                  In the United States Court of Federal Claims
                                      OFFICE OF SPECIAL MASTERS
                                                No. 15-696V
                                             (to be published)

*************************
                           *
ARLYNE ROTHENBERG,         *                                                Special Master Corcoran
                           *
               Petitioner, *                                                Filed: April 19, 2018
                           *
          v.               *
                           *                                                Tetanus Diphtheria Acellular
SECRETARY OF HEALTH        *                                                Pertussis (“Tdap”); Autoimmune
AND HUMAN SERVICES,        *                                                Injury; Lipodystrophy; Onset;
                           *                                                Preexisting Symptoms.
               Respondent. *
                           *
*************************

John McHugh, New York, NY, for Petitioner,

Heather L. Pearlman, U.S. Dep’t of Justice, Washington, DC, for Respondent.


                      DECISION ON RECORD DENYING COMPENSATION1

       On July 6, 2015, Arlyne Rothenberg filed a petition seeking compensation under the
National Vaccine Injury Compensation Program (the “Vaccine Program”).2 Petitioner claims that
a variety of symptoms she suffered (including pain in her joints, bones, and muscles, plus
abdominal cramping, neuropathies in her limbs, gastrointestinal distress, and microcytic anemia)
were autoimmune in nature, and all caused by the Tetanus-diphtheria-acellular pertussis (“Tdap”)
vaccine she received on July 21, 2012. See Petition (“Pet.”) at 1 (ECF No. 1).


1
  Because this Decision contains a reasoned explanation for my actions in this case, I will 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 (2012). As
provided by 42 U.S.C. § 300aa-12(d)(4)(B), however, the parties may object to the published Decision’s inclusion of
certain kinds of confidential information. Specifically, under Vaccine Rule 18(b), each party has fourteen days within
which to request redaction “of any information furnished by that party: (1) that is a trade secret or commercial or
financial in substance and is privileged or confidential; or (2) that includes medical files or similar files, the disclosure
of which would constitute a clearly unwarranted invasion of privacy.” Vaccine Rule 18(b). Otherwise, the whole
Decision will be available to the public. Id.
2
 The Vaccine Program comprises Part 2 of the National Childhood Vaccine Injury Act of 1986, Pub. L. No. 99-660,
100 Stat. 3758, codified as amended at 42 U.S.C. §§ 300aa-10 through 34 (2012) (“Vaccine Act” or “the Act”).
Individual section references hereafter will be to § 300aa of the Act (but will omit that statutory prefix).
        After submitting expert reports, the parties agreed to have the Petition decided on the
papers instead of via a hearing. I have now had the opportunity to review all filings in the case and
the parties’ respective arguments, and I hereby DENY entitlement. As discussed in greater detail
below, Petitioner’s symptoms and alleged injury are more readily attributable to sequelae she
experienced from gastric bypass surgery she underwent 20 years ago than to the Tdap vaccine. In
addition, Petitioner’s causation theory is unreliable and unpersuasive.



I.       Factual Background

         Vaccination and Subsequent Medical History

        Petitioner, then 55 years old, received the Tdap vaccine on July 21, 2012, at Urgent Care
Manhattan in New York City after stabbing her right hand with a box cutter a few days before. Ex.
12 at 4; Pet. at ¶2; see also Ex. 4 at 140; Ex. 10 at 3; Ex. 21 at 3. Her medical history at the time
of vaccination was extensive and included anxiety disorder, depression, and neuropathic pain, as
well as having undergone gastric bypass surgery in 1993. Ex. 3 at 4, Ex. 11-1 at 89. In addition,
Ms. Rothenberg had suffered from osteomalacia3 secondary to the gastric bypass, and had a history
of bilateral hip pain. Ex. 3 at 10, Ex. 13 at 1. She also received treatment in the past for
hypothyroidism, gluten sensitivity, colitis, anemia, Hashimoto’s disease, chronic kidney disease,
and hernia surgery. Ex. 1 at 6; Ex. 3 at 4, 10; Ex. 5 at 1; Ex. 8 at 2; Ex. 11 at 1; and Ex. 12 at 4.

