# D.G. v. Secretary of Heath and Human Services

> United States Court of Federal Claims · June 18, 2019

URL: https://www.frixlaw.com/law-library/cases/4407959

## Case

- **Court:** United States Court of Federal Claims
- **Decided:** June 18, 2019
- **Precedential status:** Published
- **Opinion:** Opinion
- **Judges:** Laura D. Millman
- **Cited by:** 0 later opinions in the Frix Law Library

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## Opinion text

In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
No. 11-577V
Filed: May 24, 2019
To be Published

*************************
D.G., *
*
Petitioner, *
*
v. * Influenza (“flu”) vaccine; seizures;
* autoimmune autonomic neuropathy;
SECRETARY OF HEALTH * gastroparesis; POTS; myasthenia
AND HUMAN SERVICES, * gravis; conversion disorder
*
Respondent. *
*
*************************
Lisa A. Roquemore, Rancho Santa Maria, CA, for petitioner.
Justine E. Walters, Washington, DC, for respondent.

MILLMAN, Special Master
DISMISSAL DECISION1
On September 9, 2011, petitioner filed a petition under the National Childhood Vaccine
Injury Act, 42 U.S.C. § 300aa-10-34 (2012), alleging that influenza (“flu”) vaccine administered
on August 23, 2009 caused her muscle weakness, fatigue, dizziness, excessive sweating
especially after meals, whose onset was 10 days post-vaccination. On September 12, 2009, she
alleged she had seizure and fainting after breakfast. On September 17, 2009, she alleged

1
Vaccine Rule 18(b) states that all decisions of the special masters will be made available to the public unless they
contain trade secrets or commercial or financial information that is privileged and confidential, or medical or similar
information whose disclosure would constitute a clearly unwarranted invasion of privacy. This means the decision
will be available to anyone with access to the Internet. When such a decision is filed, petitioner has 14 days to
identify and move to redact such information prior to the document’s disclosure. If the special master, upon review,
agrees that the identified material fits within the banned categories listed above, the special master shall redact such
material from public access. On August 16, 2017, petitioner filed a status report in which she informally moved to
change the caption to reflect just her initials “for privacy reasons.” S.R., at 2. On the same date, the undersigned
granted petitioner’s informal motion to redact her name to her initials and ordered the Clerk of Court to change the
case caption, which the Clerk of Court did. This case is already redacted.
vasovagal syncope,2 benign systolic murmur, positive ANA,3 multiple somatic complaints,
anxiety, dystonia, neurocardiogenic syncope,4 and postural orthostatic tachycardia syndrome
(“POTS”).5 Pet. at ¶¶ 9, 12, 13, 15, 15, 19, 20, 23, 25, 28. 31, 34, 38, 41. Petitioner’s affidavit,
dated September 7, 2011, was attached without an exhibit number.
PROCEDURAL HISTORY
On September 9, 2011, this case was assigned to former Special Master Daria J. Zane.
On February 21, 2012, petitioner filed a status report regarding record collection in which
petitioner’s original counsel Robert J. Krakow stated that he was having difficulty obtaining
treatment records from Dr. Rashid A. Buttar because of an unpaid bill reflected in Exhibit 56.
S.R., at 5. Mr. Krakow states that Generation Rescue offered to pay for all medical treatment
and expenses for petitioner’s medical treatment by Dr. Buttar, an osteopath. Id. at 6. The
condition for Generation Rescue’s payment of petitioner’s medical treatment and expenses was
petitioner’s agreement to being on video during Dr. Buttar’s treatment of her. Id. Mr. Krakow
states that for reasons Generation Rescue did not explain to petitioner, Generation Rescue
discontinued its involvement with Dr. Buttar’s treatment of petitioner and refused to pay her
medical bills for that treatment. Id.
On May 9, 2012, petitioner filed as Exhibit 58 an external terabyte hard drive with the
name “DG Copy” consisting of files of videos. Each video is marked by the name of the digital
file or folder as the files appear on the hard drive.
On July 16, 2012, petitioner’s counsel filed a motion to withdraw. Mot. Petitioner wrote
her counsel on May 30, 2012, stating that “she wished to ‘take over representation of my case’
and instructed counsel to discontinue representation of her before the Court for all purposes.”
Mot., at 1.
On October 2, 2012, petitioner filed a consented Motion to Substitute Attorney, which
former Special Master Zane granted on October 22, 2012.

2
Vasovagal syncope is “a transient vascular and neurogenic reaction marked by pallor, nausea, sweating,
bradycardia, and rapid fall in arterial blood pressure which, when below a critical level, results in loss of
consciousness and characteristic electroencephalographic changes. It is most often evoked by emotional stress
associated with fear or pain.” Dorland’s Illustrated Medical Dictionary 1818 (32nd ed. 2012) [hereinafter,
“Dorland’s”].
3
ANA or antinuclear antibodies are “antibodies directed against nuclear antigens; ones against a variety of different
antigens are almost invariably found in systemic lupus erythematosus and are frequently found in rheumatoid
arthritis, scleroderma (systemic sclerosis), Sjögren syndrome, and mixed connective tissue disease. Antinuclear
antibodies may be detected by immunofluorescent staining. Serologic tests are also used to determine antibody
titers against specific antigens.” Dorland’s at 101.
4
Neurocardiogenic syncope is “a serious type of vasovagal syncope precipitated by a stimulus that causes either
bradycardia, a decrease in vascular tone, or both at once.” Dorland’s at 1818.
5
Postural orthostatic tachycardia syndrome (POTS) is “a group of symptoms (not including hypotension) that
sometimes occur when a person assumes an upright position, including tachycardia, tremulousness, lightheadedness,
sweating, and hyperventilation; this is seen more often in women than in men, and the etiology is uncertain.”
Dorland’s at 1844.

2
On December 6, 2012, petitioner filed a Statement of Completion.
On March 19, 2013, respondent filed his Rule 4(c) Report, recommending against
compensation.
On June 11, 2013, petitioner filed a status report regarding her review of video footage
and attached a list of those videos which she contended were relevant and irrelevant. Videos
included interviews on the television shows “20/20,” “Inside Edition,” “60 Minutes,” “NBC
Washington,” “Fox D.C. News,” and “NBC Charlotte News,” videos of petitioner incapable of
walking forward and then running races, and multiple videos during the week she spent at Dr.
Buttar’s treatment center in North Carolina.
On July 7, 2013, former Special Master Zane issued a decision awarding interim
attorneys’ fees and costs to petitioner’s former attorney, stating that the special master concluded
a reasonable basis existed only up to the point of petitioner’s former counsel’s withdrawal.
“Whether a reasonable basis existed beyond this point and continues to exist to date cannot be
decided based on the record at present, and this decision should not be construed as making any
such decision.” Int. Fees Dec. at 5 n.7. Former Special Master Zane awarded petitioner’s former
counsel $44,961.65 in fees and costs. Id. at 8. Judgment entered on August 2, 2013.
On September 4, 2013, this case was reassigned to former Special Master Lisa Hamilton-
Fieldman.
On October 22, 2013, petitioner filed the expert report of Dr. Lawrence Steinman, a
neurologist. Ex. 65. This was over two years after she filed her petition.
On April 25, 2014, respondent filed the expert report of Dr. Peter D. Donofrio. Ex. B.
On May 30, 2014, former Special Master Hamilton-Fieldman issued a decision awarding
petitioner’s interim costs of $2,950.29. Judgment entered on July 1, 2014.
On August 14, 2014, petitioner filed the first supplemental expert report of Dr. Steinman.
Ex. 92.
On August 19, 2014, former Special Master Hamilton-Fieldman issued an Order for
petitioner to file a second supplemental report from Dr. Steinman, explaining how demyelination
led to the variety of petitioner’s symptoms.
On August 28, 2014, petitioner filed Dr. Steinman’s second supplemental report. Ex.
108.
On January 13, 2015, respondent filed the expert report of Dr. Eric Lancaster, a
neurologist. Ex. H.
On January 15, 2015, the case was reassigned to the undersigned.
On February 20, 2015, respondent filed the expert report of Dr. J. Lindsay Whitton. Ex.
Z.
On June 1, 2015, petitioner filed a third supplemental report of Dr. Steinman. Ex. 118.
3
On August 11, 2015, respondent filed a Motion for Issuance of Subpoena to obtain any
and all documentation, video files, audio files, news releases, reporting, or broadcasts, and/or
website postings/updates relating to petitioner posted on Dr. Buttar’s websites. On the same
date, the undersigned granted respondent’s motion.
On September 4, 2015, respondent filed the first supplemental expert reports of Dr.
Lancaster (Ex. RR) and Dr. Whitton (Ex. SS).
On October 13, 2015, petitioner filed a supplemental declaration in support of her
petition (Ex. 139). She explains how she became a media star by saying she alerted her family
and friends about her physical problems. Ex. 139, at 4. One of her former colleagues was
working for the county newspaper and asked if he could do an article in his paper explaining her
condition and its being tied to flu vaccine. Petitioner writes she agreed since he was a friend and
struggling to get started in his new job. Petitioner writes:
After I learned that the flu vaccine was causing my issues, I
thought I was doing a public service by speaking out as perhaps the
batch of vaccine I received was tainted. From there the media
circus began, starting with local stations contacting me to national
syndicates. However, I remember one of my doctors or
psychologists recommending later on that I should avoid the media
as the chaos was probably not helping my symptoms, but likely
contributing to them.
Id.
Petitioner continues in her supplemental declaration by saying that she thought her first
attorney Robert Krakow, whom her then-husband hired per Stan Kurtz’s recommendation, was
involved to help her deal with media relations. Id. She continues:
At this time, I was also contacted by Stan Kurtz from Generation
Rescue, who is an anti-vaccine advocate. He and his organization
quickly commandeered my injury to turn it into a poster story for
their cause against vaccines[.] [I]n exchange they promised to
“cure” me with the help of Dr. Buttar. Upon the advice of Dr.
Buttar, I declined Dr. Cintron’s plasmaparesis [sic]
recommendation and started receiving [Dr. Buttar’s] protocol of
several bags of IV hydration mixed with his own cocktail of
vitamins. This began to relieve quite a bit of the dizziness and
fainting I had when I stood up or ate. Slowly, my speech started to
improve and I could eat, but limited amounts of food. . . .
Id. at 4-5. Petitioner then goes through the videos respondent’s neurologic expert Dr. Lancaster
saw and about which he comments in his first expert report (Ex. H). Petitioner gives her own
interpretation of them. Id. at 8-25. She mentions giving an interview to channel 5 and stating
she could not walk or talk normally and the only thing she could do was run. Id. at 10. She

4
states her voice returned when she was running. She told John Henry of Channel 5 that when
she runs, her heart rate would go down to 60, whereas when she walked, her heart rate was in the
130s. Id. at 10.
She mentions that Dr. Buttar talked about getting thousands of patients after airing on
television petitioner’s treatment with him. Id. at 23. He talked about people paying $500-600
for his drops. Petitioner states she is not sure how the drops work, but they did seem to improve
her muscle weakness, but much faster than her myasthenia drugs do because of the drops’ rapid
absorption through her skin. Id. Petitioner describes getting an EEG with Ms. Preston, whom
she refers to as “Dr.” Preston even though she is a Ph.D., not a medical doctor. Id. at 24.
Petitioner says Dr. Preston determined petitioner was having seizure. Id.
On January 13, 2016, petitioner filed a fourth supplemental report of Dr. Steinman. Ex.
141.
On April 26, 2016, respondent filed a CD with Exhibits AAA-JJJ, consisting of the
following: Ex. AAA, “20/20” broadcast, approximately July 25, 2010; Ex. BBB, “Inside Edition
Update,” February 4, 2010; Ex. CCC, “20/20” broadcast followed by Robert Scott Bell show;
Ex. DDD, [D.G.] update, October 29, 2009; Ex. EEE, “NBC Washington,” October 15, 2009;
Ex. FFF, “Fox 5 DC News,” October 15, 2009; Ex. GGG, “Inside Edition,” October 16, 2009;
“Ex. HHH, “Fox 5 DC News,” October 19, 2009; Ex. III, “NBC Charlotte,” November 5, 2009;
and Ex. JJJ, “Fox 5 DC News,” November 19, 2009. 6
From June 14-17, 2016, the undersigned held a four-day hearing. On the second day of
the hearing, petitioner sank from her chair to the floor in the hearing room, making growling
noises. The undersigned asked petitioner’s expert Dr. Steinman to attend to her while the
undersigned’s law clerk called 911. Petitioner was transported by ambulance to MedStar
Georgetown University Hospital, which necessitated the obtaining of those hospital records and
the subsequent opinions of the experts interpreting those records after the hearing.
On July 14, 2016, respondent filed the second supplemental expert report of Dr. Whitton.
Ex. YYY.
Also, on July 14, 2016, petitioner filed the fifth supplemental expert report of Dr.
Steinman. Ex. 181.
On September 7, 2016, petitioner filed her second supplemental declaration (Ex. 190).
Attached to her declaration is a copy of e-mail she sent to her treater Dr. Joey R. Gee consisting
of her question and his response (Attachment 2): [D.G.] “Given the positive GAD7 antibody

6
Respondent also relied on the videos respondent identified as Respondent’s Trial Exhibit 58-1 to Respondent’s
Trial Exhibit 58-66, which were specific videos derived from petitioner’s Exhibit 58 (the external terabyte hard
drive). Doc 143. Respondent relied on additional videos identified by dates from October 17, 2009 to October 22,
2009 including nine undated videos. Multiple videos come from Dr. Buttar’s treatment center. Respondent’s expert
Dr. Lancaster identifies the videos upon which he relies as support for his opinion in his first expert report (Ex. H).
Respondent added Respondent’s Trial Exhibit 58-66 to the prior list of Respondent’s Trial Exhibit 58-1 to
Respondent’s Trial Exhibit 58-65 at the hearing, noted in a filing dated June 21, 2016. Doc 147.
7
GAD or glutamate decarboxylase or glutamic acid decarboxylase is “an enzyme of the lyase class that catalyzes

