Court Opinion

ID: 5121008
Source: CourtListenerOpinion
Date Created: 2021-10-25 20:02:59.013142+00
Date Added: 2024-06-11T08:22:20.408010
License: Public Domain

In the United States Court of Federal Claims
                                          No. 18-361V
                               (Filed Under Seal: October 8, 2021)
                          (Reissued for Publication: October 25, 2021) 1

***************************************
MICHAEL BULL,                         *
                                      *
                  Petitioner,         *
                                      *               Vaccine Act; Motion for Review; Influenza
v.                                    *               Vaccine; Nature of Injury; Brachial Neuritis;
                                      *               Consideration of Evidence; Causation;
SECRETARY OF HEALTH AND HUMAN *                       Althen Prongs Two and Three
SERVICES,                             *
                                      *
                  Respondent.         *
***************************************

Mark T. Sadaka, Englewood, NJ, for petitioner.

Mollie D. Gorney, United States Department of Justice, Washington, DC, for respondent.

                                    OPINION AND ORDER

SWEENEY, Senior Judge

        Petitioner Michael Bull seeks compensation under the National Childhood Vaccine Injury
Act of 1986 (“Vaccine Act”), 42 U.S.C. §§ 300aa-1 to -34 (2018), alleging that he developed
brachial neuritis as a result of an influenza vaccination. In an April 20, 2021 decision, the chief
special master denied petitioner’s request for compensation. Before the court is petitioner’s
motion for review of that decision. As discussed below, the court denies petitioner’s motion and
sustains the decision of the chief special master.

                                       I. BACKGROUND

        Petitioner filed his petition for compensation under the Vaccine Act on March 8, 2018.
After he filed his medical records and other relevant fact evidence, the chief special master held
a fact hearing regarding the onset of petitioner’s injury. The parties then filed expert reports and

       1
          Vaccine Rule 18(b), set forth in Appendix B of the Rules of the United States Court of
Federal Claims, affords each party fourteen days in which to object to the disclosure of (1) trade
secrets or commercial or financial information that is privileged or confidential or (2) medical
information that would constitute “a clearly unwarranted invasion of privacy.” Neither party
objected to the public disclosure of any information contained in this opinion.
medical literature, and respondent filed a motion for a ruling on the record. When respondent
filed his motion, the record included petitioner’s medical records; petitioner’s sworn affidavit;
sworn certifications from petitioner, petitioner’s coworker, and petitioner’s ex-wife; hearing
testimony from petitioner and petitioner’s ex-wife; two expert reports; and eleven pieces of
medical literature. The court briefly summarizes the relevant facts from these sources.

                                        A. Medical Records

        Petitioner was born in 1959. On October 4, 2016, he was admitted to the hospital upon
complaining of chest pain. He remained hospitalized overnight, and the following morning, he
received an influenza vaccination in his left arm. He was discharged from the hospital later that
day. 2 The records from the hospitalization do not reflect that petitioner suffered adverse effects
from the vaccination.

        On October 12, 2016, petitioner was seen by his primary care physician to follow up after
his discharge from the hospital. He was treated for a rash on his left hand, which was diagnosed
as ringworm. Absent from the provider’s record is any reference to the influenza vaccination or
any complaints concerning petitioner’s left arm.

        Petitioner next visited his primary care physician on December 6, 2016, complaining of
numbness and tingling in his left arm that began after he received his influenza vaccination. He
told his physician that he was dropping things due to the numbness and that pain radiated into his
fingers and shoulder. The physician performed a physical examination and noted decreased
sensation to light touch in petitioner’s left arm, tenderness at the vaccination site, and generally
intact grip strength. He assessed petitioner with neuropathy and prescribed a month’s supply of
gabapentin.

        On December 30, 2016, petitioner visited an urgent care center due to pain he was
experiencing in his right flank after falling from a ladder nine days previously. Although the
urgent care center record indicates a past medical history of left-arm neuropathy due to the
influenza vaccine, the physician who saw petitioner indicated that petitioner did not report any
muscle pain or weakness, and upon examination, found that petitioner had normal strength and
tone in his upper extremities.

       There are no medical treatment records dated after December 30, 2016, but pharmacy
records indicate that petitioner obtained three refills of his gabapentin prescription, with the last
one obtained on April 9, 2017.