        The medical records set forth no initial complaints of an adverse reaction to the July 2012
vaccination. The next medical record chronologically is from August 27, 2012 (nearly five weeks
post-vaccination), when Petitioner saw Dr. Ira Breit at Westside Medical Associates to treat “skin
problems.” Ex. 2 at 6-7. Ms. Rothenberg specifically complained of itchy skin, a problem she
claimed to have experienced since her teen years, and also stated that she was suffering from bone
and muscle pain. She requested that she receive some kind of hormone therapy treatment from Dr.
Breit at this time, although he agreed only to perform a blood test. Id. at 6. After examination, Dr.
Breit’s impression was that Petitioner had alopecia and a rash, along with vitamin D and iron
deficiencies of an unspecified etiology. Id. at 7. This record does not refer at all to the July Tdap
vaccination.

      On September 14, 2012, Ms. Rothenberg returned (after a two-year interval) to the
Osteoporosis Center at the NYU Hospitals Center in New York City, complaining of severe pain


3
 Osteomalacia is the adult equivalent of the childhood disease rickets, and is characterized by “inadequate or delayed
mineralization” of bone matrix in cortical or spongy bone. Dorland’s Illustrated Medical Dictionary 1346 (32nd ed.
2012) (hereinafter “Dorland’s”). Like rickets, it can be caused by vitamin D or calcium deficiencies, whether
attributable to diet or underlying malabsorption abnormalities. Dorland’s at 1644.
                                                          2
in her joints and muscles “over the past few months” (a timeframe that could extend to, or beyond,
the date of her Tdap vaccination). Ex. 3 at 1. She saw Dr. Stephen Honig, a rheumatologist with a
special interest in osteoporosis. She also complained of burning skin, and related the view that her
vitamin D deficiency (which she had found difficult to treat) interfered with her ability to remedy
her bone pain. Id. On examination, the only noted abnormality was a mild ridging of Petitioner’s
first carpal metacarpal joint on the left wrist. Id. Dr. Honig prescribed medication to increase
Petitioner’s calcium levels, and considered injections of vitamin D as well. Like the August record,
however, this medical record does not refer to the July Tdap vaccination, and Dr. Honig’s
assessment only included conditions that Ms. Rothenberg was already known to have, like
osteomalacia. Id.

        The following month, Petitioner returned to Dr. Honig several times. Ex. 3 at 1-4. On
October 12, 2012, she reported that her pain had lessened after using a sun lamp to increase her
vitamin D levels, although she was still experiencing bone and muscle pain. Id. at 1-2. Her
diagnosis remained the same from her September visit, however, and Dr. Honig characterized her
as “in no acute distress.” Id. at 2. On October 15, 2012, Dr. Honig reviewed the results of the blood
testing he had previously ordered, observing an improvement in her vitamin D level, but also
noting that she remained anemic, and displayed a high erythrocyte sedimentation rate (“ESR”),4
which can reflect ongoing inflammation. Based upon the foregoing, Dr. Honig proposed that “there
may be another reason for her diffuse pain” beyond her osteomalacia. Id. at 4.

        Then, on October 17, 2012 (now nearly three months post-vaccination), Ms. Rothenberg
returned to the NYU Hospitals Center, complaining of bone and muscle pain similar to what she
had previously reported, and was seen by Dr. Tibor Moskovits, a hematologist. Ex. 3 at 4-6.
Although Dr. Moskovits observed Ms. Rothenberg to be in “mild distress,” she was deemed
normal after examination. Id. at 6. Dr. Moskovits proposed that her persistent anemia was
attributable to an iron deficiency, and offered several possible treatments for it. He also speculated
that the observed ESR increase could be the result of a decreased hemoglobin level. Id. at 6.

        A week later, Petitioner returned to Dr. Honig at the Osteoporosis Center on October 24,
2012. Ex. 3 at 6-10. She complained of pain consistent with her prior reports, but added that she
now also felt aching in her legs. At this visit, Petitioner specifically mentioned the incident from
July that resulted in her receipt of the Tdap vaccine, and voiced her belief that her symptoms had
since that time “exploded.” Id. Dr. Honig offered no additional views as to the proper diagnosis


4
  Erythrocyte Sedimentation Rate or “ESR” is a blood test used to show inflammatory activity in the body. Sed Rate
(Erythrocyte Sedimentation Rate), Mayo Clinic, https://www.mayoclinic.org/tests-procedures/sed-rate/about/pac-
20384797 (last accessed Apr. 4, 2018). It measures the distance red blood cells fall in a test tube in one hour. Id. The
further the cells descend in the tube, the greater evidence of an inflammatory response of the immune system. Id.