5
result, do you think this explains some of the spasms and tremors you saw in the videos online
when you first took me on as a patient.” Petitioner then says that when she tried to go off
gabapentin8 a year previously, a lot of her symptoms returned, necessitating her going back on
gabapentin, and she wondered if the drug were masking her symptoms. Dr. Gee responded, “It
just might…I did think about that. The spasms can be quite extreme. I am dealing with this
same issue now with a new patient and her GAD have been fluctuating between 10 to over 100[;]
she is on IVIG now.”
On October 14, 2016, petitioner filed the sixth supplemental expert report of Dr.
Steinman. Ex. 191.
On December 16, 2016, respondent filed the third supplemental expert report of Dr.
Whitton (Ex. ZZZ) and the second supplemental expert report of Dr. Lancaster (Ex. FFFF).
On May 16, 2017, petitioner filed the seventh supplemental expert report of Dr.
Steinman. Ex. 198.
On May 17, 2017, petitioner filed her third supplemental declaration (Ex. 205), arguing
that respondent’s neurologic expert Dr. Lancaster was wrong for assuming Dr. Gee told the
treating doctors at MedStar Georgetown University Hospital that petitioner had a “non-organic
(psychogenic)9 gait disorder.” Ex. 205, at 3. She asserts that in the five years she has been
seeing Dr. Gee, he never “even insinuated” that she had an underlying psychogenic illness. Id.
Also, on May 17, 2017, the undersigned issued an Order to petitioner that she file by June
19, 2017 a statement from Dr. Gee indicating whether he believed petitioner had a high GAD
antibody in 2009 and, if she did, whether the high GAD antibody could have caused some of
petitioner’s spasms and tremors that she manifested in 2009 in her videos. Moreover, the
undersigned asked Dr. Gee to opine whether he thought petitioner had myasthenia gravis in 2009
and, if he did not think she did, then how would a purportedly high GAD antibody be connected
to her spasms and tremors in 2009. Dr. Gee never provided petitioner with answers to the
undersigned’s questions. Therefore, the undersigned never learned if petitioner’s assertions in
her third supplemental declaration (Ex. 205) as to what Dr. Gee told her were accurate.
On June 19, 2017, petitioner filed the eighth supplemental expert report of Dr. Steinman,
answering the questions the undersigned asked Dr. Gee to answer in her Order of May 17, 2017,
even though the undersigned addressed those questions to Dr. Gee and not to Dr. Steinman. Ex.
206.
On September 15, 2017, petitioner filed an amended petition, which repeats in detail her
prior allegations. She states flu vaccine caused her the following conditions: (1) autoimmune

the decarboxylation of glutamate to form ƴ-aminobutyrate (GABA). The enzyme is a pyridoxal phosphate protein,
and the reaction occurs within the mitochondria in kidney, and outside the mitochondria in brain. Deficiency of the
brain enzyme may be the cause of convulsions that begin in infancy and are responsive to pyridoxine therapy.”
Dorland’s at 790.
8
Gabapentin is “an anticonvulsant that is a structural analogue of ƴ-aminobutyric acid (GABA), used as adjunctive
therapy in the treatment of partial seizures; administered orally.” Dorland’s at 753.
9
Psychogenic means “produced or caused by psychological factors. See also psychosomatic.” Dorland’s at 1549.

6
autonomic neuropathy/dysautonomia;10 (2) myasthenia gravis11 and in parenthesis states the
following: petitioner admits myasthenia gravis is not her expert Dr. Steinman’s “favorite”
diagnosis; instead it is Dr. Geoffrey L. Sheean’s diagnosis and Dr. Steinman puts a high value on
Dr. Sheean’s opinion; and (3) autoimmunity to GAD. Am. Pet. at ¶ 60.
On October 30, 2017, petitioner filed the ninth supplemental expert report of Dr.
Steinman. Ex. 208. On the same date, respondent filed the fourth supplemental expert report of
Dr. Whitton (Ex. MMMM) and the third supplemental expert report of Dr. Lancaster (Ex.
QQQQ).
On February 7, 2018, petitioner filed her post-hearing brief.
On May 31, 2018, respondent filed his responsive post-hearing brief.
On July 2, 2018, petitioner filed her reply post-hearing brief.
Petitioner filed 209 exhibits and respondent filed 80 exhibits, for a total of 289. The
undersigned has read all of them and the entire 1,110-page transcript. The undersigned has
weighed the conflicting opinions of the experts and observed their demeanor at trial. The
undersigned has seriously considered the opinions of the 58 treating/diagnosing doctors and two
psychologists.
Because the evidence in this case as well as the more persuasive opinions of respondent’s
experts and supporting medical literature show that petitioner did not have an adverse reaction to
flu vaccine, the undersigned DISMISSES this case.
FACTS
Prevaccination Records
Petitioner was born on December 23, 1983. She is 35 years old.
Prior to vaccination, petitioner was generally healthy without significant medical
problems. She had a medical history of bronchitis, nose surgery, bulimia,12 and breast
augmentation surgery. Med. recs. Ex. 2, at 11-12; Ex. 9, at 2-3; Ex. 21, at 1-2; Ex. 22, at 24-26.
On November 29, 2004, petitioner saw Dr. Michael Rodriguez of Broadlands Family
Practice, complaining of a fungus for the past week or two. Med. recs. Ex. 11, at 33. Petitioner

10
Dysautonomia is “malfunction of the autonomic nervous system.” Dorland’s at 575.
11
Myasthenia gravis is “an autoimmune disease of neuromuscular function due to the presence of antibodies to
acetylcholine receptors at the neuromuscular junction; characteristics include muscle fatigue and exhaustion that
fluctuates in severity, without sensory disturbance or atrophy. It may be restricted to one muscle group or become
generalized with severe weakness and sometimes respiratory insufficiency. It may affect any muscle of the body,
but especially those of the eyes, face, lips, tongue, throat, and neck.” Dorland’s at 1214.
12
Bulimia is “episodic binge eating usually followed by behavior designed to negate the excessive caloric intake,
most commonly purging behaviors such as self-induced vomiting or laxative abuse but sometimes other methods
such as excessive exercise or fasting.” Dorland’s at 259.

7
weighed 137 pounds. She had a temperature of 100 degrees. Her blood pressure was 130/60.
Id. Dr. Rodriguez diagnosed petitioner with tinea nigra13 (ringworm). Id. at 34.
On November 16, 2006, petitioner saw Dr. Rodriguez of Broadlands Family Practice, for
tinea nigra. Id. at 32.
On July 2, 2008, petitioner saw PA-C Deirdre Ellis at Broadlands Family Practice,
needing a health screening for work. Med. recs. Ex. 22, at 29. Her history included rare to
occasional EtOH (ethanol). Id.
On December 16, 2008, petitioner saw Dr. Huong Thai-Kemprowski, an allergist and
immunologist, for an evaluation of environmental allergies. Id. at 82. Petitioner stated she had
rhinorrhea, nasal congestion, and constant sniffing. She said she had had constant nasal
congestion for the prior 10 years. She has sneezing and itchy eyes in the spring. Her father had
allergic rhinitis. She has post-nasal drip. Id. Physical examination of petitioner’s nose showed
enlarged turbinate with nasal obstruction left greater than right. Id. at 83. Test results showed no
sensitivity to tree pollens, grass pollens, weed pollens, dust mites, cockroach, cat, dog, horse, and
mold spores. Dr. Thai-Kemprowski’s impression was there was no evidence of allergic rhinitis.
Id.
In March 2009, petitioner became a Washington Redskins Cheerleader Ambassador14 as
a public relations representative for the Washington Redskins. Med. recs. Ex. 31, at 2.
On April 10, 2009, petitioner and her then-husband saw psychologist Christine M.
Cosgrave for petitioner’s then-husband’s psychotherapy. Med. recs. Ex. 187, at 1, 3.
On May 14, 2009, petitioner saw Dr. Elizabeth Mann at Broadlands Family Practice,
complaining of headache, sore throat, and chills. Med. recs. Ex. 31, at 27. Dr. Mann diagnosed
petitioner with allergic rhinitis. Id. at 28.
On May 18, 2009, petitioner saw Dr. Rodriguez at Broadlands Family Practice,
complaining of moderate to severe cough for several days. Id. at 25. She felt tired, achy, and
had trouble sleeping. Id. Dr. Rodriguez diagnosed her with acute bronchitis. Id. at 26.
On June 22, 2009, petitioner went to Dr. Rodriguez, complaining of moderate to severe
cough for several days. Id. at 23. She felt tired, achy and had trouble sleeping. Id. Dr.
Rodriguez diagnosed petitioner with acute bronchitis. Id. at 24.
Postvaccination Records

13
Tinea nigra is “a minor fungal infection, caused by Hortaea werneckii, having dark lesions that look like spattered
silver nitrate on the skin of the hands or occasionally other areas.” Dorland’s at 1930.
14
“Selected during the Redskins Cheerleaders auditions process every April, the Ambassadors’ main focus is
interacting with fans during all Redskins home games at FedExField. While the Redskins Cheerleaders captivate the
90,000+ fans with energetic dance routines, the Ambassadors are in the AAA Ultimate Fan Zone, Touchdown Club
and Suites—and even in the stands—bringing a personal, up-close interaction with fans.” Washington Redskins
Cheerleader Ambassadors, ULTIMATE CHEERLEADERS, https://ultimatecheerleaders.com/tag/ambassadors/ (last
visited Mar. 18, 2019).

8
On August 23, 2009, petitioner received flu vaccine at a Safeway Pharmacy in Reston,
Virginia. Med. recs. Ex. 4, at 3.
On September 12, 2009, petitioner was transported via emergency medical services
(“EMS”) to the emergency department (“ED”) at Inova Loudoun Hospital, complaining of
weakness, overall not feeling well for the last nine days, subjective fevers, body aches,
weakness, and dizziness although she worked full time and ran every day to train for a 5K race.
Med. recs. Ex. 5, at 6, and Ex. 51, at 112. Petitioner reported having bronchitis four to five times
since February 2009 treated with antibiotics, although she still had a productive cough and
fatigue. Id. The assessment was rhabdomyolysis,15 near syncope, recurrent respiratory issues,
elevated liver function test. Med. recs. Ex. 51, at 113. Petitioner had no problem getting out of
bed to a chair and her speech and thoughts were clear. Id. The nursing assessment noted
petitioner was hyperventilating, complaining of fever, syncope, dizziness, nausea, non-
productive cough, pain in her left upper quadrant, shivering, and feeling cold. Her speech was
clear and understandable. Her temperature was normal. Med. recs. Ex. 5, at 15. The onset of
symptoms was sudden. She did not have any associated shortness of breath. She reported that
she “was watching TV and almost passed out and began to shake.” Id. at 9. She reported a
history of lightheadedness, dizziness, weakness, subjective fevers, and body aches over the
previous nine days. Id. at 6, 9. Petitioner said she had a sore throat for several days the prior
week. Id. at 10.
On physical examination, Dr. Zachary Malachias noted petitioner was well-appearing,
alert and oriented, appeared comfortable, and had a normal pulse and blood pressure, but an
increased respiratory rate. Id. Neurologically, she did not have focal motor deficits, focal
sensory deficits, or nystagmus.16 She had intact cranial nerves and normal speech. She was
oriented, and had normal affect, insight, and concentration. Id. Her EKG was normal. Id. Her
oxygen saturation was normal. Id. at 11. Petitioner was admitted to the hospital. Id. On blood
testing in the ED, petitioner’s mono percentage was high at 10.9. Id. at 12. She tested negative
for both influenza A antigen and influenza B antigen, indicating she did not have the flu. She
tested negative for mono. Id. Her creatine kinase (“CK”)17 tested high at 12,018 U/L when the
normal range is between 19-204. Id. at 13. Her myoglobin18 tested high at 675 ng/mL when the

15
Rhabdomyolysis is “disintegration or dissolution of muscle, associated with excretion of myoglobin in the urine.”
Dorland’s at 1637. Myoglobin is “the oxygen-transporting pigment of muscle [which] combines with oxygen
released by erythrocytes, stores it, and transports it to the mitochondria of muscle cells, where it generates energy by
combustion of glucose to carbon dioxide and water.” Id. at 1223.
16
Nystagmus is “an involuntary, rapid, rhythmic movement of the eyeball, which may be horizontal, vertical,
rotatory, or mixed.” Dorland’s at 1307.
17
Creatine kinase (CK) is “an Mg2+-activated enzyme of the transferase class that catalyzes the phosphorylation of
creatine by ATP to form phosphocreatine. The reaction effectively stores the energy of ATP as phosphocreatine in
muscle and brain tissue and holds the muscle concentration of ATP nearly constant during the initiation of exercise.”
Dorland’s at 429. ATP is adenosine triphosphate. Id. at 173. Adenosine triphosphate is “a nucleotide, the 5’-
triphosphate of adenosine, involved in energy metabolism and required for RNA synthesis; it occurs in all cells and
is used to store energy in the form of high-energy phosphate bonds. The free energy derived from hydrolysis of
ATP is used to drive metabolic reactions including the synthesis of nucleic acids and proteins, to move molecules
against concentration gradients (active transport), and to produce mechanical motion (contraction of microfibrils and
microtubules).” Id. at 30.
18
Myoglobin (Mb) is “the oxygen-transporting pigment of muscle, a type of hemoprotein resembling a single

