Court Opinion

ID: 6114387
Source: CourtListenerOpinion
Date Created: 2022-02-01 18:01:48.39213+00
Date Added: 2024-06-11T08:13:36.176593
License: Public Domain

In the United States Court of Federal Claims
                                   OFFICE OF SPECIAL MASTERS
                                        Filed: January 6, 2022

* * * * * *                    *   *   *   *   *
PAULA BEYERL,                                      *       UNPUBLISHED
                                                   *
                 Petitioner,                       *       No. 20-32V
                                                   *
v.                                                 *       Special Master Dorsey
                                                   *
SECRETARY OF HEALTH                                *       Dismissal Decision; Failure to Prosecute;
AND HUMAN SERVICES,                                *       Insufficient Proof.
                                                   *
                 Respondent.                       *
                                                   *
*    *   *   *     *   *       *   *   *   *   *

Paula Beyerl, pro se, Leesburg, VA, for petitioner.
Claudia B. Gangi, U.S. Department of Justice, Washington, DC, for respondent.

                                               DECISION1

I.       INTRODUCTION

        On January 10, 2020, Paula Beyerl (“petitioner”) filed a petition, pro se, pursuant to the
National Vaccine Injury Compensation Program (“Vaccine Act” or “the Program”), 42 U.S.C. §
300aa-10 et seq. (2012).2 Petitioner alleged that that she developed coronary artery spasms as
the result of an influenza (“flu”) vaccination administered to her on January 10, 2017. Petition
at Preamble (ECF No. 1). Petitioner subsequently retained legal counsel and filed an amended
petition on December 2, 2020, alleging that she suffered pericarditis, coronary artery spasms,

1
  Because this Decision contains a reasoned explanation for the action in this case, the
undersigned is required to post it on the United States Court of Federal Claims’ website in
accordance with the E-Government Act of 2002. 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, upon review, the
undersigned agrees that the identified material fits within this definition, the undersigned will
redact such material from public access.
2
 The National Vaccine Injury Compensation Program is set forth in Part 2 of the National
Childhood Vaccine Injury Act of 1986, Pub. L. No. 99-660, 100 Stat. 3755, codified as amended,
42 U.S.C. §§ 300aa-10 to -34 (2012). All citations in this Decision to individual sections of the
Vaccine Act are to 42 U.S.C. § 300aa.

                                                       1
angina, paroxysmal supraventricular tachycardia (“PSTV”), temporary atrial fibrillation (“AFib”)
and/or chest pain, resulting from the adverse effects of the flu vaccination administered on
January 10, 2017. Amended (“Am.”) Petition at 1 (ECF No. 41).

         Based on all the reasons set forth below and in the Show Cause Order dated July 13,
2021, and for failure to comply with the Show Cause Order, the undersigned dismisses this case
for failure to prosecute and insufficient proof. Order to Show Cause dated July 13, 2021 (ECF
No. 57).

II.    PROCEDURAL HISTORY

        Petitioner filed her claim, pro se, on January 10, 2020, alleging she developed coronary
artery spasms as the result of a flu vaccination administered to her on January 10, 2017. Petition
at Preamble. The case was assigned to the undersigned on January 15, 2020. Order
Reassigning Case dated Jan. 15, 2020 (ECF No. 8). The undersigned held an initial status
conference on February 25, 2020 and requested petitioner file medical records to support her
claim. See Order dated Feb. 26, 2020 (ECF No. 15).

        Petitioner subsequently retained legal counsel on September 9, 2020. Motion (“Mot.”)
to Substitute Attorney, filed Sept. 10, 2020 (ECF No. 31). In October through December 2020,
petitioner filed medical records, an affidavit, an amended petition, and a statement of
completion. Petitioner’s Exhibits (“Pet. Exs.”) 1-13; Am. Petition; Statement of Completion,
filed Dec. 2, 2020 (ECF No. 43).

