# Cruz Burgos v. Secretary of Health and Human Services

> United States Court of Federal Claims · June 22, 2026

URL: https://www.frixlaw.com/law-library/cases/11346311

## Case

- **Court:** United States Court of Federal Claims
- **Decided:** June 22, 2026
- **Precedential status:** Unpublished
- **Opinion:** Opinion
- **Judges:** Brian H. Corcoran
- **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/11346311

## How later opinions describe it (automated extraction)

- noting that Moberly “addresses the petitioner’s overall burden of proving causation-in-fact under the Vaccine Act” by a preponderance standard

## Opinion text

In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
No. 23-1588V

*************************
* Chief Special Master Corcoran
GRISELDA CRUZ BURGOS, *
* Filed: May 28, 2026
Petitioner, *
*
v. *
*
SECRETARY OF HEALTH AND *
HUMAN SERVICES, *
*
Respondent. *
*
*************************

Amy Senerth, Muller Brazil, Dresher, PA, for Petitioner.

Alec Saxe, U.S. Department of Justice, Washington, DC, for Respondent.

ENTITLEMENT DECISION 1

On September 14, 2023, Griselda Cruz Burgos filed a petition for compensation
(“Petition”) under the National Childhood Vaccine Injury Act of 1986, 42 U.S.C. §§ 300aa-1 to -
34 (“Vaccine Act” or “Act”). Petitioner alleged that she developed small fiber neuropathy (“SFN”)
due to a tetanus, diphtheria, and [acellular] pertussis (“Tdap”) vaccine received on March 29, 2021.
Petition at 1.

The parties accepted my proposal to resolve this matter on the written record, and have
filed briefs in support of their positions. See Petitioner’s Brief, dated August 18, 2025 (ECF No.
21) (“Br.”); Respondent’s Response, dated September 18, 2025 (ECF No. 22) (“Opp.”);
Petitioner’s Reply, dated October 1, 2025 (ECF No. 23) (“Reply”). Now, for the reasons set forth
below, I deny entitlement.

1
Under Vaccine Rule 18(b), each party has fourteen (14) days within which to request redaction “of any information
furnished by that party: (1) that is a trade secret or commercial or financial in substance and is privileged or
confidential; or (2) that includes medical files or similar files, the disclosure of which would constitute a clearly
unwarranted invasion of privacy.” Vaccine Rule 18(b). Otherwise, the whole Decision will be available to the public
in its present form. Id.
I. Factual Summary

Prior to vaccination, Petitioner reported to her doctor, Jamie McAllister, D.O., at Adult &
Adolescent Family Medicine on March 12, 2021, that a week before (March 4, 2021), she had
developed a sharp pain on the back of the right side of her head (described as “ice pick” like),
lasting seconds and followed by a constant ache. Ex. 6 at 4. Right occipital neuralgia was
suspected. Dr. McAllister prescribed warm compresses, and starting MediGoldOne (Diclofenac
Sodium) and then taking Voltaren (another Diclonfenac Sodium medicine) to alleviate symptoms.
Id.

Petitioner subsequently received a Tdap vaccine at the age of 37 at the St. Charles Family
Care clinic in Redmond, Oregon on March 29, 2021. Ex. 1 at 148–49. There is no medical record
evidence of any immediate reaction.

About two weeks later, on April 13, 2021, Petitioner went to the emergency department
(“ED”) of Samaritan North Lincoln Hospital, complaining of right forearm pain, numbness, and
swelling. Ex. 2 at 12. Petitioner informed the treaters that an hour before seeking ED assistance,
she had been at a casino gambling, and noticed her arm “became sore and achy” when resting on
a slot machine table game, with the sensation not going away when she moved her arm to her lap
(although treatment with ice and a compression sleeve afforded some relief). Id. at 12, 14.

On examination at the ED, Petitioner displayed focal tenderness in the palm side of her
right forearm. Ex. 2 at 16. Otherwise, she had normal sensation and full range of motion of her
right upper extremity, albeit with pain. Id. Neurological examination revealed no sensory deficits
or weakness. Id. The examining emergency medicine physician diagnosed Petitioner with acute
radial nerve palsy of the right upper extremity, noting that she was “neurovascularly intact,” and
that an explanation for the pain might be “a process similar to [petitioner’s] radial nerve palsy from
resting her forearm against the slot machine.” Id. at 17. Petitioner was given a forearm splint to
maintain her wrist in a neutral position and discharged home, with instructions to follow up with
her primary care provider (“PCP”), if her symptoms worsened or did not improve. Id.

Toward the end of that same month (April 27, 2021), Petitioner followed up with a nurse
practitioner (“NP”) in her PCP’s office. Ex. 1 at 144. She recalled her recent ED visit, and also
reported “transient” symptoms of hand and feet numbness and tingling (although contemporaneous
medical records only document ED complaints of right forearm symptoms). Compare Ex. 1 at 144
with Ex. 2 at 12. She now also claimed the symptoms had begun on her left side and resolved, but
had moved to her right side. Ex. 1 at 144.

A review of systems was positive for numbness, but the examination revealed no focal
neurological deficits, sensory deficits, or weakness. Ex. 1 at 145–46. The NP was also informed

2
that Petitioner had five days earlier discontinued a thyroid medication for in vitro fertilization she
had begun on April 6, 2021, and that the symptoms had started not long after first taking the
medication (with improvement once she ceased its use). Id. at 144–45. Petitioner was referred to
a neurologist. Id. at 144.

Petitioner had that neurologic consultation almost six weeks later (June 7, 2021), with
David Schloesser, M.D. Ex. 3 at 8. She now provided a more expansive medical history, noting
that in February 2021 (hence pre-vaccination) she had developed right occipital neuralgia and
difficulty moving her neck, which resolved over several weeks. Id. She further recalled her April
13th treatment for pain in the right forearm with intermittent tingling in her fingers. Id. By April
21st, she reported, she was experiencing tingling in all extremities, numbness in her feet ascending
to the calves and upper extremities, and went to a hospital ED, where a brain MRI yielded normal
results. Id. By April 27th, she had developed difficulty ambulating, swelling in the legs, and
discomfort in the pads of her feet. Id. She added that these symptoms had persisted for several
weeks but had improved such that she felt 90% back to baseline at the time of this visit. Id.

On examination, Dr. Schloesser documented Petitioner’s full strength, normal sensory and
cerebellar testing, and reflexes of 1+ biceps, 2+ triceps, 2-3+ patellar, and 1-2+ ankles, but noted
a mild residual right-side Bell’s palsy in her face. Ex. 3 at 9. Dr. Schloesser diagnosed Petitioner
with paresthesias, and ordered a cervical spine MRI to rule out transverse myelitis or structural
lesions, laboratory testing for inflammatory and thyroid markers, and a wrist splint for nighttime
use, given possible intermittent median nerve entrapment. Id. The MRI was performed the next
day but yielded unremarkable results. Id. at 18.

On June 26, 2021, Petitioner went back to her PCP’s office complaining of abdominal
pressure when eating, extreme thirst, pharyngitis/GERD type symptoms, bilateral flank pain,
polyuria, and difficulty urinating, relating these symptoms to a “cold type” illness she had
experienced several days before (with the flank and urinary issues beginning the night before). Ex.
1 at 125. A urine culture confirmed the presence of an E. coli infection, and a NP diagnosed her
with mild pyelonephritis and acute gastritis. Id. at 128–29.

Petitioner saw Christopher Schuler, M.D., at her PCP’s office, on August 11, 2021, after
experiencing a brief, isolated vision disturbance the day before, and at this time reported persistent
paresthesias. Ex. 1 at 115. Dr. Schuler noted Petitioner’s unremarkable neurological workup thus
far, including her normal MRIs and “several labs done in June[,] . . . including standard CBC,
CMP and a variety of autoimmune labs that were negative.” Id. Dr. Schuler diagnosed Petitioner
with vision impairment thought “poss[ibly] related to her paresthesia reaction,” and advised her to
follow up with her neurologist, Dr. Schloesser. Id. at 114–15.

3
Petitioner followed up with Dr. Schloesser roughly one month later, on September 13,
2021. Ex. 3 at 5. She reported that she was “gradually improving,” but that she still “ha[d] a feeling
of discomfort in the forearms with activity.” Id. She also stated that she “fe[lt] heavy in [her] legs[,]
with some tingling of the right [leg] greater than left [leg] at times [and seemingly] associated with
activity.” Id.

On examination, Petitioner was found to have “intact cranial nerves, strength, and
sensation, with symmetrical reflexes at 2/4 throughout.” Ex. 3 at 5. A right lower extremity nerve
conduction study (“NCS”) 2 yielded normal results. Id. Dr. Schloesser diagnosed Petitioner with
unexplained paresthesias, adding that he could not “identify evidence for a resolving form of
Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, or other
peripheral nervous system problems such as mononeuritis multiplex.” Id. at 6. He also noted that
Petitioner’s lab test results and brain and cervical spine MRIs had been normal. Id. Despite his
inconclusive determination, Dr. Schloesser recommended a trial of gabapentin for treatment of
Petitioner’s “discomfort.” Id.

Two months after, on November 22, 2021, Petitioner returned to her PCP complaining of
slowly improving but ongoing paresthesias that were adversely affecting her quality of life. Ex. 1
at 90. She reported that she could not carry her daughters, use a cellular telephone, or type. Id. at
91. On exam, Petitioner exhibited objective weakness of the right upper and lower extremities,
with 4/5 right dorsiflexion, wrist extension, wrist flexion, and finger abduction strength and
decreased reflexes in the lower extremities. Id. at 92–93.

While visiting her PCP in November 2021, Petitioner requested a referral for a second
neurological opinion, and she obtained one from Anson Wilks, M.D., on December 22, 2021. Ex.
1 at 91, Ex. 5 at 42–44. She now reported acute right forearm pain that she recalled began a week
to ten days after her March 2021 vaccination, and characterized the pain as sharp and cramping,
with transient weakness of forearm flexion. Id. at 42. She further recalled (again, inconsistent with
the actual contemporaneous medical record) that soon thereafter, she developed numbness and
tingling in her feet ascending to her calves, with several days of saddle anesthesia, and that
symptoms worsened so significantly that she later required a walker due to leg weakness, swelling,
and falls. Id. She had subsequently experienced improvement without relapse, though she said she
continued to experience calf cramps (worse at night), muscle fatigue, difficulty lifting heavy
objects, numbness on the top of the right foot, and toe pain. Id.

