until 6 months ago when he noticed
worsening fatigue then new onset blurred vision.” (Ex. P3, pp. 5, 7.) Dr. Price opines
that this documentation places the onset of petitioner’s worsening fatigue and episodic
blurred vision before September 16, 2016, which suggests that petitioner developed
generalized MG prior to receiving the flu vaccination at issue. (Ex. A, p. 10; Tr. 142-44.)

Dr. Price concedes that some of the symptoms that petitioner reported at this
encounter cannot be attributed to MG. (Ex. A, pp. 9, 11.) These symptoms include pain
when lifting heavy weights, pain when walking more than half of a mile, left-sided
burning pain, and intermittent numbness of the left face, arm, and leg. (Id. at 9-10.)
However, Dr. Price attributes some of these symptoms to petitioner’s preexisting lumbar
radiculopathy. (Id. at 10.) Moreover, Dr. Price stresses that petitioner’s sensory
examination was normal, revealing no objective evidence of his reported sensory
symptoms of facial tremor and numbness in his hands and feet. (Tr. 144-45.)

At his follow up appointment with Dr. Sadeghi on October 6, 2016, petitioner
reported significant improvement in his symptoms since starting Mestinon, noting that
he does not feel as fatigued and denying further episodes of double vision and ptosis.
(Ex. A, p. 10; Tr. 148-49 (discussing Ex. P3, p. 46).) Diplopia and fatigability upon
sustained upward gaze were observed on physical examination. (Ex. A, p. 10; Tr. 148-
50 (discussing Ex. P3, p. 47).) These symptoms are all consistent with MG. (Ex. A, p.
10; Tr. 150.) Dr. Price states that petitioner’s response to Mestinon is exactly what he
would expect to see in a patient with MG. (Ex. A, p. 10; Tr. 148-49, 230.) He notes that
petitioner reported taking more Mestinon when working long shifts to counterbalance
the fact that his symptoms worsen as the day progresses. (Tr. 150.) Again, Dr. Price
opines that this fluctuation in symptoms and fatigability as the day progresses is
indicative of MG. (Id.) He explains that Mestinon is a medication that is specific to
symptomatic treatment of MG, and stresses that “[i]t is not used in the treatment of
virtually any other neurologic conditions.” (Id. at 149; see also id. at 157, 217-18.)
Specifically, Dr. Price emphasizes that Mestinon is not used to treat inflammatory
polyradiculopathy or CIDP, and that he would not expect to see an improvement in a
patient suffering from those conditions on Mestinon alone. (Id. at 149, 151.)

When petitioner first presented to Dr. Smith on November 28, 2016, he reported
a history of symptoms consistent with generalized MG, including bilateral ptosis,
choking on foods and liquids, neck weakness, weakness in his arms and legs with
activity, shortness of breath, and diplopia. (Ex. A, p. 10; Tr. 153-56 (discussing Ex. 2, p.
192).) Dr. Price describes this history as “almost textbook for myasthenia gravis.” (Tr.
156.) He also notes that petitioner’s reported multi-year history of severe fatigue with

27
overexertion is also consistent with MG, which again suggests the possibility that
petitioner developed MG prior to the vaccination at issue. (Id. at 153, 156.) Dr. Price
also concludes that Dr. Smith’s finding of bilateral, asymmetrical ptosis on exam is
again consistent with MG. (Ex. A, p. 10; Tr. 157.) Moreover, Dr. Price stresses that his
opinion that petitioner was correctly diagnosed with MG aligns with the opinions of his
treating neurologists, Dr. Sadeghi and Dr. Smith, because MG was consistently listed as
a diagnosis throughout the course of petitioner’s treatment. (Ex. A, p. 10.)