        On February 10, 2021, petitioner filed additional medical records. Pet. Ex. 14.
Respondent filed respondent’s Rule 4(c) Report recommending against compensation on March
10, 2021. Respondent’s Report (“Resp. Rept.”) at 2 (ECF No. 49). The undersigned held a
status conference on April 27, 2021, to discuss next steps in the case and ordered petitioner to
file additional medical records and for the parties to schedule a Rule 5 conference. See Order
dated Apr. 28, 2021 (ECF No. 50). Petitioner filed additional medical records on April 30,
2021. Pet. Ex. 15.

        The undersigned held a Rule 5 conference on May 13, 2021. Rule 5 Order dated May
13, 2021 (ECF No. 52). The undersigned provided a summary of petitioner’s medical records
and found “[p]etitioner’s relevant medical history, three years prior to vaccination, is significant
for prior complaints and treatment for chest pain.” Id. at 1-3. The undersigned preliminary
findings were

       the petitioner has failed to establish that she suffered any heart condition, or other
       compensable injury, related to the flu vaccine administered on January 10, 2017.
       In order to pursue this case, petitioner would need to file an expert report to
       provide preponderant evidence that there was some injury related to her flu
       vaccination and that the injury lasted longer than six months.

Id. at 4. The undersigned ordered petitioner to file an expert report in sixty days or an Order to
Show Cause would issue. Id.

                                                  2
        In July 2021, petitioner filed medical records and a motion to withdraw attorney and
continue pro se. Pet. Exs. 16-17; Mot. to Withdraw as Attorney, filed July 7, 2021 (ECF No.
56). The motion to withdraw was granted. Order dated Aug. 31, 2021 (ECF No. 62).
Petitioner did not file an expert report and the undersigned issued an Order to Show Cause.
Order to Show Cause. The Order to Show Cause ordered petitioner to file an expert report by
September 13, 2021, or the case would be dismissed. Id. at 2. “Failure to file the requested
expert report will be interpreted as an inability to provide supporting documentation for this
claim, constituting a failure to prosecute, and the case will be dismissed with prejudice.” Id.

        Petitioner contacted the undersigned’s Chambers and requested an extension to file an
expert report on September 9, 2021, which the undersigned granted. See Order dated Sept. 13,
2021 (ECF No. 65). The petitioner then missed her deadline to file an expert report on
November 12, 2021, and the undersigned extended the deadline an additional thirty days. Order
dated Nov. 16, 2021 (ECF No. 68). Petitioner subsequently missed her December 13, 2021
deadline to file an expert report.

       This matter is now ripe for adjudication.

III.   FACTUAL SUMMARY

       A.      Pre-Vaccination Medical History

        On July 26, 2014, petitioner sought emergency treatment for hypertension and chest pain.
Pet. Ex. 1 at 22. Her electrocardiogram (“EKG”) and cardiac monitoring revealed normal
results. Id. at 28. Diagnosis was gastroesophageal reflux disease, hiatal hernia,3 and
costochondritis.4 Id. at 36-40; Pet. Ex. 2 at 22, 32. In the emergency room, petitioner was seen
by Dr. Mark P. Tanenbaum who noted, “I suspect her discomfort is from a non-cardiac
etiology.” Pet. Ex. 1 at 39. On July 27, 2014, she followed up with cardiologist Dr.
Tanenbaum, who noted the following history:

       [Petitioner] is a 46-year-old woman who presents for evaluation of chest

3
  Hiatal hernia is the “abnormal protrusion of an organ or other body structure through a defect
or natural opening in a covering, membrane, muscle, or bone of an abdominal organ,” “usually
the stomach, through the esophageal hiatus into the respiratory diaphragm.” Hiatal Hernia,
Dorland’s Online Med. Dictionary,
https://www.dorlandsonline.com/dorland/definition?id=80713&searchterm=hiatal%20hernia
(last visited Jan. 5, 2022); Herniation, Dorland’s Online Med. Dictionary,
https://www.dorlandsonline.com/dorland/definition?id=22340&searchterm=herniation (last
visited Jan. 5, 2022).
4
  Costochondritis is the inflammation of the cartilaginous junction between a rib or ribs and the
sternum. Costochondritis, Dorland’s Online Med. Dictionary,
https://www.dorlandsonline.com/dorland/definition?id=11357&searchterm=costochondritis (last
visited Jan. 5, 2022).