On examination, Dr. Wilks observed normal strength, reflexes, and vibration sense, with a
pinprick gradient, in the arms and legs. Ex. 5 at 44. Dr. Wilks assessed Petitioner with paresthesias,

2
Nerve conduction studies measure the speed and strength of electrical signals in the nerves. See Nerve Conduction
Studies and Electroneurography, Dorland’s Medical Dictionary Online,
https://www.dorlandsonline.com/dorland/definition?id=15860 (last visited May 4, 2026).

4
pain, and subjective weakness following vaccination, with possible mild Guillain-Barré syndrome
(“GBS”) or acute SFN. Id. Dr. Wilks recommended an NCS and electromyography 3 (“EMG”). Id.

Petitioner underwent the EMG/NCS that day (Ex. 5 at 23), which Dr. Wilks subsequently
summarized in a January 7, 2022, addendum to his December 22, 2021, treatment note:

EMG/NCS was normal confirming clinical suspicion for small fiber neuropathy.
Laboratory investigation has been negative. The proximity of her symptom onset
to vaccination could be consistent with acute small fiber sensory neuropathy, which
some consider a mild, limited GBS, with an antecedent vaccination. However, the
association with vaccination is unclear and not definitive.

Id. at 44.

Petitioner had additional treatment in 2022 for urinary issues, including recurrent urinary
tract infections, as well as pyelonephritis 4 of the right kidney and related symptoms. See generally
Ex. 1 at 8–63. But her prior paresthesias or neurological symptomatology were not addressed at
any of these visits. No further records have been provided for the period after mid-2022 that are
relevant to this case.

II. Expert Reports

A. Petitioner’s Expert – Dr. John Hixson

Dr. Hixson is a neurologist, and he prepared two written reports for Petitioner. Report,
dated October 30, 2024, filed as Ex. 11 (ECF No. 15-2) (“First Hixson Rep.”); Report, dated June
1, 2025, filed as Ex. 26 (ECF No. 20-1) (“Second Hixson Rep.”).

Dr. Hixson attended Texas A&M University for his undergraduate degree, and Johns
Hopkins University School of Medicine for his medical degree. See Curriculum Vitae, filed Oct.
30, 2024, as Ex. 12 (ECF No. 15-3) (“Hixson CV”) at 1; First Hixson Rep. at 1. He then completed
his residency in Neurology at the University of Pennsylvania, followed by a fellowship in Epilepsy
and Neurophysiology at the University of Iowa. Hixson CV at 1. He is currently a Professor of
Neurology at the San Francisco VA Medical Center and the University of California San

3
EMG studies assess the extracellular activity of muscles at rest when introduced to electric shocks. See
Electromyography, Dorland’s Medical Dictionary Online,
https://www.dorlandsonline.com/dorland/definition?id=15854&searchterm=electromyography (last visited May 4,
2026).
4
A pyelonephritis is the inflammation of the kidney due to a bacterial infection. Pyelonephritis, Dorland’s Medical
Dictionary Online, https://www.dorlandsonline.com/dorland/definition?id=42228&searchterm=pyelonephritis (last
visited May 4, 2026).

5
Francisco. Id. at 2; First Hixson Rep. at 1. Dr. Hixson is board certified by the American Academy
of Psychiatry and Neurology. First Hixson Rep. at 1. Clinically, he sees patients in both an
outpatient and inpatient setting—on average, Dr. Hixson sees approximately 30–35 patients per
week and evaluates and treats patients with SFN as well as the most common form of GBS, acute
inflammatory demyelinating polyneuropathy (“AIDP”). Id. at 1–2.

First Report

Dr. Hixson began his initial report with a review of Petitioner’s medical history, consistent
with what is discussed above. First Hixson Rep. at 2–4. He interpreted that history to confirm the
propriety of an SFN diagnosis. SFN, Dr. Hixson explained, is a condition affecting certain
unmyelinated sensory nerve fibers that “carry pain and temperature sensation.” Id. at 6; T. Gendre
et al., Characterizing Acute-Onset Small Fiber Neuropathy, 11 Neurol. Neuroimmunol.
Neuroinflamm. 1, 7 (2024), filed as Ex. 18 (ECF No. 15-9) (“Gendre”). Individuals experiencing
SFN would “usually report a sensation of burning and numbness in the lower extremities, which
can then spread throughout the limbs.” First Hixson Rep. at 6. SFN may otherwise involve
“objectively normal findings on examination, as well as through EMG/NCS testing,” making it
important to confirm the diagnosis in other ways. Id.; Gendre at 7–8.

Dr. Hixson highlighted several features of Petitioner’s history that he felt supported the
SFN diagnosis. First Hixson Rep. at 2–4, 6–7. Within two weeks of vaccination, she complained
of initial arm concerns, and then experienced worsening paresthesias in all limbs, followed by
numbness and tingling sensations. Id. at 2. By later in the fall of 2021, the symptoms had not
abated, but no other explanations were embraced until Petitioner saw a specialist (Dr. Wilks) in
December, who proposed the diagnosis of acute SFN. Id. at 3–4. Dr. Hixson admitted, however,
that “[c]onfirmatory tests for small fiber neuropathy, such as laser-evoked potentials, quantitative
sensory testing (“QST”), or skin biopsy” were never performed on Petitioner. Id. at 6. He also did
not in this report explicitly discuss, or discount, the possibility that Petitioner’s initial symptoms
related to her arm positioning while at a casino.

The record, Dr. Hixson opined, allowed for the possibility that Petitioner had experienced
a “mild variant” of AIDP post-vaccination that was related to her ultimate SFN symptoms. First
Hixson Rep. at 3, 4–5. Petitioner’s initial presentation was somewhat consistent with “an isolated
mononeuropathy,” but as time passed “her symptoms became more suggestive of a diffuse
process,” with qualities associated with GBS (bilateral impact, ascending symptoms, ambulation
issues). Id. at 5. In addition, Dr. Wilks had proposed that Petitioner may have had a mild
GBS/AIDP precursor condition (although he seemed to rely mainly on the fact of antecedent
vaccination for that conclusion, and acknowledged (as evidenced from the contemporaneous
record) that there was no clearly-established association). Ex. 5 at 44. But because Petitioner was
never more formally tested for AIDP, the likelihood of that diagnosis could not be evaluated

6
(although Dr. Hixson allowed that later EMG testing was normal—not inconsistent with SFN, but
not confirmatory of GBS either). First Hixson Rep. at 6.

Dr. Hixson next discussed vaccine association, and concluded that the Tdap vaccine could
cause SFN. Literature recognized that acutely-presenting SFN could be preceded by infection or
vaccination. Gendre at 10. SFN was, moreover, theorized to be immune-mediated. Id. And case
reports existed describing instances in which SFN occurred temporally after vaccination. See, e.g.,
J. Finsterer, Small Fiber Neuropathy as a Complication of SARS-CoV-2 Vaccinations, 11 J. Fam.
Med. Prim. Care 4071–72 (2022), filed as Ex. 21 (ECF No. 15-12); J. Kafaie et al., Small Fiber
Neuropathy Following Vaccination, 18 J. Clin. Neuromuscul. Dis. 37–40 (2016), filed as Ex. 22
(ECF No. 15-13) (describing a case report of a fourteen year-old girl developing an acute onset of
SFN after receiving a human papillomavirus vaccination).

There was also reliable support for a possible connection between SFN and GBS, in Dr.
Hixson’s view. He noted that GBS was already deemed to be likely caused by some vaccines—
and that there was “controversy” in the medical literature as to whether an acute SFN was itself a
kind of GBS variant. First Hixson Rep. at 6; U. Seneviratne & S. Gunasekera, Acute Small Fibre
Sensory Neuropathy: Another Variant of Guillain-Barré Syndrome? 72 J. Neurol. Neurosurg.
Psych. 540 (2002), filed as Ex. 24 (ECF No. 15-15) (“Seneviratne & Gunasekera”) (following six
patients with SFN over the course of fifteen months). If so, then the same causal reasoning
applicable to GBS could reasonably be applied to SFN.

Dr. Hixson also opined that the Tdap vaccine likely caused Petitioner’s SFN. First Hixson
Rep. at 6–7. Her post-vaccination course logically fit, in his estimation, with a vaccine-induced
injury (although Dr. Hixson’s reasoning seemed rooted in the temporal association and progression
of symptoms after vaccination). Id. at 7. Petitioner also had experienced no comparable symptoms
pre-vaccination (and Dr. Hixson did not deem her prior Bell’s palsy or occipital neuralgia to have
any medical relationship with her post-vaccination symptoms). Id. And there was no other
evidence of a possibly-explanatory cause such as an antecedent infection (although again Dr.
Hixson made no mention of Petitioner’s initial reports of physical harm to her arm due to
positioning). Dr. Hixson concluded by deeming the post-vaccination timeframe in which
Petitioner’s symptoms began (two weeks after) to be medically acceptable, noting that it fell
“squarely within the 3–42 day timeframe that is accepted for autoimmune neurologic processes.”
Id.

Second Report

Dr. Hixson’s supplemental report responded to the opinions expressed by Respondent’s
two experts. First, he repeated his review of Petitioner’s medical history, highlighting the fact that
by December 2021 (over eight months post-vaccination), Petitioner had seen Dr. Wilks, who

7
interpreted her overall course and then-current presentation as consistent with either a mild form
of GBS or SFN—an opinion Dr. Hixson shared. Second Hixson Rep. at 1–2. Although Dr. Hixson
admitted that Petitioner’s “initial clinical course and full constellation of symptoms was not
straightforward,” he felt that beginning within a month of her late-March vaccination her
symptoms were mainly sensory in character. Id. at 2. He did acknowledge, however, that “typical
testing” to confirm the presence of either GBS or SFN (such as a lumbar puncture to test for
inflammation in the cerebrospinal fluid) did not occur. Id.

Dr. Hixson reiterated his arguments about the diagnostic features of acute onset SFN,
contesting the views of Respondent’s neurologic expert (Dr. Brian Callaghan). Second Hixson
Rep. at 2–3. He noted (referencing Gendre) that this form of SFN was increasingly recognized,
but may be “challenging in clinical practice” to identify. Gendre at 7. And SFN, like GBS, had
been associated with infections and vaccinations, plus a “pure sensory” form of GBS was
understood to exist. Second Hixson Rep. at 2; Seneviratne & Gunasekera at 540.