                                                           3
for her symptoms or their etiology, however – nor did he state that he concurred with Petitioner’s
suspicions as to a potential relationship between her Tdap vaccination and her ongoing symptoms.

        Efforts to Identify Alternative Causes for Petitioner’s Pain

        Later in the fall of 2012, Petitioner saw other kinds of specialists in a quest to identify the
cause of her symptoms. On November 5, 2012, Ms. Rothenberg was evaluated by Dr. Michael
Holick, an endocrinologist at Boston Medical Center in Massachusetts. Ex.13 at 1-3. The record
from this visit reveals that Ms. Rothenberg had been “in touch” with Dr. Holick since 2005,
“complaining of osteomalacia symptoms” which she associated (consistent with prior records)
with her gastric bypass surgery. Id. The record’s notations are consistent with those from October
2012 (e.g. an ongoing vitamin D deficiency, complaints of aches and pains, etc.), but Petitioner
did not mention her Tdap vaccination. Dr. Holick noted that Petitioner was “healthy-appearing,”
but ordered additional tests to see if some explanation for her pain and related symptoms could be
obtained. Id. at 2.

        Next, in mid-November, Ms. Rothenberg saw another endocrinologist, Dr. Robert Lind of
the NYU Hospital Center, based on Dr. Honig’s prior referral. Ex. 3 at 10-11. Dr. Lind understood
the reason for the visit was to evaluate and treat Petitioner’s long-existing vitamin D deficiency
plus “hyperparathyroidism,” although Petitioner did inform Dr. Lind that she believed her bone
and muscle pain had worsened after the July vaccination. Id. at 10. She informed Dr. Lind of her
recent visit to Dr. Holick, and that he had speculated that she might have Ehlers-Danlos syndrome.5
Id. at 11. Dr. Lind was unable to propose an explanation for Ms. Rothenberg’s symptoms other
than her “underlying osteomalacia,” but suggested additional testing, including a bone and skeletal
survey. Id. at 13. X-rays of Petitioner’s hands and feet performed later that month were consistent
only with osteomalacia, however, as was the skeletal survey, although the bone scan that had been
ordered could not be completed. Id. at 14-21.

        2013 Hospitalizations

        The next records most directly relevant to Petitioner’s claim are from February 2013 – now
over six months from the date of vaccination.6 On February 1, 2013, Ms. Rothenberg was admitted

5
 Ehlers-Danlos syndrome is an umbrella term describing a group of connective tissue disorders and characterized by
hyperextensible joints, bruisability, and poor wound healing, among other things. Dorland’s at 1828.
6
  In the late evening of December 26, 2012, Ms. Rothenberg went to the emergency department of New York
Presbyterian-Weill Cornell Hospital, primarily complaining of a “funny feeling on face.” Ex. 4 at 2. In the process,
she also complained of muscle dysfunction over the prior 10 days, but did not mention any of the bone or muscle pain
symptoms previously described herein. Id. at 4. Her vital sign measurements were normal, however, and the record
from this emergency visit sets forth no diagnosis or assessment of the cause of her complained symptoms. Id. at 5-6.
                                                         4
to Mount Sinai Hospital in New York from its emergency department after complaining of a
number of symptoms. See generally Ex. 11-1 at 30-34. In particular, she reported experiencing
painful diarrhea that had been ongoing for two weeks, but added as well her belief that her
“problems” had begun six months before, after her Tdap vaccine had triggered a “neuropathy” in
her arms and stomach (although she also admitted that she had repeatedly experienced similar
symptoms once or twice a year since the gastric bypass operation, and that the symptoms typically
resolved on their own). Id. at 30, 38.

        Ms. Rothenberg obtained an initial evaluation from a gastroenterologist, Dr. Peter Chang.
Ex. 5 at 1-14. Her vital signs were deemed normal and stable over the time of her admission, and
her oxygen saturations were normal, as was the physical examination. Ex. 11-1 at 40-41. The initial
differential diagnosis focused on a variety of possible gastroenterologic illnesses and disorders,
and a wide variety of tests were proposed, including performance of a colonoscopy, stool studies,
endoscopic evaluations of the upper gastrointestinal system, and gut tissue biopsies. Id. at 42.
Besides Dr. Chang, Petitioner also received treatment from a hematologist, Dr. Robert Krafter,
who evaluated her anemia and recommended that it could be treated if Petitioner more strictly
followed the proper diet for a person who had previously received gastric bypass surgery. Id. at
43, 48.