                                                   3
       discomfort. She states she was in [her] usual state of health until 5 days ago
       when while at work, she noted onset of chest discomfort. She described it as a
       deep pressure-like sensation, did not change with activity. She continued to do
       her normal activities. . . . She continued with chest discomfort 2 days ago while
       at work and states she went to an urgent care center where she was told that she
       probably had costochondritis and [was] discharged home. She still had
       discomfort that evening and yesterday continued discomfort throughout the day.
       She decided to come to the emergency room for further evaluation and cardiology
       consultation is requested. . . . Cardiac history dates back to August of 2008 when
       she was admitted to the hospital with chest discomfort. Echocardiogram at that
       time was normal. She underwent an exercise nuclear perfusion study on August
       12, 2008, noting normal myocardial perfusion.

Pet. Ex. 2 at 22-23. Her current medications that day were nitroglycerin, metoprolol, Zofran,
and Lipitor. Id. at 23. There were no abnormalities in her physical exam, and an EKG and
chest x-ray were both normal, as were all of the lab results. Id. at 23-24. Dr. Tanenbaum
repeated he suspected that “her discomfort [wa]s from a noncardiac etiology,” but requested a
stress echocardiogram. Id. at 24. Petitioner had the echocardiogram the following day, July
28, 2014, and the results were unremarkable. Id. at 2, 10-11.

        On July 4, 2015, petitioner sought emergency care from Kaiser Permanente for chest
pain. Pet. Ex. 3 at 43-69. She complained of left-sided chest pain she described as “burning to
crushing 10/10 constant.” Id. at 45. She also had transient tingling in her left hand. Id. Her
work-up was normal and the assessment was chest pain, “[symptoms consistent with]
musculoskeletal etiology . . . Had similar episode 1yr ago but did not [follow up] for stress test.”
Id. at 63. “Similar episode last year told costochondritis.” Id. at 72. She was discharged
home with a strong recommendation for follow-up. Id. at 63.

        The following day, July 5, 2015, petitioner presented to INOVA Loudoun Hospital with
chest pain. Pet. Ex. 5-1 at 82. She was placed on a cardiac monitor and her EKG was normal.
Id. at 21. She also had a CT angiogram that was negative for a pulmonary embolism. Id. at 19-
20. She was discharged on July 6, 2015, with diagnoses of costochondritis, Tietze’s disease,5
hypertension, and an abnormal coagulation profile. Id. at 2, 48.

       B.      Post-Vaccination Medical Care

        On January 10, 2017, petitioner received a flu vaccine in her left deltoid. Pet. Ex. 15 at
1. That same day she presented to Dr. Melissa Matthews, at Kaiser Permanente with complaints
of an allergic reaction. Pet. Ex. 3 at 180. Petitioner stated that about one hour after receiving a
flu shot earlier that afternoon, she developed throat tightening. Id. She took two Benadryl per

5
  Tietze syndrome is the “idiopathic painful nonsuppurative swellings of one or more costal
cartilages, especially of the second rib; the anterior chest pain may mimic that of coronary artery
disease.” Tietze Syndrome, Dorland’s Online Med. Dictionary,
https://www.dorlandsonline.com/dorland/definition?id=111518&searchterm=Tietze%20syndrom
e (last visited Jan. 5, 2022).

