12/9/2014
                    In the Missouri Court of Appeals
                            Eastern District

                                       DIVISION FOUR

SHANNON BROWN,                       )
Successor Personal Representative for the
                                     )               No. ED100593
Estate of Daniel Kruse, and Personal )
Representative for the Estate of     )               Appeal from the Circuit Court
Sharon Kruse,                        )               of St. Louis County
                                     )
     Appellant,                      )               Circuit Court No. 12SL-CC03169
                                     )
vs.                                  )
                                     )               Honorable Steven H. Goldman
SEVEN TRAILS INVESTORS, LLC, et al., )
                                     )               December 9, 2014
     Respondents.                    )



                                            Introduction

       Shannon Brown (Plaintiff), as successor personal representative for the estate of Daniel

Kruse and personal representative for the estate of Sharon Kruse, appeals the circuit court’s order

granting summary judgment for Seven Trails Investors, LLC and Madison Apartment Group, LP

(Defendants) on Plaintiff’s claims of negligence, nuisance, res ipsa, and gross negligence. In her

sole point relied on, Plaintiff claims that the circuit court’s summary judgment order is erroneous

because Plaintiff presented evidence demonstrating the existence of a material factual dispute.

We affirm in part, reverse in part, and remand for further proceedings.
                                                 Factual Background

           In July 2003, Sharon and Daniel Kruse1 began residing in an apartment located in

Ballwin, Missouri, which Defendants owned and managed. Over the years, the Kruses, who

were both smokers with severe chronic obstructive pulmonary disease (COPD), suffered from

numerous respiratory problems. In the fall of 2008, Daniel was admitted to the hospital and

developed a severe wound in his presacral area.2 The following spring of 2009, the Kruses

discovered what they believed to be mold in the apartment. The Kruses moved out of the

apartment in mid-July 2009. Daniel returned to the apartment once in late July 2009 to retrieve

the rest of their belongings. In August 2012, believing that mold had caused their respiratory

problems and that a brown recluse spider bite had caused Daniel’s wound, the Kruses filed a

petition against Defendants alleging negligence, nuisance, res ipsa, and gross negligence.

           Defendants moved for summary judgment, relying on the expert opinions of Drs. H.

James Wedner and Thomas Arnold. Dr. Wedner opined, to a reasonable degree of medical

certainty, that Sharon did not suffer adverse health effects from any mold that may have been

present in the apartment and that Sharon’s COPD was the most likely cause of her ailments.

Similarly, Dr. Wedner determined that Daniel’s repeated hospitalizations for pneumonia were

not caused by mold and that the most significant cause of Daniel’s respiratory ailments was his

smoking habit combined with other serious health conditions. Regarding the alleged spider bite,

Dr. Arnold determined that Daniel’s wound was not caused by a brown recluse spider bite, but a

pressure sore. Accordingly, because this evidence showed that mold and a brown recluse spider



1
 Sharon and Daniel Kruse originally filed this action. Both Sharon and Daniel are now deceased and Plaintiff is the
personal representative of their claims. We use the Kruses’ first names when referring to them individually. No
disrespect is intended.
2
    The presacral area is an area within the buttocks.


                                                         2
bite did not cause the Kruses’ alleged injuries and the Kruses had failed to present any contrary

evidence, Defendants asserted that they were entitled to summary judgment.

       In response, the Kruses filed a motion seeking additional time for discovery and to make

a response to Defendants’ motion. The circuit court granted the request. The Kruses then

deposed their treating physician, Dr. Jason Hand, and filed a supplemental response to

Defendants’ motion.    In their supplemental response, the Kruses asserted that Dr. Hand’s

testimony refuted Dr. Wedner’s opinion that the mold did not contribute to or cause their

ailments and also established that Daniel’s wound was consistent with a spider bite. Ultimately,

and without providing its reasons, the circuit court entered an order granting summary judgment

for Defendants. This appeal followed.

                                      Standard of Review

       Summary judgment is properly granted if there is no genuine issue of material fact and

the moving party is entitled to judgment as a matter of law. Rule 74.04(c)(6). If a party meets

its burden of establishing a prima facie case for summary judgment, the burden shifts to the

nonmoving party to demonstrate a genuine issue of the material fact. ITT Commercial Fin.