Dr. Price recognizes that petitioner tested negative for both acetylcholine
receptor binding antibody and MuSK antibody. (Ex. A, p. 10; Tr. 151-53 (discussing Ex.
2, pp. 179-80).) However, as Dr. Price explained, 20% of patients with generalized MG
are seronegative. (Ex. A, p. 10; Tr. 128-29, 216, 224-25, 266-67.) While he concedes
that petitioner’s EMG studies were normal with no evidence of decrement on repetitive
nerve stimulation, Dr. Price stresses that a decrement is only observed in 60-70% of
patients with MG. (Tr. 168, 204.) Moreover, he notes that petitioner had been on
Mestinon at the time of the study, which could have impacted sensitivity of the test. (Id.
at 168.) Petitioner was also never tested for low density lipoprotein c receptor-related
protein 4 antibodies (“LRP4”), nor did he ever undergo single fiber EMG testing, which
is the most sensitive test for diagnosing MG. (Ex. A, p. 10; Tr. 133, 241.)

While Dr. Price stresses that petitioner’s initial marked improvement on Mestinon,
especially with respect to his bulbar symptoms, is indicative of MG (Ex. A, pp. 10, 13-
14; Tr. 149-50, 157, 230), he acknowledges that petitioner subsequently experienced a
regression in the management of some of his symptoms, specifically fatigue and
weakness (Tr. 193-94, 196). He explains that generalized MG is typically not controlled
indefinitely with symptomatic treatment alone. (Id. at 150-51, 193.) While a patient may
experience an initial improvement in their symptoms after initiating Mestinon, the
underlying problem in generalized MG is the immune system. (Id. at 150, 193.)
Therefore, effective treatment requires symptomatic therapy with medications like
Mestinon in combination with medications like prednisone, CellCept, methotrexate, and
IVIG, that suppress or attempt to suppress the antibody production in MG, even if the
specific antibody cannot be identified. (Id. at 150-51, 193-94.) Accordingly, he states
that it is typically standard practice to start a patient with generalized MG on prednisone
and a prednisone-sparing agent, such as CellCept, in addition to Mestinon. (Id. at 193-
94.) Given petitioner’s delay in starting prednisone, Dr. Price opines that it is not
surprising that petitioner, after experiencing a period of initial improvement, started to
notice that some of his symptoms were not responding as well to Mestinon and required
immunosuppression. (Id. at 194.)

Moreover, Dr. Price opines that petitioner’s persistent and excessive fatigue is
likely multifactorial, and points to documentation in the medical records to support this
contention. (Tr. 196-98, 208-09, 214-15, 223, 230.) While MG would contribute to
petitioner’s fatigue, Dr. Price notes that MG would not be expected to cause brain
fogginess, and neither would inflammatory polyradiculopathy. (Id. at 197.) He stresses
that Dr. Smith was concerned that petitioner was suffering from undiagnosed
obstructive sleep apnea, which was ultimately later confirmed via a sleep study. (Id. at

28
197-98; Ex. A, p. 11.) Dr. Smith also diagnosed petitioner with work shift sleep disorder.
(Tr. 198; Ex. A, p. 11.) Given that both of these sleep disorders are not autoimmune in
nature, they would not respond to Mestinon, anti-inflammatories, or steroids. (Tr. 198.)
Accordingly, Dr. Price opines that these untreated sleep disorders likely contributed to
petitioner’s persistent and excessive fatigue. (Id.) He also notes that Dr. Smith
diagnosed petitioner with a distal symmetrical neuropathy in 2019, highlighting that his
neuropathy included a severe pain component that limited petitioner’s sleep thereby
contributing to his fatigue. (Id. at 213-14.)

Dr. Price opines that petitioner does not suffer from CIDP. (Ex. A, pp. 11-12; Tr.
138, 159.) Dr. Price opines that petitioner’s clinical presentation is not indicative of
CIDP, noting that petitioner’s “prominent bulbar symptoms” are not characteristic of
CIDP. (Ex. A, p. 12.) Typically, a loss of reflexes is one of the first symptoms observed
in a demyelinating polyneuropathy. (Tr. 159.) Dr. Price notes that petitioner’s reflexes
were symmetrical and intact throughout 2016, 2017, and 2018, and therefore not
suggestive of CIDP. (Id. at 159 (discussing Ex. P2, p. 196), 236-37.) Furthermore, Dr.
Price indicates that the brief episodic nature of petitioner’s symptoms is inconsistent
with CIDP. (Ex. A, p. 12.) Additionally, petitioner’s lumbar puncture did not reveal
albuminocytologic dissociation, which is typically seen in individuals with CIDP involving
the nerve roots. (Id.)