                                                 4
instructions from the Kaiser Permanente nurse, and the throat tightening improved. Id. She
had no shortness of breath, rash, cough, or difficulty swallowing. Id. She also stated that she
had never had a reaction to previous flu vaccinations, but she did have a similar reaction to
Lisinopril. Id. Dr. Matthews treated petitioner with one intramuscular injection of epinephrine
and intravenous Solumedrol. Pet. Ex. 15 at 13. Petitioner’s symptoms improved but she had
ongoing intermittent mild sensations of throat tightening. Pet. Ex. 3 at 182. Dr. Matthews was
“suspicious this may be more anxiety than an allergic reaction.” Id.

        Petitioner received emergency care for chest pain on January 12 and 13, 2017, at the
INOVA Loudoun Hospital and Reston Hospital, respectively. Pet. Ex. 5-1 at 96-123; Pet. Ex. 6
at 911, 947-49. She reported that she was very anxious. Pet. Ex. 6 at 911. On January 13, she
was brought to Kaiser Permanente via ambulance with a history of non-radiating left-sided chest
pain for two days. Pet. Ex. 3 at 198. “Of note, [patient] reports she had an allergic reaction to
(throat swelling and tightness) flu shot she received a few days ago and was treated with epi.
States she has had diarrhea since.” Id. Dr. Albert Cheung documented, “[t]he chest pain seems
to be elicited on palpation at the left costochondral junction consistently.” Id. at 199. Dr.
Cheung performed several labs and an EKG and assessed petitioner with “[n]o acute
cardiopulmonary disease.” Id. at 201-03. A repeat EKG was similar to the EKG in 2015. Id.
at 204.

        Dr. James Hollis interviewed and examined petitioner before approving discharge. Pet.
Ex. 3 at 205. He noted she received Toradol and felt “a little better.” Id. She rated her pain
“10/10 but was resting comfortabl[y] and walking in halls with no obvious discomfort. Also
making jokes and laughing.” Id. Diagnosis was “atypical chest pain likely costochondritis.”
Id. at 206. She was discharged with recommendations for rest, ice, or heat if they provided
relief of her symptoms, scheduled naproxen, Tylenol and Tramadol as needed. Id.

        Petitioner continued to seek emergency care for chest pain on multiple occasions
throughout 2017, and continued to report that her chest pain began in January after she received
her flu vaccine. Multiple repeat work ups were negative, repeat EKGs were unremarkable, and
the diagnosis remained costochondritis. See, e.g., Pet. Ex. 1 at 190, 217, 272; Pet. Ex. 3 at 233-
34, 278, 296, 329-38, 400, 403, 634-37, 648-70, 767, 774-76; 791-812, 824, 839; Pet. Ex. 5-1 at
305-81, 400; Pet. Ex. 6-9 at 347; Pet. Ex. 6-17 at 681; Pet. Ex. 6-22 at 868-70. On December
11, 2017, petitioner’s past medical history included “coronary artery spasms per patient-not
confirmed by cardiology.” Pet. Ex. 1 at 284. Additional diagnoses in December 2017 were
pericarditis6 and transient ischemic attack (“TIA”). Id.

        In July 2017, she was treated for reactive pericarditis “possibly related to the allergic
reaction after flu shot.” Pet. Ex. 3 at 766. However, a subsequent echocardiogram in May

6
  Pericarditis is inflammation of the pericardium, the fibrous sac surrounding the heart.
Pericarditis, Dorland’s Online Med. Dictionary,
https://www.dorlandsonline.com/dorland/definition?id=37749&searchterm=pericarditis (last
visited Jan. 5, 2022); Pericardium, Dorland’s Online Med. Dictionary,
https://www.dorlandsonline.com/dorland/definition?id=37750&searchterm=pericardium (last
visited Jan. 5, 2022).

                                                  5
2018 showed no evidence of pericarditis. Pet. Ex. 2 at 20.

