1

In the United States Court of Federal Claims 

OFFICE OF SPECIAL MASTERS

No. 15-1553V

Filed: December 3, 2021

UNPUBLISHED

JONATHAN PATTON,

 Petitioner,

v.

SECRETARY OF HEALTH AND 

HUMAN SERVICES,

 Respondent.

Michael Andrew London, Douglas & London, P.C., New York, NY, for petitioner.

Claudia Barnes Gangi, U.S. Department of Justice, Washington, D.C., for respondent.

Ruling on Entitlement1

On December 21, 2015, petitioner Jonathan Patton2 filed a petition under the 

National Childhood Vaccine Injury Act, 42 U.S.C. § 300aa-10-34 (2012),3 alleging that 

he suffered brachial neuritis4 as a result of his January 11, 2013 influenza vaccination. 

(ECF No. 1.) He later amended his claim to allege that he also experienced 

radiculomyelitis as a result of the same vaccination. (ECF No. 34.) Initially, I found 

petitioner was not entitled to compensation (ECF No. 83); however, the Court of Federal 

Claims granted petitioner’s motion for review of that decision and remanded the case for 

1 Because this decision contains a reasoned explanation for the special master’s action in this case, it will 

be posted on the United States Court of Federal Claims’ website in accordance with the E-Government 

Act of 2002. See 44 U.S.C. § 3501 note (2012) (Federal Management and Promotion of Electronic 

Government Services). This means the decision will be available to anyone with access to the 

Internet. In accordance with Vaccine Rule 18(b), petitioner has 14 days to identify and move to redact 

medical or other information the disclosure of which would constitute an unwarranted invasion of privacy. 

If the special master, upon review, agrees that the identified material fits within this definition, it will be 

redacted from public access.

2 In fact, when the petition was filed, Mr. Patton was a minor and the action was brought by his mother on 

his behalf. Petitioner was subsequently substituted as petitioner on February 18, 2016. (ECF No. 10.)

3 All references to “§ 300aa” below refer to the relevant section of the Vaccine Act at 42 U.S.C. § 300aa10-34. 

4 Throughout the record of this case, three terms – i.e. brachial neuritis, Parsonage-Turner syndrome, and 

neuralgic amyotrophy – have been variously used to describe the same basic condition. Notwithstanding 

any nuances, the parties and experts have treated the terms as interchangeable. 

Special Master Horner

Remand; Ruling on Entitlement; 

Influenza Vaccination; Brachial 

Neuritis
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further proceedings (ECF No. 91). On remand I find that petitioner is entitled to 

compensation for brachial neuritis caused-in-fact by his influenza vaccination for all the 

reasons discussed below.

I. Factual and Procedural History5

a. Factual history, briefly

Apart from a history of nosebleeds, petitioner was a healthy 15-year-old boy prior 

to receiving a flu vaccine on January 11, 2013. (Ex. 2, p. 3.)6 Petitioner received the 

typical childhood vaccines during his infancy and never experienced any neurological 

symptoms nor was he ever diagnosed with any neurological or autoimmune condition. 

(Ex. 1, pp. 1-2; ECF No. 72, p. 1.) Petitioner’s pertinent medical history begins on 

January 11, 2013, when he received the flu vaccine that serves as the basis for this 

claim.

On January 17, 2013, six days after receiving the flu vaccine, petitioner awoke 

early in the morning with a nosebleed that was more severe than usual. (Ex. 2, p. 2.) 

Petitioner was unable to move his arms, describing the feeling as “dead weight.” (Id.) 

After alerting his mother of his condition, petitioner was brought and admitted to the All 

Children’s Hospital (“ACH”) Emergency Department. (Id.) Petitioner’s arms were so 

weak at this point that he was unable to dress himself or fasten his seatbelt on his own. 

(Ex. 7, p. 59.) He also reported he had experienced an occipital headache, neck pain, 

and bilateral shoulder pain since waking. (Id.)