Dr. Callaghan had pointed to Petitioner’s weakness and gait issues as inconsistent with
SFN. Second Hixson Rep. at 3. Dr. Hixson agreed that SFN mainly featured “sensory phenomena,”
but contended that these kind of problems could secondarily impact gait or balance, as Petitioner’s
evolving course revealed. And Petitioner’s apparent subjective weakness observed by Dr. Wilks
did not result in his rejection of the SFN diagnosis. Id. Other symptoms identified by Dr. Callaghan
as inconsistent with SFN were not given weight by Petitioner’s treaters in embracing the SFN
diagnosis. Id. At bottom, Dr. Hixson described Petitioner’s course as “a relatively acute onset of
distal paresthesias” leading to ascending symptoms and gait issues a few weeks later as supportive
of the SFN diagnosis—and other comorbidities or conditions she had experienced did not
invalidate the diagnosis. Id.

Dr. Hixson next addressed the views of Respondent’s immunologic expert (Dr. Robert
Fujinami) regarding what mechanism might be involved in Tdap vaccine-caused SFN. He accepted
Dr. Fujinami’s opinion that insufficient evidence established either that SFN is autoimmune in
nature, or that the Tdap vaccine could provoke it immunologically. Second Hixson Rep. at 3. But
he asserted in response that some proof supported both contentions, and that he had filed it in this
case. See, e.g., Gendre. Dr. Hixson also vouched for case reports as good evidence, argued that Dr.
Fujinami appeared to require proof of certainty, and that the Vaccine Program only required “a
plausible theory with supportive evidence” to meet the evidentiary threshold for entitlement. Id.
at 3–4 (emphasis added).

Dr. Hixson further reiterated why he felt onset of Petitioner’s symptoms occurred in a
medically-acceptable timeframe, measured from the date of vaccination. He disputed Dr.
Callaghan’s proposal that Petitioner’s neurological issues pre-dated vaccination, with head pain
that could be attributed to occipital neuralgia as unrelated to SFN. He also embraced a 3–42 day

8
timeframe for post-vaccination adverse events as an “accepted window for a predicated vaccine-
mediated immune response” driven by an autoimmune cross-reaction. Second Hixson Rep. at 4.

B. Respondent’s Experts

1. Dr. Brian Callaghan – Dr. Callaghan, a practicing and academic
neurologist like Dr. Hixson, offered an opinion on behalf of Respondent. Report, dated March 3,
2025, filed as Ex. A (ECF No. 18-1) (“Callaghan Rep.”). Dr. Callaghan did not accept SFN as the
best diagnosis for Petitioner’s symptoms. Callaghan Rep. at 8.

Dr. Callaghan is Professor of Neurology and an Associate Program Director for Research
at the University of Michigan. Curriculum Vitae, filed as Ex. B (ECF No. 18-4) at 2. Dr. Callaghan
both received his medical degree and completed his residency in Neurology at the University of
Pennsylvania Medical Center. Id. at 1. Afterwards, he earned his master’s degree and completed
two postdoctoral fellowships at the University of Michigan. Id. Dr. Callaghan is board certified in
both Neurology and Electrodiagnostic Medicine. Id. Throughout his practice, Dr. Callaghan has
served as the Director of the Amyotrophic Lateral Sclerosis Clinic at the University of Michigan
Health System, treated many patients with neuropathies and neurologic disorders, and has
published over one-hundred peer reviewed articles. Id. at 2, 19–29.

Dr. Callaghan summarized Petitioner’s overall medical record history before providing his
opinion. Callaghan Rep. at 1–4, 5–6. He took greater note than Dr. Hixson, however, of Petitioner’s
reported history at the time of her April 2021 emergency presentation, emphasizing that she had
stated that “[s]he was gambling at a casino, with her right arm placed on a table, when she noted
that her right arm became sore and achy. She had pain when she flexed or extended her wrist. The
pain was noted to be in the part of the forearm that rested on the table.” Id. at 2 (referencing Ex. 2
at 12). Dr. Callaghan also highlighted her documented ambulation limits early on and that summer,
as well as her overall weakness plus pain in 2022. Id. at 2–4.

Dr. Callaghan did not deem Petitioner’s history to fit the diagnostic criteria for SFN.
Callaghan Rep. at 6–7. First, he identified a lengthy list of symptoms experienced by Petitioner
but inconsistent with SFN. Id. at 6 (“difficulty moving her neck, swelling of her right arm and legs,
trouble with ambulating, heavy legs, weakness requiring a walker and wheelchair, inability to carry
her daughters, use a cellular telephone, or type, falls, cramping in her calves, muscle fatigue,
trouble with carrying heavy loads in her arms, barely being able to walk, . . . burning in her right
eye and in her hands and feet after starting ciprofloxacin (previous adverse event as well with this
medication), burning in her stomach, worsening headaches, nausea, . . .”). Second, Dr. Callaghan
deemed the clinical exam evidence that Petitioner was experiencing weakness and reduced reflexes
to be proof of a “large fiber neuropathy. Id. Dr. Callaghan also noted that Petitioner had received
two neurologic exams that were deemed to produce normal results. Id.

9
Dr. Callaghan also did not find compelling Dr. Hixson’s contention that Petitioner’s SFN
may have followed an undiagnosed case of GBS. In so opining, Dr. Hixson relied on statements
made by Dr. Wilks in December 2021, 5 but Dr. Callaghan felt Dr. Schloesser’s prior diagnostic
view from June 2021 (that Petitioner had experienced some kind of “unexplained paresthesias”)
more persuasive in light of exam and testing findings. Callaghan Rep. at 6. He felt it “highly
unlikely” that Petitioner had experienced both AIDP and SFN, which constituted “two separate
diagnoses.” Id. at 7.

SFN, Dr. Callaghan maintained, is not reasonably associated with vaccination. Callaghan
Rep. at 7. Dr. Callaghan maintained that he was unaware of scientific evidence linking the two,
and disputed the evidentiary significance of case reports on the question of causation. Id. He
questioned whether a flu vaccine-GBS association had applicability in the context of a different
vaccine like Tdap. Id. Dr. Callaghan also denied it had been shown that receipt of the Tdap vaccine
could provoke SFN later via autoantibody production attributable to cross-reaction between
vaccine components (through the mechanism of molecular mimicry between self and presenting
antigen). Id. While that theory applied to a “demyelinating neuropathy” like GBS (which involved
myelinated larger peripheral nerves), the unmyelinated sensory nerves were distinguishable, and
involved a wholly-different set of clinical symptoms attributable to their harm. Id.; N. Yuki, et al.,
Carbohydrate Mimicry Between Human Ganglioside GM1 and Campylobacter Jejuni
Lipooligosaccharide Causes Guillain–Barré Syndrome, 101 PNAS 11404 (Aug. 3, 2004), filed as
Ex. C Tab 8 (ECF No. 19-9).

Finally, Dr. Callaghan addressed the timeframe in which Petitioner’s injury manifested
after vaccination. He denied the relevance of the Vaccine Table’s 3–42 day period for flu vaccine-
caused GBS, since Petitioner had not likely experienced GBS, and did not receive the flu vaccine
either. Callaghan Rep. at 7. In addition, the record established a neurologic symptom experienced
by Petitioner (right-sided head pain thought to reflect occipital neuralgia) before vaccination—
meaning any condition she suffered from may already have existed when she received the Tdap
vaccine. Id. at 7–8. It was not reasonable to ignore the potential relationship between these
symptoms and what Petitioner experienced later.

2. Dr. Robert Fujinami – Dr. Fujinami, a renowned immunologist, prepared a
single Report for Respondent. Report, dated March 4, 2025, filed as Ex. C (ECF No. 19-1)
(“Fujinami Rep.”). He disputed Petitioner’s contention that the Tdap vaccine could cause SFN in
the manner proposed. Fujinami Rep. at 10.

5
Dr. Callaghan seemed to partially question the accuracy of Dr. Wilks’s exam, noting that he deemed a toe vibration
sensation test result normal, when it was in fact inconsistent with accepted parameters. Callaghan Rep. at 6.

10
Dr. Fujinami holds a Ph.D. in immunology from Northwestern University, where he
studied how autoimmune nervous system diseases are initiated in the neonate. Curriculum Vitae,
filed as Ex. D (ECF No. 19-10) (“Fujinami CV”) at 1; Fujinami Rep. at 1. He attended postdoctoral
training at The Scripps Research Institute where he investigated how viruses and infections could
induce autoimmune disease. Fujinami Rep. at 1. He was a pioneer of the concept of molecular
mimicry, and helped introduce the concept to the medical field. Id. Dr. Fujinami has served as an
Associate Professor in University of California, San Diego’s Department of Pathology and studied
virus triggers for neuroinflammatory autoimmune disease, before becoming a professor at The
University of Utah. Id.; Fujinami CV at 1. Dr. Fujinami still serves as a professor at The University
of Utah in its Department of Neurology, where he continues to study virus-host interactions.
Fujinami Rep. at 1–2. Dr. Fujinami expressly deferred to Dr. Callaghan as to the propriety of the
disputed SFN diagnosis. Id. at 3.

Overall, Dr. Fujinami opined that Petitioner’s causation theory seeking to link SFN to the
Tdap vaccine had “little or no support from the scientific literature.” Fujinami Rep. at 3. Dr.
Fujinami argued that Dr. Hixson had identified insufficient independent support for the contention
that SFN was likely an autoimmune neuropathy, noting that the evidence that was provided came
in the form of case reports (with one even concluding the discussed patient had experienced not
SFN but a sensory form of GBS). Id. at 3–4; J. Yang, et al., Pure Sensory Guillain-Barré
Syndrome: A Case Report and Review of the Literature¸ 8 Experimental Therapeutic Med. 1397
(2014), filed as Ex. 23 (ECF No. 15-14). Dr. Fujinami, like Dr. Callaghan, deemed SFN and GBS
to be distinguishable. Id. at 4; N. Yuki & H-P. Hartung, Guillain–Barré Syndrome, 336 N. Engl.
J. Med. 2294 (2012), filed as Ex. C Tab 7 (ECF No. 19-8) (“Yuki & Hartung”) (SFN not identified
as a GBS variant). And the medical record did not establish that Petitioner likely had GBS in the
first place. As a result, evidence about the autoimmune nature of GBS and its potential triggers
had little value in establishing a vaccine-SFN relationship. Fujinami Rep. at 4–5. 6

The specific mechanism proposed by Petitioner for how the Tdap vaccine could potentially
lead to SFN—molecular mimicry between components of the vaccine and self amino acid peptide
sequences in nerve components, leading to cross-reactive attack by antibodies first generated
against the vaccine antigens—was also inadequately substantiated, in Dr. Fujinami’s view. One of
the primary items of literature offered for this contention by Petitioner was a review article. M.
Blank et al., Molecular Mimicry in Autoimmunity and Vaccinations, filed as Ex. 15 (EC No. 15-6)
(“Blank”). But although Blank does mention an animal study looking at the association between
tetanus-containing vaccines and “antiphospholipid syndrome” (an unrelated disease believed to be
mediated by molecular mimicry), it did not have analogous force for SFN (and the findings of the

6
Dr. Fujinami also discussed his evaluation of certain items of literature filed by Petitioner, which not only involved
GBS but stood (in his reading) for the proposition that certain vaccines did not likely exacerbate preexisting GBS or
likely cause it. Fujinami Rep. at 4–5. But this aspect of his opinion goes somewhat beyond the more immediate
question of the SFN-vaccine relationship, and I therefore do not summarize it in detail.