        On August 29, 2017, petitioner visited cardiologist Dr. Joseph Kiernan, at Virginia Heart
for follow up of chest pain. Pet. Ex. 2 at 5. Dr. Kiernan documented,

       [Petitioner] is a 49-year-old female who is a consult to the office, referred by Dr.
       Benson Yu, for an evaluation of her persistent severe chest discomfort. She first
       noticed her left-sided chest pain several hours after receiving the flu shot in
       January. At that time, a cardiac evaluation was performed by her Kaiser doctors
       and her treadmill stress test was reportedly unremarkable. She is currently
       undergoing cardiac monitoring with a Zio patch. Subsequently, [petitioner] has
       noted eight episodes since the initial episode, lasting from one hour to all day.
       Less frequently, [petitioner] has experienced a severe central chest pressure.
       Over the past month, she reports that her symptoms have become more frequent,
       now occurring daily. She does not associate any triggers with her symptoms. . . .
       She does not smoke and her history is remarkable for atrial fibrillation,
       hypertension, Tietze syndrome, and a hiatal hernia. She has a family history of
       atrial fibrillation and stroke.

Id. Following examination, Dr. Kiernan’s impression was “Chest pain. Her recurring episodes
of chest pain over the past several months appear very atypical of angina.” Id. at 7. He also
noted petitioner’s previously documented hiatal hernia and esophagitis, “so esophageal spasm
may well be the underlying cause. Some features of her discomfort are also suggestive of chest
wall pain. She would appear to have a lower likelihood of significant coronary disease in the
absence of risk factors other than hypertension.” Id. Dr. Kiernan referred petitioner to a
gastrointestinal specialist. Id.

        On March 20, 2019, petitioner visited cardiologist Dr. Nadim Geloo, at Virginia Heart
“to discuss her diagnosis of coronary artery spasm.” Pet. Ex. 2 at 3. Dr. Geloo noted that
petitioner “apparently was told that she has coronary artery spasm. This first came to attention
when she received a flu shot and got chest pain.” Id. Petitioner reported she had continued
intermittent episodes of chest pain and her physician and a cardiologist at Kaiser Permanente
stated that “she might have coronary artery spasm and therapy was initiated . . . with amlodipine,
beta blocker and isosorbide mononitrate.” Id. Following evaluation, Dr. Geloo’s impression
was “[a]typical chest discomfort - she has previously been evaluated and there was some concern
about coronary artery spasm, however, it is not clear to me that she actually has spasm.
Regardless, she is on therapy for this.” Id. at 4. Under “Recommendation,” Dr. Geloo stated
that he was “not convinced that the patient truly ha[d] coronary artery spasm.” Id. Petitioner
asked for a prescription for Ativan and Dr. Geloo deferred this request to her primary care
provider or a pain specialist. Id.

        On January 21, 2020, petitioner returned to Virginia Heart for evaluation of hypertension
and recurrent chest pain. Pet. Ex. 2 at 1. Her allergy list included “Fluzone, irregular heart
rate,” and nitrates was listed as medication for chest pain. Id. Cardiologist, Dr. Subash B.
Bazaz, wrote,

                                                6
       She apparently has a history of chest pain felt to be due to coronary spasm. This
       occurred initially after she received a flu shot and developed what sounds like a
       severe inflammatory reaction which included chest pain, possible pericarditis, and
       what she describes as a fib. She was seen by a cardiologist at Kaiser and it was
       felt she might have had coronary vasospasm. She did bring it to my attention
       that Ativan in the past has worked very well for controlling her chest pain.

Id. Petitioner’s physical exam was normal, and an echocardiogram performed that day was
“within normal limits.” Id. at 2. Dr. Bazaz’s main impression was

       [c]hest pain with prior diagnosis of coronary vasospasm. Starting seemingly
       after a flu shot. Uncertain at this point if her chest pain is related to continued
       coronary vasospasm or not. I did tell [petitioner] that it can be very difficult to
       diagnose whether chest pain is truly due to vasospasm or other etiologies.