Corp. v. Mid-Am. Marine Supply Corp., 854 S.W.2d 371, 381-82 (Mo. banc 1993).                 “A

‘genuine’ dispute is a real and substantial one, not one consisting merely of conjecture, theory,

and possibilities.” Mueller v. Bauer, 54 S.W.3d 652, 657 (Mo. App. E.D. 2001).

       We review a circuit court’s decision on a motion for summary judgment de novo. Id. at

656. In doing so, we view all the legally admissible evidence in a light most favorable to the

non-moving party, giving the non-movant the benefit of all reasonable inferences from the

record. ITT Commercial Fin., 854 S.W.2d at 376. Where the circuit court does not set forth its

reasoning in its order granting summary judgment, we presume that the trial court based its




                                               3
decision on grounds specified in the movant’s motion for summary judgment. Central Mo. Elec.

Co-op. v. Balke, 119 S.W.3d 627, 635 (Mo. App. W.D. 2003).

                                                    Discussion

         In her sole point, Plaintiff asserts that the circuit court’s summary judgment order is

erroneous because Plaintiff presented evidence demonstrating the existence of a material factual

dispute. Specifically, in four subpoints, Plaintiff asserts that a genuine issue of fact exists

because: (1) this “battle of the experts” is not a proper forum for summary judgment; (2)

Plaintiff presented expert testimony to rebut Defendants’ motion; (3) this matter is subject to the

“sudden onset doctrine;” and (4) the nuisance claim does not require medical testimony. As

explained in the argument portion of Plaintiff’s brief, these arguments center on whether Plaintiff

met the burden of demonstrating a genuine issue of material fact as to whether the mold and the

brown recluse spider’s venom caused the Kruses’ injuries.3 For ease of resolution, we consider

Plaintiff’s subpoints out of turn.

         As in any tort case, Plaintiff is required to establish that Defendants’ conduct was an

actual cause of the Kruses’ injuries.4 Wagner v. Bondex Int’l, Inc, 368 S.W.3d 340, 348 (Mo.

App. W.D. 2012). Commonly referred to as “but for” cause or “cause in fact,” this requirement


3
  Plaintiff’s point relied on presents at least three claims of error and fails to concisely state the legal reason for
reversal or explain, in the context of the facts of this case, why these legal reasons support reversal, which violates
Rule 84.04(d). A deficient point relied on preserves nothing for review. See Jeffus v. Jeffus, 375 S.W.3d 862, 863
n.1 (Mo. App. W.D. 2012). However, because we are able to discern the basic contentions of Plaintiff’s arguments,
we exercise our discretion to ex gratia consider Plaintiff’s point.
4
  Causation is an element of all of Plaintiff’s claims. See Bickerton, Inc. v. Am. States Ins. Co., 898 S.W.2d 595, 600
(Mo. App. W.D. 1995) (“The elements of a negligence action are a legal duty . . . , breach of the duty, proximate
cause and actual damages.”); Christ v. Metro. St. Louis Sewer Dist., 287 S.W.3d 709, 711-12 (Mo. App. E.D. 2009)
(“Injury, damage, and causation are essential elements required for recovery on the basis of nuisance.”); Green v.
Plaza in Clayton Condo. Ass’n, 410 S.W.3d 272, 282 (Mo. App. E.D. 2013) (“[N]egligence under the res ipsa
loquitur doctrine [requires] three elements: (1) the incident would not ordinarily occur in the absence of negligence;
(2) the incident was caused by an instrumentality under the defendant’s control; and (3) the defendant has superior
knowledge about the cause of the incident.”); Edwards v. Gerstein, 363 S.W.3d 155, 165 (Mo. App. W.D. 2012)
(gross negligence requires the same showing as ordinary negligence, but requires a heightened mental state of
culpability).


                                                          4
stems from the common sense dictate that “there be some causal relationship between the

defendant’s conduct and the injury or event for which damages are sought.”                            Callahan v.

Cardinal Glennon Hosp., 863 S.W.2d 852, 862 (Mo. banc 1993). Once actual causation is

established, it is necessary to establish proximate cause, or legal cause, which requires some sort

of direct connection between the defendant’s conduct and the injury, in that the “harm is a

reasonable and probable consequence of the defendant’s conduct.” St. Louis v. Benjamin Moore

& Co., 226 S.W.3d 110, 114 (Mo. banc 2007).