Petitioner’s initial presentation seemed to confuse his treating physicians at ACH 

who initially listed 13 differential diagnoses including central nervous system mass, 

carbon monoxide poisoning, dehydration, electrolyte abnormality, unspecified 

headache, migraine, tension headache, intracranial hemorrhage, meningitis, postconcussion syndrome, shunt malfunction, and stroke. (Ex. 7, p. 60.) However, as 

petitioner was further examined, his treating physicians and physical therapists settled 

on a diagnosis of possible or probable brachial neuritis (referenced as ParsonageTurner syndrome) that they related to his flu vaccination. (Ex. 7, pp. 17, 47, 85.) 

b. Initial decision denying entitlement to compensation

As noted above, petitioner’s claim was filed on December 21, 2015, alleging that 

Mr. Patton suffered brachial neuritis caused by his flu vaccination. (ECF No 1.) 

However, during the pendency of the claim petitioner also alternatively alleged he 

5 The facts and procedural history are described in greater detail in the now vacated May 17, 2021

Decision dismissing this case (ECF No. 83 (vacated); see also Patton v. Sec’y of Health & Human Servs., 

No. 15-1553V, 2021 WL 2389835 (Fed. Cl. Spec. Mstr. May 17, 2021)) as well as in the Court’s Opinion 

and Order granting petitioner’s motion for review (ECF No. 91; see also Patton v. Sec’y of Health & 

Human Servs., No. 15-1553V, 2021 WL 5445549 (Nov. 22, 2021).)

6 Exhibit 2 was not bates-stamped. This decision cites to the pagination generated by CM/ECF. 
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suffered radiculomyelitis. (ECF No. 34.) Petitioner initially filed a supporting expert 

opinion by neurologist Thomas Morgan, M.D., who opined petitioner suffered 

radiculomyelitis, but not brachial neuritis. (Exs. 12, 17.) Dr. Morgan later became 

unavailable to continue the case and petitioner then relied on an opinion by neurologist 

Salvatore Napoli, M.D., who agreed that petitioner suffered radiculomyelitis, but also 

opined that petitioner suffered brachial neuritis as originally pled. (Ex. 21.) Respondent 

offered a competing opinion by neurologist Vinay Chaudhry, M.D., who opined 

petitioner’s condition was not consistent with either condition and, in fact, defied 

diagnosis. (Exs. A, G, H.)

Neither radiculomyelitis nor brachial neuritis constitutes a Table Injury 7 relative to 

the flu vaccine at issue in this case. (Brachial neuritis is a Table Injury relative to 

tetanus-containing vaccinations only.) Accordingly, petitioner is obligated to prove by 

preponderant evidence that his flu vaccination “caused-in-fact” his injury. See 42 C.F.R. 

§ 100.3(a); § 300aa-13(a)(1)(B); § 300aa-11(c)(1)(C)(ii). To meet this burden, 

petitioners must generally satisfy what has come to be known as the three-part Althen

test, which requires: (1) a medical theory causally connecting the vaccination and the 

injury; (2) a logical sequence of cause and effect showing that the vaccination was the 

reason for the injury; and (3) a showing of proximate temporal relationship between 

vaccination and injury. Althen v. Sec’y of Health & Human Servs., 418 F.3d 1274, 1278 

(Fed. Cir. 2005).

An entitlement hearing was held on October 27, 2020. (See ECF No. 80, 

Transcript of Proceedings (“Tr”), October 27, 2020). Thereafter, I issued a decision 

denying entitlement to compensation on May 17, 2021. (ECF No. 83 (vacated).) That 

decision sought to resolve three overarching questions: whether there is preponderant 

evidence petitioner suffered radiculomyelitis; whether there is preponderant evidence 

petitioner suffered brachial neuritis; and whether there is preponderant evidence 

petitioner’s injury was caused-in-fact by his flu vaccination. (ECF No. 83, p. 20.)

First, as a threshold matter, I concluded that there was preponderant evidence 

supporting the diagnosis of brachial neuritis, which was the diagnosis reached by the 

treating physicians, but not preponderant evidence supporting the diagnosis of 

radiculomyelitis, which was proposed by petitioner’s experts, but not considered by the 

treating physicians. (ECF No. 83, p. 23.) Having determined that petitioner

substantiated only the brachial neuritis diagnosis, I conducted an analysis pursuant to 

the Althen test focused on that condition. (Id.)