Id. Dr. Bazaz prescribed translingual nitroglycerin up to three times per day as needed for chest
pain. Id. He also ordered a stress test “to rule out any structural heart issues with the heart.”
Id. Finally, he told the petitioner that the fact that Ativan works well with her chest pain “raises
the issue of whether there is a muscular component to her chest pain symptom or perhaps even
an element of anxiety.” Id.

IV.    ANALYSIS

         When a petitioner fails to comply with Court orders to prosecute her case, the Court may
dismiss the case. Sapharas v. Sec’y of Health & Hum. Servs., 35 Fed. Cl. 503 (1996);
Tsekouras v. Sec’y of Health & Hum. Servs., 26 Cl. Ct. 439 (1992), aff’d, 991 F.2d 819 (Fed.
Cir. 1993); Vaccine Rule 21(c); see also Claude E. Atkins Enters., Inc. v. United States, 889 F.2d
1180, 1183 (Fed. Cir. 1990) (affirming dismissal of case for failure to prosecute for counsel’s
failure to submit pre-trial memorandum); Adkins v. United States, 816 F.2d 1580, 1583 (Fed.
Cir. 1987) (affirming dismissal of cases for failure of party to respond to discovery requests).
Petitioner’s failure to file an expert report indicates a disinterest in pursuing her claim. Thus,
the undersigned finds it appropriate to dismiss this case for failure to prosecute.

        Additionally, to receive compensation under the Act, a petitioner must prove either (1)
that she suffered a “Table Injury”—i.e., an injury falling within the Vaccine Injury Table—
corresponding to one of her vaccinations, or (2) that she suffered an injury that was actually
caused by a vaccine. See §§ 11(c)(1), 13(a)(1)(A).

        Here, a review of the records does not show that the petitioner suffered any heart
condition, or other compensable injury, related to the flu vaccine administered on January 10
2017. Petitioner had a previous history of chest pain prior to the flu vaccine dating back to 2008
and 2009. The chest pain was diagnosed as costochondritis. After receiving the vaccine,
petitioner reported that her throat tightened and that she had a similar reaction to lisinopril in the
past. Petitioner was treated with Benadryl, epinephrine, and Solumedrol, and she improved.
She was discharged home on the evening of her vaccination. There is no evidence of permanent
injury related to that episode of throat tightening and/or allergic reaction.

                                                  7
        On January 12 and 13, 2017, petitioner sought treatment for chest pain. She was
evaluated by two different ER physicians and had several EKGs, all assessed as normal, with no
significant changes from an EKG done in 2015. She had two or three sets of cardiac enzymes
drawn, which were all normal and did not show any evidence of heart ischemia or coronary
artery disease. All of the physicians who saw petitioner on those two days concluded that her
chest pain was not acute coronary syndrome or angina, and she was discharged home. The
chest pain was thought to be costochondritis. Additionally, petitioner was worked up for
pericarditis and that condition was ruled out. The petitioner has failed to submit expert opinion
that provides evidence of any vaccine related condition or illness arising from petitioner’s
admissions in January 2017.

        Two years after the vaccination at issue there is a reference to coronary artery spasms.
There is no evidence in the records that establish that petitioner underwent a cardiac
catheterization, an angiogram, or other diagnostic study that showed evidence of coronary artery
spasm. However, the records suggest that she was told she might have coronary artery spasms.
Assuming that petitioner did have coronary artery spasms, the petitioner has failed to provide
any expert opinion which shows that the condition was caused by her flu vaccine.

        Without an expert report providing evidence of vaccine causation, the undersigned finds
that the record does not support a claim under the Vaccine Act, or otherwise include
preponderant evidence demonstrating that petitioner sustained any vaccine injury.

        The undersigned expresses her sympathy for petitioner, and for the pain and suffering
that she has experienced, but unfortunately the case cannot proceed without proof of causation.

       Thus, this case is dismissed for failure to prosecute and for insufficient proof. The
Clerk shall enter judgment accordingly.

       IT IS SO ORDERED.

                                                    s/Nora Beth Dorsey
                                                    Nora Beth Dorsey
                                                    Special Master

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