        Further, in an action regarding liability for exposure to a toxic substance, establishing

causation often involves evidence of multiple factual predicates, including: “(l) an exposure to an

identified harmful substance significant enough to activate disease; (2) a demonstrable

relationship between the substance and biologic disease; (3) diagnosis of such disease in the

plaintiff; (4) expert opinion that the disease found in plaintiff is consistent with exposure to the

harmful substance; (5) defendant was responsible for the etiologic agent of the disease diagnosed

in plaintiff.”    Lewis v. FAG Bearings Corp., 5 S.W.3d 579, 585 (Mo. App. S.D. 1999).5

However, in considering whether Plaintiff has met her burden of establishing a genuine issue of

material fact as to causation, we are mindful of the Supreme Court’s cautionary explanation of

the causation analysis. Mainly, in undertaking such an analysis, courts “should not lose sight of

the ultimate issue:”

        All of this discussion concerning the semantics of causation is less important in
        Missouri than in most jurisdictions because under [the Missouri Approved
        Instructions] we do not use the terms 1) “proximate cause,” 2) “but for causation,”
        or 3) “substantial factor” when instructing the jury. We merely instruct the jury

5
  In the argument portion of her brief, Plaintiff suggests that the trial court applied the incorrect standard of
causation, asserting that she merely had to show that the mold contributed to the Kruses’ disease and suggesting that
the “manifold” level of proof necessary in toxic tort cases, such as Lewis, is inapplicable. This allegation of legal
error is not encompassed by Plaintiff’s point relied on and it is not preserved for our review. See Rule 84.04(e).
We, therefore, do not consider it.



                                                         5
        that the defendant’s conduct must “directly cause” or “directly contribute to
        cause” plaintiff’s injury. (Emphasis added).

Sundermeyer v. SSM Regional Health Servs., 271 S.W.3d 552, 555 (Mo. banc 2008) (citing

Callahan, 863 S.W.2d at 863).

                                         1. Sudden Onset Doctrine6

        We first address Plaintiff’s third subpoint that the “sudden onset doctrine” applies to this

case, meaning that expert testimony is not necessary to establish that the mold caused the

Kruses’ injures. Relying on State v. Norwood, 8 S.W.3d 242 (Mo. App. W.D. 1999), Plaintiff

asserts that the link between mold and respiratory problems is common knowledge and that the

jury could infer that the mold caused the injuries because the Kruses were sick while residing in

the apartment and “became better when they left.”7 Defendants respond that the sudden onset

doctrine does not apply.

        As noted, proof of causation in cases involving exposure to a toxic substance typically

requires a certain degree of scientific expertise. See Lewis, 5 S.W.3d at 585. This is because

“[t]he diagnosis of disease induced by environmental factors is essentially ‘a scientific

undertaking’ requiring proof which ‘the scientific community deems sufficient for that causal

link.’” Id. (citation omitted). As Defendants note, the requirement for expert testimony in cases

like the instant matter, coincides with the requisite proof of causation in medical injury cases,

where the cause of sophisticated injuries is not within a layperson’s common understanding and,

therefore, the plaintiff must establish the causal relationship through expert medical testimony.




6
  Plaintiff cites no authority to support her first subpoint that summary judgment is not permitted if the evidence
adduced involves a “battle of the experts.” Accordingly, we deem this subpoint abandoned. See Grant v. Sears, 379
S.W.3d 905, 917 (Mo. App. W.D. 2012).
7
  Plaintiff limits this argument to the mold and, therefore, we do not consider whether the sudden onset rule would
also apply to the spider bite.


                                                        6
See Brickey v. Concerned Care of the Midwest, Inc., 988 S.W.2d 592, 596-97 (Mo. App. E.D.

1999).

         The sudden onset doctrine, however, provides a limited exception to the necessity of

medical expert testimony to establish causation “when the facts fall within the realm of lay

understanding.” Williams v. Jacobs, 972 S.W.2d 334, 340 (Mo. App. W.D. 1998) (citation and

quotations omitted). Under the rule, causation may be established through the testimony of a lay

witness “where the obvious symptoms of the injury follow the trauma immediately, or with only

short delay, and the injury is the type that is normally sustained in the kind of trauma involved.”