        Ms. Rothenberg was discharged from Mt. Sinai on February 12, 2013. Ex. 11-1 at 27-28.
On discharge, she was diagnosed as having “intestinal malabsorption,” the treatment of which
would require follow-up testing. Id. at 28. But the anemia, diarrhea, and vitamin deficiencies she
displayed after hospital testing were all deemed to have been successfully treated. Id. A few weeks
after, Dr. Chang prepared a handwritten summary of his treatment and assessment of Petitioner
after seeing her for a follow-up visit. Ex. 5 at 15. That note stated that the esophago-duodenal
(EGD) biopsy that was performed on Petitioner was negative. Id. Dr. Chang also allowed for the
possibility that all of Petitioner’s symptoms were ultimately related to nutritional deficiency, but
proposed that he see Ms. Rothenberg again in a few weeks to evaluate her overall recovery. Id.

        On March 8, 2013, Ms. Rothenberg was admitted a second time to Mt. Sinai after returning
to its emergency room, now complaining of shortness of breath and headache, along with acute
chest and left arm pain. Ex. 11-4 at 328, 330. The pain had begun after Ms. Rothenberg had ceased
receiving intravenous feeding from a catheter line inserted after her last hospitalization, and there
was an initial concern that the site of the line’s insertion might be infected. Id. at 330; Ex. 11-6 at
595. The attending ER physician recommended that Petitioner be admitted as an inpatient because
she appeared “chronically ill” and malnourished, and felt there was a risk of “short term
decompensation” if she were not admitted. Ex. 11-4 at 328.



                                                  5
        Petitioner remained at Mt. Sinai until March 21, 2013. Ex. 11-4 at 335-38. Eventually her
treaters determined that she had experienced a thrombus in the left subclavian vein associated with
the point of insertion of the intravenous feeding line, and also likely did have a related infection.
Id. at 338; Ex. 11-6 at 532. Test results were otherwise normal. Id. at 596-605. Her discharge
summary included no reference to her other prior conditions, like osteomalacia, as having any
connection to the hospitalization, nor did it mention her July 2012 vaccination.

           Subsequent Treatments and Record References to Lipodystrophy

        Over the next nine months, Petitioner’s health remained mostly stable - although it was not
especially robust, as the same kinds of problems that led her to seek treatment before continued to
plague her. In the spring and summer of 2013, Ms. Rothenberg sought additional treatment for her
anemia and concurrent iron deficiency. See, e.g., Ex. 6 at 1, 4, and 6-8. She also obtained medical
assistance with her feeding catheter. Ex. 11-8 at 715; Ex. 5 at 15-16. She had an additional
overnight hospitalization on October 21-22, 2013, due to complaints of chest pain, palpitations
and shortness of breath. Ex. 11-9 at 756, 770. The main assessment from that short admission was
gastric malabsorption attributable to her dependence on intravenous feeding. Id. at 786, 789.

        Petitioner’s primary identified vaccine injury is lipodystrophy, or defective fat metabolism
that can result in the absence of subcutaneous fat.7 Record references to this disorder exist – but
they are spotty at best, and do not suggest that Ms. Rothenberg was in fact ever formally so
diagnosed. For example, Petitioner went to Dr. Joseph Jorizzo, a dermatologist, in October 2013
complaining of a growth on her face that she feared was related to scleroderma (attributable in turn
to the same kind of malabsorption issues she had experienced in the past). Ex. 14 at 1. Dr. Jorizzo
did not confirm her suspicions, however, and after examination largely counseled her to protect
her skin in commonly-understood ways, such as through the use of sunblock. Id. at 4.8

         Ms. Rothenberg also returned to Dr. Chang again in October 2013, reporting concerns of
“abdominal distending” that had occurred “overnight.” Ex. 5 at 16. Dr. Chang observed a
“significant excess of skin and adipose tissue above [the] abdominal musculature,” but maintained
that “the problem” was attributable merely to a lack of exercise and resulting muscle loss, adding
that it was unlikely the change had occurred as quickly as Petitioner maintained. Id.