Moreover, Dr. Price opines that petitioner’s electrodiagnostic testing does not
support a diagnosis of CIDP. (Ex. A, pp. 11-12.) While he recognizes that Dr. Smith
found evidence of demyelination on petitioner’s first EMG and considered a diagnosis of
CIDP, Dr. Price stresses that petitioner did not satisfy any of the electrodiagnostic
criteria for a diagnosis of CIDP on either of his two EMG studies. (Id. at 7, 11-12; Tr.
163-64, 204, 207, 209.) He notes that petitioner’s nerve conduction studies were
“mostly normal” with some “very minimal abnormalities.” (Tr. 162.) Dr. Price disagrees
with Dr. Smith’s finding of possible early demyelinating changes on petitioner’s initial
EMG. (Id. at 162-64, 204.) Although he acknowledges that petitioner’s distal latencies
in his right ulnar nerve and some of his sensory nerves were slightly longer than
expected, Dr. Price explains that the distal latencies were not prolonged enough to meet
formal, definitive criteria for demyelination. (Id. at 163-64.) Therefore, he contends that
Dr. Smith’s finding of evidence of demyelination on petitioner’s first EMG that showed
signs of improvement on his second EMG represents an “overinterpretation” of
petitioner’s nerve conduction studies. (Id. at 209.) Dr. Price stresses that there were no
demyelinating features on either of petitioner’s nerve conduction studies. (Id. at 204.)
He also notes that petitioner’s F wave studies were normal with no evidence of proximal
demyelination or axonal loss. (Id. at 164-65.)

Dr. Price also opines that petitioner’s condition is inconsistent with inflammatory
polyradiculopathy. (Ex. A, pp. 12-13.) He explains that inflammatory polyradiculopathy,
a condition distinct from MG, is a disease involving multiple nerve root injuries. (Tr.
137.) The most common cause of a radiculopathy or polyradiculopathy is degenerative
changes to the spine. (Id. at 137-38.) Other causes include infections and
inflammatory processes, meaning “more of an autoimmune-type condition.” (Id. at 138.)

29
Dr. Prices agrees that inflammatory polyradiculopathy represents a large umbrella
category of various conditions, including CIDP and acute inflammatory demyelinating
polyradiculopathy (“AIDP”). (Id.) Typical symptoms depend on which nerve roots and
cranial nerves are impacted, as well as the cause of the inflammatory polyradiculopathy.
(Id. at 139.) Dr. Price acknowledges that an individual can develop a cranial neuropathy
that causes double vision, dysphagia, or weakness or numbness in particular areas.
(Id.) However, he notes that those symptoms are usually “relatively fixed” with an
inflammatory polyradiculopathy, and therefore likely would not fluctuate as the day
progresses. (Id. at 139-40, 195.)

Dr. Price emphasizes that petitioner’s brief episodes of predominantly bulbar
symptoms and fatigable weakness on examination are not consistent with a diagnosis
of inflammatory polyradiculopathy. (Ex. A, p. 12.) For example, he discusses notations
in petitioner’s medical records that indicate his symptoms would emerge or worsen at
the end of his work shift. (E.g., Tr. 195 (discussing Ex. P6, p. 48).) Dr. Price notes that
these subjective reports demonstrate fatigability within the day, which is very typical for
MG but atypical and not expected in patients with inflammatory polyradiculopathy. (Id.)
He also stresses that petitioner’s sensory examinations were normal. (E.g., id. at 144-
45.) Although petitioner reported some sensory symptoms at his first neurology
encounter on September 21, 2016, including a facial tremor and numbness and tingling
in his face, arm, and leg, Dr. Price highlights that there was no objective evidence of
these sensory symptoms on exam. (Id. at 144-45, 159-60, 195, 229-30, 235, 264-66.)
While he acknowledges that later medical records indicate that petitioner had objective
evidence of a tremor, Dr. Price notes that the tremor was said to be an essential tremor,
which is an inherited tremor unrelated to inflammatory polyradiculopathy. (Id. at 268-
70.) Additionally, Dr. Price stresses that petitioner’s lumbar puncture was normal and
showed no evidence of pleocytosis or elevated cerebrospinal fluid protein, which would
be inconsistent with inflammatory polyradiculopathy. (Ex. A, p. 12; Tr. 190-92, 230-31.)