9
normal range is 0-62. Id. at 14. Her CKMB19 mass tested high at 7.49 ng/mL when the normal
range is 0.00-3.38. Id.
As an inpatient, petitioner reported during a History and Physical that she had bronchitis
four to five times since February 2009 and was treated with antibiotics, although she still had a
productive cough and fatigue. Id. at 6. Despite her symptoms, petitioner was working full-time
and running every morning to train for a 5K race. Id. Petitioner had a history of eating disorder
years ago. Id. Her history also includes turbinate20 reduction, rhinoplasty,21 and breast
augmentation. She reported a questionable blood transfusion during her breast augmentation
surgery. Id. Her white count was 10.9. Id. She had no acute findings on chest x-ray. Id. She
was negative for flu. Id. at 7.
On physical examination, petitioner was alert and oriented. Id. She was not in acute
distress. The diagnosis was rhabdomyolysis, leukocytosis,22 and near syncope. Petitioner did
not have any gross neurologic deficits. She was out of bed to a chair without difficulty. Her
speech and thoughts were clear. Petitioner had recurrent respiratory issues of an ongoing cough
and fatigue. Id. She had an increased respiratory rate, but she was otherwise afebrile with no
abnormalities. Id. at 10. Petitioner was diagnosed with rhabdomyolysis, leukocytosis, near
syncope, recurrent respiratory issues, elevated liver function tests, and a heart murmur. Id. at 7.
She was admitted to the hospital for hydration with IV fluids. Id. at 7. The results of her chest
x-ray on September 12, 2009 and brain CT scan were normal. Id. at 25, 26. Her chest x-ray on
September 13, 2009 showed small non-specific hypodensities in her thyroid. Id. at 28. Her EKG
on September 12, 2009 was normal. Id. at 31.
Petitioner was discharged on September 14, 2009. Med. recs. Ex. 5, at 2. Dr. Brian A.
Hazen wrote the discharge summary stating serial laboratory tests included a CPK which was
12,018 on September 12, 2009, but 6,546 on September 13, 2009; an AST23 which was 366 on
September 12th, but 167 on September 14th; and an ALT24 which was 102 on September 12th, but
80 on September 14th. Id. Dr. Hazen stated these test results were probably reflective of muscle
damage and not a hepatic process. Petitioner’s long-term goal was long-distance running. Dr.
Hazen told her to get one more test of her CPK and liver function before ensuring she had
completely resolved from the muscle damage of rhabdomyolysis. In the meantime, he said it

subunit of hemoglobin, composed of one globin polypeptide chain and one heme group (containing one iron atom);
it combines with oxygen released by erythrocytes, stores it, and transports it to the mitochondria of muscle cells,
where it generates energy by combustion of glucose to carbon dioxide and water.” Dorland’s at 1223.
19
CKMB is “CK2 (MB) … primarily in cardiac muscle.” Dorland’s at 429.
20
Turbinate is “any of the nasal conchae.” Dorland’s at 1991.
21
Rhinoplasty is “a plastic surgical operation on the nose, either reconstructive, restorative, or cosmetic.” Dorland’s
at 1640.
22
Leukocytosis is “a transient increase in the number of leukocytes in the blood; seen normally with strenuous
exercise and pathologically accompanying hemorrhage, fever, infection, or inflammation.” Dorland’s at 1028.
23
AST is aspartate transaminase. Dorland’s at 167. “The serum level of aspartate transaminase (SGOT) and that of
other transaminases are frequently elevated in a variety of disorders causing tissue damage.”
24
ALT is alanine transaminase. Dorland’s at 54. Alanine transaminase is “an enzyme found in serum and body
tissues, especially in the liver. Serum enzyme activity (SGPT) is greatly increased in liver disease and also elevated
in infectious mononucleosis.” Id. at 43.

10
was all right for her to do very light, brief aerobic exercise, to stay hydrated, not to do anaerobic
exercise, and to avoid excessive heat. Id. Petitioner’s diagnosis was mild rhabdomyolysis. Id.
On September 17, 2009, petitioner returned to the ED at Inova Loudoun Hospital,
complaining of sudden lightheadedness, blackout, and shortness of breath, noting immediate
restoration of normal mental status. Med. recs. Ex. 51, at 13. Dr. Pranav Vermani did a physical
examination, noting weakness bilaterally in the upper extremities and profound weakness
bilaterally in the lower extremities. Id. at 14. On the same day, during a consultation with Dr.
Sarbjot S. Dulai, a neurologist, petitioner reported that she had subjective fevers, chills, body
aches, generalized fatigue, weakness, and intermittent lightheadedness. Id. at 21. She had
shortness of breath and tingling in her feet and hands when she was hyperventilating. Id.
Petitioner continued to train for a 5K race. Although she was admitted to Inova Loudoun
Hospital on September 12, 2009 and discharged on September 14, 2009, she continued to have
subjective chills and fevers, generalized body aches, and intermittent lightheadedness. She
claimed multiple brief episodes of passing out which occurred only when she was sitting or
standing. She thought her shortness of breath was related to hyperventilation, when she would
get some tingling in her feet and hands. Petitioner received intravenous hydration in the
emergency room. She reported some headaches without visual changes or problems with
speech, swallowing, or balance. Id. Dr. Dulai noted petitioner had very minimal weakness
proximally in the lower extremities. Id. at 4, 23. Petitioner’s neurologic examination was
otherwise unremarkable. Id. at 23. Dr. Dulai’s impression was that petitioner’s symptoms were
due to a continuation of her viral syndrome and possibly a component of dehydration. Id.
On September 17, 2009, petitioner’s AST was high at 60 U/L when the normal range is
5-40. Med. recs. Ex. 6, at 6. Her ALT was also high on September 17, 2009 at 61 U/L when the
normal range is 7-56. Id. On September 17, 2009, petitioner’s ANA was 1:80 when normal is
less than 1:40. Med. recs. Ex. 22, at 76. On September 18, 2009, petitioner’s AST returned to
normal at 38 and her ALT returned to normal at 48. Med. rec. Ex. 6, at 6. On September 17,
2009, petitioner’s CK was elevated at 485 U/L when the normal range is 19-204. Id. at 7. It was
still elevated, but less so, on September 18, 2009 when the CK measured 236 U/L. Id. On
September 17, 2009, petitioner’s C-reactive protein was negative. Id. at 17.
On September 17, 2009, petitioner had a brain MRI with and without contrast. Id. at 37,
and Ex. 51, at 48. Dr. Ho-Song Lee wrote the brain MRI was normal. There was no mass,
hemorrhage, or extra-axial fluid collection. The gray matter, intracranial vessels and
postcontrast exam were normal. Petitioner had mild left maxillary sinus membrane thickening.
Id.
On September 18, 2009, petitioner had a consultation with Dr. Jeffrey S. Luy, a
cardiologist, who observed normal muscle strength and tone on physical exam. She also had
normal and appropriate affect. Med. recs. Ex. 51, at 25; Ex. 6, at 1-4; Ex. 22, at 58-59. Dr.
Luy’s impression was that petitioner’s syncope was “probably vasovagal due to some relative
element of dehydration,” prior rhabdomyolysis which had improved, and benign systolic heart
murmur. Med. recs. Ex. 51, at 25. Dr. Luy recommended discharge with fluid, Tylenol, and
rest. Id. On the same day, petitioner was discharged with a diagnosis of “syncope, likely

11
vasovagal, history of recent rhabdomyolysis, underlying etiology not clear, possible viral illness
with complaint of still being tired and fatigued” and instructions to follow up with her primary
care physician (“PCP”). Id. at 4-5 and med. recs. Ex. 22, at 48.
On September 21, 2009, petitioner visited her primary care physician (“PCP”) Dr.
Michael Rodriguez at Broadlands Family Practice with concerns of multiple episodes of near
syncope over the past couple of weeks. Med. recs. Ex. 22, at 19. She said that she would feel
dizzy, nauseated, and as if she were going to pass out. Id. She asked Dr. Rodriguez to review
her ED records and tests because she was convinced that her symptoms were due to Lyme
disease even though a Lyme test was negative. Id. On physical examination, Dr. Rodriguez
observed normal joints and muscles. Id. at 20. Dr. Rodriguez referred petitioner to an infectious
diseases specialist, Dr. Sarfraz A. Choudhary, and a rheumatologist, Dr. Alexia Gospodinoff. Id.
On September 22, 2009, petitioner visited Dr. Choudhary with complaints of headache,
neck pain, multiple joint pains, and pseudoseizures. Id. at 56. On physical examination, Dr.
Choudhary found nothing remarkable. Id. Dr. Choudhary stated the possibilities included
“psychological as [petitioner] had a history of bulimia, tick borne illness like Lyme disease, and
viral illnesses like West Nile.” Id. at 57. He ordered a spinal tap with Inova Loudoun Hospital
to rule out any neurological etiology. Id. Dr. Choudhary also recommended counseling and
reassurance, discussed different infection control precautions, and had petitioner follow up with
her neurologist and cardiologist. Id. A lumbar puncture was performed on September 24, 2009
and the evaluation of lupus was negative. Med. recs. Ex. 7 at 1 and Ex. 44, at 16, 29.
Petitioner’s lumbar puncture showed a normal cerebrospinal fluid (“CSF”) of 24 mg/dL when
the normal range is 15-60. Med. recs. Ex. 7, at 2.
On September 26, 2009, petitioner went to Inova Fairfax Hospital ED, complaining of
three days of unsteady gait, difficulty with speech, syncope when standing up, shakiness,
constant fatigue, an achy neck, headache, and difficulty sleeping. Med. recs. Ex. 44, at 136.
Petitioner told Dr. Scott Weir that she was recently discharged from Loudon Hospital on
September 21, 2009 for the same symptoms and that she received flu vaccine three days before
her symptoms began. Id. Petitioner arrived via stretcher since she was unable to ambulate. Id.
at 137. Petitioner’s speech was clear and understandable. Her bilateral hand grasp was weak
and toes were progressing upward. Petitioner reported “it feels like numb spots in my mind.” Id.
Petitioner’s family reported petitioner seemed confused at times and sometimes could not finish
her sentences. Id. Her C-reactive protein was normal. Id. at 142. Petitioner said the onset of
symptoms was gradual and occurred on September 3, 2009, starting with a fever and headache.
She developed syncopal episodes after meals, difficulty speaking and concentrating, tremors in
her neck, head, and arms, weakness in her legs, and a wide-based and unsteady gait. She said
she received flu vaccine on August 30, 2009 (the wrong date; she received flu vaccine on August
23, 2009). She was admitted to Loudoun Hospital for a cardiac syncopal workup and discharged
on September 21, 2009 with no definitive diagnosis. Petitioner stated she developed intermittent
paresthesia25 in her legs and arms. She developed seizure-like episodes two days previously with

25
Paresthesia is “an abnormal touch sensation, such as burning, prickling, or formication, often in the absence of an
external stimulus.” Dorland’s at 1383.

12
jerking of her arms and legs, but no postictal period or incontinence. Petitioner states she knew
what was happening but could not stop her muscles. She denied slurred speech and stated she
has difficulty concentrating and difficulty getting words out. Id. Petitioner reported chills,
fatigue, weakness, vision changes, seeing visual spots, syncope, nausea, arthralgias, myalgias,
and joint stiffness. Id.
Physical examination showed petitioner was ill-appearing and uncomfortable. Id. at 143.
The range of movement of her neck was within normal but difficult due to tremulous movements
and stiff motions. She had a tremulous head. Her extremities had 4/5 strength. She had
dysmetria26 on cerebellar examination. Petitioner was admitted to the hospital for neurologic
examination. Id.
On admission, petitioner complained of a four-day history of worsening and bilateral
lower and upper extremity weakness, difficulty ambulating, and generalized tremors with
multiple vague somatic complaints. Med. recs. Ex. 9, at 1-2; Ex. 44, at 1 (complaining of
syncope, low blood pressure, with an admitting diagnosis of other malaise and fatigue); Ex. 22,
at 50. She complained of having “sweating” in the central core area and mid-epigastric pain that
stopped beneath the sternum. Med. recs. Ex. 44, at 55. She was discharged on September 29,
2009 with a principal diagnosis of abnormal involuntary movement not elsewhere classified
(“NEC”), and secondary diagnoses of lack of coordination, other malaise and fatigue, conversion
disorder,27 obstructive sleep apnea, and stuttering. Med. recs. Ex. 44, at 8.
Dr. Mohammed A. Mannan was petitioner’s attending physician. Med. recs. Ex. 9, at 1.
Petitioner told Dr. Mannan that she had been in excellent health until around August 30, 2009
(which would be one week after she received flu vaccine). Id. She said within a few days after
getting a flu vaccination, she had a flu-like illness with upper respiratory symptoms,
bronchorrhea,28 sore throat, mild nonproductive cough, fevers, chills, and diffuse myalgias. She
had some lightheadedness, dizziness, and syncopal episodes and presented to Inova Loudon
Hospital. (She went to Inova Loudon Hospital on September 12, 2009.) Id. Dr. Mannan notes
in petitioner’s records that petitioner had a positive ANA “which was only 1:80.” Id.

26
Dysmetria is “a condition in which there is improper estimation of distance in muscular acts, with disturbance of
the power to control the range of muscular movement, often resulting in overreaching.” Dorland’s at 578.
27
Conversion disorder is “a mental disorder characterized by conversion symptoms (loss or alteration of voluntary
motor or sensory functioning suggesting physical illness, such as seizures, paralysis, dyskinesia, anesthesia,
blindness, or aphonia) having no demonstrable physiological basis and whose psychological basis is suggested by
(1) exacerbation of symptoms at times of psychological stress, (2) relief from tension or inner conflicts (primary
gains) provided by the symptoms, or (3) secondary gains (support, attention, avoidance of unpleasant
responsibilities) provided by the symptoms. Many patients exhibit “la belle indifference,” a lack of concern about
the impairment caused by the symptoms; histrionic personality traits are also common. Symptoms are neither
intentionally produced nor feigned, and are not limited to pain or sexual dysfunction.” Dorland’s at 549.
Dyskinesia is “distortion or impairment of voluntary movement, as in tic, spasm, or myoclonus.” Id. at 578.
Myoclonus is “shocklike contractions of a portion of a muscle, an entire muscle, or a group of muscles, restricted to
one area of the body or appearing synchronously or asynchronously in several areas.” Id. at 1222. Aphonia is loss
of voice, mutism. Id. at 115.
28
Bronchorrhea is “excessive discharge of mucus from the bronchi.” Dorland’s at 253.