11
reviewed study had not also been shown to have applicability to humans). Fujinami Rep. at 5;
Blank at 4.

Another article involved GBS or known immune-mediated neuropathies—again, not SFN.
B. Kieseier et al., Immune-Mediated Neuropathies, 4 Nature Rev. Disease Primer 1 (Oct. 11,
2018), filed as Ex. 16 (ECF No. 15-7). And a third (also focused on GBS) referred to a very old
case report in which an individual developed a form of GBS (not SFN) after repeated exposure to
tetanus toxoid-containing vaccines. P. Haber et al., Vaccines and Guillain-Barre Syndrome, 32
Drug Safety 309 (2009), filed as Ex. 17 (ECF No. 15-8) (“Haber”). 7 Haber also referenced
surveillance data that supported the view that the risk of GBS post-receipt of tetanus toxoid-
containing vaccines was no greater than the expected background rate, further undermining a
possible vaccine connection here (assuming that any evidence relating to GBS had evidentiary
value in the context of SFN). Fujinami Rep. at 5–6; Haber at 314.

Studies more specific to SFN were equally unhelpful to Petitioner, Dr. Fujinami contended.
Gendre, he noted, was a case series involving only one patient (out of 20 studied) whose SFN was
speculated to have been associated with a vaccine comparable to Tdap—and that individual had
been diagnosed only with probable SFN. Gendre at 6. Moreover, the study’s authors used an
incomplete methodology (as part of an animal test) to determine if antibodies potentially produced
in reaction to the vaccine were actually specific for a putative target of attack leading to SFN (as
opposed to also cross reactive with other tissues in the body). Fujinami Rep. at 6; Gendre at 2–5.
And the source/target nerve tissue used for the study was obtained from dorsal root ganglia near
the spine—raising the possibility of contagion of the tissue sample by central nervous system
tissues, and thus again underscoring the need for better controls lacking in this study. Fujinami
Rep. at 6; Gendre at 3.

Dr. Fujinami leveled other criticisms against the contention that the Tdap vaccine could be
linked to SFN. For example, he observed that Petitioner’s vaccination was a booster—and yet she
never developed SFN after the prior Tdap doses she had received. Fujinami Rep. at 5. Dr. Hixson
also relied on a number of case reports (a form of evidence not all that probative in resolving
causation) involving distinguishable vaccines, like the COVID-19 vaccine. Id. at 7.

A parallel deficiency in the proposed causation theory, Dr. Fujinami argued, was the fact
that vaccination generally could not be assumed to have the same overall immune impact as a wild
viral or bacterial infection. Fujinami Rep. at 8 (“[m]icrobial infections are very different from

7
The case report mentioned in Haber relating to exposure to the tetanus toxoid vaccine (comparable to the tetanus
component of Tdap) is one often referenced by claimants when trying to prove a GBS-Tdap relationship. Haber at 315
(citing J. Pollard & G. Selby, Relapsing Allergic Neuropathy due to Tetanus Toxoid: Report of a Case, 14 J. Neurol.
Sci. 113–25, (1978)). But I have repeatedly noted that Pollard & Selby only applies at best to a particular GBS variant
(chronic inflammatory demyelinating polyneuropathy)—and even then is of dubious evidentiary value. DeVaughn v.
Sec'y of Health & Hum. Servs., No. 22-832V, 2025 WL 758128, at *6 (Fed. Cl. Spec. Mstr. Feb. 10, 2025).

12
vaccinations with subunit vaccines, such as Tdap”). Wild infections infect, then replicate and
disseminate within the human body, but “subunit” 8 vaccines like Tdap are by-design inactivated,
and cannot result in replication or dissemination. Id. This means it is far less likely vaccination can
ever cause disease, given its more focused and limited impact on the immune system.

Specific studies had, in fact, revealed that this distinction was meaningful in understanding
the relative risk of wild infection versus vaccination. J. Croxford et al., Viral Delivery of an Epitope
from Haemophilus Influenzae Induces Central Nervous System Autoimmune Disease by Molecular
Mimicry, 174 J. Immunol. 2:907 (2005), filed as Ex. C-2 (ECF No. 19-3) (“Croxford”). Croxford’s
authors identified a molecular mimic between a viral microbe and an “encephalitogenic peptide”
(antigenic target for precipitating disease) in mice, then tested whether exposure to the foreign
antigen could trigger disease. A genetically-engineered version of the virus (with “the mimicking
peptide encoded in its genome”) did trigger disease when the study mice were immunized with
it—but exposure to the non-engineered form did not (even in the context of a powerful
experimental adjuvant used to heighten the response for purposes of study). Fujinami Rep. at 8;
Croxford at 909. Thus, exposure to the peptide alone did not spark disease, even if it was an
identified mimic—and that kind of exposure was akin to what a person experiences when
vaccinated. Fujinami Rep. at 8.

Dr. Fujinami also addressed some of the other elements Petitioner must establish to prove
causation. First, Dr. Fujinami disputed that Petitioner had shown receipt of the Tdap vaccine likely
“did cause” her to experience SFN. Fujinami Rep. at 9. Dr. Hixson seemed to place great weight
on the temporal association between the time of vaccination and Petitioner’s subsequent
development of SFN over weeks to months, but without citing other evidence demonstrating how
a putative disease process actually unfolded. Id. But multiple criteria would need to be satisfied to
get from vaccination to autoimmune disease—with none fulfilled. N. Shahrizaila & N. Yuki,
Guillain-Barre Syndrome Animal Model: The First Proof of Molecular Mimicry in Human
Autoimmune Disorder, 2011 J. Biomedicine Biotechnology 1 (Dec. 15, 2010), filed as Ex. C-6
(ECF No. 19-7).

Dr. Fujinami further denied that it had been preponderantly demonstrated that the
timeframe between Petitioner’s late-March 2021 vaccination and onset was medically acceptable.
Fujinami Rep. at 9. Because it was not established by Dr. Hixson that SFN was necessarily
autoimmune pathogenically, arguments about what is known regarding the timeframe for GBS to
develop post-trigger were not relevant. Id. Petitioner had not even been diagnosed with GBS to
begin with (and many treaters had expressed doubt her presentation fit its diagnostic requirements).
Id. at 9–10; Ex. 3 at 6 (treatment by neurologist Dr. Schloesser in September 13, 2021). As a result,

8
Subunit means a type of vaccine that uses only specific, purified parts of a pathogen, rather than the entire virus or
bacterium, to stimulate an immune response. They are distinguishable from vaccines that contain live viral or bacterial
components. Subunit, Dorland’s Illustrated Medical Dictionary (33rd ed. 2020).

13
there was no evidence establishing what would be a reasonable timeframe for SFN developing
after vaccination.

III. Procedural History

This case was initiated in the early fall of 2023. Almost one year later, Respondent filed
his Rule 4(c) Report opposing compensation. ECF No. 14. Thereafter, the parties obtained the
aforementioned expert opinions, completing the process of filing reports by June 2025. I
subsequently set a schedule for Ruling on the Record (in particular focusing on diagnosis), and the
matter became ripe last October.

IV. Parties’ Arguments

Petitioner

Petitioner argues that she experienced acute-onset SFN, and that the record supports this
as the best diagnosis for her injury, pointing to her submitted medical literature as reflecting the
diagnosis’s propriety. Br. at 10–11. Acute-onset SFN is characterized by sudden onset of
symptoms, normal EMG/NCS studies, and has been observed following preceding events such as
infection or vaccination. Id. at 10 (citing Gendre at 2, 4, 7). Symptoms of pain, tingling, sensory
disturbances, and partial and gradual improvement are associated with SFN. Id. at 8.

Comparing her medical records to Gendre and other items of literature, Petitioner claims
that her clinical course and symptoms align with the diagnostic criteria of acute-onset SFN. Br. at
10–11. Petitioner’s medical records show that she experienced right forearm pain, paresthesias,
and swelling when she was admitted to the hospital just shy of two weeks after her vaccine. Id. at
8 (citing Ex. 2 at 12–17). Her neurologic symptoms developed into generalized numbness and
tingling in her extremities and she soon experienced gait difficulty, imbalance, and pain on the
pads of her feet. Id. (citing Ex. 3 at 8–9). Other symptoms, particularly her paresthesias and pain,
were repeated and persistent throughout her course despite normal neurological imaging and
normal NCS testing. Id. at 9 (citing Ex. 3 at 5–6, 17). Petitioner claims these symptoms are aligned
with the diagnostic criteria for SFN. See id. at 8–9.

Petitioner also argues that her ongoing clinical course further supports a SFN diagnosis.
To this day, Petitioner continues to experience neurologic symptoms of burning and tingling
sensations. Br. at 9–10 (citing Ex. 5 at 42). Petitioner has complained of continuous nocturnal calf
cramps and trouble with strenuous activity, such as walking long distances, exercising, and picking
up her children. Id. (citing Ex. 4 at 29–35, 56). Petitioner also demonstrated partial and gradual
improvement, which she claims is consistent with SFN that improves but does not completely
resolve. Id. at 10 (citing Ex. 18. at 6).

14
In addition, Petitioner offers her treating providers’ testing results and diagnostic opinions
as further support for a SFN diagnosis. Br. at 9–10. Dr. Wilks noted that Petitioner’s EMG/NCS
findings were normal after documenting pinprick gradient in the arms and legs. Id. at 9 (citing Ex.
5 at 44). Dr. Wilks deemed this sufficient to confirm his clinical suspicion for SFN. Id. (citing Ex.
5 at 44). Dr. Hixson also opined that Petitioner’s proper diagnosis is SFN because Petitioner’s
clinical course, symptom pattern, and normal MRI and NCS results are consistent with such. Id.
at 10 (discussing First Hixson Rep. at 4–5).