While Dr. Price recognizes that petitioner’s EMG conducted on December 7,
2016, did show “chronic denervation with increased motor unit amplitude and duration
of the bilateral lower extremity muscles and C7/C8 muscles, with preservation of
sensory responses consistent with lumbar radiculopathies and a C7/8 radiculopathy,” he
opines that the needle EMG findings are not consistent with an inflammatory
radiculopathy beginning after September 16, 2016. (Ex. A, p. 12; see also Ex. E, p. 3;
Tr. 173.) He maintains that the needle EMG findings suggest that petitioner had mild to
moderate nerve root axonal injury prior to receiving his flu vaccination on September 16,
2016. (Ex. A, p. 12; Ex. E, p. 3; Tr. 173.) Dr. Price states that axonal loss has “a very
predictable pattern of changes” demonstrated on needle EMG examination. (Tr. 170.)
He notes that “[w]ith acute motor axonal loss from a radiculopathy of any cause, there
will be denervation of muscle cells that were supplied by the injured axons.” (Ex. E, p.
4.) When a muscle cell is denervated, “meaning it no longer has a neuromuscular
junction or a nerve controlling it,” the muscle cell will start turning itself on after about
two to three weeks from when the injury occurred. (Tr. 170; see also Ex. A, p. 13; Ex.
E, p. 4.) This spontaneous electrical activity is referred to as fibrillation potentials or
positive sharp waves. (Tr. 170.) With a needle EMG examination, Dr. Price explains

30
that, when you put a needle close to a muscle that is denervated, these spontaneous
electrical activities will be observed when the patient is asked not to move. (Id. at 171.)
The denervated muscle cell will continue to electrically turn itself on for at least two
years if it never gets reinnervated, or until collateral reinnervation is complete. (Id.; Ex.
A, p. 13; Ex. E, p. 4.)

When a denervated muscle cell undergoes collateral reinnervation, meaning the
muscle cell is now controlled by a remaining motor axon, the motor unit amplitude and
duration will increase on EMG. (Ex. E, p. 4; Tr. 171-72.) Dr. Price explains that this
finding typically begins to develop three to six months after the acute denervation. (Ex.
E, p. 4; Tr. 172.) During the early stages of reinnervation, the motor units may have
prolonged durations with normal amplitudes. (Ex. E, p. 4.) Therefore, if petitioner had
developed inflammatory polyradiculopathy with axon loss beginning on September 16,
2016, his EMG on December 7, 2016 should have shown “fibrillation potentials or
positive sharp waves without increased motor unit amplitudes.” (Ex. A, p. 13; see also
Ex. E, p. 4.)

Dr. Price stresses that petitioner’s EMG study on December 7, 2016,
demonstrated increased motor unit amplitude and duration, which are findings that
indicate complete reinnervation of the denervated muscle and typically develop three to
six months after the acute denervation. (Ex. A, pp. 12-13; Ex. E, p. 4; Tr. 172.)
Furthermore, he emphasizes that petitioner’s needle examination did not reveal
fibrillation potentials or positive sharp waves, which are signs of subacute denervation.
(Ex. A, p. 13; Ex. E, p. 4; Tr. 174-75.) Accordingly, Dr. Price opines that petitioner’s
EMG findings are consistent with chronic denervation and complete reinnervation
occurring at least three to six months prior. (Ex. E, p. 4; Tr. 173-75; Ex. A, pp. 12-13.)
Thus, Dr. Price argues that the findings of petitioner’s EMG conducted on December 7,
2016, evidence that his radiculopathies predate petitioner’s flu vaccine that he received
on September 16, 2016. (Ex. A, p. 12; Ex. E, p. 3; Tr. 173-75.) He also emphasizes
that Dr. Smith described petitioner’s polyradiculopathy as longstanding and inactive,
rather than subacute or recent, which he argues is consistent with his opinion that
petitioner’s polyradiculopathy clearly predates vaccination. (Tr. 182-83.) Dr. Price also
opines that petitioner’ second EMG/never conduction study is consistent with a chronic,
more than six-month old polyradiculopathy without significant progression or evidence
of worsening injury. (Id. at 203-06 (discussing Ex. P29, pp. 395-96).)