13
Petitioner complained that she had progressive deterioration in the prior four days and
some new symptoms, including symmetric lower greater than upper extremity weakness and
difficulty ambulating, as if her legs were going to buckle due to weakness. She was much more
fatigued and very easily winded with minimal exertion. However, she denied any shortness of
breath at rest, but stated she got very exhausted and short of breath with any minimal exertion.
She reported difficulty sleeping. She stated she had onset of worsening uncontrollable tremors at
times that became worse with effort or exertion. She had intermittent headaches, but no vision
changes. She stated that, at times, she had trouble concentrating and had stuttering speech, but
not specific slurring. She denied the following: difficulty swallowing, chest pain, recent cough,
palpitations, nausea, vomiting, abdominal pain, diarrhea, constipation, urinary changes, calf pain,
swelling, orthopnea, or PND (paroxysmal nocturnal dyspnea29). She described occasional
shooting tingling pains in her lower extremities more than in her upper extremities which was
symmetric. She stated her sensation was intact. She reported intermittent, mainly frontal but
occasionally diffuse, headaches, giving a vague description of occasionally feeling cold spots in
the back of her head. She reported some fainting episodes and occasional lightheadedness which
was somewhat worse when she was upright. She described recent fevers as occasional hot
flashes but did not measure them. She said she received a flu vaccine two to three years ago
without problems. Id. at 2. Her past medical history included chronic bronchitis, bulimia,
obstructive sleep apnea with turbinate reduction around 2008, rhinoplasty, breast augmentation,
intestinal surgery in early childhood, and oral and genital herpes. Id. at 2-3. A chest x-ray done
on September 26, 2009 because petitioner complained of shortness of breath was stable. Dr.
Elise Berman noted petitioner had degenerative change to her right AC (acromioclavicular) joint.
Id. at 7.
On physical examination, petitioner’s blood pressure was 110/60 and her pulse 70. Id. at
3. She was alert and oriented, well-nourished, somewhat anxious, and generally fatigued, but
generally comfortable. She was very easily fatigued with minimal activity. Id. She did not have
a heart murmur. Id. at 4. Her C3 and C4 complement levels were normal at 85 and 15
respectively.
Dr. Mannan’s impression was multiple somatic complaints following flu vaccination
initially with flu-like illness with myalgia, rhabdomyolysis, and mild transaminitis (high level of
enzymes), all of which resolved. She had recurrent near syncope and syncope. Id. Petitioner
did not lose her distal deep tendon reflexes. Conversely, she complained of generalized tremors
and possible hyperreflexia, more so in the upper extremities and worse with effort. Dr. Mannan
wrote that “Etiology regarding above constellation of symptoms is not entirely clear at present.”
Id.
On September 27, 2009, Dr. Jonathan Bresner, a neurologist, saw petitioner because of
abnormal movements. Med. recs. Ex. 44, at 29. Petitioner said that on September 23, 2009, she
had shooting pains in various parts of her body and sensory changes in her head. She felt as
though her whole body was hot although her hands and feet were cold. She described seeing
white spots in her vision and had intermittent headaches. She had lab work done and the only

29
Dyspnea is “breathlessness or shortness of breath; difficult or labored respiration.” Dorland’s at 582.

14
abnormality was an ANA of 1:80. Petitioner’s lumbar puncture was normal. Id. A family friend
who is a physician was concerned petitioner had GBS because of her difficulty breathing, which
is why she returned to the ED. Id. at 29-30. She had a history of bronchitis five times in the last
year and going to the ED for severe abdominal pain. Id. at 30. On physical examination,
petitioner had fluent speech, but also stuttering and halting speech. She was alert, oriented, and
anxious. Her strength was 5/5 throughout. Her tone was alternating and uncoordinated with
tremors, contractions, dystonic30 posturing, and myoclonic jerks. She had spastic jerking
movements of the limbs and at times dystonic posturing as well. Her reflexes were 1 to 2+. She
was able to walk unassisted, but had jerking movements of her entire body while she was
walking. Id.
Petitioner’s lab results were normal for CK, C-reactive protein, and erythrocyte
sedimentation rate. Id. at 31. The protein in her CSF was 24. Dr. Bresner’s impression was
multiple complaints progressing over the last month as well as progressive tremulousness and
abnormal body movements for the prior several days. Dr. Bresner states:
The observed movements are extremely peculiar and not easily
described from a neurological standpoint. It is also odd that the
patient’s symptoms resolved for a long enough period each
morning for her to apply makeup but then return so forcefully that
she is unable to speak or move her limbs in any sort of coordinated
motion. The patient is able to walk despite her inability to control
her limbs . . . . I am reassured that her neurological exam is
otherwise normal and had an extensive workup including
laboratory CSF and reportedly a brain MRI are also unremarkable,
excluding a borderline elevated ANA. … I was originally asked to
assess the patient for Guillain-Barre syndrome. There is [sic]
currently no signs or symptoms on her exam to suggest this
diagnosis. A psychogenic etiology to the patient’s symptoms
remains a consideration. The patient might benefit from
psychological counseling or psychiatric evaluation. . . .
Id. at 31-32.
On September 28, 2009, petitioner had a psychiatric consultation on a question of
conversion disorder with Dr. Paul M. Dellemonache. Med. recs. Ex. 21, at 1-6, and Ex. 44, at
33-38. Petitioner reported that she had a history of bulimic and self-induced vomiting behavior
during her teens “to control something since my father controlled me.” Med. recs. Ex. 21, at 2.
Neurology had seen petitioner and did not feel her signs and symptoms were consistent with a
clear neurologic etiology and questioned a psychogenic element. Id. at 1. The only stressor
petitioner could mention within the past year was her younger sister’s suicide attempt. Id.
Petitioner felt her sister did that to get attention as she had apparently done before. Petitioner
stopped speaking with her sister who had since moved out of petitioner’s house and back in with

30
Dystonia is “dyskinetic movements due to disordered tonicity of muscle.” Dorland’s at 582.

15
petitioner’s father. Petitioner reported her other siblings agree with her regarding her sister, but
denied that this caused any difficult family strife. Petitioner did not speak to her mother after her
parents’ separation when she was 18 years old. Id. Petitioner thought her mother was jealous of
petitioner’s relationship with her father. Id. at 3. She was not distressed when her parents
separated because she felt her father could do better. Petitioner moved out of the house when she
was 18 to her own house which she then flipped and moved into a bigger house but lost its equity
when the housing market declined. She went straight to work at AOL after high school. In order
to get onto the Washington Redskins cheerleading team, she had breast augmentation which she
felt was a necessity to get onto the team. She practices once or twice a month and enjoys it. She
also enjoys marathon running. Id. Petitioner noted that her illness had brought her then-husband
and her “even closer together.” Id. at 5.
Petitioner said she had bronchitis several times over the prior year and thought her
symptoms might be due to Lyme disease because she had several coworkers and friends who
themselves or their family members had Lyme disease with similar presentations and she had
many tick bites on her legs in the past from running outside. Id. at 2. She also mentioned that
she had a flu vaccination at the end of August which might or might not be related to her
symptoms. Id. Dr. Dellemonache noted that conversion disorder is a “diagnosis of exclusion,”
which could not be conclusively diagnosed until all other workups were exhaustive and
continued to be negative. Id. A lupus anticoagulant evaluation done on September 28, 2009
resulted in no detection. Med. recs. Ex. 8, at 6, 9. Testing for Epstein-Barr virus antibody and
IgG was positive, but IgM was negative. Id. at 10. Cytomegalovirus was not detected. Id. at 16.
On September 28, 2009, petitioner and her then-husband met with a social worker
Michelle Ougheltree. Med. recs. Ex. 44, at 57. Petitioner still had a significant stutter.
Petitioner was assisted in walking that morning by two persons because her knees buckled and
currently her knees and hips hurt. Petitioner was interested in outpatient therapy. Petitioner’s
then-husband requested SW Ougheltree complete a short-term disability form as petitioner’s sick
leave had run out. The social worker would give the form to petitioner’s PCP. Id.
On September 29, 2009, petitioner was discharged. Dr. Mannan diagnosed her with
“multiple somatic complaints and progressive but fluctuating neurologic deficits (including
abnormal movements/tremors and speech) of unclear etiology, not fitting any particular pattern.
Possible psychogenic etiology. No evidence of GBS.” Id. at 13. He also said that petitioner’s
orthostatic hypotension was likely due to volume depletion and it improved with intravenous
hydration. Dr. Mannan writes that at the time of petitioner’s presentation, she had “very odd
neurological symptoms with difficulty walking and tremors during evaluation of strength.” Id.
However, petitioner’s reflexes were normal, and she did not have any focal findings. Id. Dr.
Bresner in the ED suspected petitioner’s neurological symptoms were not consistent with GBS
and there could be a psychogenic component to her symptoms. Id. at 13-14.
In his discharge summary, Dr. Mannan drew attention to the fact that petitioner “was
unable to hold a cup of water in her hand without spilling; however, she was able to fully put
makeup on in the morning during hospitalization, including eyeliner, without complication until
confronted by the nursing staff, after which she no long could do this task.” Id. at 14. All of

16
petitioner’s lab tests, including Lyme disease, repeat ANA, antiphospholipid antibody panel,
West Nile, and H1 N1, were negative. Id. Dr. Mannan discussed with petitioner’s then-husband
putting petitioner on doxycycline even though multiple tests for Lyme disease were negative.
Her then-husband said petitioner had been very concerned about possible Lyme disease after
researching it on the internet and he felt petitioner would be greatly reassured by empiric
treatment for it. Dr. Mannan gave petitioner a one-week course of doxycycline upon discharge.
In addition, petitioner was treated with IV hydration to help with orthostatic and volume
depletion during this hospitalization. Id. Dr. Mannan spoke with petitioner’s PCP Dr. Rodriguez
who also did not see any clear evidence of obvious organic etiology, and seemed concerned
about a psychogenic etiology, and agreed with a psychiatric evaluation. Id. Petitioner requested
a note for short-term disability but Dr. Mannan suggested she follow up with Dr. Rodriguez
because there was no clear diagnosis. Id. Lab results showed a negative C-reactive protein and a
sedimentation rate of 19. Her cortisol at 10.7 was normal as was her B-12. ANA was detected
with a ratio of 1:80. Lyme antibodies were negative. Med. recs. Ex. 22, at 49.
On October 2, 2009, petitioner saw Dr. Garry Ho at Broadlands Family Practice, for a
consultation and to review her recent medical problems. Med. recs. Ex. 22, at 15-17. She
discussed multiple sclerosis (“MS”) with Dr. Ho. Id. at 15. Petitioner reported that she woke up
on September 24, 2009 with trouble walking “like I had MS.” Id. She also reported that she
developed dysarthria and stuttering when she tried to talk out loud on September 26, 2009. Id.
At that time, petitioner was in the process of setting up an admission to Johns Hopkins Hospital’s
neuromuscular neurology service. Id. On physical examination, Dr. Ho found petitioner had a
broad-based, spastic, stamping and waddling gait, and dysarthric and stuttering speech. Id. at 16-
17.
On October 2, 2009, petitioner went to Johns Hopkins Medicine ED and spoke to Dr.
Julius C. Pham. Med. recs. Ex. 55, at 24. Johns Hopkins was to evaluate whether petitioner had
GBS since she reported lower leg weakness that progressed to her upper legs, increased
difficulty speaking and walking, and shortness of breath. Id. She had uncontrollable bobbing of
her head when speaking or making intentional movements. She also described electric-like
shooting pains starting in her legs and moving around her body. She also had symptoms of
dysphonia that whispering or singing in a high-pitched voice relieved. She had difficulty using
her lower limbs for prolonged periods of time because either they gave out or she had
uncontrollable movements in them. Id. Petitioner complained of a headache at the base of her
neck which was constant and dull. Id. When it went away, she had diffuse, cool spots all around
or she developed a headache behind her right eye and again had cool sensations. Id. at 24-25.
Petitioner said she had episodes of uncontrollable blinking that she was unaware of and
photophobia. Id. at 25. She had mild congestion and intermittent tinnitus in her left ear that
woke her. She had dysgeusia.31 Petitioner had inappropriate episodes of uncontrollable laughter.
She had autonomic dysfunction with hot flushing at the core and cool extremities. She had
syncopal episodes associated with eating, and loss of consciousness without incontinence or
tongue biting after she had bobbing of her head. Her sleep cycle was off. She had increased

31
Dysgeusia is parageusia. Parageusia is “a bad taste in the mouth.” Dorland’s at 577, 1375.

17
appetite and a recent two-pound weight loss. Warm water worsened her symptoms, particularly
at her knees. Petitioner told Dr. Pham she received flu vaccine on August 30, 2009 (not the true
date of August 23, 2009). She was taking doxycycline and prednisone.32 Id.
On physical examination, petitioner did not have nystagmus. Id. Her lower extremities
were cool to the touch. Id. at 26. On motor examination, petitioner had an abnormal, ataxic,
waddling/wide stance. Her strength was 4/5 in the upper and lower extremities. Her right upper
extremities were weaker, but her grip was equal. Petitioner tapped her foot and her head bobbed.
Dr. Pham’s final assessment was that petitioner presented with multiple neurologic findings both
central and peripheral in nature. The final diagnosis was weakness. Dr. Pham wrote petitioner
had a complex problem, which was likely neurological, but for which she had not received a
diagnosis even though several outside medical facilities and neurologists had evaluated her.
About one month ago, she was normal. Since then, she developed lower extremity weakness,
paresthesia, and some dysphonia. The differential diagnosis included GBS, MS, Lyme, and
myasthenia gravis. Id. Petitioner awaited admission to neurology for unexplained ascending
weakness and head bobbing. Id.
A nursing assessment dated October 2, 2009 notes that petitioner was brought to a room
by wheelchair with ED staff. Id. at 27. Petitioner told RN Michelle E. Charron that she had pain
in both ears when she tried to speak. Petitioner said she had difficulty breathing “like I can’t get
enough oxygen.” Id. She said she had nausea after eating and weight loss despite increased food
intake. She had 5/5 muscle strength throughout. She had severely stuttering speech which began
one week previously. She reported progressive weakness in her lower extremities moving up her
legs. Id. RN Pia L. Bolano did a reassessment, during which petitioner denied shortness of
breath, and denied nausea, vomiting, diarrhea or abdominal pain. Id. RN Czereyna C. Pearl
similarly wrote petitioner denied shortness of breath, nausea, vomiting, diarrhea or abdominal
pain. Id. at 28. RN Pearl noted petitioner’s positive stuttering. Id. at 28. A chest x-ray done on
October 2, 2009 was normal. Id. at 33. On October 2, 2009, petitioner had an MRI of her
lumbar spine which did not show abnormal enhancement within the cervical, thoracic, or lumbar
spinal cord or cauda equina. Id. at 18. She had mild degenerative changes including a T7-T8
disc bulge and annular tears in the L4-L5 and L5-S1 discs. Id.
On October 3, 2009, petitioner was admitted to Johns Hopkins Hospital. Med. recs. Ex.
2, at 11. Dr. Anjajl Sharrief took a history that petitioner received flu vaccine on August 30,
2009 (not the true date of August 23, 2009). Three days afterward, she woke with a sore throat
and congestion, progressing to fever and fatigue. She then had severe fatigue and muscle aches
but continued to work. She came to the emergency department on September 12, 2009 with
generalized weakness and lightheadedness. On the day she presented, she reportedly had
generalized convulsions and an episode of syncope. Her CK was 12,000 on presentation with
MB of 7.5. Myoglobin was 75. Troponin was negative. AST and ALT were elevated at 366
and 102 respectively. Her white blood cell count was 10.6 on admission. This was thought to be
secondary to a viral illness. CK and liver function tests came down with IV fluid hydration. She

32
Prednisone is “a synthetic glucocorticoid derived from cortisone, administered orally as an anti-inflammatory and
immunosuppressant in a wide variety of disorders.” Dorland’s at 1509.