Petitioner and her experts maintain that SFN is the proper diagnosis even in the absence of
traditional testing results. Br. at 10. Petitioner’s record is notably void of skin biopsy or QST, and
laser-evoked potentials—common tests for diagnosing SFN. See id. However, as Petitioner’s
expert noted, these test are not a requirement for diagnosis, and Petitioner’s medical record is
strong enough to support a SFN diagnosis without them. Id. In addition, Petitioner maintains that
her unsteady gait is consistent with SFN and not evidence of a different condition. Id. at 10. In
support, she referenced Dr. Hixson’s opinion that sensory loss can produce imbalance and
unsteady gait even without motor weakness. Id.

In her reply, Petitioner reiterated the arguments set forth in her brief and maintains that she
has shown her proper diagnosis is SFN by a preponderance of the evidence. See generally Reply.

Respondent

Respondent disputes Petitioner’s diagnosis, maintaining it lacks record support and is
otherwise inconsistent with the filed literature. Opp. at 9. To begin, Respondent argues that
Petitioner’s early post-vaccination symptoms and pathologic course are not consistent with SFN.
Id. at 10. Petitioner’s records show that her earliest presentation featured unilateral pain,
paresthesias, and swelling affecting only her right forearm, whereas SFN presents symmetrically.
Id. at 11 (citing Br. at 8; Ex. 2 at 12; and Gendre at 2). Dr. Callaghan’s review of her medical
records also revealed instances of edema, swelling, and significant gait disturbance, which are not
clinical features of SFN. Id. (discussing Callaghan Rep. at 6). Similarly, Petitioner complained
symptoms of trouble exercising and carrying her children and heavy loads are also inconsistent
with SFN. Id. (citing Callaghan Rep. at 6).

Petitioner’s testing and persistence of paresthesias in light of her results does not support
SFN either. Opp. at 12. Respondent notes that SFN affects small fibers that are characteristically
thinly or unmyelinated, and presents with symptoms such as neuropathic pain, paresthesia, and
loss of pinprick and thermal sensitivity. Id. at 9–10 (citing Gendre at 2). Testing typical to diagnose
SFN includes quantitative sudomotor axon reflex testing (“QSART”) testing, QST, and skin
biopsies to assess the epidermal nerve fiber density. Id. at 10 (citing C. Gibbons, Small Fiber

15
Neuropathies, 20 Continuum 1398 (2014), filed as Ex. 19 (ECF No. 15-10) (“Gibbons”)).
However, Petitioner never underwent QSART testing. See id.

Petitioner at most underwent EMG and NCS testing. Opp. at 10. But because SFN involves
only small fibers, not large fibers, EMGs and NCS are unreliable for diagnosing SFN (and in fact
will yield normal results in SFN patients—as here). Id. (citing Gibbons at 1402). However,
Petitioner’s reliance on persisting paresthesias in light of her normal EMG and NCS testing as
evidence of SFN is misplaced. Id. at 12. Dr. Schloesser did not diagnose her with SFN after her
test results. Id. (citing Ex. 3 at 6). Rather, Dr. Schloesser documented “unexplained paresthesias”
alongside normal NCS results, and recommended gabapentin to alleviate her symptoms. Id. (citing
Ex. 3 at 6). The records from this visit and Petitioner’s test results do not show a confirmatory
diagnosis of SFN. Id.

In addition, Dr. Wilks also never reached a confirmatory diagnosis of SFN. Opp. at 13.
Rather, Respondent argues, Dr. Wilks’s medical notes only opine that it was “possible” that
Petitioner was suffering from a mild form of GBS or acute SFN. Id. (citing Ex. 5 at 44). While Dr.
Wilks did include that his suspicion of SFN was confirmed later, after Petitioner’s normal EMG
and NCS test results, Respondent argues that this is the product of flawed logic, for it makes no
sense to favor SFN simply because GBS or some other comparable neuropathy could not be
confirmed. Id.

Respondent also claims that Dr. Hixson’s expert opinion does not stand as reliable support
for the SFN diagnosis. Opp. at 15. Dr. Hixson’s conclusions did not account for the numerous
symptoms not associated with SFN that Petitioner exhibited, such as stiff neck, limb swelling,
general weakness, diminished reflexes, cramping, muscle fatigue, and urinary and gastrointestinal
complaints. Id. (citing Callaghan Rep. at 6). Dr. Callaghan specifically explained these symptoms
reflect complications of large fiber processes—not small fibers. Id. (citing Callaghan Rep. at 6;
Ex. 3 at 5). Dr. Hixson’s efforts to attribute Petitioner’s imbalance and unsteady gait to sensory
loss are undermined by Petitioner’s medical records that show diminished reflexes and
weakness—further implications of large fiber processes. Id. at 16 (citing Second Hixson Rep. at
6; Ex. 1 at 92–93; Ex. 3 at 9).

At most, Petitioner has shown a temporal association between her vaccine and injury, but
even this does not salvage her claim. Opp. at 16–17. Petitioner’s submitted medical literature does
not offer more than describing potential clinical scenarios and does not support SFN diagnosis
based on Petitioner’s symptoms. Id. at 17. Based on the above, Respondent argues that Petitioner
has failed to establish she suffered from SFN by a preponderance of the evidence. See id.

Respondent did not address vaccine causation in his opposition brief, but did incorporate
by reference his Rule 4(c) Report, which challenges Petitioner’s causation argument. See Opp. at

16
2 (citing Respondent’s Report, dated Aug. 14, 2024 (ECF No. 14) (“Report”) at 12–15).
Respondent argues that, even if Petitioner did suffer SFN, Petitioner has failed to provide a medical
theory causally connecting the Tdap vaccine to SFN. Id. (citing Report at 12–15). Petitioner’s
theory rests upon Dr. Wilks’ opinion that Petitioner could be suffering from acute SFN, and “[t]he
proximity of [petitioner’s] symptoms onset to vaccination could be consistent” with such a
diagnosis. Report at 13 (quoting Ex. 5 at 44). However, Dr. Wilks next wrote “the association with
vaccination is unclear and not definitive.” Id. (quoting Ex. 5 at 44). To the extent that Dr. Wilks’
statements count as a causation opinion, Respondent asserts that it is equivocal, and only has a
temporal association to support such a claim. Id. at 14. Therefore, Petitioner has failed to put
forward a medical theory causally connecting the Tdap vaccine to her injury, and she has failed
her requisite showing. Id. at 14–15.

V. Applicable Legal Standards

A. Petitioner’s Overall Burden in Vaccine Program Cases

To receive compensation in the Vaccine Program, a petitioner must prove either: (1) that
he suffered a “Table Injury”—i.e., an injury falling within the Vaccine Injury Table—
corresponding to one of the vaccinations in question within a statutorily prescribed period of time
or, in the alternative, (2) that his illnesses were actually caused by a vaccine (a “Non-Table
Injury”). See Sections 13(a)(1)(A), 11(c)(1), and 14(a), as amended by 42 C.F.R. § 100.3; §
11(c)(1)(C)(ii)(I); see also Moberly v. Sec’y of Health & Hum. Servs., 592 F.3d 1315, 1321 (Fed.
Cir. 2010); Capizzano v. Sec’y of Health & Hum. Servs., 440 F.3d 1317, 1320 (Fed. Cir. 2006). 9
There is no Table claim for SFN after receipt of any covered vaccine.

For both Table and Non-Table claims, Vaccine Program petitioners bear a “preponderance
of the evidence” burden of proof. Section 13(1)(a). That is, a petitioner must offer evidence that
leads the “trier of fact to believe that the existence of a fact is more probable than its nonexistence
before [he] may find in favor of the party who has the burden to persuade the judge of the fact’s
existence.” Moberly, 592 F.3d at 1322 n.2; see also Snowbank Enter. v. United States, 6 Cl. Ct.
476, 486 (1984) (mere conjecture or speculation is insufficient under a preponderance standard).
Proof of medical certainty is not required. Bunting v. Sec’y of Health & Hum. Servs., 931 F.2d
867, 873 (Fed. Cir. 1991). In particular, a petitioner must demonstrate that the vaccine was “not
only [the] but-for cause of the injury but also a substantial factor in bringing about the injury.”
Moberly, 592 F.3d at 1321 (quoting Shyface v. Sec’y of Health & Hum. Servs., 165 F.3d 1344,
1352–53 (Fed. Cir. 1999)); Pafford v. Sec’y of Health & Hum. Servs., 451 F.3d 1352, 1355 (Fed.

9
Decisions of special masters (some of which I reference in this ruling) constitute persuasive but not binding authority.
Hanlon v. Sec’y of Health & Hum. Servs., 40 Fed. Cl. 625, 630 (1998). By contrast, Federal Circuit rulings concerning
legal issues are binding on special masters. Guillory v. Sec’y of Health & Hum. Servs., 59 Fed. Cl. 121, 124 (2003),
aff’d 104 F. App’x. 712 (Fed. Cir. 2004); see also Spooner v. Sec’y of Health & Hum. Servs., No. 13-159V, 2014 WL
504728, at *7 n.12 (Fed. Cl. Spec. Mstr. Jan. 16, 2014).

17
Cir. 2006). A petitioner may not receive a Vaccine Program award based solely on his assertions;
rather, the petition must be supported by either medical records or by the opinion of a competent
physician. Section 13(a)(1).

In attempting to establish entitlement to a Vaccine Program award of compensation for a
Non-Table claim, a petitioner must satisfy all three of the elements established by the Federal
Circuit in Althen v. Sec’y of Health and Hum. Servs., 418 F.3d 1274, 1278 (Fed. Cir. 2005): “(1) a
medical theory causally connecting the vaccination and the injury; (2) a 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.”

Each Althen prong requires a different showing. Under Althen prong one, petitioners must
provide a “reputable medical theory,” demonstrating that the vaccine received can cause the type
of injury alleged. Pafford, 451 F.3d at 1355–56 (citations omitted). To satisfy this prong, a
petitioner’s theory must be based on a “sound and reliable medical or scientific explanation.”
Knudsen v. Sec’y of Health & Hum. Servs., 35 F.3d 543, 548 (Fed. Cir. 1994). Such a theory must
only be “legally probable, not medically or scientifically certain.” Id. at 549.

Petitioners may satisfy the first Althen prong without resort to medical literature,
epidemiological studies, demonstration of a specific mechanism, or a generally accepted medical
theory. Andreu v. Sec’y of Health & Hum. Servs., 569 F.3d 1367, 1378–79 (Fed. Cir. 2009) (citing
Capizzano, 440 F.3d at 1325–26). Special masters, despite their expertise, are not empowered by
statute to conclusively resolve what are essentially thorny scientific and medical questions, and
thus scientific evidence offered to establish Althen prong one is viewed “not through the lens of
the laboratorian, but instead from the vantage point of the Vaccine Act’s preponderant evidence
standard.” Id. at 1380. Distinguishing between “preponderant evidence” and “medical certainty”
is important because special masters must take care not to impose an evidentiary burden that is too
high. Bunting, 931 F.2d at 873 (“The standard of proof required by the [Vaccine] Act is simple
preponderance of evidence; not scientific certainty.... [I]t is not plaintiff's burden to disprove every
possible ground of causation suggested by defendant nor must the findings of the court meet the
standards of the laboratorian.”) (citations and internal quotation marks omitted).