Dr. Price dismisses Dr. Steinman’s reliance on Doppler et al. as evidence of
diagnosis in this case. (Ex. A, p. 13; Tr. 233-39 (discussing Doppler et al., supra, at Ex.
P24, Tab 6).) Specifically, Dr. Price argues that petitioner’s clinical picture is not similar
to the clinical picture of the four patients with anti-contaction-1-associated neuropathy in
Doppler et al. (Ex. A, p. 13; Tr. 233-39.) In Doppler et al., the four patients were all
initially diagnosed with GBS after presenting with an acute onset of rapidly progressing
proximal and distal weakness and distal sensory symptoms. (Ex. A, p. 13; Tr. 234-35.)
Dr. Price acknowledges that petitioner experienced some proximal weakness; however,
he stresses that petitioner did not have progressive distal weakness. (Ex. A, p. 13; Tr.
235.) Additionally, while petitioner reported some numbness and tingling in his hands

31
and feet, Dr. Price observes that those symptoms were never objectively corroborated
on physical exam. (Tr. 235.) Moreover, Dr. Price explains that GBS typically involves
an acute presentation of severe ascending weakness with absent reflexes. (Id. at 236-
37.) He argues that petitioner’s reflexes were intact on exam when he first sought care
in 2016 and 2017, and notes that petitioner never had severe weakness. (Id. at 237.)
The four patients in Doppler experienced initial improvement with IVIG treatment,
whereas petitioner experienced initial improvement on Mestinon. (Id. at 236.) Dr. Price
highlights that there is no evidence in the medical records to suggest that petitioner’s
treating providers initially suspected he was suffering from GBS, nor do the authors in
Doppler et al. suggest that myasthenia gravis was considered as an initial diagnosis for
any of the four patients. (Id. at 238.)

Dr. Price also explains that petitioner’s clinical course differs from the patients in
Doppler et al. from an electrophysiological perspective. (Ex. A, p. 13; Tr. 237.) Prior to
the detection of contactin-1 autoantibodies, the diagnosis for the four patients in Doppler
et al. was modified from GBS to CIDP, a condition that Dr. Price and Dr. Steinman
agree petitioner does not suffer from. (Ex. A, pp. 12-13.) Nerve conduction studies for
all four patients revealed prolonged distal latencies, decreased nerve conduction
velocity, and prolonged F wave latencies, supporting their modified diagnosis of CIDP.
(Id. at 13; Tr. 237.) Dr. Price opines that petitioner’s nerve conduction studies were
normal with no evidence of demyelination. (Ex. A, p.13; Tr. 237.) Lastly, Dr. Price
emphasizes that, while all four patients in Doppler et al. had elevated protein in their
cerebrospinal fluid, petitioner’s lumbar puncture was normal. (Ex. A, p. 13; Tr. 238.)