Tucker v. Wibbenmeyer, 901 S.W.2d 350, 351 (Mo. App. E.D. 1995).

         Application of the rule depends on the facts of each case, but most often the rule is

applied in cases where a person suffers a broken bone or an open wound immediately after an

accident or within a short period of time after the accident. See id. In some instances, the rule

has even been applied where the person suffers from a pre-existing condition. See, e.g., Berten v.

Pierce, 818 S.W.2d 685, 687 (Mo. App. W.D. 1991) (applying sudden onset rule despite pre-

existing condition of a related, but different nature, which did not require scientific expertise).

But see Handshy v. Hasty, 444 S.W.2d 48, 53 (Mo. App. 1969) (declining to apply sudden onset

rule where pre-existing condition was very similar to the one for which the plaintiff claimed

damages and matter was highly complex). Comparatively, the rule will not apply where the

onset of the symptoms, complaints, or disability are sufficiently delayed from the event that

allegedly caused the injury.    See Tucker, 901 S.W.2d at 351; Berten, 818 S.W.2d at 687.

Additionally, the sudden onset doctrine will not apply “where there is specific medical evidence

suggesting that the cause of the injury was contrary to that suggested by the lay person’s [sic]

testimony.” Norwood, 8 S.W.3d at 248.




                                                7
       Here, the Kruses’ pre-existing conditions, including severe COPD and respiratory

ailments, are very similar to—if not the same as—those for which Plaintiff claims damages.

Because the claimed injuries and pre-existing conditions are not readily separable based on

common knowledge, this is exactly the type of highly complex case where expert medical

testimony is necessary to establish causation. See Handshy, 444 S.W.2d at 53. Moreover, the

medical opinion of Defendants’ expert directly contradicts Sharon’s testimony that the mold was

the cause of the Kruses’ injuries. Sharon testified that she did not have respiratory problems

until living in the apartment, that she continued to have breathing problems as a result of her

exposure to the mold, and that her condition improved after moving out of the apartment. She

also testified that Daniel contracted pneumonia “seven times in a year in a half” as result of the

mold and that he never contracted pneumonia before living in the apartment. Contrarily, Dr.

Wedner attested that the Kruses’ pre-existing respiratory ailments, including COPD and years of

smoking, were the cause of their health conditions, not mold. He further indicated that had mold

been the cause of the Kruses’ ailments, that they would have experienced a significant and

sustained improvement after moving out of the apartment, but that neither Daniel nor Sharon

experienced such an improvement.

       Under these circumstances, where a plaintiff’s pre-existing conditions are substantially

the same as the injuries alleged and expert testimony directly contradicts the lay opinion, a jury’s

common knowledge and experience is insufficient to aid it in reaching a reliable conclusion as to

causation. As such, Norwood, on which Plaintiff relies, is inapposite—the present claimed

injuries are clearly unlike the head injury and sudden onset of memory problems that the victim

suffered in Norwood, and which justified application of the rule. See Norwood, 8 S.W.3d at 248.

Sharon’s testimony that the mold caused her and Daniel’s injuries because her condition




                                                 8
improved when she left the apartment and because Daniel contracted pneumonia multiple times

while he resided in the apartment but not before, was not sufficient proof on the matter of

causation. We reject Plaintiff’s argument that the sudden onset rule obviates the need for expert

testimony. Subpoint denied.

                                 2. Expert Testimony of Causation

       Having concluded that expert testimony is necessary to establish causation in this case,

we turn to Plaintiff’s second subpoint that Plaintiff demonstrated a genuine issue of material fact

as to causation sufficient to avoid summary judgment. Because Plaintiff asserted that two

different toxins—mold and brown recluse spider venom—caused the Kruses’ injuries, Plaintiff’s

burden required her to demonstrate a causal connection between each of those toxins and the

alleged harm each of them suffered.           Accordingly, we consider the mold and spider bite

separately.

                                                 Mold

       Plaintiff asserts that Dr. Jason Hand’s testimony is sufficient to demonstrate a material

question of fact because Dr. Hand testified that the mold contributed to the Kruses’ medical

conditions and hospitalizations. Defendants respond that Plaintiff presented “no evidence” of

causation, that Dr. Hand’s opinion is based on assumptions, and that Plaintiff, thus, failed to

establish a genuine issue of material fact.