In discussing the evidentiary standard applicable to the first Althen prong, the Federal
Circuit has consistently rejected the contention that it can be satisfied merely by establishing the
proposed causal theory’s scientific or medical plausibility. See Cerrone v. Sec’y of Health & Hum.
Servs., 146 F.4th 1113, 1122 (Fed. Cir. 2025); Kalajdzic v. Sec’y of Health & Hum. Servs., No.
2023-1321, 2024 WL 3064398, at *2 (Fed. Cir. June 20, 2024) (arguments “for a less than
preponderance standard” deemed “plainly inconsistent with our precedent” (citing Moberly, 592
F.3d at 1322)); Boatmon v. Sec’y of Health & Hum. Servs., 941 F.3d 1351, 1359 (Fed. Cir. 2019);
see also Demore v. Sec’y of Health & Hum. Servs., No. 20-1265V, 2024 WL 4542934 (Fed. Cl.

18
Spec. Mstr. Sept. 26, 2024), aff'd, No. 20-1265V, 2025 WL 868902, at *4 (Fed. Cl. Mar. 20, 2025)
(rejecting the argument that a petitioner’s burden is to prove that a causation theory is plausible
and instead requiring petitioner to prove the theory by a preponderance of the evidence) (emphasis
added). And petitioners always have the ultimate burden of establishing their overall Vaccine Act
claim with preponderant evidence. W.C. v. Sec’y of Health & Hum. Servs., 704 F.3d 1352, 1356
(Fed. Cir. 2013) (citations omitted); Tarsell v. United States, 133 Fed. Cl. 782, 793 (2017) (noting
that Moberly “addresses the petitioner’s overall burden of proving causation-in-fact under the
Vaccine Act” by a preponderance standard).

The second Althen prong requires proof of a logical sequence of cause and effect, usually
supported by facts derived from a petitioner’s medical records. Althen, 418 F.3d at 1278; Andreu,
569 F.3d at 1375–77; Capizzano, 440 F.3d at 1326; Grant v. Sec’y of Health & Hum. Servs., 956
F.2d 1144, 1148 (Fed. Cir. 1992). In establishing that a vaccine “did cause” injury, the opinions
and views of the injured party’s treating physicians are entitled to some weight. Andreu, 569 F.3d
at 1367; Capizzano, 440 F.3d at 1326 (“medical records and medical opinion testimony are favored
in vaccine cases, as treating physicians are likely to be in the best position to determine whether a
‘logical sequence of cause and effect show[s] that the vaccination was the reason for the injury’”)
(quoting Althen, 418 F.3d at 1280). Medical records are generally viewed as particularly
trustworthy evidence, since they are created contemporaneously with the treatment of the patient.
Cucuras v. Sec’y of Health & Hum. Servs., 993 F.2d 1525, 1528 (Fed. Cir. 1993).

Medical records and statements of a treating physician, however, 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. Section 13(b)(1) (providing that “[a]ny such diagnosis, conclusion, judgment,
test result, report, or summary shall not be binding on the special master or court”); Snyder v. Sec’y
of Health & Hum. Servs., 88 Fed. Cl. 706, 746 n.67 (2009) (“there is nothing . . . that mandates
that the testimony of a treating physician is sacrosanct—that it must be accepted in its entirety and
cannot be rebutted”). As with expert testimony offered to establish a theory of causation, the
opinions or diagnoses of treating physicians are only as trustworthy as the reasonableness of their
suppositions or bases. The views of treating physicians should be weighed against other, contrary
evidence also present in the record—including conflicting opinions among such individuals.
Hibbard v. Sec’y of Health & Hum. Servs., 100 Fed. Cl. 742, 749 (2011) (not arbitrary or capricious
for special master to weigh competing treating physicians’ conclusions against each other), aff’d,
698 F.3d 1355 (Fed. Cir. 2012); Veryzer v. Sec’y of Dept. of Health & Hum. Servs., No. 06-522V,
2011 WL 1935813, at *17 (Fed. Cl. Spec. Mstr. Apr. 29, 2011), mot. for review den’d, 100 Fed.
Cl. 344, 356 (2011), aff’d without opinion, 475 F. Appx. 765 (Fed. Cir. 2012).

The third Althen prong requires establishing a “proximate temporal relationship” between
the vaccination and the injury alleged. Althen, 418 F.3d at 1281. That term has been equated to the
phrase “medically-acceptable temporal relationship.” Id. A petitioner must offer “preponderant

19
proof that the onset of symptoms occurred within a timeframe which, given the medical
understanding of the disorder’s etiology, it is medically acceptable to infer causation.” De Bazan
v. Sec’y of Health & Hum. Servs., 539 F.3d 1347, 1352 (Fed. Cir. 2008). The explanation for what
is a medically acceptable timeframe must align with the theory of how the relevant vaccine can
cause an injury (Althen prong one’s requirement). Id. at 1352; Shapiro v. Sec’y of Health & Hum.
Servs., 101 Fed. Cl. 532, 542 (2011), recons. den’d after remand, 105 Fed. Cl. 353 (2012), aff’d
mem., 503 F. Appx. 952 (Fed. Cir. 2013); Koehn v. Sec’y of Health & Hum. Servs., No. 11-355V,
2013 WL 3214877 (Fed. Cl. Spec. Mstr. May 30, 2013), mot. for rev. den’d (Fed. Cl. Dec. 3,
2013), aff’d, 773 F.3d 1239 (Fed. Cir. 2014).

B. Legal Standards Governing Factual Determinations

The process for making determinations in Vaccine Program cases regarding factual issues
begins with consideration of the medical records. Section 11I(2). 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.” Section 13(b)(1)(A). The special master is then
required to weigh the evidence presented, including contemporaneous medical records and
testimony. See Burns v. Sec’y of Health & Hum. Servs., 3 F.3d 415, 417 (Fed. Cir. 1993)
(determining that it is within the special master’s discretion to determine whether to afford greater
weight to contemporaneous medical records than to other evidence, such as oral testimony
surrounding the events in question that was given at a later date, provided that such determination
is evidenced by a rational determination).

As noted by the Federal Circuit, “[m]edical records, in general, warrant consideration as
trustworthy evidence.” Cucuras, 993 F.2d at 1528; Doe/70 v. Sec’y of Health & Hum. Servs., 95
Fed. Cl. 598, 608 (2010) (“[g]iven the inconsistencies between petitioner’s testimony and his
contemporaneous medical records, the special master’s decision to rely on petitioner’s medical
records was rational and consistent with applicable law”), aff’d, Rickett v. Sec’y of Health & Hum.
Servs., 468 F. App’x 952 (Fed. Cir. 2011) (non-precedential opinion). A series of linked
propositions explains why such records deserve some weight: (i) sick people visit medical
professionals; (ii) sick people attempt to honestly report their health problems to those
professionals; and (iii) medical professionals record what they are told or observe when examining
their patients in as accurate a manner as possible, so that they are aware of enough relevant facts
to make appropriate treatment decisions. Sanchez v. Sec’y of Health & Hum. Servs., No. 11–685V,
2013 WL 1880825, at *2 (Fed. Cl. Spec. Mstr. Apr. 10, 2013); Cucuras, 993 F.2d at 1525 (“[i]t
strains reason to conclude that petitioners would fail to accurately report the onset of their
daughter’s symptoms”).

20
Accordingly, if the medical records are clear, consistent, and complete, then they should
be afforded substantial weight. Lowrie v. Sec’y of Health & Hum. Servs., No. 03–1585V, 2005
WL 6117475, at *20 (Fed. Cl. Spec. Mstr. Dec. 12, 2005). Indeed, contemporaneous medical
records are often found to be deserving of greater evidentiary weight than oral testimony—
especially where such testimony conflicts with the record evidence. Cucuras, 993 F.2d at 1528;
see also Murphy v. Sec’y of Health & Hum. Servs., 23 Cl. Ct. 726, 733 (1991), aff’d per curiam,
968 F.2d 1226 (Fed. Cir. 1992), cert. den’d, Murphy v. Sullivan, 506 U.S. 974 (1992) (citing United
States v. United States Gypsum Co., 333 U.S. 364, 396 (1947) (“[i]t has generally been held that
oral testimony which is in conflict with contemporaneous documents is entitled to little evidentiary
weight.”)).

However, the Federal Circuit has also noted that there is no formal “presumption” that
records are accurate or superior on their face to other forms of evidence. Kirby v. Sec’y of Health
& Hum. Servs., 997 F.3d 1378, 1383 (Fed. Cir. 2021). There are certainly situations in which
compelling oral or written testimony (provided in the form of an affidavit or declaration) may be
more persuasive than written records, such as where records are deemed to be incomplete or
inaccurate. Campbell v. Sec’y of Health & Hum. Servs., 69 Fed. Cl. 775, 779 (2006) (“like any
norm based upon common sense and experience, this rule should not be treated as an absolute and
must yield where the factual predicates for its application are weak or lacking”); Lowrie, 2005 WL
6117475, at *19 (“[w]ritten records which are, themselves, inconsistent, should be accorded less
deference than those which are internally consistent”) (quoting Murphy, 23 Cl. Ct. at 733)).
Ultimately, a determination regarding a witness’s credibility is needed when determining the
weight that such testimony should be afforded. Andreu, 569 F.3d at 1379; Bradley v. Sec’y of
Health & Hum. Servs., 991 F.2d 1570, 1575 (Fed. Cir. 1993).

When witness testimony is offered to overcome the presumption of accuracy afforded to
contemporaneous medical records, such testimony must be “consistent, clear, cogent, and
compelling.” Sanchez, 2013 WL 1880825, at *3 (citing Blutstein v. Sec’y of Health & Hum. Servs.,
No. 90–2808V, 1998 WL 408611, at *5 (Fed. Cl. Spec. Mstr. June 30, 1998)). In determining the
accuracy and completeness of medical records, the Court of Federal Claims has listed four possible
explanations for inconsistencies between contemporaneously created medical records and later
testimony: (1) a person’s failure to recount to the medical professional everything that happened
during the relevant time period; (2) the medical professional’s failure to document everything
reported to her or him; (3) a person’s faulty recollection of the events when presenting testimony;
or (4) a person’s purposeful recounting of symptoms that did not exist. La Londe v. Sec’y of Health
& Hum. Servs., 110 Fed. Cl. 184, 203–04 (2013), aff’d, 746 F.3d 1334 (Fed. Cir. 2014). In making
a determination regarding whether to afford greater weight to contemporaneous medical records
or other evidence, such as testimony at hearing, there must be evidence that this decision was the
result of a rational determination. Burns, 3 F.3d at 417.