       2
          In his decision, the chief special master states that petitioner was hospitalized from
October 4 to October 6, 2016. See Bull v. Sec’y of HHS, No. 18-361V, slip op. at 2 (Fed. Cl.
Spec. Mstr. Apr. 20, 2021). However, the hospital’s records reflect that petitioner was
discharged on October 5, 2016. See Pet’r’s Ex. 2 at 17, 53. This minor discrepancy does not
affect the outcome of the case.

                                                 -2-
                    B. Affidavits, Certifications, and Hearing Testimony

        In written and oral testimony, petitioner and his ex-wife provided additional details
regarding the vaccination, the symptoms petitioner experienced thereafter, and the reasons for
the paucity of medical records addressing those symptoms. 3 With respect to the latter issue, they
explained that they had a general reluctance to visit health care providers or take medicine unless
there was a serious problem, that there was a lack of financial resources during periods of time
when petitioner was uninsured, and that when seeing a health care provider, petitioner tended
only to discuss symptoms related to the reason for the visit.

        The chest pain that petitioner was experiencing in October 2016 was serious enough for
petitioner to seek medical treatment. Ultimately, he was admitted to the hospital where he
received the influenza vaccine. The vaccination was painful and he immediately had difficulty
raising his left arm, but he did not say anything to the nurse at that time. However, at his ex-
wife’s urging, he later told a nurse about the pain, and the nurse advised him that the pain would
go away. The day after he was discharged from the hospital, the pain evolved into a burning
sensation from his shoulder to his hand. He continued to work through the pain, but was unable
to perform certain tasks at his job rehabbing houses, such as hanging kitchen cabinets and
drywall.

        Petitioner was still experiencing pain, numbness, and tingling in his left arm when he
visited his primary care physician one week after his hospitalization. He did not mention these
symptoms, however, because they were not the purpose of the visit and he thought that the
symptoms would go away. In fact, he did not even mention the rash on his hand. Rather, the
physician noticed it himself and prescribed a treatment.

        In conjunction with his left-arm symptoms, petitioner began to drop things, such as
cigarettes, without realizing that he had dropped them. He also dropped paint pots he was using
at work, and was unable to carry forty- or fifty-pound feed bags. The numbness and tingling
were occurring every four or five minutes. By Thanksgiving, he was unable to grasp or hold
heavy objects with his left hand, and was unable to help clean and set the table like he normally
did. He continued to experience pain, as well as stinging and burning at the vaccination site.

        When petitioner ultimately saw his primary care physician for his left-arm symptoms on
December 6, 2016, the physician advised him that there was not much he could do except to
prescribe gabapentin, and that the symptoms should resolve in six-to-twelve months. Petitioner’s
symptoms continued to affect his work, preventing him from performing certain tasks and
requiring him to compensate by using his right hand as much as he could. He also continued to
drop things, such as Christmas ornaments, without noticing. Eventually, the frequency of his
symptoms decreased and his range of motion improved, but he continued to experience pain and
to drop things.

       3
          The chief special master found petitioner and petitioner’s ex-wife to be honest and
therefore credited their testimony regarding petitioner’s postvaccination symptoms.

                                                -3-
        Since his last gabapentin refill, petitioner’s pain symptoms have improved, but he still
suffers from occasional numbness and tingling.

                          C. Expert Reports and Medical Literature

        In support of his petition for compensation, petitioner submitted an expert report from an
orthopedic surgeon, Paul F. Nassab, M.D.; two pieces of medical literature attached to Dr.
Nassab’s report (a case series and a case report); and six other pieces of medical literature (four
case reports, a book chapter, and a case series). In his expert report, Dr. Nassab opined that
based on his symptoms, petitioner suffered from Parsonage-Turner syndrome, which is also
known as brachial plexus neuritis or just brachial neuritis. Dr. Nassab further opined that
brachial neuritis can be caused by an influenza vaccination, as demonstrated by the case report
he attached to his expert report; that the onset and timing of petitioner’s symptoms were
consistent with a postvaccination brachial neuritis; and that the prevailing cause of petitioner’s
injury was the influenza vaccination. The case series attached to Dr. Nassab’s expert report (but
not discussed by Dr. Nassab) is a retrospective review of magnetic resonance image findings and
clinical information for twenty-seven patients diagnosed with Parsonage-Turner syndrome. Of
the four case reports submitted by petitioner separate from Dr. Nassab’s expert report, two
concern brachial neuritis following an influenza vaccination, one concerns brachial neuritis
following a swine flu vaccination, and one concerns brachial neuritis following rotator cuff
surgery. The book chapter submitted by petitioner generally addresses brachial neuritis, and the
case series submitted by petitioner focuses on the treatment of neuropathic and musculoskeletal
pain with gabapentin.