7
    Dorland’s at 1062.
8
  In May 2015, Ms. Rothenberg consulted Dr. Harry Spiera, a rheumatologist, who stated unequivocally: “I do not
find any evidence of scleroderma [petitioner expressed concern that she had it] or any other autoimmune disease.” Ex.
8 at 2. In so doing, he referenced Petitioner’s self-reported history of experiencing dramatic health changes after
receipt of the Tdap vaccine. Id. at 1.

                                                         6
        Ms. Rothenberg saw Dr. Jorizzo again in December 2013 – now representing that she was
experiencing “skin thinning” all over her body. Ex. 14 at 5. She also reported to Dr. Jorizzo that
her condition had been “diagnosed to be acquired lipodystrophy” – although the medical record
contains no such diagnosis prior to this time. Id. Dr. Jorizzo examined Ms. Rothenberg again, and
although the “encounter diagnoses” include the phrase “partial lipodystrophy,” it does not appear
from this record that Dr. Jorizzo was embracing this as a reasonable potential diagnosis. Id. at 7.
Indeed – consistent with his examination two months before, Dr. Jorizzo largely seems to have
concluded that Petitioner had no identifiable skin problems, and spent some time explaining this
to her. See, e.g., id. at 7 (“rediscuss why not scleroderma”).

        From this point on, there are large temporal gaps in the medical record before Petitioner’s
alleged injuries are again referenced. Petitioner returned to Dr. Jorizzo six months later, on June
28, 2014, at which time she complained that her skin condition remained “unstable,” but after
examination Dr. Jorizzo identified “no objective derm findings.” Ex. 14 at 9, 11. Although he
included lipodystrophy in the encounter diagnoses section of his write-up, he recorded his view
that “the subcutaneous manifestations the patient describes are . . . from delayed metabolic issues
from bariatric surgery.” Id. at 11. No mention of lipodystrophy as an ongoing issue or concern is
included in the record from Petitioner’s September 2014 visit with Dr. Jorizzo. Id. at 13-15.

       In September 2014, Petitioner returned to Westside Medical Associates and saw Dr.
Stephanie Rein, an internist (whom Petitioner had also seen earlier that year as well). Ex. 2 at 83-
84. A “progress note” from this visit references “lipodystrophy - loss of connective tissue.
Triggered by tetanus shot??” Id. at 83. But the reference is not explained, and this record overall
suggests Petitioner’s primary reason for seeking medical help on this occasion was for treatment
of insomnia. Id. at 84. The diagnoses from this visit with Dr. Rein do not include lipodystrophy.
Id.

        In mid-December 2014, Ms. Rothenberg went to Dr. Zvi Osterweil - an ear, nose, and
throat (“ENT”) specialist – for evaluation of possible obstructive sleep apnea. Ex. 7 at 1. The notes
from this visit include lipodystrophy in Petitioner’s medical history, and also mention it as a feature
of her current health. Id. at 2. It does not appear, however, that Dr. Osterweil so diagnosed
Petitioner. Five months later, in May 2015, Petitioner consulted with Dr. Eric Smouha, another
ENT at Mount Sinai Hospital. Ex. 9 at 1. Dr. Smouha stated that the consult was for “problems
with both ears secondary to lipodystrophy,” and that Petitioner was there because she “was
diagnosed with lipodystrophy 3 years ago after a DPT shot.” Id. If temporally accurate, this would
mean that Petitioner received the diagnosis in May 2012 – before the vaccination – although as
noted above there is no such diagnosis found anywhere in the medical records from 2012 filed in
this case. Dr. Smouha deemed the reports of ear shrinking “subjective,” although (apparently

                                                  7
accepting as true Petitioner’s reported lipodystrophy diagnosis) he allowed for the possibility that
some of her condition could be reflective of lipodystrophy. Id. at 2.