21
C. Analysis of Expert Testimony

Establishing a sound and reliable medical theory often requires a petitioner to present
expert testimony in support of his claim. Lampe v. Sec’y of Health & Hum. Servs., 219 F.3d 1357,
1361 (Fed. Cir. 2000). Vaccine Program expert testimony is usually evaluated according to the
factors for analyzing scientific reliability set forth in Daubert v. Merrell Dow Pharm., Inc., 509
U.S. 579, 594–96 (1993). See Cedillo v. Sec’y of Health & Hum. Servs., 617 F.3d 1328, 1339 (Fed.
Cir. 2010) (citing Terran v. Sec’y of Health & Hum. Servs., 195 F.3d 1302, 1316 (Fed. Cir. 1999).
Under Daubert, the factors for analyzing the reliability of testimony are:

(1) whether a theory or technique can be (and has been) tested; (2) whether the
theory or technique has been subjected to peer review and publication; (3) whether
there is a known or potential rate of error and whether there are standards for
controlling the error; and (4) whether the theory or technique enjoys general
acceptance within a relevant scientific community.

Terran, 195 F.3d at 1316 n.2 (citing Daubert, 509 U.S. at 592–95).

In the Vaccine Program the Daubert factors play a slightly different role than they do when
applied in other federal judicial settings, like the district courts. Typically, Daubert factors are
employed by judges (in the performance of their evidentiary gatekeeper roles) to exclude evidence
that is unreliable or could confuse a jury. By contrast, in Vaccine Program cases these factors are
used in the weighing of the reliability of scientific evidence proffered. Davis v. Sec’y of Health &
Hum. Servs., 94 Fed. Cl. 53, 66–67 (2010) (“uniquely in this Circuit, the Daubert factors have
been employed also as an acceptable evidentiary-gauging tool with respect to persuasiveness of
expert testimony already admitted”). The flexible use of the Daubert factors to evaluate the
persuasiveness and reliability of expert testimony has routinely been upheld. See, e.g., Snyder, 88
Fed. Cl. at 742–45. In this matter (as in numerous other Vaccine Program cases), Daubert has not
been employed at the threshold, to determine what evidence should be admitted, but instead to
determine whether expert testimony offered is reliable and/or persuasive.

Respondent frequently offers one or more experts in order to rebut a petitioner’s case.
Where both sides offer expert testimony, a special master’s decision may be “based on the
credibility of the experts and the relative persuasiveness of their competing theories.”
Broekelschen v. Sec’y of Health & Hum. Servs., 618 F.3d 1339, 1347 (Fed. Cir. 2010) (citing
Lampe, 219 F.3d at 1362). However, nothing requires the acceptance of an expert’s conclusion
“connected to existing data only by the ipse dixit of the expert,” especially if “there is simply too
great an analytical gap between the data and the opinion proffered.” Snyder, 88 Fed. Cl. at 743
(quoting Gen. Elec. Co. v. Joiner, 522 U.S. 146 (1997)); see also Isaac v. Sec’y of Health & Hum.

22
Servs., No. 08–601V, 2012 WL 3609993, at *17 (Fed. Cl. Spec. Mstr. July 30, 2012), mot. for
review den’d, 108 Fed. Cl. 743 (2013), aff’d, 540 F. App’x. 999 (Fed. Cir. 2013) (citing Cedillo,
617 F.3d at 1339). Weighing the relative persuasiveness of competing expert testimony, based on
a particular expert's credibility, is part of the overall reliability analysis to which special masters
must subject expert testimony in Vaccine Program cases. Moberly, 592 F.3d at 1325–26
(“[a]ssessments as to the reliability of expert testimony often turn on credibility determinations”);
see also Porter v. Sec’y of Health & Hum. Servs., 663 F.3d 1242, 1250 (Fed. Cir. 2011) (“this
court has unambiguously explained that special masters are expected to consider the credibility of
expert witnesses in evaluating petitions for compensation under the Vaccine Act”).

D. Consideration of Medical Literature

Both parties filed medical and scientific literature in this case, but not all such items factor
into the outcome of this decision. While I have reviewed all the medical literature submitted, I
discuss only those articles that are most relevant to my determination and/or are central to
Petitioner’s case—just as I have not exhaustively discussed every individual medical record filed.
Moriarty v. Sec’y of Health & Hum. Servs., No. 2015–5072, 2016 WL 1358616, at *5 (Fed. Cir.
Apr. 6, 2016) (“[w]e generally presume that a special master considered the relevant record
evidence even though he does not explicitly reference such evidence in his decision”) (citation
omitted); see also Paterek v. Sec’y of Health & Hum. Servs., 527 F. App’x 875, 884 (Fed. Cir.
2013) (“[f]inding certain information not relevant does not lead to—and likely undermines—the
conclusion that it was not considered”).

E. Resolution of Claim Upon Written Record

I have opted to decide entitlement in this case based on written submissions and evidentiary
filings, including the expert reports filed by each side. The Vaccine Act and Rules not only
contemplate but encourage special masters to decide petitions on the papers rather than via
evidentiary hearing, where (in the exercise of their discretion) they conclude that the former means
of adjudication will properly and fairly resolve the case. Section 12(d)(2)(D); Vaccine Rule 8(d).
The choice to do so has been affirmed on appeal. See D’Toile v. Sec’y of Health & Hum. Servs.,
No. 15-85V, 2018 WL 1750619, at *2 (Fed. Cir. Apr. 12, 2018); see also Hooker v. Sec’y of Health
& Hum. Servs., No. 02-472V, 2016 WL 3456435, at *21 n.19 (Fed. Cl. Spec. Mstr. May 19, 2016)
(citing numerous cases where special masters decided on the papers in lieu of hearing and that
decision was upheld). I am simply not required to hold a hearing in every matter, no matter the
preferences of the parties. Hovey v. Sec’y of Health & Hum. Servs., 38 Fed. Cl. 397, 402–03 (1997)
(special master acted within his discretion in denying evidentiary hearing); Burns, 3 F.3d at 417.

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ANALYSIS

I. Overview of SFN and its Treatment as Program Injury

As noted above, SFN is defined as a disorder affecting the small, mainly-unmyelinated
somatic and autonomic nerve fibers. See Gibbons at 1398; see also Gendre at 2. It results in the
loss of cold and pain perception, along with developing sensations of burning and numbness in the
feet and toes, which gradually spreads through the patient’s limbs and atypically to the trunk and
face. Gibbons at 1399. Most neurologic evaluations of SFN patients yield normal results, however,
so confirmation of the diagnosis via a skin biopsy or QST/QSART test is necessary. Id. at 1402–
04.

SFN is readily distinguishable from other neuropathic injuries thought to be vaccine-
associated, like GBS, the diagnosis of which requires proof of the existence of several criteria, and
under different diagnostic schema. Yuki & Hartung at 2295–96. Those diagnostic criteria include
evidence of “[p]rogressive weakness of the arms and/or legs, ranging from minimal weakness of
the legs to total paralysis of all four limbs, and including the trunk, bulbar and facial muscles, and
external ophthalmoplegia” and “[a]reflexia or decreased deep tendon reflexes in weak limbs.” S.
Chandrashekhar & M. Dimachkie, Guillain-Barré Syndrome in Adults: Pathogenesis, Clinical
Features, and Diagnosis, Wolters Kluwer: UpToDate, 16–17 (July 19, 2022), filed as Ex. 13 (ECF
No. 15-4), https://www.uptodate.com/contents/guillain-barre-syndrome-in-adults-pathogenesis-
clinical-features-and-diagnosis (last visited May 27, 2026). The Brighton diagnostic criteria for
GBS requires at the very least evidence of bilateral and flaccid weakness of the limbs; decreased
or absent deep tendon reflexes in weak limbs; monophasic illness pattern and interval between
onset and nadir of weakness between 12 hours and 28 days and subsequent clinical plateau; and
absence of identified alternative diagnosis for weakness. Haber at 2296. SFN has at best been
deemed a possible secondary result of GBS, but it is not defined as a GBS variant. Seneviratne &
Gunasekera at 542.

SFN has been alleged as a vaccine injury in prior cases, and petitioners have succeeded in
these claims, although such decisions shed little light on the analytical basis for these
determinations. 10 See, e.g., Coons v. Sec’y of Health & Hum. Servs., No. 20-1067V, 2024 WL
1741619, at *23–31 (Fed. Cl. Spec. Mstr. Mar. 29, 2024); Swaiss v. Sec'y of Health & Hum. Servs.,
No. 15-286V, 2019 WL 6520791, at *17, 27 (Fed. Cl. Spec. Mstr. Nov. 4, 2019) (granting
entitlement but noting that “the limited case reports proposing a GBS small fiber variant invoke

10
Prior decisions from different cases do not control the outcome herein. Boatmon, 941 F.3d at 1358–59; Hanlon , 40
Fed. Cl. at 630. But special masters reasonably draw upon their experience in resolving Vaccine Act claims. Doe v.
Sec’y of Health & Hum. Servs., 76 Fed. Cl. 328, 338–39 (2007) (“[o]ne reason that proceedings are more expeditious
in the hands of special masters is that the special masters have the expertise and experience to know the type of
information that is most probative of a claim”) (emphasis added). They would therefore be remiss in ignoring prior
cases presenting similar theories or factual circumstances, along with the reasoning employed in reaching such
decisions.

24
molecular mimicry and call for further research on the specific cross-reactivity involved”); Doe v.
Sec’y of Dep't of Health & Hum. Servs., 2007 WL 3120297, at *7 (Fed. Cl. Spec. Mstr. Oct. 18,
2007) (finding that the flu vaccine caused petitioner’s serum sickness and SFN).