I explained with respect to Althen prong one (petitioner’s required medical 

theory), that Dr. Napoli theorized that brachial neuritis can be caused by the flu vaccine 

via the well-known concept of molecular mimicry. (ECF No. 83, p. 28 (citing Tr. 16, 38-

7 In some cases, a petitioner may simply demonstrate the occurrence of what has been called a “Table 

Injury.” That is, petitioners may show that they suffered an injury of the type enumerated in the “Vaccine 

Injury Table,” corresponding to the vaccination in question, within an applicable time period following the 

vaccination also specified in the Table. In such cases, the Table Injury is presumed to have been caused 

by the vaccine. § 300aa-13(a)(1)(A); § 300 aa-11(c)(1)(C)(i); § 300aa-14(a); § 300aa-13(a)(1)(B).
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39; ECF No. 77, pp. 35-39).) In addition to citing case reports, his opinion was based

largely on the ideas that brachial neuritis is understood to be an autoimmune condition 

generally and that the flu vaccine has separately, but more specifically, been shown to 

cause another peripheral nerve condition, Guillain Barre Syndrome (“GBS”), via 

molecular mimicry. (Id. at 29 (citing Tr. 94; Ex. 21, pp. 5-6; Ex. 268, p. 3; Ex. 239, p. 

16).) However, I accepted respondent’s expert’s opinion which suggested that this was 

not a reliable theory because the evidence supporting vaccine causation of GBS only 

supports molecular mimicry between the flu vaccine and the myelin sheath of the nerve. 

The condition of brachial neuritis at issue in this case, by contrast, is generally 

understood to be a condition specifically affecting nerve axons rather than myelin. (Id. 

at 29 (citing Tr. 131-33, 279-80; Ex. C10, p. 7; Medlink, supra, at Ex. 23, p. 2).)

Dr. Chaudhry testified that the myelin and axons are susceptible to different 

antigens and also filed literature showing that the understanding that brachial neuritis is

an autoimmune condition is supported by studies demonstrating the nerve axons 

specifically to be the autoimmune target in that particular condition. (ECF No. 83, pp. 

29-30 (citing Tr. 131-32; Van Eijk, Groothuis & Van Alfen, supra, at Ex C, p. 5).) I 

concluded that Dr. Napoli had not demonstrated that the flu vaccine can cause axonal 

loss lesions as seen in brachial neuritis as opposed to the type of demyelinating injury 

seen in GBS. Thus, I found that Dr. Napoli had not demonstrated that the flu vaccine 

can cause brachial neuritis and petitioner did not meet his burden of proof under Althen

prong one with respect to the condition of brachial neuritis. (Id. at 31.) 

With respect to Althen prong two, petitioner is obligated to come forward with 

evidence demonstrating a logical sequence of cause and effect showing that his 

vaccination did cause his own injury. Because the Althen analysis was predicated on 

petitioner’s preponderant showing that his condition was diagnosed as brachial neuritis, 

my analysis pursuant to Althen prong two flowed directly from the analysis under Althen

prong one. 

In this case, petitioner’s treating physicians had concluded both that petitioner’s 

injury was brachial neuritis and that it was caused by his flu vaccine; however, the latter

conclusion was supported only by temporal association and the lack of an alternative 

explanation. (ECF No. 83, p. 32 (citing Ex. 7, pp. 17, 47, 53, 85).) Accordingly, 

because I had concluded there is not preponderant evidence that the flu vaccine can 

cause brachial neuritis as a matter of general causation, I afforded their opinions as to

specific causation only “little” weight. (Id. (citing D'Angiolini v. Sec'y of Health & Human

Servs., No. 99-578V, 2014 WL 1678145 (Fed. Cl. Spec. Mstr. Mar. 27, 2014) (noting 

that “there is a difference between a doctor’s opinion regarding diagnosis and a doctor’s 

opinion regarding etiology and quoting Tamraz v. Lincoln Electric Co, 620 F. 3d 664, 

8 Penina Haber et al., Vaccines and Guillain-Barre Syndrome, 32DRUG SAFETY 309(2009).

9 Mark A Ferrante & Francesc Graus, Neuralgic Amyotrophy, NEUROLOGY MEDLINK (2020) (herein 

“Medlink”).