Dr. Price further notes that Kadoya et al. studied patients with CIDP; however,
because petitioner does not suffer from a CIDP, a conclusion Dr. Steinman agrees with,
Dr. Price opines that this study has no relevance to this case. (Id. (citing Kadoya et al.,
supra, at P25, Tab 6).) Additionally, both Vural et al. and Kadoya et al. studied patients
with antibodies against human neurofascin155. (Id. at 2 (discussing Kadoya et al.,
supra, at P25, Tab 6; Vural et al., supra, at Ex. P25, Tab 5).) However, there is no
evidence in the medical records that suggests petitioner was ever assessed for human
neurofascin155 antibodies. (Id.) Moreover, Dr. Price stresses that petitioner’s clinical
presentation is not consistent with the patients in Kadoya et al. and Vural et al., which
suggests that petitioner does not have antibodies against human neurofascin155. (Id.
at 2-3.) Specifically, petitioner “did not have loss of proprioception sensation, or diffuse
areflexia, or hyporeflexia as seen with a peripheral cause of a sensory ataxia or tremor.”
(Id. at 3.) Nor did the medical records show elevated cerebrospinal fluid protein,
prolonged distal motor or f-wave latencies, or enhancement or enlargement of the spinal
root on MRI. (Id.) Lastly, petitioner was treated with IVIG, not Rituximab. (Id.)
Considering patients with human nuerofascin155 antibodies typically respond poorly to
IVIG treatment, Dr. Price contends that petitioner’s treating physicians were clearly not
considering a nuerofascin155 antibody mediated condition. (Id.)

In sum, Dr. Price contends that it is “exceedingly more likely than not” that
petitioner suffers from autoimmune, seronegative MG based on his clinical presentation.
(Tr. 228, 241.) Based on documentation in the medical records, Dr. Price opines that

32
the onset of petitioner’s MG was likely before petitioner received his flu vaccination on
September 16, 2016. (Id. at 142-44, 153, 156.) In addition to MG, Dr. Price states that,
based on his review of the medical records, petitioner also has bilateral lumbar
radiculopathies caused by his spinal stenosis, sensory polyneuropathy likely secondary
to prolonged steroid use, shift work sleep disorder, obstructive sleep apnea, and a
chronic, longstanding, inactive polyradiculopathy that likely predates petitioner’s flu
vaccine at issue. (Id. at 228.) He maintains that petitioner’s clinical presentation is not
consistent with inflammatory polyradiculopathy or a contactin-1 mediated disease. (Id.
at 232-33, 242.) Lastly, Dr. Price agrees with Dr. Steinman that petitioner does not
suffer from CIDP as his EMG studies did not reveal evidence of demyelination. (Id. at
228, 231.)

c. Respondent’s Expert, John T. Bates, Ph.D.10

Respondent’s second expert, Dr. Bates, submitted two expert reports in this case
and testified at the entitlement hearing. (Exs. C, F; Tr. 274-320.) He was proffered as
an expert in immunology without objection. (Tr. 6-7.) Dr. Bates defers to Dr. Price on
the issue of petitioner’s diagnosis and addresses Dr. Steinman’s theory of causation as
it relates to inflammatory polyradiculopathy, the diagnosis endorsed by Dr. Steinman.
(Ex. C, p. 3; Tr. 312-13.) Accordingly, his opinion is not further summarized.

V. Analysis

In this case, petitioner initially alleged that the flu vaccine at issue caused him to
develop MG and CIDP. (ECF No. 1.) Following his expert’s assessment, petitioner filed
an amended petition alleging that the flu vaccine caused him to suffer MG, CIDP, and/or
inflammatory polyradiculopathy. (ECF No. 44.) In their prehearing submissions, the
parties indicated that they agree that petitioner’s injury is not CIDP. (ECF No. 69, p. 1;
ECF No. 70, p. 16, n.4; ECF No. 72, p. 15, n.5.) Additionally, both Dr. Steinman and Dr.
Price testified that petitioner does not suffer from CIDP. (Tr. 108, 159.) However, the
parties dispute whether MG or inflammatory polyradiculopathy is the best supported
diagnosis in this case.

Petitioner asserts that he suffers from inflammatory polyradiculopathy, stressing
that all of the documentation from his treating physicians and Dr. Steinman’s expert
opinion support the diagnosis. (ECF No. 70, pp. 16-19.) In his prehearing submissions,
petitioner emphasizes that Dr. Steinman and his treating neurologist, Dr. Smith, agree
that MG is not an appropriate diagnosis, and that they both opine that he is
experiencing polyradiculopathy. (Id.; ECF No. 74, p. 2.) After the conclusion of the
entitlement hearing, petitioner released any claim that he suffered vaccine-caused MG.