        Respondent, in turn, submitted an expert report from a neurologist, Raymond S. Price,
M.D., and four pieces of medical literature relied upon by Dr. Price (three case series and the
same case report relied upon by Dr. Nassab). In his expert report, Dr. Price opined that
petitioner’s presentation of symptoms was inconsistent with a diagnosis of brachial neuritis. He
explained that muscle weakness and wasting is a hallmark of brachial neuritis, but that there is
no evidence that petitioner suffered from such symptoms. Rather, he elaborated, the medical
records reflect that petitioner had normal strength in his left arm and an intact left grip, and
petitioner’s dropping of items and inability to fully raise his arm were reasonably explained by,
respectively, petitioner’s numbness and pain. Dr. Price further opined that the timing of the
onset of petitioner’s symptoms was inconsistent with brachial neuritis because brachial neuritis is
presumed to be immune-mediated, and immune-mediated processes require time to activate the
immune system. Indeed, Dr. Price observed, in the case report that Dr. Nassab relied upon,
symptoms of brachial neuritis did not begin to occur until three days after the vaccination.
Finally, Dr. Price remarked that petitioner never received a confirmed diagnosis of brachial
neuritis––either through examination by a neurologist or with testing (nerve conduction studies
and needle electromyography).

                            D. The Chief Special Master’s Decision

        On April 20, 2021, the chief special master decided respondent’s motion for a ruling on
the record. After a review of petitioner’s medical history, the expert reports, and the applicable
law, the chief special master concluded that petitioner had not established that he suffered from

                                                -4-
brachial neuritis due to the lack of such a diagnosis by his treating physicians, as well as the lack
of demonstrated muscle weakness and wasting. With respect to the latter reason, the chief
special master was persuaded by Dr. Price’s opinion that petitioner “lacked the required clinical
indicia or other testing results . . . that would confirm a diagnosis of brachial neuritis.” Bull, slip
op. at 18. The chief special master determined, in short, that “brachial neuritis does not ‘more
likely than not’ explain Petitioner’s injury––and this could reasonably be grounds for the claim’s
dismissal . . . .” Id.

        Nevertheless, the chief special master assumed, for the sake of argument, that petitioner
suffered from brachial neuritis and thus analyzed petitioner’s claim under the test for causation
set forth in Althen v. Secretary of HHS:

       [Petitioner]’s burden is to show by preponderant evidence that the vaccination
       brought about [the] injury by providing: (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 a
       proximate temporal relationship between vaccination and injury.

418 F.3d 1274, 1278 (Fed. Cir. 2005). With respect to the first prong, he concluded that
petitioner had submitted reliable evidence––in the form of case reports––to support his
contention that the influenza vaccine can cause brachial neuritis, but that such evidence was not
preponderant. Turning to the third prong, the chief special master found, based on the honest,
credible testimony of petitioner and petitioner’s ex-wife, that petitioner’s left-arm symptoms
began immediately after his vaccination. Given that finding, he determined that petitioner had
not established that the onset of his injury occurred within a medically accepted period of time
because––as reflected by the case report relied upon by Dr. Nassab, Dr. Price’s expert report, and
an article relied upon by Dr. Price––symptoms of brachial neuritis would not manifest
immediately after vaccination. Next, addressing the second prong, the chief special master
concluded that petitioner did not establish that the influenza vaccine did cause his injury, noting
that there was no evidence that petitioner experienced an inflammatory process that would
indicate an immune-mediated response to the vaccine.

        As a final matter, the chief special master explained that the overall thinness of the record
hampered petitioner’s ability to establish a preponderance of the evidence in support of his
claim. This thinness specifically affected petitioner’s ability to establish that he suffered from
brachial neuritis, that the influenza vaccine could cause brachial neuritis, and the severity of his
injury. The chief special master ultimately granted respondent’s motion and dismissed
petitioner’s claim.

       Petitioner timely sought review of the chief special master’s decision. Respondent
subsequently filed his response to the motion for review, and the court heard argument on
October 8, 2021. The motion is now ripe for adjudication.