II.     Expert Reports

        A.       Dr. Yehuda Shoenfeld

        Dr. Shoenfeld prepared two reports filed on Petitioner’s behalf in this case. Report, dated
December 1, 2016, filed as Ex. 20 (ECF No. 42) (“First Shoenfeld Rep.”); Report, dated April 24,
2017, filed as Ex. 22 (ECF No. 48-1) (“Second Shoenfeld Rep.”). Dr. Shoenfeld identifies himself
as the current head of the Center for Autoimmune Diseases, which he founded at the Sheba
Medical Center in Israel. Shoenfeld CV, dated Dec. 1, 2016, filed as Ex. 21 (ECF No. 42). He is
also the Laura Schwarz-Kipp Chair for Research of Autoimmune Diseases at Tel Aviv University.
Id. His experience focuses on autoimmune and rheumatic diseases, and he has published many
peer-reviewed papers in journals and books on these topics. Id. He is on the editorial board of 32
journals in the field of autoimmunity. Id. Dr. Shoenfeld’s background does not reveal expertise
with the particular disease or illness claimed as the injury in this case.

         Dr. Shoenfeld’s first report began with a five-page summary of Ms. Rothenberg’s medical
history largely consistent with what is set forth above. First Shoenfeld Rep. at 6-11. He
characterized lipodystrophy as “generalized or partial fat loss,” adding that it can partially affect
one half of a person’s body. Id. at 11. Although he allowed for the fact that the etiology of
lipodystrophy was generally unknown, he proposed that “signs of auto-immunity” had been
identified in certain patients. Id. Specifically, cases of partial lipodystrophy have been associated
with “complement abnormalities”9 as manifested by the presence of a particular autoantibody. Id.
In addition, case reports also demonstrated that individuals experiencing a variety of known
autoimmune illnesses (lupus mainly, but also myasthenia gravis, immune thrombocytopenic
purpura, scleroderma, and Hashimoto’s thyroiditis) experienced lipodystrophy as well, suggesting
it too is autoimmune in derivation. Dr. Shoenfeld added that Petitioner herself had suffered from
a thyroid disease likely autoimmune, thereby rendering her susceptible to other autoimmune
illnesses. Id. at 14.

      Dr. Shoenfeld next discussed the link between vaccination and lipodystrophy.
Lipodystrophy can be a “local adverse reaction” to corticosteroid injections, or the result of

9
  The complement system is a component of the innate immune system, and is comprised of various blood serum
proteins that assist antibodies and phagocytic cells in clearing microbes and damaged cells from an organism, promote
inflammation, and attack pathogens. See, e.g., P. Sissons, et al., The Complement Abnormalities of Lipodystrophy, 294
New Eng. J. Med. 461-65 (1976), filed as Ex. 20-04 (ECF No. 42). Antibodies generated by the adaptive immune
system can help cause the activation of the complement system.

                                                         8
“inappropriate” (meaning improperly administered) intramuscular injections. First Shoenfeld Rep.
at 12. Vaccine-induced lipodystrophy is rare, but has been associated with the measles or human
papillomavirus vaccines. Id. He also noted a single case report in which a woman experienced
delayed lipodystrophy five months after receipt of the influenza (“flu”) vaccine, plus case reports
in which individuals receiving the HPV vaccine experienced localized lipodystrophy after the HPV
vaccine. Id. at 13; see E. Javelle, et al., Delayed Focal Lipoatrophy After AS03-Adjuvanted
Influenza A (H1N1) 2009 Vaccine, 29 Vaccine 1123 (2011), filed as Ex. 20-20 (ECF No. 42) (case
report detailing single female patient who developed a small skin depression five months following
flu vaccination); S. Ojaimi, et al., Quadrivalent Human Papillomavirus Recombinant Vaccine
Associated Lipoatrophy, 27 Vaccine 48676 (2009), filed as Ex. 25-1 (ECF No. 54-1) (“Ojaimi”)
(case report discussing two female patients from Australia who developed skin depressions at the
site of a HPV vaccine dose, which then worsened following subsequent doses); F. Stephan, et al.,
A Case of Lipoatrophy Following Quadrivalent Human Papillomavirus Vaccine Administration,
70 J. Am. Acad. Dermatology E132 (2014), filed as Ex. 20-22 (ECF No. 42).