10 Jeroen van Eijk, Jan T. Groothuis & Nens van Alfen, Neuralgic Amyotrophy: An Update on Diagnosis, 

Pathophysiology, and Treatment Muscle Nerve, 53MUSCLE AND NERVE 337(2016).
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674 (6th Cir. 2010) for the proposition that physicians “may testify to both [diagnosis and 

etiology] but the reliability of one does not guarantee the reliability of the other”), mot. for 

rev. denied, 122 Fed. Cl. 86 (2015), aff'd, 645 F. Appx 1002 (Mem.) (Fed. Cir. 2016).))

Although Dr. Napoli had opined that petitioner’s condition could be explained as 

brachial neuritis, I explained that his causal opinion was also predicated on his 

identification of both radiculomyelitis and brachial neuritis as relevant demyelinating 

conditions. (ECF No. 83, p. 33 (citing Tr. 107).) However, as described above, record 

evidence was persuasive in showing brachial neuritis to be a condition of axonal loss 

lesions. (Id. (citing Tr. 131-33, 279-80; Van Eijk, Groothuis & Van Alfen, supra, at Ex C, 

p. 7).) With respect to petitioner’s own medical history, Dr. Napoli had indicated he 

could not determine from the record evidence whether petitioner’s own condition was 

axonal or demyelinating. (Id. (citing Tr. 107).) 

Pursuant to Althen prong one, my analysis indicated that Dr. Napoli had only 

demonstrated that demyelination injuries, but not axonal nerve injuries, were potentially 

caused by the flu vaccine. (ECF No. 83, pp. 28-31.) Accordingly, to the extent Dr. 

Napoli relied on a brachial neuritis diagnosis to explain petitioner’s condition, he was not 

persuasive under Althen prong two in suggesting a logical sequence of cause and effect 

demonstrating that petitioner’s flu vaccination actually did cause what was likely (by

virtue of the nature of the diagnosis being relied upon) an axonal, rather than (as Dr. 

Napoli had assumed) a demyelinating nerve injury. (Id. at 33.) More specifically, I 

indicated that “[p]etitioner has failed to show by preponderant evidence a logical 

sequence of cause and effect whereby the flu vaccine would have induced an 

autoimmune reaction that caused his axonal-loss lesion resulting in brachial neuritis.” 

(Id.) Alternatively, the specific condition Dr. Napoli had shown to be vaccine-caused, 

GBS, did not fit petitioner’s own clinical presentation and there likewise was not 

preponderant evidence supporting the presence of the demyelinating radiculomyelitis

proposed by petitioner’s experts. (ECF No. 83, p. 33.) 

Based on all of the above, I concluded that “[a]lthough petitioner’s condition does 

remain somewhat enigmatic, he has not articulated any basis for concluding that his flu 

vaccine could be responsible for a logical sequence of cause and effect leading to his 

constellation of symptoms.” (ECF No. 83, p. 33.) Thus, I found that petitioner had not

satisfied his burden of proof under Althen prong two. (Id.)

Althen prong three, requiring a medically appropriate temporal relationship 

between vaccination and injury, was not litigated by the parties. I found that Althen 

prong three was satisfied, but nonetheless explained that petitioner’s failure to meet 

Althen prongs one and two was dispositive. Accordingly, I issued a decision dismissing 

the case. (ECF No. 83, pp. 33-34.)

c. Motion for review and Court of Federal Claims remand order

Petitioner subsequently filed a motion for review which was granted by the Court 

of Federal Claims on November 5, 2021. (ECF No. 91.) Petitioner did not challenge 
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the finding that he did not suffer radiculomyelitis, but did challenge the finding that his 

brachial neuritis was not vaccine caused. (Id. at 2, n. 3.) On review, the Court of 

Federal Claims accepted Dr. Napoli’s opinion that the flu vaccine can cause brachial 

neuritis and remanded the case for further proceedings. 

The Court concluded that I had erred by giving too little weight both to Dr. 

Napoli’s description of molecular mimicry as a well-accepted immunological concept 

and to the case reports cited by Dr. Napoli to specifically support a connection between 

the flu vaccine and brachial neuritis. (ECF No. 91, pp. 6-8.) Additionally, with respect to 

Dr. Napoli’s reliance on literature addressing the relationship between the flu vaccine 

and demyelinating GBS, the Court held that it was error to accept Dr. Chaudhry’s 

opinion that brachial neuritis is a distinct, axonal, injury. (Id. at 9-10.) The Court 

reasoned that the distinction drawn by Dr. Chaudhry cannot be applied in this case,

even with respect to whether the flu vaccine can cause brachial neuritis pursuant to 

Althen prong one, because there is not sufficient evidence on this record to determine 

whether petitioner’s own nerve lesions were axonal or demyelinating. (Id. at 10.) 