       To establish causation, the Kruses presented the deposition testimony of Mr. Jonah

Behrmann and Dr. Hand. Mr. Behrmann testified that he is an industrial hygienist employed by

a company that tests structures for environmental hazards, including mold. Mr. Behrmann

indicated that he investigated the Kruses’ apartment for mold in June 2009. Mr. Behrmann said

that he observed possible mold activity on the walls of the laundry room and ceiling in the




                                                   9
hallway. After making these observations, Mr. Behrmann took four samples to test for mold: a

“tape lift” from the suspect wall in the laundry room and an air sample from the laundry room,

living room, and balcony outside the apartment.8 The results of the tape lift indicated the

presence of high levels of stachybotrys, which is a type of mold, and the air samples also

reflected elevated levels of stachybotrys. Although these tests did not identify the specific

species of stachybotrys, only the genus level, Mr. Behrmann testified that stachybotrys is

“capable” of producing harmful “mycotoxins” and “may play a role in the development of sick

building syndrome.”

         Dr. Hand was Sharon’s treating physician since 2007 and testified that Sharon suffered

from morbid obesity, obesity hypoventilation syndrome,9 and severe COPD from being a former

smoker. Dr. Hand testified that throughout 2008 and 2009 Sharon experienced shortness of

breath and prolonged hypoxia, or low oxygen, and had to be provided with oxygen tanks.

According to Dr. Hand, Sharon’s oxygenation “miraculously” and dramatically improved—to

the extent that she no longer needed the oxygen tanks—after she moved out of the apartment in

July 2009. Given this “objective evidence” and assuming the existence of high levels of mold,

Dr. Hand testified to a reasonable degree of medical certainty that the mold contributed to the

shortness of breath and exacerbations of COPD that Sharon experienced before moving out of

the apartment. The following testimony was elicited:

                [Plaintiff’s counsel:] Now, let me ask you this. I want you to assume that
         there were high levels of mold in her apartment . . . . Within a reasonable degree


8
  A tape lift is a technique used to directly examine an area of possible mold growth, by pressing a piece of tape onto
the area and submitting it to laboratory analysis. An air sample is taken with a device that uses a flowmeter to force
15 liters of air per minute through a spore trap for approximately 10 minutes. Mr. Behrmann indicated that he
conducted these tests consistent with industry standards and that he sent the samples to a laboratory to obtain the
tests’ results.
9
  Dr. Hand explained that this syndrome affects morbidly obese people and makes it difficult to breathe because of
the excess tissue pushing against the diaphragm.


                                                         10
       of medical certainty, was this mold contributing to cause the problems that she
       was having with her breathing and COPD?

               [Dr. Hand:] It’s – it’s much more likely with her because we saw
       objective evidence of dramatic improvements in her oxygenation after she moved
       out.

              [Plaintiff’s counsel:] And therefore, within a reasonable degree of
       medical certainty, is it – would you believe that that shortness of breath problem
       she was experiencing would have been due to these high levels of mold?

             [Dr. Hand:] Much more likely. Probably 70 or 80 percent certainty. . . .
       Reasonable certainty.

Dr. Hand further testified “to a reasonable degree of certainty” that the mold contributed to

Sharon’s continued and ongoing respiratory problems because her exposure to high amounts of

mold would make her sensitive to future re-exposure.

       Dr. Hand was also Daniel’s treating physician beginning in 2009. Dr. Hand indicated

that Daniel had been a smoker for many years and suffered from heart disease, vascular disease,

and advanced COPD. Dr. Hand explained that exposure to high concentrations of mold will

cause a person who is sensitive to mold to have exacerbation of their disease and that Daniel was

“definitely more susceptible to changes in environmental exposures.” In his testimony, Dr. Hand

recounted Daniel’s multiple admissions for pneumonia over the summer of 2009 and noted that

once the Kruses’ moved out of the apartment, Daniel had one admission for an “unrelated”

cardiac event, but was admitted again for respiratory failure in January 2010. Based on the

assumption that high levels of mold existed in the Kruses’ apartment, Dr. Hand testified that the

mold contributed to Daniel’s multiple hospitalizations for pneumonia in the summer of 2009 by

making the COPD worse and putting a strain on his heart. Dr. Hand explained:

              [Daniel] had multiple admissions for respiratory problems over the
       summer . . . and then bam, they move out, he’s reexposed [in late July 2009], he
       has one more admission. They move out and then the next admission is several
       months later . . . [for a] completely unrelated issue . . .