                                                  -5-
                                         II. DISCUSSION

        In his motion for review, petitioner enumerates, pursuant to Vaccine Rule 24, two
objections to the chief special master’s decision. 4 First, petitioner avers that the chief special
master did not consider medical facts and medical literature supporting a diagnosis of brachial
neuritis. Second, petitioner asserts that the chief special master did not consider facts and peer-
reviewed medical literature relating to the onset and causation of his injury. 5 As a consequence
of these purported errors, petitioner contends, the chief special master improperly raised his
burden of proof such that he was required to establish with certainty that the influenza vaccine
caused his injury. Petitioner further contends that the chief special master’s fact findings were
arbitrary and capricious. Petitioner accordingly requests that the court set aside the chief special
master’s findings of fact and conclusions of law, and either (1) issue its own findings and
conclusions, and determine that he is entitled to compensation, or (2) remand the case to the
chief special master for further proceedings.

                                      A. Standard of Review

       The United States Court of Federal Claims has jurisdiction to review the record of the
proceedings before a special master, and upon such review, may:

       (A) uphold the findings of fact and conclusions of law of the special master and
       sustain the special master’s decision,

       (B) set aside any findings of fact or conclusion of law of the special master found
       to be arbitrary, capricious, an abuse of discretion, or otherwise not in accordance
       with law and issue its own findings of fact and conclusions of law, or

       (C) remand the petition to the special master for further action in accordance with
       the court’s direction.

42 U.S.C. § 300aa-12(e)(2). The standards set forth in section 12(e)(2)(B) “vary in application
as well as degree of deference. . . . Fact findings are reviewed . . . under the arbitrary and
capricious standard; legal questions under the ‘not in accordance with law’ standard; and
discretionary rulings under the abuse of discretion standard.” Munn v. Sec’y of HHS, 970 F.2d
863, 870 n.10 (Fed. Cir. 1992). Specifically, with respect to the special master’s fact findings,

       4
          Petitioner numbered his objections differently in his memorandum in support of his
motion for review. Objections “1” and “2” in the motion for review are numbered “1.1” and
“1.2” in the supporting memorandum. Objections “1” and “2” in the memorandum set forth
petitioner’s arguments regarding the legal consequences of the purported deficiencies described
in objections “1.1” and “1.2.” The court addresses petitioner’s arguments regarding the legal
consequences in conjunction with the purported deficiencies.
       5
          Petitioner characterizes this objection as relating only to the onset of his injury (Althen
prong 3), but two of the arguments he advances relate to whether his injury was caused by the
influenza vaccine (Althen prong 2).

                                                 -6-
the court does “not reweigh the factual evidence, assess whether the special master correctly
evaluated the evidence, or examine the probative value of the evidence or the credibility of the
witnesses—these are all matters within the purview of the fact finder.” Porter v. Sec’y of HHS,
663 F.3d 1242, 1249 (Fed. Cir. 2011); see also Hodges v. Sec’y of HHS, 9 F.3d 958, 961 (Fed.
Cir. 1993) (“[O]n review, the Court of Federal Claims is not to second guess the Special
Master[’]s fact-intensive conclusions; the standard of review is uniquely deferential for what is
essentially a judicial process.”). “Rather, as long as a special master’s finding of fact is ‘based
on evidence in the record that [is] not wholly implausible, [the court is] compelled to uphold that
finding as not being arbitrary or capricious.’” Porter, 663 F.3d at 1249 (first alteration in the
original) (quoting Cedillo v. Sec’y of HHS, 617 F.3d 1328, 1338 (Fed. Cir. 2010)).

                                        B. Legal Standard

        The objections set forth in petitioner’s motion for review relate to the chief special
master’s determination that petitioner did not meet his burden of proving that the influenza
vaccine caused his injury, which he identifies as brachial neuritis. As an initial matter, because
injuries may have significantly different causes and pathologies, “identifying the injury is a
prerequisite to the analysis” of causation. Broekelschen v. Sec’y of HHS, 618 F.3d 1339, 1346
(Fed. Cir. 2010). Indeed, “if the existence and nature of the injury itself is in dispute, it is the
special master’s duty to first determine which injury was best supported by the evidence
presented in the record before applying the Althen test to determine causation of that injury.”
Lombardi v. Sec’y of HHS, 656 F.3d 1343, 1352 (Fed. Cir. 2011); accord Hibbard v. Sec’y of
HHS, 698 F.3d 1355, 1365 (Fed. Cir. 2012) (“If a special master can determine that a petitioner
did not suffer the injury that she claims was caused by the vaccine, there is no reason why the
special master should be required to undertake and answer the separate (and frequently more
difficult) question whether there is a medical theory, supported by ‘reputable medical or
scientific explanation,’ by which a vaccine can cause the kind of injury that the petitioner claims
to have suffered.” (quoting Althen, 418 F.3d at 1278)).