        A connection to the Tdap vaccine and lipodystrophy, by contrast, was only documented in
passing by any of the literature reviewed by Dr. Shoenfeld. First Shoenfeld Rep. at 12. But Dr.
Shoenfeld noted that reports of adverse effects after the Tdap vaccine were not rare. He also cited
an observational study in which eight infants experienced injection site lipoatrophy10 after
receiving a DPT vaccination. Id. at 12-13; see K. Sardana, et al., DPT Vaccine-Induced
Lipoatrophy: An Observational Study, 46 Int’l J. Dermatology 1050 (2007), filed as Ex. 20-19
(ECF No. 42) (retrospective case report review of all patients presenting with lipoatrophy
following DPT administration between 2000 and 2005 in three hospitals in New Delhi, India). The
study concluded, however, that the exact cause of lipoatrophy in these eight infants “was difficult
to ascertain[,]” although the vaccine was considered a “possible factor.” Id. at 1053. According to
Dr. Shoenfeld, the local reactions were likely attributable to the antigens contained in the vaccine
– and in particular use of whole cell pertussis or tetanus toxoid. First Shoenfeld Rep. at 14.

        Dr. Shoenfeld went on to propose biological mechanisms by which the Tdap vaccine could
produce lipodystrophy. In particular, he cited the vaccine’s adjuvant, aluminum. First Shoenfeld
Rep. at 14-15. He noted that aluminum has been shown to have toxic effects on the human body
with respect to many different physiologic systems, and that it has been identified as the “culprit”
in adverse reactions to vaccination. Id. at 14. “Direct aluminum toxicity” had, he maintained, been
proposed as the actual mechanism for lipoatrophy after receipt of the HPV vaccine, pointing out
that what looked to be aluminum residues could be seen at the site of injury. Id. at 15.




10
     Lipoatrophy is defined as “atrophy of subcutaneous fat.” Dorland’s at 1062.
                                                           9
       Dr. Shoenfeld’s second report was a two-page letter largely aimed at addressing points
included in the first report of Respondent’s expert, Dr. Levinson. In it, he made a number of points
about Petitioner’s purported lipodystrophy. First, he maintained that the diagnosis had been
“confirmed” by several physicians (in particular referencing the trustworthiness of Dr. Jorizzo’s
comments – which, as noted above, report claims of a prior diagnosis of lipodystrophy but do not
make one – because of his dermatologic expertise). Second Shoenfeld Rep. at 1. Second, he
emphasized that Petitioner did not have lipodystrophy pre-vaccination, and that the disease in his
view was progressive, with a long incubation period, thus explaining Ms. Rothenberg’s overall
course and the length of time it took for her symptoms to manifest. Id. Dr. Shoenfeld also
contended that the autoimmune nature of lipodystrophy could not be credibly rebutted. Id. at 2.
And he otherwise more clearly proposed an onset for Petitioner’s symptoms – October 12, 2012
(almost three months after vaccination), when she saw Dr. Honig about her bone pain and ongoing
vitamin D deficiency – and deemed it medically acceptable, although he did not elaborate as to
why this was the case. Id. at 1.11


        B.       Dr. Arnold Levinson

       Respondent offered two reports from Dr. Levinson. Report, dated April 3, 2017, filed as
Ex. A (ECF No. 44-1) (“First Levinson Rep.”); Report, dated July 31, 2017, filed as Ex. C (ECF
No. 49-4) (“Second Levinson Rep.”).

        Dr. Levinson is currently an Emeritus Professor of Medicine and Neurology at the
Perelman School of Medicine at the University of Pennsylvania. See Curriculum Vitae, filed as
Ex. B (ECF No. 49-3) (“Levinson CV”); First Levinson Rep. at 1. During his career with the
Perelman School, Dr. Levinson previously held the following positions: Chief of the Allergy and
Immunology Section, Director of the Fellowship Training Program in Allergy and Immunology,
and Director of the Center for Clinical Immunology. Levinson CV at 2. He received his
undergraduate degree and medical degrees from the University of Maryland. Id. at 1. He is also
currently board certified in internal medicine and allergy and clinical immunology. Id. at 2.

        Over the course of his career, Dr. Levinson also conducted a clinical practice where he
evaluated and treated patients with immune-mediated diseases, including autoimmune,
hypersensitivity, and immunodeficiency disorders. First Levinson Rep. at 1. He has served on the
editorial board of multiple journals, including the Journal of Allergy and Clinical Immunology.
Levinson CV at 4. He has also published articles centering on immune-mediated diseases. Id. at

11
   Respondent also correctly notes that Dr. Shoenfeld’s second report mistakenly concludes with reference to the HPV
vaccine as causal (Second Shoenfeld Rep. at 2) – although because the report begins with mention of the Tdap vaccine,
I interpret this as merely a typographical error.
                                                         10
6-21. Dr. Levinson considers himself an expert in the field of allergic and immunologic diseases.
First Levinson Rep. at 1.