                                               11
               So what’s compelling is when he was exposed to the environment he had
        multiple admissions for respiratory issues. When he was removed from the
        environment he had a relatively stable few months . . . .

                                           *        *        *

               Given that [Daniel’s] hospitalization stopped for lung disease for a three-
        month span for – well, longer than that. So – so his last hospitalization for a
        pulmonary issue was in August [2009], his next hospitalization for a pulmonary
        issue was in January. So given that all of that stopped when he moved out of the
        apartment, I – there is some degree of medical certainty, a reasonable amount, that
        mold contributed to his COPD, to his exacerbations.[10]

        Contrary to Defendants’ assertions, the testimony of Mr. Behrmann and Dr. Hand, and

the reasonable inferences drawn therefrom, establishes the requisite evidence of causation

necessary to avoid summary judgment. Mr. Behrmann’s testimony sufficiently demonstrates

that the Kruses were exposed to high levels of mold, which was capable of producing

mycotoxins. Dr. Hand opined to a reasonable degree of medical certainty that the Kruses’

exposure to this high level of mold contributed to and worsened their respiratory problems.

Based on his observations in the course of the Kruses’ treatment and review of their medical

records, Dr. Hand concluded that these effects were consistent with the Kruses’ exposure to

harmful mold given that both Daniel’s and Sharon’s medical conditions improved after vacating

the apartment.

        This evidence plainly refutes Defendants’ assertion that Plaintiff presented “no evidence”

of “any particular airborne agent capable of [producing] disease” in the Kruses and “no

evidence” of “sensitivity to any particular airborne agent.” Certainly, Plaintiff did not adduce

any direct evidence as to the identity of the harmful mold or that the Kruses were sensitive to

such a mold, i.e., evidence of the exact species of stachybotrys present or that either Daniel or

10
  With respect to the January 2010 admission, Dr. Hand testified that the mold did not cause this admission but that
he was “100 percent” certain that the summer admissions left Daniel in a weaker state and contributed to the January
admission.


                                                        12
Sharon had tested positive for an allergy to stachybotrys after an allergy test. However, such

direct evidence is not required to establish causation. The “identity of the toxic substances to

which the harm is attributed may be shown by circumstantial evidence,” Lewis, 5 S.W.3d at 585,

as may the connection between the Kruses’ exposure to that substance and the harm suffered,

Coggins v. Laclede Gas Co., 37 S.W.3d 335, 339 (Mo. App. E.D. 2000). Here, when the

evidence is viewed in a light most favorable to Plaintiff, it is clear that she provided sufficient

evidence, if just barely, from which to reasonably deduce that the mold in the Kruses’ apartment

exacerbated their respiratory ailments.

       Defendants also contend, citing Thomas v. FAG Bearings Corp., 846 F. Supp. 1382

(1994), that Plaintiff’s causation evidence is insufficient because Dr. Hand’s causation testimony

is based on three assumptions: (1) that high levels of mold existed in the Kruses’ apartment; (2)

that the Kruses’ are sensitive to an unidentified airborne agent; and (3) that that agent induced

allergic reactions in Daniel and Sharon. It is true that to have probative value, an expert opinion

must not consist of conjecture or speculation, but be founded upon facts and data. Gaddy v.

Skelly Oil Co., 259 S.W.2d 844, 849 (Mo. 1953). As such, “[i]f an expert witness is called, the

facts in evidence, coupled with those available to the witness from the witness’s own

investigation, must be sufficient to take the expert testimony out of the realm of guesswork.”

Mueller, 54 S.W.3d at 658. If an expert’s opinion is premised on such guesswork, or is mere

conjecture or imagination, then it is insufficient to demonstrate a genuine issue of material fact

necessary to avoid summary judgment. See City of Green Ridge v. Kreisel, 25 SW 3d 559, 561

(Mo. App. W.D. 2000).