10
Dr. John T. Bates received his Ph.D. in microbiology from the University of Alabama at Birmingham in
2005, before going on to complete two post-doctoral fellowships, one in the Department of Microbiology
and Immunology at Wake Forest University School of Medicine in 2010 and another in the Vanderbilt
Vaccine Center at Vanderbilt University School of Medicine in 2014. (Ex. D, p. 1.) He currently works as
an assistant professor at the University of Mississippi Medical Center in both the Department of Medicine
and the Department of Microbiology and Immunology. (Id. at 2.) He has authored 19 publications. (Id. at
2-4.)

33
(ECF No. 77.) In his post-hearing briefing, petitioner argues that his flu vaccination
caused significant aggravation of his preexisting lumbar spine radiculopathy which he
alleges developed into polyradiculopathy involving his cervical spine. (ECF No. 83, p. 2;
ECF No. 85, p. 2.) Petitioner acknowledges that his treating neurologist diagnosed him
with both MG and polyradiculopathy and maintains that an individual can suffer from
both conditions. (ECF No. 85, pp. 2-3.)

Respondent asserts that petitioner was correctly diagnosed with MG, which is the
best supported diagnosis in this case. (ECF No. 72, pp. 15-17; ECF No. 84, pp. 15-18.)
He contends that petitioner’s clinical presentation is inconsistent with inflammatory
polyradiculopathy and thus cannot be preponderantly supported given the record
evidence. (ECF No. 72, pp. 16-17; ECF No. 84, pp. 17-18.) Therefore, respondent
maintains that, because petitioner cannot demonstrate that he suffers from inflammatory
polyradiculopathy by a preponderance of the evidence, petitioner’s claim fails as his
proposed causal theory is based only on a diagnosis of inflammatory polyradiculopathy.
(ECF No. 84, p. 18.)

For the reasons discussed below, I find that there is preponderant evidence that
petitioner suffers from MG rather than an inflammatory polyradiculopathy.

a. Petitioner’s symptoms are consistent with MG

Dr. Price emphasized that petitioner’s symptoms were primarily bulbar with some
proximal weakness which is “perfectly consistent” with MG. (Tr. 229; see also id. at
201, 267; Ex. A, pp. 13-14.) Specifically, he noted that petitioner’s symptoms of
worsening fatigue, ptosis, dysphagia, diplopia, blurred vision, slurred nasal speech,
shortness of breath, and fatigable weakness with activity, support a diagnosis of MG.
(Ex. A, pp. 9-11,13-14 (citing Ciafaloni, supra, at Ex. A, Tab 1); Tr. 141-45, 148-50, 153-
57, 267.) While petitioner experienced some proximal weakness throughout his clinical
course (e.g., Tr. 196 (discussing Ex. P6, p. 52)), Dr. Price stressed that there was not
much evidence of distal weakness in the medical records, which is consistent with MG
(Id. at 229, 235). Moreover, throughout the hearing, Dr. Price testified that even when
Dr. Smith started to suspect that petitioner suffered from CIDP, petitioner’s clinical
presentation remained consistent with MG. (E.g., id. at 218-19, 221-23, 226.) While Dr.
Price acknowledged that some of petitioner’s subjective sensory complaints cannot be
explained by MG, all of petitioner’s objective findings are consistent with MG. (Id. at
265-66.)

Moreover, Dr. Price stressed that fluctuating and fatigable weakness of muscle
groups that worsens with activity and improves with rest is the core clinical feature of
MG. (Ex. A, p. 9 (citing Ciafaloni, supra, at Ex. A, Tab 1); Tr. 135-36.) As pointed out
by Dr. Price, there are several notations in the medical records indicating that
petitioner’s symptoms fluctuated, worsening as the day progressed and with repetitive
use. For example, at his initial neurology encounter on September 21, 2016, petitioner
reported experiencing episodic blurred vision that was associated with fatigue and
occurred at night. (Ex. P3, p. 5.) Additionally, at his encounter with Dr. Sadeghi on

34
October 6, 2016, petitioner reported needing to take an increased dose of Mestinon
when he is working long shifts to counterbalance the fact that his symptoms recur at the
end of the day. (Id. at 46.) This fluctuating and fatigable weakness was also objectively
demonstrated on physical exam, with instances of diplopia and fatigability being
observed with sustained upward gaze and mild fatigability of the right upper extremity
with repetitive effort. (Id. at 6, 47.)