       As noted above, to prove causation under the Vaccine Act, a petitioner must

       show by preponderant evidence that the vaccination brought about [his] injury by
       providing (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 a proximate temporal relationship
       between vaccination and injury.

Althen, 418 F.3d at 1278; see also Boatmon v. Sec’y of HHS, 941 F.3d 1351, 1355 (Fed. Cir.
2019) (noting that a petitioner must “prove[] all three Althen prongs by a preponderance of the
evidence”). Under the first prong, a petitioner must demonstrate that the vaccine at issue can
cause the injury alleged. Pafford v. Sec’y of HHS, 451 F.3d 1352, 1355-56 (Fed. Cir. 2006). To
make this showing, “a petitioner must provide a reputable medical or scientific explanation that
pertains specifically to the petitioner’s case, although the explanation need only be ‘legally
probable, not medically or scientifically certain.’” Broekelschen, 618 F.3d at 1345 (quoting
Knudsen v. Sec’y of HHS, 35 F.3d 543, 548-49 (Fed. Cir. 1994)). The second prong requires a
petitioner to show “that the vaccine was the ‘but for’ cause of the harm,” Pafford, 451 F.3d at

                                                -7-
1356, or, in other words, “‘that the vaccine actually caused the alleged symptoms in [the]
particular case,’” id. (quoting the decision of the special master as recited by the trial court).
Establishing the third prong “requires preponderant proof that the onset of symptoms occurred
within a timeframe for which, given the medical understanding of the disorder’s etiology, it is
medically acceptable to infer causation-in-fact.” de Bazan v. Sec’y of HHS, 539 F.3d 1347,
1352 (Fed. Cir. 2008); accord Althen, 418 F.3d at 1281 (describing the requirement as “a
medically-acceptable temporal relationship between the vaccination and the onset of the alleged
injury”). In short, a petitioner is required “to prove, by a preponderance of the evidence, that the
vaccine was not only a but-for cause of the injury but also a substantial factor in bringing about
the injury.” Shyface v. Sec’y of HHS, 165 F.3d 1344, 1352 (Fed. Cir. 1999); see also Moberly v.
Sec’y of HHS, 592 F.3d 1315, 1322 n.2 (Fed. Cir. 2010) (“The burden of showing something by
a ‘preponderance of the evidence,’ the most common standard in the civil law, simply requires
the trier of fact to believe that the existence of a fact is more probable than its nonexistence
before [he] may find in favor of the party who has the burden to persuade the [judge] of the
fact’s existence.” (quoting Concrete Pipe & Prods. of Cal., Inc. v. Constr. Laborers Pension Tr.
for S. Cal., 508 U.S. 602, 622 (1993))).

        Generally, “[t]he determination of causation in fact under the Vaccine Act involves
ascertaining whether a sequence of cause and effect is ‘logical’ and legally probable, not
medically or scientifically certain.” Knudsen, 35 F.3d at 548-49. Thus, causation can be
established with circumstantial evidence––in other words, with medical records or medical
opinion. Althen, 418 F.3d at 1279-80 (citing 42 U.S.C. § 300aa-13(a)(1)); see also Knudsen, 35
F.3d at 548 (observing that the “‘logical sequence of cause and effect’ must be supported by a
sound and reliable medical or scientific explanation” (citing Daubert v. Merrell Dow Pharms.,
Inc., 509 U.S. 579 (1993); Jay v. Sec’y of HHS, 998 F.2d 979, 984 (Fed. Cir. 1993))). A
petitioner “need not produce medical literature or epidemiological evidence to establish
causation,” but “where such evidence is submitted, the special master can consider it in reaching
an informed judgment as to whether a particular vaccination likely caused a particular injury.”
Andreu v. Sec’y of HHS, 569 F.3d 1367, 1379 (Fed. Cir. 2009). But see LaLonde v. Sec’y of
HHS, 746 F.3d 1334, 1341 (Fed. Cir. 2014) (“In Vaccine Act cases, petitioners must proffer
trustworthy testimony from experts who can find support for their theories in medical literature
in order to show causation under the preponderance of the evidence standard. The level of
specificity of such support may vary from circumstance to circumstance.”).