18
was admitted from September 12 to 14, 2009 and discharged home. She went back to work on
September 17, 2009 and began feeling weak with nausea and fainting at work. She began
trembling uncontrollably and was readmitted to the hospital. She was discharged the following
day.
Since her lethargy continued, she saw her PCP on September 21, 2009 who said
petitioner’s ANA was positive at 1:80 and that she had systemic lupus erythematosus (“SLE”).33
Petitioner began having reproducible chest pain and was referred to an infectious disease
specialist and a rheumatologist. When she saw the infectious disease specialist on September 22,
2019, she fainted with convulsions. The doctor had a lumbar puncture performed. Petitioner
began having difficulty ambulating with knees buckling and continued nausea, chills, sweats,
and lightheadedness. She described that at this point she began having vivid dreams and
difficulty sleeping. Id. Petitioner also began having headaches which she told Dr. Sharrief felt
like cold spots in the back of her head. She returned to the hospital on September 27, 2009 with
unsteadiness and difficulty speaking. She described it as pain in her face and neck when she
spoke. She sounded as if she were stuttering. She could talk normally if she whispered. She
began to have symptoms in her toes which petitioner described as their moving erratically and
misfiring. Several specialists whom she saw could not determine the etiology of her symptoms.
She began taking doxycycline for possibly Lyme disease. She also started taking
methylprednisolone34 Dosepak for chest pain which her PCP prescribed. Petitioner’s symptoms
persisted and progressed to intermittent uncontrollable blinking, difficulty focusing, pain in her
neck muscles, uncontrollable shaking, cold feelings in her feet, and sharp pain in her legs. She
was referred to Johns Hopkins ED. Id.
Petitioner’s history was rhinoplasty, breast augmentation, and oral and genital herpes. Id.
at 12. She has a half-sister who had an autoimmune disorder at age four. Her cousin has
Grave’s disease and now breast cancer. Her maternal great aunt has multiple sclerosis. Her
mother’s father’s mother had fibromyalgia. Her maternal grandmother had breast cancer. Her
maternal grandfather had lung cancer. Her father has a benign brain tumor. Petitioner said she
has possible tick bites from a 5K run in August 2009. Id.
On physical examination, Dr. Sharrief noted that petitioner was well-appearing, sitting up
in a stretcher in no apparent distress. Her face was “very well made up.” Id. Her heart rate was
77, and blood pressure 111/63. Neurologically, petitioner was spontaneously alert and oriented.
She was able to give a full history which was limited only by her inability to speak properly. She
had good attention and a normal fund of knowledge. She registered 4 out of 4 items and recalled
4 out of 4 after five minutes. Id. Petitioner spoke in a broken voice taking deep gasps of air
between words. Id. at 13. Her speaking appeared labored. She was able to whisper without a

33
Systemic lupus erythematosus is “a chronic, inflammatory, often febrile multisystemic disorder of connective
tissue that proceeds through remissions and relapses; it may be either acute or insidious in onset and is characterized
principally by involvement of the skin …, joints, kidneys, and serosal membranes.” Dorland’s at 1080.
34
Methylprednisolone is “a synthetic glucocorticoid derived from progesterone, used in replacement therapy for
adrenocortical insufficiency and as an anti-inflammatory and immunosuppressant in a wide variety of disorders.”
Dorland’s at 1154.

19
broken voice. Petitioner explained this by saying speaking in a normal voice caused a strain on
her face and neck muscles.
Petitioner’s shoulder shrug was 5 out of 5. She had normal bulk and tone. She had a
jerky vertical tremor of her head which waxed and waned in intensity depending on her level of
exertion. Tremor also affected her arms and legs. Her strength was 5 out of 5 proximally in the
upper extremities including deltoids, biceps, and triceps. Petitioner had mild weakness (4+ out
of 5) in wrist extension, finger extension, and finger flexors on the left hand. She was strong in
these groups on the right. Her lower extremity strength was notable for some component of
giveaway weakness. Id. Her reflexes were 2+/brisk in her bilateral biceps, triceps,
brachioradialis, patellae, and Achilles. She did not have clonus. Her toes were downgoing
bilaterally. She had intact and symmetric sensation to light touch and temperature proximally
and distally. Her vibratory sensation was intact. Her finger-nose-finger coordination was slow
and brought out severe vertical head tremor as did heel-to-shin testing. She was able to stand
without assistance. Her gait was narrow-based. After taking 2-3 steps, she began to have severe
shaking of her head in a vertical motion and then a bouncing motion of her legs as if her knees
were going to give way. She asked to sit down. Id.
Petitioner’s lab studies showed erythrocyte sedimentation rate on September 26, 2009 of
12, negative results for: ANA, anti-double stranded DNA, lupus, Epstein Barr virus (“EBV”)
IgM. Her EBV IgG was greater than 5, and her EBV viral capsule antigen IgG was 3.8 high. On
September 17, 2009, her C-reactive protein was low titer negative, cortisol was 10.7, ANA was
detected at 1:80, and HIV western blot negative. A lumbar puncture on September 24, 2009
showed zero white blood cells, and a protein of 24. Her Lyme antibodies were negative. Id. On
October 4, 2009, petitioner’s erythrocyte sedimentation rate was normal at 6 mm/hr when normal
is 4-25. Med. recs. Ex. 55, at 66. On October 4, 2009, petitioner’s ANA was positive at 1:320.
Her Lyme disease antibody was negative. Id.
Petitioner’s September 17, 2009 brain MRI was normal with no mass hemorrhage or
extra-axial fluid. She had mild left maxillary sinus membrane thickening. A chest CT on
September 13, 2009 showed soft tissue in the anterior mediastinum probably residual findings
without mass effect. A head CT done on September 12, 2009 was normal. Dr. Sharrief
reviewed the September 17, 2009 brain MRI. The T1 and T2 images showed no signal
abnormality. Id. There was no evidence of masses, ischemic stroke, bleeding, or a
demyelinating process. Med. recs. Ex. 2, at 14.
Dr. Sharrief’s assessment was petitioner did not have significant medical problems until
four weeks before she came to Johns Hopkins. Her presentation began with what seemed like a
viral illness. She had constitutional symptoms and upper respiratory symptoms. She was
admitted to another hospital and found to have elevated CK and elevated liver function tests.
These tests eventually normalized. She had progressive symptoms including some
lightheadedness, many episodes of syncope, tremor in her head, pain in her neck and face which
affected her voice, and inability to ambulate because of perceived weakness in her legs. An
extensive workup included brain MRI, lumbar puncture, and multiple laboratory studies, none of
which were revealing. Her ANA was positive with a low titer of 1:80. Lyme studies were

20
negative. Inflammatory markers were not elevated. She began on doxycycline and prednisone,
but there was no evidence to begin these drugs. Petitioner’s neurologic examination had many
components which were not physiologic. Nevertheless, it was possible that her viral syndrome
had persistent effects which debilitated her. She could have had exposure to ticks within weeks
of her initial presentation. Tickborne illness might explain some of her symptoms, but not many
of her neurologic complains. Dr. Sharrief thought there was currently a likely component of
“psychological overlay contributing to her symptoms.” Id.
Dr. Victor C. Urrutia, a neurologist, assessed that petitioner’s symptoms clearly had a
strong psychogenic component but noted that petitioner did have elevated liver enzymes and
CPK, and could have had a mild post-vaccination reaction with neurological symptoms. Id. He
reassured petitioner that she did not have GBS and there was no evidence that she had SLE or
Lyme. He recommended she stop taking doxycycline and prednisone. He thought if the workup
were negative, she might have had a mild reaction and she would get better soon without specific
treatment. Petitioner told him she saw a psychologist that ruled out stress. Petitioner was
admitted because she could not walk. Id. and med. recs. Ex. 55, at 12. A neurology progress
note dated October 3, 2009 states astasia-abasia.35 Med. recs. Ex. 55, at 85.
On October 3, 2009, petitioner had a brain MRI, which did not show an acute process or
abnormal enhancement. Id. at 15.
On October 4, 2009, Dr. Urrutia further evaluated petitioner. Med. recs. Ex. 2, at 10.
Petitioner stated she felt better and was able to walk backwards and sideways but still not
forward. A physical therapist mentioned dystonia to her. After receiving Ativan36 the prior
night, petitioner felt much better. An MRI of her brain was normal. On examination, petitioner
continued to stutter when she spoke but talked normally if she whispered. She did not have any
focal deficits. She was able to get off the bed and walk normally backwards, but when she
walked forward, she buckled and seemed jerky, but did not fall or hit herself. She managed to
turn around and sit on the bed. Dr. Urrutia’s assessment was that petitioner had “symptoms that
do not fit a physiologic paradigm.” Id. Her symptoms might be a reaction due to anxiety. He
suggested petitioner see a therapist. He prescribed clonazepam37 for management of her
symptoms as they were likely related to anxiety and because she felt better after taking Ativan.
His impression was speech dysfunction and gait dysfunction. Id. On the same day, petitioner
was discharged.
On October 4, 2009, Dr. Christopher B. Oakley wrote the discharge summary. Med.
recs. Ex. 55, at 6. Under the impression that petitioner received flu vaccine on August 30, 2009,

35
Astasia-abasia is “motor incoordination with an inability to stand or walk despite normal ability to move the lower
limbs when sitting or lying down, a form of hysterical ataxia.” Dorland’s at 167. Ataxia is “failure of muscular
coordination; irregularity of muscular action.” Id. at 170. Hysterical ataxia is “ataxia that is part of a conversion
disorder.” Id. at 171.
36
Ativan is “trademark for preparations of lorazepam.” Dorland’s at 173. Lorazepam is “a benzodiazepine with
anxiolytic and sedative effects, administered orally in the treatment of anxiety disorders and short-term relief of
anxiety symptoms and as a sedative-hypnotic agent.” Id. at 1074.
37
Clonazepam is “a benzodiazepine used as an anticonvulsant in the treatment of Lennox-Gastaut syndrome and of
atonic and myoclonic seizures and as an antipanic agent in the treatment of panic disorders.” Dorland’s at 373.

21
Dr. Oakley wrote that petitioner developed URI symptoms that progressed to severe fatigue and
muscles aches, but she continued to work. Petitioner told Dr. Oakley that she was told she had
lupus and Lyme disease. MRIs of petitioner’s cervical, thoracic, and lumbar spine were normal
as was a brain MRI. After receiving Valium,38 she improved. With no other intervention, her
symptoms improved and she was discharged on clonazepam. Her symptoms were thought to be
a stress reaction to what happened weeks earlier when her liver enzymes and CPK were elevated.
Her symptoms might be an anxiety reaction, which was explained to her. She was advised to
undergo physical therapy and have psychological support with a therapist or psychiatrist. “She
was also informed that the relationship with the flu vaccine was not clear.” Id. She was
expected to improve on clonazepam, positive encouragement, and time. Id. Petitioner was able
to speak without abnormalities in a soft whisper with some mild stuttering that improved with
encouragement. Id. at 7. Her eyes did not have nystagmus. On motor examination, she had
normal bulk and tone. Her strength was 5 out of 5 in all extremities. Her reflexes were 2+/brisk
with no clonus and downgoing toes. Finger-nose-finger was slow and brought out severe
vertical head tremor as did heel-to-shin-testing. She was able to stand without assistance. Her
gait was narrow-based. After taking two to three steps, she began to have severe shaking of her
head in a vertical motion, then began to have a bouncing motion of her legs as if her knees were
going to give way, but she did not fall. Her gait improved with reassurance and encouragement.
On October 6, 2009, petitioner visited her PCP Dr. Ho. Med. recs. Ex. 22, at 12.
Petitioner reported that when she touched her anterior left thigh or fastened a belt around her left
thigh, she could walk completely normally. Id. When she did not do this, she could only run
forward, but she could walk backward and sideways normally. Id. She also reported that her
difficulty with talking was relieved by placing a hand on her chin. Id. Petitioner also claimed
that when she took her husband’s 5mg Valium tabs, she was “perfectly normal” for about 10
hours. Id. She had plans to see a dystonia specialist at Mayo Clinic in November 2009. Id.
Upon physical examination, Dr. Ho noted that petitioner was well-nourished and well-groomed,
and had normal strength and tone overall with no atrophy, spasticity or tremors while seated. Id.
at 14. Dr. Ho suggested that if further extensive workups were unrevealing, he would strongly
consider a conversion disorder, delusional disorder, or other psychogenic etiology. Id. at 14.
On October 7, 2009, petitioner completed a Vaccine Adverse Event Reporting System
(“VAERS”) form, giving the wrong date of vaccination, August 30, 2009, and stating onset was
on September 3, 2009 at 6:20 a.m. Med. recs. Ex. 3, at 2. She described the adverse event
symptoms as sore throat, nasal congestions, followed by fever, body aches, chills, and headache.
She states she was hospitalized for eight days and her reaction resulted in permanent disability.
She states that three days after her flu vaccination, on September 3, 2009 (which was 10 days
after her flu vaccination on August 23, 2009), she came down with flu-like symptoms. On
September 12, 2009, she began fainting and going into violent convulsions. Two weeks later,
her legs began to fatigue and her neck began to shake periodically. On September 23, 2009, she
lost the ability to walk and walked as if she had MS. She could not walk straight and her entire

38
Valium is “trademark for preparations of diazepam.” Dorland’s at 2020. Diazepam is “a benzodiazepine used as
an anti-anxiety agent in the treatment of anxiety disorders and for short-term relief of anxiety symptoms, … also as a
skeletal muscle relaxant, anticonvulsant, antitremor agent, antipanic agent . . . .” Id. at 512.