Ultimately, Dr. Price is persuasive in opining that petitioner’s clinical presentation
is consistent with a diagnosis of MG. (Tr. 267.) Dr. Steinman likewise agreed that
petitioner’s presenting symptoms post-vaccination were predominantly bulbar in nature.
(Id. at 118.) He also acknowledged that petitioner’s presenting symptoms, specifically
double vision and trouble chewing and swallowing, are symptoms typically observed in
patients with MG. (Id.) Moreover, petitioner’s treating neurologist, Dr. Smith, classified
many of the symptoms identified above as “myasthenic symptoms.” (E.g., Ex. P6, p.
48.) Therefore, both experts and petitioner’s treating physician appear to agree that
petitioner’s presentation is consistent with MG.

b. Petitioner’s antibody and electrodiagnostic testing results are not
inconsistent with a diagnosis of MG

Petitioner points to his antibody and EMG testing as support for his argument
that MG is not the most appropriate diagnosis in this case. (Tr. 45-46, 100, 118, 323;
ECF No. 70, pp. 17-19; Ex. P24, p. 5.) Dr. Steinman testified that individuals who have
MG “rarely” test negative for both the acetylcholine receptor and MuSK antibodies. (Tr.
45.) He also stressed that Dr. Smith conducted a comprehensive electrodiagnostic
study, which was negative for MG. (Id. at 100.) While he conceded that there is “a
small chance” that petitioner could have seronegative, EMG negative MG, he stated he
would put “[v]ery low weight” on that. (Id.)

However, Dr. Price explained that a sizeable minority of individuals with
autoimmune MG will lack a known antibody and have no evidence of decrement on
repetitive nerve stimulation. (Tr. 128-29, 133-35, 241.) Specifically, Dr. Price testified
that seronegative MG, meaning an individual is negative for both the acetylcholine
receptor and MuSK antibodies, is observed in approximately 15-20% of cases of
autoimmune MG. (Id. at 128-29, 216, 224-25, 266-67; Ex. A., pp. 9-10 (citing Caifaloni,
supra, at Ex. A, Tab 1).) Additionally, Dr. Price explained that a decrement on repetitive
nerve stimulation is only observed in about 60-70% of individuals with MG. (Tr. 133-34,
165-68.) He noted that the sensitivity of repetitive nerve stimulation depends upon the
muscle being tested, indicating that if the muscle is not a weak muscle, then the
sensitivity of the test declines. (Id. at 133-34.)

Moreover, petitioner was already on Mestinon at the time of his EMGs (Ex. P6,
pp. 9, 91-92, 111-12), which may have impacted the sensitivity and quality of the
testing. (Tr. 232.) Although petitioner was instructed to hold his Mestinon for 36 hours
prior to his EMG (Ex. P6, p. 9), his treating neurologist, Dr. Smith, raised the possibility
of a false negative in a later treatment record, noting that Mestinon may not have been

35
“completely ‘out of [petitioner’s] system’” at the time of his EMG testing (Ex. P28, p.
1479). Dr. Price explained that

if you are trying to stress the neuromuscular junction with multiple repetitive
stimulations within a second and the patient is able to keep more
acetylcholine in the neuromuscular junction because of the presence of
Mestinon, then you are not stressing it as much as you think and therefore
you will have a false negative test.

(Tr. 232.)

Dr. Price testified that it is not uncommon for neurologists at academic medical
centers to see patients who are seronegative and had a normal repetitive nerve
stimulation who are only found to have MG by a single-fiber EMG of a weak muscle.
(Tr. 134-34; see also Ex. A, p. 9.) A single-fiber EMG, the diagnostic test for MG with
the highest sensitivity, and is positive in 97% of affected patients. (Ex. A, p. 9 (citing
Caifaloni

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Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/11246071. Public record. Not legal advice.