   C. The Chief Special Master’s Consideration of Evidence Related to the Diagnosis of
                 Petitioner’s Injury Was Not Arbitrary and Capricious

        Petitioner’s first enumerated objection is that the chief special master did not consider all
of the evidence in the record supporting a diagnosis of brachial neuritis, and therefore improperly
raised his burden of proof. In particular, petitioner contends that the chief special master
“overemphasized and/or misapprehended the role of ‘muscle weakness and wasting’”; 6 failed “to

       6
         Petitioner contends that “both experts agree that [muscle weakness and wasting] can
sometimes only be seen by expensive testing,” Pet’r’s Mem. 4, but Dr. Nassab’s report does not
mention testing at all, and Dr. Price merely states that electromyography testing “is frequently
                                                 -8-
consider that only 30% of the people who develop brachial neuritis have muscle wasting,” 7
failed “to consider testimony that [petitioner] had documented weakness and was unable to lift
bags of feed”; failed to consider “direct evidence that petitioner was suffering from brachial
neuritis”––the tingling and numbness petitioner reported to his primary care physician on
December 6, 2016—despite the “classical presentation of brachial neuritis [being] the sudden
onset of intense shoulder pain any time after the triggering event followed by localized weakness
or hypothesia/paresthesia”; 8 and did not recognize that “the presence of weakness is not required
for a diagnosis of brachial neuritis.” 9 Pet’r’s Mem. 4-5. Respondent counters that the chief
special master properly concluded that the record did not support a diagnosis of brachial neuritis,
remarking that none of petitioner’s treating physicians diagnosed petitioner with brachial
neuritis; that the contemporaneous medical records lack any evidence of muscle weakness or
wasting; that medical literature submitted by petitioner confirms that muscle weakness is a main
characteristic of brachial neuritis; that petitioner’s inability to lift feed bags was never attributed
to muscle weakness (rather than pain or numbness); and that the chief special master’s decision
to credit Dr. Price’s opinion was proper, especially given Dr. Nassab’s failure to explain why
petitioner’s symptoms supported a diagnosis of brachial neuritis.

helpful in distinguishing neuromuscular weakness from weakness secondary to pain,” Resp’t’s
Ex. A at 3.
       7
         In support of this contention, petitioner relies on a case series of twenty-seven patients
diagnosed with Parsonage-Turner syndrome in which all of the “patients either reported having
shoulder weakness or were found to have shoulder weakness,” Pet’r’s Ex. 13 at 3, and “[n]ine
(30%) shoulders were noted at [magnetic resonance] imaging to have muscular atrophy,” id. at 4.
       8
           The case report from which petitioner derives this classical presentation provides:

       [Parsonage-Turner syndrome] usually occurs after an inciting event . . . .

               Historically, the classical form of this syndrome presents with excruciating
       pain, anytime up to a few weeks following an inciting event, with subsequent
       localized weakness or hypothesia/paresthesia in certain areas innervated by the
       affected nerves. However, motor deficits are more common than sensory
       involvement.

Pet’r’s Ex. 19 at 1; accord id. at 4 (“The classical presentation typically manifests within the first
few weeks of inciting events and is characterized by pain and motor weakness.”). The onset of
the “right upper extremity weakness” in the patient described in the case report occurred ten
weeks after rotator cuff surgery. Id. at 1.
       9
         The authors of the case report on which petitioner relies for this proposition do not state
that muscle weakness is not required for a brachial neuritis diagnosis. See generally Pet’r’s Ex.
16. Moreover, they describe a patient who had “mild, but detectable, left deltoid weakness.” Id.
at 3.

                                                  -9-
        Petitioner primarily focuses on the chief special master’s findings pertaining to muscle
weakness and wasting, challenging the chief special master’s statement that these two symptoms
were important features of brachial neuritis. Petitioner’s argument is not persuasive because the
chief special master’s statement is amply supported by the evidence in the record, including Dr.
Price’s expert report and every piece of medical literature submitted by the parties that addresses
brachial neuritis. 10 Furthermore, it was reasonable for the chief special master to rely on Dr.
Price’s opinion that there is a lack of clinical evidence of brachial neuritis in the record. Dr.
Price explained that petitioner’s medical records from December 2016 indicate that petitioner
had normal strength in his left arm, and lack any indication that he lost muscle bulk in his left
arm. Consequently, Dr. Price concluded and the chief special master agreed that the most
reasonable explanations for petitioner’s dropping of objects and inability to lift his left arm was
numbness and pain, respectively, and not muscle weakness.