Specifically, the Court stated: 

It also appears that the Special Master rejected Dr. Napoli’s opinion that the 

flu vaccine can cause brachial neuritis because he adopted Respondent’s 

expert Dr. Chaudhry’s opinion “that cases of brachial neuritis 

overwhelmingly result in axonal damage and not demyelination” . . . The 

Special Master concluded that Dr. Napoli did not provide evidence that a 

vaccine causing one type of nerve damage (demyelination) via molecular 

mimicry should be assumed capable of causing the other (axonal). But this 

distinction that Dr. Chaudhry drew between demyelinating nerve damage 

versus axonal damage cannot be applied to Petitioner on this record. As 

the Special Master found, “there is no evidence on this record distinguishing 

whether petitioner’s symptoms were caused by demyelination or axonal 

damage.” 

(ECF No. 91, pp. 9-10. (internal citations and footnote omitted).)

Consistent with Dr. Napoli’s framing of his opinion, the Court cited approvingly to 

literature filed by petitioner associating the flu vaccine to demyelinating GBS combined 

with literature asserting that unspecified vaccines are among the recognized triggers for 

brachial neuritis as evidence that the flu vaccine can cause brachial neuritis. (Id. at 10-

11.)

The Court held that:

Petitioner demonstrated a sound and reliable medical theory that the flu 

vaccine can cause brachial neuritis via molecular mimicry. This theory is 

supported by the expert opinion of an experienced neurologist, four case 

reports, three medical articles, and the diagnoses of four treating physicians 

that the flu vaccine likely did cause Petitioner’s brachial neuritis. By 

disregarding this evidence and noting the absence of studies supporting 
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Petitioner’s theory, the Special Master placed too high an evidentiary 

burden on Petitioner with respect to Althen’s prong one.

(Id. at 11.) 

Noting that my Althen prong two analysis had been colored by my Althen prong 

one analysis, the Court remanded the case with the following instruction: “On remand, 

the Special Master shall reassess entitlement in particular whether Petitioner satisfied 

Althen’s prong two in light of this Court’s finding that Petitioner met Althen’s prong one.”

(Id. at 12.)

II. Discussion

As discussed above, petitioner is obligated to prove by preponderant evidence 

that his flu vaccination “caused-in-fact” his injury. See 42 C.F.R. § 100.3(a); § 300aa13(a)(1)(B); § 300aa-11(c)(1)(C)(ii). To meet this burden, petitioner must demonstrate: 

(1) a medical theory causally connecting the vaccination and the injury; (2) a logical 

sequence of cause and effect showing that the vaccination was the reason for the 

injury; and (3) a showing of proximate temporal relationship between vaccination and 

injury. Althen v. Sec’y of Health & Human Servs., 418 F.3d 1274, 1278 (Fed. Cir. 2005).

I previously found that there is not preponderant evidence that petitioner suffered 

radiculomyelitis and that finding was not challenged on review. Although I did find that 

preponderant evidence supported petitioner’s brachial neuritis diagnosis, I concluded 

that condition was not vaccine caused owing largely to my analysis of general causation 

under Althen prong one. On review, the Court of Federal Claims held that petitioner 

satisfied Althen prong one specifically with respect to his brachial neuritis diagnosis, 

necessitating a reexamination of entitlement relative to that condition.

It is uncontroversial that brachial neuritis is, in general, an autoimmune condition 

associated with multiple triggers. (Ex. 21, p. 4 (citing Mark A. Ferrante & Asa J. 

Wilbourn, Lesion Distribution Among 281 Patients with Sporadic Nerualgic Amyotrophy, 

55 MUSCLE & NERVE 858 (2017) (herein “Ferrante and Wilbourn”) (Ex. 27).) 

Additionally, the parties agree that onset of petitioner’s symptoms occurred within six 

days of his vaccination and therefore falls within the “medically appropriate timeframe 

for the onset of an immunological injury.” (See ECF No. 74, p. 18; see also ECF No. 77 

pp. 39-41.) Petitioner’s treating physicians further concluded that petitioner’s own 

medical history was indicative of vaccine-caused brachial neuritis based on the fact of 

petitioner’s recent flu vaccination. (Ex. 7, pp. 17, 47, 53, 74, 78, 80, 85; Ex. 3, p. 6; Ex. 