22
body shook when she walked. Id. On September 24, 2009, she lost the ability to talk (stuttering)
and had neck pulls and strains when talking. Her symptoms continued and she was diagnosed
with dystonia. Id. at 3.
On October 9, 2009, petitioner saw Dr. Christine M. Cosgrave, a psychologist, for her
cognitive and emotional issues.39 Med. recs. Ex. 45, at 1-3. Petitioner displayed significant
physical and neurological difficulties and Dr. Cosgrave recommended that petitioner seek an
evaluation by a neurologist and neuropsychologist. Id. at 2. Dr. Cosgrave referred petitioner to
Dr. Sidney W. Binks III, a clinical neuropsychologist, for a neuropsychological evaluation. Id.
On October 12, 2009, petitioner saw physical therapist Dallas A. Simons, a visit that Ms.
Simons described in a letter entitled “To Whom It May Concern,” dated May 12, 2010. Med.
recs. Ex. 16, at 1. Petitioner told PT Simons that she had a muscular problem, which she felt was
a complication of flu vaccination. On October 12, 2009, PT Simons evaluated petitioner’s gait
and found petitioner could walk backward fairly normally, but was very ataxic walking forward.
If petitioner held her thigh, she could walk much more normally. Petitioner spoke very softly,
but if she held her chin, her volume and cadence improved. PT Simons felt this was beyond her
competency to evaluate and did not complete a formal evaluation. PT Simons gave petitioner the
name and phone number of a physical therapist more experienced in neurological problems and
dystonia and did not provide petitioner with treatment. Id.
On October 13, 2009, petitioner saw Dr. Ho, requesting a medical letter supporting
extension of her disability benefits. Med. recs. Ex. 22, at 9. She said that when she touched her
anterior left thigh or fastened a belt around her left thigh, she could walk completely normally.
When she did not do this, she could only run forward, not walk, but she could walk backward
and sideways normally. Her difficulty talking was eased by placing a hand on her chin. She was
discharged from Johns Hopkins on Klonopin40 but, after her first dose, she had “convulsions.”
Id. When she took one of her husband’s Valium tablets, she was perfectly normal for about 10
hours. Id. Dr. Ho discussed petitioner’s findings in her rather extensive work up and said if
further extensive workups at academic centers were unrevealing, he “would strongly consider a
conversion d/o [disorder], delusional d/o, or other psychogenic etiology.” Id. at 10 and 11. Dr.
Ho performed a physical examination and found her reflexes normal, but her gait broad-based
“(VERY ERRATIC [Dr. Ho’s emphasis])”, spastic, stamping (sensory ataxia) and waddling. Id.
at 11. Dr. Ho provided a letter to excuse petitioner from work or school due to her “undergoing
work up and treatment for dystonia of uncertain etiology.” Id. at 38.

39
Petitioner first met Dr. Christine M. Cosgrave on April 10, 2009, when she accompanied her then-husband, B.J.,
for an initial psychotherapy intake session for him. Med. recs. Ex 187, at 3. However, by referral from her
physician, petitioner began her own individual psychotherapy with Dr. Cosgrave on October 9, 2009 to obtain
cognitive and emotional help “associated with possible reaction to an influenza vaccine she reportedly received in
September 2009.” Id. Subsequently, petitioner obtained services from Dr. Cosgrave on October 9, 2009, December
7, 2009, February 12, 2010, and March 5, 2010. Id.
40
Klonopin is “trademark for a preparation of clonazepam.” Dorland’s at 989. For the definition of Clonazepam,
see supra, n.33.

23
On October 15, 2009, petitioner and her then-husband saw Dr. Ruben Cintron,41 a
neurologist. Med. recs. Ex. 1, at 10. The history was that within a few weeks of flu vaccination
in August, she developed flu-like and numerous neurological symptoms, including sensory
symptoms. She had a fair amount of difficulty with her motor system, i.e., speech, gait,
movements, tolerance to eating, and syncope, which had been labeled as a dystonic reaction or
disorder related to vaccination. Id. She was initially diagnosed with rhabdomyolysis with a
CPK in the 13,000 range and elevation of her liver enzymes. MRI of the brain, spinal fluid
analysis, and multiple serologies were all unremarkable. She could not walk forward or
sideways,42 only backward. When she walks, she has jerking episodes. Id. During physical
examination, petitioner was alert and oriented. Her speech was interrupted and non-fluid,
although much better when whispering or singing. Id. at 10. She did not have visual
dysmorphism or dystonic features. Id. at 10-11. When she tried to exert power, she had a fair
amount of clinical rhythmic jerking throughout her shoulder girdles. Id. at 11. At least once,
petitioner lost control with an episode of jerking that seemed to take over her ability to function
motorally. During that time, her heart rate did not seem to have changed, she was aware, and she
came back quickly without lying down. When petitioner tried to walk forward, her legs
collapsed. When she walked backward, she did better. Her reflexes were symmetrical with
downgoing toes. She had normal CSF, brain MRI, test results for Lyme disease and other
serologies. Her CPK elevation ranged from 13,000 to 300. Id. Dr. Cintron’s impression was
that petitioner’s history did “suggest vaccination induced motor disorder, with some dystonic and
myoclonic features.” Id. Dr. Citron did not believe that petitioner had a functional disorder
based on her behavior and the consistency of the behavior. Id. Dr. Cintron prescribed
Cogentin43 and gave petitioner and her then-husband information on plasmapheresis44 and
intravenous immunoglobulin (“IVIG”). Id.
From October 19-22, 2009 and October 26-28, 2009, and on November 18, 2009, and
December 1, 2009, petitioner had treatments with Dr. Rashid Buttar, D.O.45 at his Center for

41
Dr. Cintron received his MD at Wake Forest School of Medicine. He did an internship in internal medicine at
Georgetown University Hospital, followed by a residency there in neurology. He did a fellowship in Neuromuscular
Diseases and Electrodiagnostic Medicine at George Washington University Medical Center. In 1995-1996, Dr.
Cintron became board certified in Adult Neurology and Neuromuscular /EMG. He considers himself a general
neurologist with special interest in neuromuscular disorders/EMG, migraines, movement disorders and memory
disorders. Physicians and Practitioners, NEUROSCIENCE CONSULTANTS, PLC, www.nscpic.com/ruben-cintron-m-d/
(last visited Jan. 9, 2019).
42
This is the first medical record to note petitioner could not walk sideways. In previous histories, she said she
could walk sideways and backward.
43
Cogentin is “trademark for preparations of benztropine mesylate.” Dorland’s at 382. Benztropine mesylate is “an
antidyskinetic believed to act by partially blocking central cholinergic receptors, so that cholinergic and
dopaminergic activity in the basal ganglia is more balanced; used in the treatment of parkinsonism . . . .” Id. at 209.
44
Plasmapheresis is “the removal of plasma from withdrawn blood, with retransfusion of the formed elements into
the donor; generally, type-specific fresh frozen plasma or albumin is used to replace the withdrawn plasma.”
Dorland’s at 1456.
45
The North Carolina Board of Medical Examiners issued a reprimand to Dr. Buttar on March 26, 2010 for not
informing his patients about the types of treatment and therapies he was recommending to them. Dr. Buttar
consented to the reprimand. Licensee Information: Rashad Ali Buttar- DO Full and Unrestricted, NORTH CAROLINA
MEDICAL BOARD,
https://wwwapps.ncmedboard.org/Clients/NCBOM/Public/LicenseeInformation/Details.aspx?EntityID=66840&Pub

24
Advanced Medicine & Clinical Research in Huntersville, North Carolina. See med. recs. Ex. 59,
at 59-83. Petitioner arrived at Dr. Buttar’s clinic with her then-husband, brother-in-law, Stan
Kurtz,46 and a camera crew on October 19, 2009. Id. at 80. Petitioner heard about Dr. Buttar47
from Generation Rescue. Id. at 304.
Petitioner gave Dr. Buttar a timeline including her impression she received flu vaccine on
August 30, 2009. Id. at 90. She described waking up on September 3, 2009 with a sore throat
and congestion. That afternoon, she started feeling fatigue and was very hot. She took a
decongestant and two Aleve. After dinner, she started feeling hot and nauseated. She lay on the
couch and had body aches all over, most severely at the hip muscle and biceps where she had
been working out. From September 4-7, 2009, she mostly slept, had no appetite, and was very
lethargic. Her sore throat and congestion continued. Id. From September 8-11, 2009, she went
back to work, but was constantly lethargic and fatigued. She had a mild sore throat in the
morning, continuing congestion, and a green ball of mucus in the morning. In the evening of
September 11th, she drank a glass of wine and two mixed drinks over a four-hour period starting
at 7:00 p.m. At 11:00 p.m., she started vomiting violently and uncontrollably. On September
12th, she woke up very weak, dehydrated, and tired. She drank lots of fluids and ate breakfast.
Around 11:00 a.m., she became very lightheaded and hot, but her hands and feet were cold. Id.
She fainted while sitting on the couch. She lost all muscle control while trying to walk. She
states she began convulsing and hyperventilating in the car. Id. From September 18-20, 2009,
petitioner states she was still lethargic and weak. She “finally figured out I was fainting and
going into convulsions after eating.” Id. Petitioner would eat while lying down to avoid
fainting. She still was congested with greenish yellow mucus each morning. Id. Petitioner
notes that even by September 28, 2009, she still had congestion with yellow and white mucus.
Id. at 95.
Dr. Buttar stated that petitioner presented to his clinic “in emergent state, in severe
distress with labored breathing, experiencing multiple witnessed, back to back seizures or
contractures, extraordinary gross motor deficits, loss of coordination, absence of fine motor
skills, inability to articulate with dysphonia, and unable to ambulate.” Id. at 74. Petitioner
reported that she had done an 8K race two days previously. Id. Petitioner claimed that she was
able to breathe better while running than at rest. Id. Petitioner lost ten pounds over the last five

licFile=1 (last updated Jan. 16, 2019). On February 10, 2011, the Hawaii Medical Board denied Dr. Buttar’s
application for medical licensure due to the NC Board action. Id. Dr. Buttar lists his area of practice as
occupational and environmental medicine. Id. He was licensed in Texas until 1994. Id. Dr. Buttar does not have
any hospital affiliations. Health, U.S. NEWS & WORLD REPORT, https://health.usnews.com/doctors/rashid-buttar-
626895 (last visited Jan. 19, 2019).
46
Mr. Kurtz has invented treatments to cure autism and was awarded top 20 “Hall of Fame” status by Generation
Rescue. www.stankurtz.org/about/affiliations.html (last visited Jan. 10, 2019). Generation Rescue is an
organization promoting treatment for autism. www.generationrescue.org/who-we-are/ (last visited Jan. 10, 2019).
47
Dr. Buttar has a website: https://www.drbuttar.com (last visited Feb. 12, 2019). It states on its home page that
The Center for Advanced Medicine and Clinical Research specializes in addressing the needs of patients suffering
from chronic disease, treatment failures, difficult to diagnose conditions, cancer, autism, cardiovascular disease,
neurodegenerative disease, environmental toxicity, heavy metal toxicity, chemical toxicity, and metabolism
disorders. It also states its treatments are “so effective that even the North Carolina Medical Board is trying to
suppress the truth” and cites to another website: DrButtarTruth.org. Id.