        There is no requirement that a special master discuss every piece of evidence in the
record when making a factual finding. See, e.g., Snyder v. Sec’y of HHS, 36 Fed. Cl. 461, 466
(1996) (“The special master need not discuss every item of evidence in the record so long as the
decision makes clear that the special master fully considered a party’s position and arguments on
point.”), aff’d, 117 F.3d 545 (Fed. Cir. 1997); see also Hazlehurst v. Sec’y of HHS, 604 F.3d
1343, 1352 (Fed. Cir. 2010) (noting that a reviewing court presumes that the fact finder has
considered all of the material in the record, regardless of whether it is mentioned in his or her
decision). In this case, it is readily apparent from the extensive factual recitation in his decision
that the chief special master considered all of the evidence in the record, even if he did not
specifically mention each potentially relevant fact. Further, his factual findings were supported
by that record: brachial neuritis is characterized by muscle weakness and there is limited
evidence in the record that petitioner suffered from muscle weakness. Petitioner had the burden
of establishing that he suffered from brachial neuritis by preponderant evidence, and the chief
special master did not heighten that burden by seeking objective evidence that petitioner
experienced a key symptom of that injury.

        In short, it was not arbitrary or capricious for the chief special master to conclude that
petitioner had not established by a preponderance of evidence that he suffered from brachial
neuritis. Because petitioner’s theory of causation depends upon a diagnosis of brachial neuritis,
this conclusion alone requires the court to deny petitioner’s motion for review. Nevertheless, the
court will address petitioner’s other objection to the chief special master’s decision.

    D. The Chief Special Master’s Consideration of Evidence Related to the Onset and
           Causation of Petitioner’s Injury Was Not Arbitrary and Capricious

        In his second enumerated objection, petitioner asserts that the chief special master did not
consider facts and medical literature related to the onset and causation of his injury, specifically
identifying four purported deficiencies. First, petitioner contends that the chief special master
ignored the book chapter on brachial neuritis, which supports the possibility of a one-day onset
of brachial neuritis after the triggering event. Second, in apparent contradiction to his first

       10
          Only one article does not concern brachial neuritis: the case series concerning the
treatment of neuropathic and musculoskeletal pain with gabapentin.

                                                -10-
argument, his own testimony (which the special master found to be credible), and his own
expert’s report, petitioner contends that the onset of his injury was not immediate because no
symptoms related to his left arm are mentioned in the record of his visit with his primary care
physician on October 16, 2016. Third, petitioner maintains that the record includes evidence that
the influenza vaccination caused an inflammatory response (indicating an immune-mediated
reaction that is generally understood to be the cause of brachial neuritis) 11––the tenderness on his
left arm at the vaccination site noted by his primary care physician on December 6, 2016––and
that the chief special master improperly required him to provide evidence of an inflammatory
process when such evidence does not exist due to the cost of obtaining the necessary medical
treatment and testing. Fourth, petitioner asserts that the chief special master did not consider the
causal link purportedly drawn by his primary care physician between the influenza vaccination
and his injury. In response, respondent contends that there is no indication that the chief special
master disregarded evidence in the record concerning the onset of petitioner’s injury, that the
evidence in the record supports the chief special master’s finding that the onset of whatever
injury petitioner sustained from the vaccination was immediate rather than between one and
twenty-eight days, that the evidence in the record supports the chief special master’s finding that
the onset of brachial neuritis could not occur immediately after an influenza vaccination, and that
Dr. Nassab did not explain how the tenderness petitioner exhibited on December 6, 2016, was
evidence of an inflammatory response to the October 5, 2016 influenza vaccination.