       Contrary to Defendants’ characterization of the record, Dr. Hand did not assume that the

Kruses would be susceptible to the mold or that mold caused their symptoms. All that Plaintiff’s




                                                13
attorney asked Dr. Hand to assume was that the Kruses had been exposed to high levels of mold

in their apartment. After making this assumption, Dr. Hand then concluded that the Kruses were

susceptible to the mold and that the mold contributed to their ailments. Significantly, this

opinion was not based on assumptions, but on Dr. Hand’s medical training and experience, his

review of Daniel’s and Sharon’s relevant medical records, and his medical observations during

the treatment of both Daniel and Sharon. Further, the “assumption” that the Kruses were

exposed to high levels of mold is not simply conjecture or speculation, as Defendants assert, but

is supported by actual facts in the record—mainly Mr. Behrmann’s testimony as to the high

levels of mold found in the Kruses’ apartment. This case is thus unlike Thomas, where the

expert’s opinion was not based on any factual data in the record, and instead relied on conjecture.

See Thomas, 846 F. Supp at 1394. Consequently, Dr. Hand’s causation testimony cannot

reasonably be characterized as lacking factual support for summary judgment purposes.

Subpoint granted as to the mold.

                                           Spider Bite

       Plaintiff also asserts that she demonstrated a genuine issue of fact as to the cause of

Daniel’s presacral wound because Dr. Hand testified that the wound was the result of either a

brown recluse spider bite or necrosis. Defendants respond that the uncontroverted evidence

shows that a brown recluse spider did not cause Daniel’s wound.

       The only evidence of causation that Plaintiff provided regarding the cause of Daniel’s

wound was Dr. Hand’s testimony that he had reviewed Daniel’s medical records, that both a

spider bite and necrosis were included in the differential diagnosis, and that there was “no degree

of certainty which caused it.” “When a party relies on expert testimony to provide evidence of

causation when there are two or more possible causes, that testimony must be given to a




                                                14
reasonable degree of medical certainty.” Mueller, 54 S.W.3d at 657. Clearly, Dr. Hand was

unable to determine the cause of Daniel’s wound with reasonable probability and simply

indicated it was a matter of speculation whether a spider bite or necrosis caused the wound.

Because the gist of Dr. Hand’s testimony is that a spider bite might have caused the wound, his

testimony does not constitute “substantive, probative evidence on which a jury could find

ultimate facts and liability.” See id. Plaintiff has failed to demonstrate a genuine issue of fact

sufficient to avoid summary disposition. Rice v. Hodapp, 919 S.W.2d 240, 243 (Mo. banc 1996)

(a “genuine” dispute is a “real and substantial one,” not one consisting merely of conjecture,

theory, and possibilities). Subpoint denied as to the spider bite.

                                            3. Nuisance

       In her fourth subpoint, Plaintiff asserts that the trial court erred in granting summary

judgment because a nuisance claim requires no medical expert testimony. In support, Plaintiff

discusses Frank v. Envtl. Sanitation Mgmt, Inc., 687 S.W.2d 876 (Mo. banc 1985), and the

distinction between nuisance per se and nuisance in fact, but does not explain the relevance of

her assertion that medical expert testimony is not necessary to support a nuisance claim. In any

case, Frank does not stand for the proposition that medical expert testimony is not required in

nuisance cases. Moreover, because causation is an essential element of recovery for a nuisance

claim, Plaintiff was required to establish causation. See Christ v. Metro. St. Louis Sewer Dist.,

287 S.W.3d 709, 711-12 (Mo. App. E.D. 2009). As we have already concluded, expert medical

testimony is required to show causation under the facts of this case. Subpoint denied.

                                            Conclusion

       Having reviewed the record in a light most favorable to Plaintiff, we conclude that

Plaintiff demonstrated a genuine issue of material fact with respect to whether the mold caused




                                                 15
the Kruses’ injuries. However, Plaintiff failed to demonstrate a genuine issue of material fact

with respect to whether a brown recluse spider bite caused Daniel’s wound. Accordingly, the

circuit court erred by granting Defendants summary judgment as to claims related to the mold,

but did not err by granting Defendants summary judgment as to claims related to the spider bite.

We affirm the trial court’s judgment in part, reverse in part, and remand for further proceedings

consistent with this opinion.



                                            ________________________________
                                            Philip M. Hess, Judge

Lisa Van Amburg, P.J. and
Patricia L. Cohen., J. concur.




                                               16