25
to seven days and experienced inability to “keep foods down.” Id. Dr. Buttar noted that
petitioner experienced nausea, vomiting, and dry heaving throughout the day. Id. at 80. Dr.
Buttar diagnosed petitioner with dystonia by history, acute respiratory distress; acute viral, post-
immunization encephalopathy; allergic reaction to medicinal substance; and rule out heavy metal
toxicity. Id. at 75.
During the following days after arriving at Dr. Buttar’s office on October 19, 2009,
petitioner received IV chelation therapy to “have ability to speak and walk.” Id. at 68-80. Dr.
Buttar noted on October 19, 2009 that petitioner tolerated the IV well and it made a “huge
difference.” Id. at 70-71. In his note of October 20, 2009, Dr. Buttar stated petitioner was
“ecstatic” and the nursing staff was “celebrating” since petitioner was able to walk into the IV
suite and talk in a normal voice. Id. at 69. On October 21, 2009, petitioner received IV
treatment and hyperbaric oxygen therapy (“HBOT”). Id. at 79. On the same day, petitioner
called Dr. Buttar with complaints of seizing again and her voice going out. Id. at 67. Dr. Buttar
visited petitioner and gave her TD-DMPS,48 and eventually petitioner stated that she felt good.
Id.
On October 22, 2009, petitioner continued to have the ability to speak and walk and
underwent a quantitative electroencephalogram (“qEEG”). Id. Myra A. Preston,49 Ph.D.,
evaluated petitioner’s qEEG data and concluded petitioner’s left parietal and temporal regions
contained abnormal activity that should be further investigated. Id. at 87-89. During the time
that Ms. Preston thought petitioner was having a seizure, the qEEG recording consisted of
muscle artifact as petitioner had strong muscle contractions in her facial muscles. Id. at 88.
Then the “seizure” subsided and the qEEG returned to baseline. Petitioner applied a cream to
her forearms and the qEEG data began to appear more normal in the parietal and temporal

48
TD-DMPS stands for transdermal 2,3-Dimercaptopropane-1-sulfonate, which “is a metal chelator approved in
Europe for oral or intravenous use for heavy metal poisoning. Transdermally applied DMPS (TD-DMPS) is used by
some alternative practitioners to treat autism, despite the absence of evidence for its efficacy.” Plasma and urine
dimercaptopropoanesulfonate concentrations after dermal application of transdermal DMPS (TD-DMPS), 9 J MED
TOXICOL 9-15, at 9 (2013).
49
Ms. Preston has a website called www.siberimaging.com in which she states that she offers through qEEG and
neurofeedback enhancement of central nervous system functioning to promote peak performance, intelligence,
alertness, focus, strength, balance, positive mood, and awareness. She claims she and Kim Phillips, Clinical
Director, developed and patented this in 1993. SIBER IMAGING, WWW.SIBERIMAGING.COM (last visited Jan. 11,
2019). Ms. Preston claims success in training individuals with the following disorders: alcohol & substance abuse,
medical reduction & withdrawal, depression, post-traumatic stress disorder, panic disorder, obsessive compulsive
disorder, bipolar disorder, dementia, eating disorders, attention deficit disorder, attention deficit hyperactivity
disorder, adult attention deficit disorder, chronic fatigue syndrome/myalgic encephalomyelitis, various sleeping
disorders, fibromyalgia, post-viral syndromes, premenstrual stress syndrome, migraine headache, hypertension,
gastrointestinal dysfunction, bowel dysfunction, bladder dysfunction, heart rate regulation, chronic pain syndrome,
vulvodynia pain, dysautonomia, epilepsy seizure disorders, Tourette’s syndrome, tic disorder, autism, autism
spectrum disorders, brain injury, closed head injury, spinal cord injury, anoxic brain injury, and stroke. Id. Chronic
Fatigue Immune Dysfunction Syndrome (“CFIDS”) was the focus of Ms. Preston’s Ph.D. dissertation. Id. She
claims that the reasons CFIDS clients have normal EEG results on conventional EEGs is that they are done with the
client’s eyes closed. Ms. Preston does qEEGs on CFIDS clients with their eyes open, and gets an abnormal response
showing the clients have metabolic encephalopathy. Id. Ms. Preston received her doctorate in Psychophysiology in
1994 from The Union Institute. Id. The North Carolina Medical Board accused Ms. Preston of practicing medicine
without a license through her company Siber Imaging, and selling a BrainMaster “brain mapping machine.”
Medicine, COURTHOUSE NEWS SERVICE (Feb. 22, 2011), http://www.courthousenews.com/medicine-2.

26
regions for 10 to 15 minutes. However, neither region became completely normal. Ms. Preston
did not see any additional seizures and petitioner began to speak normally. Id. During the next
21 minutes, petitioner applied more of the cream and the qEEG maintained improvements. Id.
Ms. Preston characterized the one seizure as an absence seizure. Id. In addition, Ms. Preston
added that, in her experience, “the data acquired from the left temporal and parietal regions most
resemble data correlated with myoclonic seizures,” and went on to note that medical literature
identifies these types of findings with acute insults. Id. at 89. However, Ms. Preston also noted
that “this evaluation should not be considered diagnostic.” Id. at 87.

While seeking treatment at Dr. Buttar’s office, petitioner’s urine tests revealed high levels
of mercury, nickel, copper, lead, zinc, and manganese. Id. at 16-40. Petitioner’s urine test
revealed low levels of molybdenum. Id. at 42.
On October 30, 2009, petitioner visited Dr. Cintron for a neurological follow-up. Med.
recs. Ex. 1, at 13. She reported that she had been working in Charlotte with chelating therapy
and felt that she was making progress. Dr. Cintron thought petitioner had a minor seizure in his
waiting area but by using a compound that Dr. Buttar gave her, she dropped into her forearm and
was able to calm down. Her speech seemed somewhat easier to understand. Id. Dr. Cintron also
ordered an EEG, the result of which was normal. Id.
On December 7, 2009, petitioner saw Dr. Cosgrave again and her gait and speech had
“somewhat improved.” Med. recs. 45, at 2.
Also, on December 7, 2009, petitioner visited Dr. Randolph R. Stephenson, a neurologist.
Med. recs. Ex. 22, at 36-37. Petitioner stated that in September, she was hospitalized for
rhabdomyolysis following either a viral illness or flu vaccination. Afterward, she started
developing problems with walking and speech. She felt as though she had difficulty moving her
legs while walking, but “remarkably,” she had no problems running. Id. at 36. She had
problems with stuttering. She said numerous doctors suggested she might be having a stress
reaction and suggested she see a neuropsychologist. She was going to North Carolina for
chelation therapy, “although it is unclear what is being chelated.” Id. She reported that she was
having frequent “seizures” at the rate of around 60 per day, during which she would shake
frequently. She denied losing consciousness or having urinary incontinence during these
episodes. She did not appear to be having these episodes anymore at the same frequency. Id. at
36. Petitioner also reported that she continued to exercise regularly, but after running she
sometimes passed out. Id.
On physical examination, petitioner’s blood pressure was 166/86. Id. at 37. Dr.
Stephenson noted petitioner had normal cognition, comprehension, and vocabulary, but
frequently talked in a British or Australian accent. Id. Petitioner said it was part of the changes
in her speech. Id. She also had frequent stuttering. Petitioner had normal muscle bulk, strength,
and tone. Id. When Dr. Stephenson asked her to point or hold or write something, petitioner
would start shaking her head and hands vigorously. The tremor would be in several planes of
direction and was highly distractible. There was also a highly suggestible component to it so that
Dr. Stephenson could easily bring out the tremor just by having petitioner talk about it. She had
normal light touch, pinprick, temperature, and vibratory sensation. Her reflexes were 1 to 4 and
27
symmetric at the biceps, triceps, patellae, and ankles. Her toes were downgoing. Petitioner had
a “very clear” astasia-abasia gait when walking. Id. She would often appear off balance without
actually falling. When Dr. Stephenson watched her closely, he saw clearly that her balance was
actually better than average given some of the positioning her body took while walking. Id. Dr.
Stephenson’s stated he was not entirely sure what caused all of petitioner’s movement
complaints. However, he wrote she had “a very clear functional component to the majority of
her exam. There were no neurological findings that would suggest any particular organic disease
process.” Id.
On December 11, 2009, petitioner saw Dr. Sidney W. Binks, III, Ph.D., at the
recommendation of Dr. Christine Cosgrove, the clinical psychologist. Med. recs. Ex. 19, at 1.
Dr. Binks is a neuropsychologist and clinical psychologist. Id. While giving a history to Dr.
Binks, petitioner said that her MRI had been painful as if she were on fire. Id. at 2. She said that
looking at carpet patterns could cause her whole body to shake and a speech problem. She said
she was having 60 seizures a day. She reported great difficulty with fine motor coordination.
Her mental health history was positive for bulimia at age 13 for one year. She was currently in
psychotherapy with Dr. Cosgrove. Her sister had attempted suicide. Dr. Binks interviewed
petitioner on December 11, 2009 and evaluated her on December 19, 2009 and January 16, 2010
for about seven hours. Petitioner drove herself to and from the testing on both days. She did not
have any muscle contractions or involuntary movement as she entered or exited Dr. Binks’ office
on either testing day. However, on the day of the interview, she walked extremely awkwardly.
She could not walk forward but instead walked sideways. Dr. Binks interviewed her when she
was with her then-husband who often reported her history because she had difficulty speaking
and recalling. Id.
Petitioner frequently became frustrated during testing when she was asked to pronounce
words. She had muscle contractions and seemed to put great effort into producing the answer.
She also had a stutter. Her arm muscles and face muscles would simultaneously contract during
these times. Her right-sided muscle movement was more pronounced, including her arm and
face. The more frustrated she became, the more the muscle movements increased. Dr. Binks
did not observe these muscle contractions during general conversations. Her general speech had
somewhat of a British accent. Her volume would occasionally be high-pitched. Id.
Petitioner reported she had difficulty focusing on a page when asked to perform certain
tasks such as sentence comprehension, and she used a piece of blank paper with a small cut in
the middle to read line by line. She would spell a word out loud as she wrote it on the paper
because she indicated that made it easier. She said attempting to look at pages gave her a
headache. Id. Petitioner had great difficulty pressing her finger down on a button and had
muscle contraction increase in the finger tapping test. Id. at 3. Petitioner reported that some of
her physical complaints had lessened, but her speech and cognitive symptoms had recently
worsened. Id.
Dr. Binks also conducted a personality/psychopathology test in addition to the interview.
Id. Petitioner’s validity scales suggested that she was “uncomfortable acknowledging personal
faults” and presented herself in an extremely positive light by denying many minor faults and

28
shortcomings that most people acknowledge.” Id. Dr. Binks noted that “this level of virtuous
self-presentation is uncommon and likely resulted in an underestimate of personality-related
clinical findings.” Id. Dr. Binks stated that due to petitioner’s preoccupation with physical
health concerns, “she is likely prone to developing physical symptoms in response to stress.” Id.
at 4. Dr. Binks concluded, “Problems with her emotional life, thought process and behavior
could not be ruled out given the tendency to under-report even normal psychological
imperfections.” Id. Dr. Binks’ impression was that petitioner had weakened, but not impaired,
cognitive skills. Id. Dr. Binks believed that intensive speech and language evaluation/therapy
should be pursued, working on lowering petitioner’s expectations to realistic levels could be
helpful, and stress reduction techniques would be useful. Id. Although petitioner’s cognitive
skills were currently weakened, Dr. Binks did not consider them impaired but at functional
levels. He suggested psychotherapy to help lower her perfectionism to realistic levels. Dr. Binks
noted petitioner was under tremendous stress and he suggested stress reduction. He stated, “She
would do well to avoid the pull toward being a public spokesperson for others and instead focus
on her own wellbeing and rehabilitation. It is clear that stress exacerbates her symptoms.” Id.
On December 18, 2009, petitioner saw Dr. Cintron for a neurological follow-up. Med.
recs. Ex. 1, at 14. Petitioner’s gait and speech were better, but she still had difficulty walking
unless she walked sideways, and her speech tone changed during her visit. The EEG50 done in
Charlotte implied petitioner had epilepsy, but Dr. Cintron did an EEG himself and it was normal.
He looked at the Charlotte EEG with petitioner and did not see any abnormalities. Petitioner
“alleged” [Dr. Cintron’s verb] that her heart beat went to almost 200 when she exercised and Dr.
Cintron told her to stop exercising until she saw a cardiologist. He states, “Ultimately, this
appears to be a very complicated situation with post vaccination disorder. . . .” Id.
On December 18, 2009, petitioner saw Dr. Mark P. Tanenbaum at the Cardiovascular
Group, P.C., for a cardiology assessment for her increased heart beat while running. Med. recs.
Ex. 13, at 7. Petitioner said she received flu vaccine on August 23, 2009 and, within a couple of
weeks, she developed apparent flu-like symptoms, neurologic symptoms, and sensory symptoms.
She had some motor, gait, and speech abnormalities. She had an episode including syncope on
September 12th after eating. She was admitted to Loudoun Hospital which diagnosed her with
rhabdomyolysis. She was discharged on September 14th but readmitted on September 17th with
recurrent syncope. She was discharged, but she was readmitted with similar symptoms at Fairfax
Hospital on September 26th. She said she was told she may have GBS related to her flu
vaccination. She went to Johns Hopkins University Hospital and was treated with Ativan and
Klonopin. She had an EEG which was normal. She went to Charlotte, NC, for chelation therapy
to remove apparent excess mercury. She had been usually quite active, running three miles in 25
minutes. During the last several months, when she ran, her heart rate would increase more
quickly up to 180 beats a minute associated with fatigue. Id. In a review of systems, Dr.
Tanenbaum wrote petitioner denied any difficulty speaking. On physical examination, petitioner
did not have any gross motor or sensory deficits. Id. at 8. Dr. Tanenbaum’s impression was

50
This must be the qEEG that Ms. Preston did since there is no other EEG that petitioner underwent while staying in
North Carolina to receive evaluation and treatment from Dr. Buttar.

29
“apparent vaccination-induced motor disorder, along with apparent dystonic and myoclonic
features.” Id. Dr. Tanenbaum suspected that petitioner’s elevated heart rate represented sinus
tachycardia, which “might be exacerbated by her ongoing problem with apparent vaccination-
induced motor disorder, along with apparent dystonic and myoclonic features.” Id. at 8.
On December 21, 2009, petitioner had a stress echocardiogram. Id. at 11. Dr. Nick
Cossa concluded petitioner had a normal stress echocardiogram without evidence of ischemia.
She had a normal heart rate and blood pressure response to exercise, normal exercise capacity,
no chest pain, ischemic EKG changes, or left ventricular wall motion abnormalities with
exercise. She had a transient syncope after exercise secondary to neurocardiogenic hypotension.
Id.
On December 28, 2009, petitioner went to a follow up appointment with Dr. Cintron.
Med. recs. Ex. 1, at 15. He thought petitioner walked better and her speech was more fluid. She
still had an “accent” [quotation marks are by Dr. Cintron]. She sounded dystonic and still had
some occasional syncopal episodes although her blood pressure in Dr. Cintron’s office was fine.
Apparently, she had a syncopal episode while on a treadmill in the cardiologist’s office, but the
office felt she did not have arrhythmia. Petitioner found that Valium allowed her to run better
and she took it sporadically. She still had better heat intolerance to some extent, and she was
better with not being overwhelmed in a stimulating environment. Dr. Cintron concluded that
petitioner’s problem was vaccine related consisting of dystonia and possibly some autonomic
problem. Id.
On January 19, 2010, petitioner saw Dr. Cintron. Med. recs. Ex. 1, at 9. She seemed
better. She had learned that with pain in her left quadriceps, she was able to walk better because
she got distracted. She also learned that by looking to the left, she could walk straighter.
Petitioner’s speech was significantly better that day. Dr. Cintron thought petitioner had some
type of dystonia related to her insult and he did not believe her situation was functional,
“although certainly there is some bizarre aspects to her disease.” Id.
On February 5, 2010, Dr. Cintron had petitioner undergo a Transcranial Doppler because
of her vertigo/dizziness and vertebrobasilar51 syndrome. Med. recs. Ex. 1, at 22. The result was
normal. He also checked her carotid arteries for stenosis52 because of transient ischemic attacks.
Id. at 23. The result was no significant stenosis in the right internal carotid artery and minimal 1-
15% stenosis in her left internal carotid artery. Both external carotid arteries had no significant
stenosis. Id.
On February 5, 2010, petitioner went to the Reston Hospital ED, complaining of
vomiting. Med. recs. Ex. 50, at 5. This started the day before. Id. at 6. Petitioner said she felt
dizzy on standing and had increased thirst. On physical examination, her motor exam was
normal in all extremities and her sensory exam intact. She had no abnormalities on the
cerebellar exam. Her cardiac rate and rhythm were normal. Her extremities were normal.
Petitioner told Dr. David Kruse that she had autonomic dysfunction after a flu shot. Id.