         In his first two contentions, petitioner complains that the chief special master did not
consider evidence in the record (a book chapter and a medical record) related to the timing of the
onset of brachial neuritis postvaccination. He argues that this evidence, which pertains to the
third Althen prong, demonstrates that his injury did not manifest until at least eleven days after
his influenza vaccination and, to the extent the weight of the evidence instead reflects a one-day
onset, that brachial neuritis can occur between one and twenty-eight days postvaccination.
Petitioner’s argument fails for two reasons. First, there is no indication that the chief special
master failed to consider the book chapter or medical record identified by petitioner. In his
decision, the chief special master described the contents of the medical record and quoted the
portion of petitioner’s response brief for which petitioner relied on the book chapter. 12 Second,
the chief special master reasonably found that petitioner’s injury manifested before the one-to-
twenty-eight-day time frame petitioner urges. Petitioner and his ex-wife testified that petitioner
experienced pain and was unable to fully lift his arm immediately after he received the influenza
vaccination. Because the chief special master regarded petitioner and his ex-wife to be honest,
he credited this testimony and found that the onset of petitioner’s injury was immediate (in other
words, before the one-day minimum petitioner espouses). Further, to the extent that petitioner’s
failure to mention his left-arm symptoms to his primary care physician on October 16, 2016,
constitutes evidence of a later onset date, the chief special master was entitled to give little
weight to that evidence, especially since petitioner explained that he was in fact experiencing

       11
          Petitioner avers that “both experts agree that brachial neuritis is caused by an
inflammatory process,” Pet’r’s Mem. 6, but Dr. Nassab does not make such a statement in his
expert report.
       12
          The chief special master refers to this portion of petitioner’s response brief as “Pet.
Reply at 12” rather than “Pet. Resp. at 12.”

                                                -11-
symptoms at that time. See, e.g., Koehn v. Sec’y of HHS, 773 F.3d 1239, 1244 (Fed. Cir. 2014)
(remarking “that it is within the Special Master’s discretion to weigh the relevant evidence”).

        In his remaining two contentions, petitioner asserts that the chief special master
disregarded evidence in the record indicating that the influenza vaccine did, in fact, cause his
injury––the third prong of Althen. He specifically identifies this evidence as vaccination-site
tenderness that his primary care physician observed in December 2016 and his primary care
physician’s purported linking of his injury to his vaccination. With respect to the former,
petitioner does not identify any evidence in the record supporting the proposition that
vaccination-site tenderness two months postvaccination indicates an inflammatory response to
the vaccine. With respect to the latter, the record lacks any evidence that petitioner’s primary
care physician ever linked petitioner’s left-arm symptoms to his vaccination. There is, however,
an urgent care center record on which it is noted that petitioner had a history of left-arm
neuropathy due to the influenza vaccine. But there is no indication that this notation reflects the
treating physician’s determination that petitioner’s injury was caused by the vaccine. 13

        More generally, petitioner claims that by requiring him to produce “evidence, direct or
indirect, of an inflammatory process that could be attributed to an immune reaction,” Bull, slip
op. at 21, the chief special master was penalizing him for lacking the financial resources to visit a
medical provider more frequently or undergo testing that could confirm his diagnosis. While the
court is sympathetic to petitioner’s situation, the Vaccine Act provides no mechanism for the
special masters or the court to take into account a petitioner’s financial circumstances when
ascertaining whether he or she has provided a preponderance of evidence that a vaccine caused
the complained-of injury. Moreover, it does not heighten petitioner’s burden to require him to
provide such evidence.

        In sum, it was not arbitrary or capricious for the chief special master to conclude that
petitioner did not establish by a preponderance of evidence that his injury manifested within a
medically acceptable time frame postvaccination and that his injury was actually caused by the
influenza vaccine.

                                       III. CONCLUSION

        As the chief special master found, the evidence in the record reflects that petitioner
experienced a painful, debilitating injury to his left arm that manifested when he received an
influenza vaccination on October 5, 2016, and that he continues to suffer residual effects from
that injury. And it very well may be that the vaccine caused that injury. But, given petitioner’s
insistence that his injury was brachial neuritis, the chief special master could not reach that
conclusion in the absence of preponderant evidence that petitioner actually suffered from
brachial neuritis and that the influenza vaccine caused that brachial neuritis. The chief special
master reasonably concluded that petitioner had not satisfied his burden on either point.

       13
           Indeed, petitioner testified that he “might have” given that history to the providers at
the urgent care center. Hr’g Tr. 64.

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Accordingly, the court DENIES petitioner’s motion for review and SUSTAINS the decision of
the chief special master. The clerk is directed to enter judgment accordingly.

      IT IS SO ORDERED.

                                                  s/ Margaret M. Sweeney
                                                  MARGARET M. SWEENEY
                                                  Senior Judge

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