However, as often as not claims alleging SFN as an injury have been unsuccessful—and
the decisions reaching that finding are more robust and illuminating in explaining their rationales.
See, e.g., Fantini v. Sec’y of Health & Hum. Servs., No. 15-1332V, 2022 WL 1760730, at *21
(Fed. Cl. Spec. Mstr. May 2, 2022); Todd v. Sec’y of Health & Hum. Servs., No. 15-860V, 2020
WL 727973 at *21 (Fed. Cl. Spec. Mstr. Jan. 8, 2020) (denying entitlement for SFN allegedly
caused by flu vaccine where petitioner failed to establish the existence of systemic inflammation
that would be associated with a chronic autoimmune neuropathy); Lapierre v. Sec’y of Health &
Hum. Servs., No. 17-227V, 2019 WL 6490730, at *20 (Fed. Cl. Spec. Mstr. Oct. 18, 2019); Jones
v. Sec’y of Health & Hum. Servs., No. 15-1239V, 2018 WL 7139212, at *17 (Fed. Cl. Spec. Mstr.
Dec. 21, 2018) (finding that a petitioner’s non-specific symptoms were not a basis for entitlement);
Shaw v. Sec’y of Health & Hum. Servs., No. 1-0707, 2013 WL 2897425, at *16 (Fed. Cl. Spec.
Mstr. May 24, 2013) (“. . .the medical literature does not specifically link the hepatitis B
vaccination or any vaccination to the injury of small fiber neuropathy”).

I have acknowledged in a prior decision that it cannot be assumed SFN is even
pathogenically autoimmune. E.S. v. Sec’y of Health & Hum. Servs., No. 17-480V, 2020 WL
9076620, at *45 (Fed. Cl. Spec. Mstr. Nov. 13, 2020), mot. for review den’d, 154 Fed. Cl. 149
(2021). And in many cases the SFN diagnosis appears to be applied without all that much in the
way of clinical corroboration. The neurologist who first diagnosed the petitioner in Fantini, for
example, observed some symptoms of SFN that he believed could be autoimmune in origin—but
he did not fully embrace this diagnosis years later. 2022 WL 1760730, at *20. In addition, another
treater who diagnosed the Fantini claimant with SFN was less reliable, as her diagnosis was arrived
at without seeing the patient first hand, and was made after the case was initiated. Id. In addition,
this diagnosis had little record support and lacked staunch corroboration from treating providers.
Id.

II. Petitioner Has Not Preponderantly Established SFN as Her Likely Injury

It is often appropriate for a special master to first determine whether an alleged injury has
evidentiary support before applying the Althen test—particularly when the injury is disputed, so
that “the special master [can] subsequently determine causation relative to the injury.”
Broekelschen, 618 F.3d at 1346. In some cases, determining the injury obviates entirely the need
for an Althen analysis, since the petitioner’s claim, and causation theory, is dependent on a finding
of a specific injury. Id.

In this case, the parties dispute the SFN diagnosis (the sole injury alleged). Although I
cannot ascertain on this record the most likely nature of (and hence proper descriptor for)
Petitioner’s symptoms, I find she has not preponderantly established SFN as the likely injury, for

25
several reasons. First, Petitioner’s presentation and constellation of symptoms are not generally
consistent with SFN. Petitioner’s edema, swelling, significant gait disturbance, and difficulty
exercising and carrying heavy loads are not clinical features of SFN. See generally Gibbons. And
it has not been shown SFN evolves from nonspecific concerns to sensory issues months later.

Second, test results that would confirm the presence of SFN are absent from the record. In
particular, no QST or QSART tests were performed (which would actually measure the amount of
small fiber loss in a section of skin, sufficient to confirm the absence of the relevant sensory
nerves). See Br. at 10. Without this testing, Petitioner’s diagnosis was not objectively confirmed—
and this is so even if such testing is not a diagnostic criterion. Otherwise, Petitioner’s treating
physicians based their opinions on the lack of confirmatory diagnoses of other neuropathies that
have not been shown related to SFN, like GBS, and Petitioner’s myriad of symptoms. See Ex. 5 at
44; First Hixson Rep. at 5–6. Petitioner’s treating physicians also discounted many of Petitioner’s
complaints in their analysis. See First Hixson Rep. at 5–6; Ex. 1 at 92–93; Ex. 3 at 9. Petitioner’s
diminished reflexes, edema, gait instability, cramping, muscle fatigue, neck stiffness, and urinary
and gastrointestinal complaints are indicative of implications to large fiber processes. See First
Hixson Rep. at 5–6; Ex. 1 at 92–93; Ex. 3 at 9; Callaghan Rep. at 6. When assessed as a whole,
the record establishes that Petitioner’s symptoms were largely nonspecific.

Third (and particularly compelling), Petitioner’s immediate post-vaccine medical
presentation establishes medical facts undermining the conclusion that Petitioner’s later-diagnosed
SFN (many months later) was present much earlier. Petitioner herself described an onset of
neurologic symptoms in her arm due to its positioning while she was seated gambling at a casino
for a period of time. Ex. 2 at 14. Further, Petitioner’s initial complaint was isolated to her right
arm. Ex. 2 at 12; Ex. 25 at 272. Unilateral sensory disturbance, pain, and paresthesia are not
indicative of SFN—which presents symmetrically. See id.; Gendre at 2. It is true that Dr. Hixson
deemed Petitioner’s initial symptoms as an isolated mononeuropathy episode in his analysis, which
still allowed for a diagnosis of SFN. See First Hixson Rep. at 5. But the finding of a SFN is still
unsupported by this record evidence.

Finally, Petitioner’s treating physician’s diagnosis and opinions are not all that persuasive.
Dr. Wilks’s opinion, in particular, that Petitioner suffered from SFN is unreliable. This opinion
was provided long after onset of Petitioner’s initial symptoms, and it largely appears to have been
based on Petitioner’s reported symptoms rather than confirmatory testing in light of the
contemporary medical record. First Hixson Rep. at 5. Further, Dr. Wilks originally suggested that
Petitioner could be suffering from GBS—which was inconsistent with her overall presentation,
was not endorsed by initial treaters (around the time of vaccination and onset), and never
corroborated by EMG or NCS results. Id. The most reliable statement Dr. Wilks made was that
the association between vaccination and SFN is “unclear and not definitive.” Id.

26
III. Petitioner Has Not Established Her Alleged SFN was Vaccine-Caused

Even if SFN had been proven as the proper diagnosis, Petitioner has not preponderantly
established a causal relationship between the Tdap vaccine and SFN. Because the first Althen
prong is unmet, there is no need to evaluate the remaining two. Dobrydnev v. Sec’y of Health &
Hum. Servs., 566 F. App’x 976, 979 (Fed. Cir. 2014).

The fact that reliable science establishes an association between GBS and the flu vaccine
does not inerrantly lead to the conclusion that SFNs can also be deemed to be similarly-associated,
given the facial differences in the nature of these conditions (and indeed the obvious distinctions
between the kinds of nerves involved—with SFN affecting unmyelinated thin nerves that perform
a wholly different function from the peripheral nerves involved in GBS). See Gendre at 9–10;
Seneviratne & Gunasekera at 541.

Petitioner thus needed to offer scientific or medical evidence showing how a flu vaccine
could harm the relevant nerves in SFN or initiate the condition generally (as opposed to it
developing secondarily to GBS). But she did not do so. Dr. Hixson opined that SFN mirrored other
vaccine caused injuries, like GBS, and could similarly be triggered by molecular mimicry after
vaccination. First Hixon Rep. at 5. But Dr. Hixson did not produce any evidence particularly
supportive of the conclusion that SFN could develop after vaccination due to molecular mimicry.
See generally id. Rather, Dr. Hixson he offered case report-style evidence of instances where SFN
developed after infection or vaccination. Id. at 6 (citing Gendre at 10). In addition, little reliable
evidence was offered showing cytokine overproduction could be instigated by the vaccine—let
alone that this in turn could cause a harmful result. Petitioner did not even discuss the innate
immune system, which is arguably the aspect of the immune response associated with an
overproduction of cytokines.

Petitioner’s theory of molecular mimicry was no better supported. In a prior case, I rejected
the theory when offered in a different context (to substantiate how the HPV and Hepatitis A
vaccines—arguably different vaccines than those alleged here—could instigate an autoimmune
process leading to autonomic dysfunction), where the expert witness “struggled… to specify where
in the body this autoimmune cross-reaction was purportedly occurring.” See McKown v. Sec’y of
Health & Hum. Servs., No. 15-1451V, 2019 WL 4072113, at *21 (Fed. Cl. Spec. Mstr. July 15,
2019) (emphasis in original). In more similarly situated cases I have emphasized that “. . . merely
chanting the magic words ‘molecular mimicry’ in a Vaccine Act case does not render a causation
theory scientifically reliable, absent additional evidence specifically tying the mechanism to the
injury and/or vaccine in question.” See, e.g., Mason v. Sec’y of Health & Hum. Servs., No. 17-
1383V, 2022 WL 600415, at *27 (Fed. Cl. Spec Mstr. Feb. 4, 2022) (alleging unsuccessfully that
the flu vaccine caused petitioner’s CIDP, with experts opining on other possible diagnoses, which
included GBS and SFN), citing McKown, 2019 WL 4072113, at *21, *50. Petitioner’s contention
herein was similarly conclusory and vague—and in fact, Dr. Hixson admitted he could not supply

27
all that much in the way of evidence to support the contention that the Tdap vaccine can cause
SFN, relying mainly on an association with GBS to do the work form him. By contrast, Dr.
Fujinami’s opinion was more straightforward and persuasive.

In so maintaining, moreover, Dr. Hixson embraced a plausibility standard for evidence that
is not applicable in Program cases. See, e.g., Second Hixson Rep. at 3. But as noted above,
claimants must establish the first Althen prong with preponderant evidence, and cannot prevail
simply by contending that it is plausible a vaccine could lead to an identified injury. Cerrone, 146
F.4th at 1122; Kalajdzic, 2024 WL 3064398, at *2. While Dr. Hixson may have been able to point
to some individually-reliable items of evidence that support possibly-plausible ways SFN might
arise, coupled with some evidence that it may be autoimmune, and may be associated in part with
GBS, this evidence collectively does not add up to a causation theory that has been preponderantly
established, such that I can conclude it is “more likely than not” that receipt of the Tdap vaccine
can lead to SFN.

CONCLUSION
Because Petitioner has not carried her burden of proof, she is not entitled to damages. In the
absence of a motion for review filed pursuant to RCFC Appendix B, the Clerk of the Court SHALL
ENTER JUDGMENT in accordance with the terms of this Decision. 11

IT IS SO ORDERED.

/s/ Brian H. Corcoran
Brian H. Corcoran
Chief Special Master

11
Pursuant to Vaccine Rule 11(a), the parties may expedite entry of judgment if (jointly or separately) they file notices
renouncing their right to seek review.

28

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Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/11346311. Public record. Not legal advice.