1, p. 2.) 

Because the Court of Federal Claims has determined that petitioner has 

demonstrated that the flu vaccine can cause brachial neuritis as a matter of general 

causation (ECF No. 91, pp. 9-10), the treating physician opinions carry significant 

weight as to specific causation pursuant to Althen prong two. The Federal Circuit has 

recognized generally that “treating physicians are likely to be in the best position to 
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determine whether ‘a logical sequence of cause and effect show[s] that the vaccination 

was the reason for the injury.’” Capizzano v. Sec'y of Health & Human Servs., 440 F.3d 

1317, 1326 (Fed. Cir. 2006) (quoting Althen v. Sec'y of Health and Human Servs., 418 

F.3d 1274, 1280 (Fed. Cir. 2005)). With diagnosis and general causation decided in 

petitioner’s favor, there is no remaining reason on this record to doubt the treating 

physicians’ opinions as to specific causation. Respondent has not asserted any other 

explanation for petitioner’s condition and agrees that the post-vaccination timing is 

medically appropriate for an immunological injury. 

There remains a disconnect within petitioner’s supporting expert opinion by Dr. 

Napoli. On the one hand, his causal explanation was premised on his assumption that

what petitioner suffered was a demyelinating injury. (Tr. 107-10 (Dr. Napoli testifying 

that he believes petitioner’s brachial neuritis and radiculomyelitis are both demyelinating 

injuries and agreeing that his opinion is based on the idea that “causal evidence relating 

to one demyelinating condition is relevant in discussing other demyelinating 

conditions”).) On the other hand, Dr. Napoli was ultimately persuasive in opining that

petitioner’s condition is best explained by the diagnosis of brachial neuritis. This 

diagnosis is strongly suggestive of an axonal injury. (Medlink, supra, at Ex. 23, p. 2 

(petitioner’s exhibit explaining that regarding brachial neuritis “available evidence 

suggests that an autoimmune pathogenesis, likely related to a genetic susceptibility 

most commonly generates an axon loss lesion (focal or multifocal) that involves 

predominantly motor axons”); see also Van Eijk, Groothuis & Van Alfen, supra, at Ex C, 

p. 5.) 

Even in the absence of evidence definitively identifying the nature of petitioner’s 

own nerve lesions (axonal versus demyelinating), this inconsistency potentially defeats 

the internal logic of Dr. Napoli’s opinion if demyelinating and axonal nerve lesions point 

to different etiologies. However, the Court of Federal Claims has held that petitioner 

has shown that brachial neuritis can be caused by the flu vaccine via molecular mimicry 

irrespective of any distinction between axonal and demyelinating injuries. (ECF No. 91, 

p. 11.) In the context of that holding, it is not necessary to further probe this 

inconsistency in Dr. Napoli’s opinion, because either type of lesion can be linked to the 

flu vaccine pursuant to petitioner’s Althen prong one theory. Dr. Napoli’s assessment of 

petitioner’s brachial neuritis was otherwise reasonable and in agreement with the 

treating physicians’ opinions.

The Court of Federal Claims has already held that petitioner satisfied his burden 

of proof under the first Althen prong with respect to the injury of brachial neuritis. In light 

of the Court of Federal Claims’ holding, all of the above indicates that petitioner has also 

satisfied Althen prongs two and three by preponderant evidence. Further, respondent 

has not presented any factor unrelated to vaccination that would explain petitioner’s 

condition. Accordingly, petitioner is entitled to compensation for his injury of brachial 

neuritis.
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III. Conclusion

For all the reasons described above, I find that petitioner is entitled to 

compensation. Specifically, I find that petitioner has established by preponderant 

evidence that he suffered brachial neuritis caused-in-fact by his January 11, 2013

influenza vaccination. A separate damages order will be issued. Pursuant to Vaccine 

Rule 28.1(a), the clerk of court is directed to notify the assigned judge of the filing of this 

decision on remand.

IT IS SO ORDERED.

s/Daniel T. Horner

Daniel T. Horner

Special Master