51
Vertebrobasilar pertains to vertebrae and arteries. Dorland’s at 2051.
52
Stenosis is “an abnormal narrowing.” Dorland’s at 1769.

30
Petitioner had driven herself to see Dr. Cintron that morning and “developed a syncopal episode
with thickened speech with a British accent and inability to walk.” Id. at 12. Her glucose was
low at 73 when the normal range is 74-106 mg/DL. Id. at 19. Dr. Kruse diagnosed petitioner
with clinical dehydration and discharged her. Id. at 7.
On February 8, 2010, petitioner went to Inova Fair Oaks Hospital Rehabilitation Center
Speech-Language Pathology (SLP) for an evaluation, to which Dr. Cintron sent her. Med. recs.
Ex. 17, at 7. The onset of petitioner’s speech difficulty was noted as September 3, 2009. The
history was that petitioner developed an adverse reaction to a flu vaccination, and was
hospitalized for seizures and decreased ambulation. She also developed vasodepressor syncope
and reported a decrease in speech manifesting as stuttering, foreign accent, and blocks. She
stated she had a decrease in doing simple math and in memory. Id. The assessment was
moderately severe cognitive, language processing/mild speech production disorders. Processing
deficits were noted for combined modalities. She had significant breakdowns in attention skills,
including selective and divided. This impacted her ability to complete basic routines of activities
of daily living (“ADLs”). When petitioner’s cognition, processing, and attention are challenged,
this impacted her verbal expression complicated by dysfluencies/blocks. Id. The pathologist
(whose signature is illegible) wrote petitioner would benefit from skilled speech therapy
intervention to improve her cognitive skills for ADLs. Id. As part of petitioner’s evaluation, the
therapist noted petitioner spoke English with an Australian accent and when stressed, her speech
became extremely dysarthric with spasmodic head movements which the therapist diagnosed as
transient neurogenic stuttering brought on by stress, cognitive stress vs. distraction and auditory
distraction. Id. at 8. During more testing on February 15, 2010, the therapist noted that
petitioner was able to jog in place to “refresh” herself with more normalized speech afterwards.
Id. at 9. On March 15, 2010, the therapist noted that a low dosage of Valium appeared to
facilitate petitioner’s ability to tolerate multi-modal stimulation and function more optimally. Id.
at 5.
On February 12, 2010, Dr. Cintron sent petitioner to Cardiovascular Group again.
Petitioner saw Dr. Pradeep Nayak. Med. recs. Ex. 13, at 4; Ex. 53, at 66. Dr. Nayak diagnosed
petitioner with vasodepressor53 syncope, demonstrated following her stress echocardiogram
about six weeks previously. Med. recs. Ex. 12, at 5. He also diagnosed her with “apparent
vaccination-induced motor disorder,” elevated heart rate early in exercise, mild rhabdomyolysis
in 2009, and a leg injury with desire to return to running. Id. He recommended she see Dr.
Walter L. Atiga.
On February 23, 2010, petitioner saw Dr. Cintron. Med. recs. Ex. 1, at 8. Her speech
was mildly impaired with mild dystonic-type filter. Dr. Cintron found that her
neuropsychological testing was somewhat confusing in his interpretation. He thought it
interesting that when petitioner exercised, she did better.

53
Vasodepression is a “decrease in vascular resistance with hypotension.” Dorland’s at 2027.

31
On February 26, 2010, Dr. Cosgrave, petitioner’s psychologist, mailed a letter to
petitioner’s former attorney. Ex. 11, at 1, and Ex. 45, at 2. She states that the extent of
petitioner’s impairments was beyond her scope of expertise. Id.
On March 2, 2010, petitioner underwent a brain MRI for foreign accent syndrome.54
Med. recs. Ex. 53, at 68. Dr. Arun Kumar compared the results with petitioner’s brain MRI,
done October 3, 2009. Petitioner’s ventricles, sulci, and cisterns were normal for her age. She
did not have hydrocephalus, abnormal signal intensity in the brain parenchyma, hemorrhage,
mass, mass effect, or midline shift. She did not have evidence of restricted diffusion to suggest
an acute or subacute infarction. Her mesial temporal lobe structures were symmetric. She did
not have evidence of cortical dysplasia. Her flow voids were maintained. There was mucosal
inflammation in the mastoid sinuses, ethmoidal air cells, and frontal sinuses. Her orbits were
normal. Her mastoid air cells were clear. Dr. Kumar’s impression was petitioner did not have an
acute intracranial process and she had mild sinus disease. Id.
On March 3, 2010, petitioner underwent a F-18 FDG PET/55CT scan of her brain for
cognitive impairment and foreign accent syndrome. Id. at 69. Dr. Stuart A. Fruman compared
the results with petitioner’s brain MRI, done on October 2, 2010. Petitioner had symmetric
distribution of FDG metabolism through her brain parenchyma. She did not have any abnormal
areas of increased or decreased isotope accumulation. Dr. Fruman wrote petitioner had a normal
brain PET/CT scan. Id.
On March 16, 2010, petitioner and her then-husband saw Dr. Cintron. Med. recs. Ex. 1,
at 7. Petitioner’s PET scan was normal. He told petitioner and her then-husband that he had not
seen any evidence of any irreversible changes to any part of her central nervous system and he
felt confident she would recover. At this point, he empirically labeled petitioner as having
dystonic-type illness with other “not very well explained features and possible autonomic
dysfunction secondary to her vaccination.” Id. She seemed to have an exaggerated vasovagal
syndrome because she faints after eating and exercising. Dr. Cintron states, “From the
neurological perspective the symptoms are still bizarre, she has an accent which fluctuates, she is
able to walk sideways but not forward, but no objective evidence on exam of where the problems
are coming from.” Id.
On March 23, 2010, petitioner saw Dr. Atiga, a cardiologist, for an evaluation and
management of syncope. Med. recs. Ex. 13, at 1. Dr. Nayak referred petitioner to Dr. Atiga for

54
“Foreign accent syndrome (FAS) is speech disorder that causes a sudden change to speech so that a native speaker
is perceived to speak with a ‘foreign’ accent. FAS is most often caused by damage to the brain caused by a stroke or
traumatic brain injury. Other causes have also been reported including multiple sclerosis and conversion disorder
and in some cases no clear cause has been identified.” What is Foreign Accent Syndrome?, THE UNIVERSITY OF
TEXAS AT DALLAS, https://www.utdallas.edu/research/FAS/ (last visited Jan. 25, 2019).
55
Positron emission tomography (PET) is “tomography accomplished by detection of gamma rays emitted from
tissues after administration of a natural biochemical substance (e.g., glucose, fatty acids) into which positron-
emitting isotopes have been incorporated. The paths of the gamma rays, which result from collisions of positrons
and electrons, are interpreted by a computer, and the resultant tomogram represents local concentrations of the
isotope-containing substance.” Dorland’s at 1935. FDG is 18fluorodeoxyglucose. Neil M. Davis ed., MEDICAL
ABBREVIATIONS 144 (12th ed. 2005) [hereinafter “Med. Abbrev.”].

32
management of vasovagal syncope. Petitioner stated she was healthy and active as a runner until
she started having problems late summer 2009. She received flu vaccine for the third year in a
row. A couple of weeks later, she started having recurrent episodes of syncope preceded by
lightheadedness, warmth, and cold hands and feet. These would always occur soon after eating.
The symptoms got so bad she would take a sip of water and then pass out, having nausea and
vomiting afterwards. She went to Loudoun Hospital, and then Johns Hopkins, but was not able
to get a clear and definitive diagnosis. She was featured on the local channel 5 news because she
thought her symptoms were due to flu vaccine. Having read that news story, an organization that
believes vaccines may cause autism contacted her because her symptoms could be consistent
with mercury toxicity. As a result, she went to North Carolina and underwent chelation
treatment because of elevated levels of mercury. The chelation therapy helped her feel better,
but since it was prohibitively costly, she could not continue with it.
Presently, petitioner discovered that if she exercised, such as went running, she could eat
without becoming nauseated, vomiting, or passing out. On days when she did not run, she had
presyncope or syncope. She tore her left quadriceps and could not run. Since then, she has had a
recurrence of symptoms so that she cannot eat without passing out. She is very sensitive to heat
and, if she goes out on a warm day, she has lightheadedness, warmth, presyncope, syncope,
nausea, and vomiting. Her then-husband hugged her tightly and compressed her neck at one
point, and she passed out and had seizure-like activity. She had the same symptoms while
undergoing a carotid Doppler examination. At her worst, she was unable to walk forward but
could walk sideways or backward. However, when she began taking Neurontin56 and after the
dosage was increased, she was able to walk forward. Another “interesting” symptom was that
she developed what sounds like a British accent although she is from Ohio. Id. at 1. She
increased her salt intake by 2,000 mg of sodium and increased her fluids, but they did not have
an effect. Id. at 1-2. Under job description, Dr. Atiga wrote professional cheerleader. Id. at 2.
Dr. Atiga’s impression was that petitioner’s symptom complex “does certainly time out
with her receiving the flu vaccination.” Id. Her symptoms were consistent with a vasovagal or
neurocardiogenic mechanism. He writes, “It is interesting that on days when she has heavier
physical exertion, her symptoms are improved enough that she can actually eat,” but on days
when she does not do this, her symptoms are worse. She also seemed to have evidence of carotid
sinus hypersensitivity. Dr. Atiga writes, “I believe that she has an unusual form of
neurocardiogenic syncope in that she has very heightened vagal tone and the reason that the
exercise improves her on that day is because it increases her sympathetic tone.” Id. To reduce
petitioner’s vagal tone, Dr. Atiga offered her either a Scopolamine57 patch or Norpace.58 Either

56
Neurontin is “trademark for preparations of gabapentin.” Dorland’s at 1268. For a definition of gabapentin, see
supra, n.8.
57
Scopolamine is “an anticholinergic alkaloid, derived from several solanaceous plants, including Atropa
belladonna, Hyoscyamus niger, Datura species, and Scopolia species. It has effects on the autonomic nervous
system similar to those of atropine. It is used as an antiemetic, particularly in motion sickness.” Dorland’s at 1681.
58
Norpace is “trademark for preparations of disopyramide phosphate.” Dorland’s at 1291. Disopyramide is “a
cardiac depressant with anticholinergic properties, used as an antiarrhythmic.” Id. at 547. An antiarrhythmic is “an
agent that prevents or alleviates cardiac arrhythmia.” Id. at 100.

33
drug would put her parasympathetic and sympathetic tone in more balance. He prescribed
Norpace. Id.
On March 25, 2010, petitioner saw Dr. Cintron. Med. recs. Ex. 1, at 6. He states she is a
very pleasant woman whom he follows for neurological implications secondary to exposure to a
flu vaccine. She was doing significantly better since he increased her Neurontin to 200mg twice
a day. She could walk forward. Her voice sounded much better. but she still had some difficulty
eating unless she exercised. She was working with Dr. Atiga to help with her dysautonomia. Id.
Throughout February and April 2010, petitioner sought treatment at the Physical
Medicine and Rehabilitation unit at Inova Fair Oaks Hospital. Med. recs. Ex. 53, at 41-59.
Petitioner sought cognitive treatment that focused on processing multiple stimuli simultaneously
and tuning out extraneous stimuli. Id. at 41. Through a hierarchy of graduated attention tasks
and possibly a change in medications to help control her dystonia, Wendy Morgan, MS, CCC-
SLP, wrote that petitioner had made significant gains in all cognitive areas. Petitioner was
discharged because she moved out of the area. Id.
On May 21, 2010, petitioner saw Dr. Cintron. Med. recs. Ex. 1, at 5. Petitioner was
trying to control her syncopal episodes that occurred when she was overheated. She seemed to
be somewhat able to prevent them by exercising excessively as if she were trying to get her
adrenaline going. Petitioner was seeing Dr. Atiga to see if she could get help with what appeared
to be autonomic imbalance. From a neurological perspective, petitioner continued to have
dystonia and speech difficulty, but had significantly improved over time. She was getting ready
to move to California. Id.
On May 24, 2010, petitioner saw Dr. Farhad Zangeneh for an endocrine evaluation.
Med. recs. Ex. 43, at 28. Petitioner was on disability and wanted Dr. Zangeneh to evaluate her
adrenal gland, thyroid, and overall endocrine status. Id. A comprehensive metabolic test result
was normal. Id. at 29. Dr. Zangeneh wrote that petitioner’s blood pressure both sitting and
standing was nearly identical, and she did not have orthostatic hypotension. Petitioner was on
Depo-Provera. Dr. Zangeneh discussed with petitioner that, from an endocrine standpoint, he
did not recommend Depo-Provera because of an increased risk for bone loss and for the
development of metabolic syndrome. Id. On June 4, 2010, Dr. Zangeneh informed Dr. Ho that
petitioner’s lab results were normal and there was no endocrine etiology for petitioner’s
symptoms. Id. at 27.
On July 2, 2010, after petitioner moved to California, she saw Dr. Neil Q. Tran as her
new PCP, at the Mission Internal Medicine Group. Med. recs. Ex. 42, at 28. In his n

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Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/4407959. Public record. Not legal advice.