        Like Dr. Shoenfeld, Dr. Levinson began his opinion with an overview of the relevant
medical records. First Levinson Rep. at 2-6. But he also provided a more detailed discussion of
lipodystrophy and its clinical characteristics. Id. at 7-8. As Dr. Levinson explained, there are
several kinds of lipodystrophy, but all are “characterized by decreased body fat,” distributed
generally or only in one area of the body (in which case it is deemed “partial”). Id. at 7. Because
Petitioner alleged that her lipodystrophy was vaccine-caused, Dr. Levinson focused on “acquired
lipodystrophy,” rather than congenital versions of the condition. Id.

        A generalized form of acquired lipodystrophy is “Lawrence syndrome,” which, though
rare, can occur after an acute viral infection and is thought potentially to be autoimmune-
associated. First Levinson Rep. at 7; see J. Capeau et al., Human Lipodystrophies: Genetic and
Acquired Diseases of Adipose Tissue, 19 Endocrine Dev. 1, 12 (2010), filed as Ex. 20-1 (ECF No.
42) (“Capeau”). But it has a number of common comorbidities, including insulin resistance,
cholesterol concentrations, and diabetes, among others. Id.; Capeau at 15. It also usually manifests
within days or weeks of its instigation. First Levinson Rep. at 7. For an example of partial acquired
lipodystrophy, Dr. Levinson referenced Barraquer-Simmons syndrome, which usually presents
with outer-layer, subcutaneous fat loss in the upper body, although intramuscular and fat deposits
within the body remain normal. Capeau at 13. As with generalized acquired lipodystrophy, a
potential autoimmune association has been observed. First Levinson Rep. at 8.

       Based on his review of the records. Dr. Levinson opined that Ms. Rothenberg had never
experienced partial lipodystrophy. First Levinson Rep. at 9. He observed that he could find no
evidence that any treater had actually so diagnosed her; rather, the records revealed that she
informed treaters this was the case. Id. at 10. The very first reference to anything close to
lipodystrophy, Petitioner’s visit with Dr. Chang in October 2013, involved her claims of loss of
muscle tissue, not fat, and did not include reported loss of fat in her upper body. Id. at 9. Thereafter,
when Petitioner began to complain of skin problems or concerns about scleroderma, no evidence
of abnormal fat distribution was observed, and some treaters disputed the accuracy of a
lipodystrophy diagnosis to explain her symptoms, especially given the sequelae she had been
experiencing for many years in the wake of her gastric bypass surgery. Id. at 10-11, 13.

        Dr. Levinson also disputed Dr. Shoenfeld’s assertions that lipodystrophy could be vaccine-
caused. See generally First Levinson Rep. at 11-13. He noted there was a general lack of
epidemiologic evidence supporting a connection. Id. at 11. To the extent case reports discussed in
studies were the basis for such a link, he observed that most involved instances specific to the site
of vaccine administration, rather than involving “adipose tissue site distant to the injection site.”
                                                   11
Id. at 11-12. For example, Dr. Levinson cited to the Dahl and Morgan studies (also relied on by
Dr. Shoenfeld in support of his theory). See P. Dahl, et al., Localized Involuntary Lipoatrophy: A
Clinicopathologic Study of 16 Patients, 35 J. Am. Acad. Dermatology 523 (1996), filed as Ex. 20-
12 (ECF No. 40); A. Morgan, et al., Localized Reactions to Injected Therapeutic Materials, 22 J.
Cutaneous Pathology 289 (1995), filed as Ex. 20-13 (ECF No. 42). Neither of these studies,
however, involved vaccine-caused “lipodystrophy at sites remote from the site of injection, a point
duly noted by the authors.” First Levinson Rep. at 12 (emphasis added).

         Dr. Levinson otherwise maintained that cases that seemed to suggest a relationship between
vaccines (as opposed to other kinds of injections, like corticosteroids) and lipodystrophy were
extremely rare, or otherwise distinguishable. First Levinson Rep. at 12. According to Dr. Levinson,
the case reports by Dr. Shoenfeld (involving the HPV, H1N1 flu, and DPT vaccines), all seemed
to exemplify the localized nature of any lipodystrophy observed. Id.12 Of equal significance was
the post-vaccination onset. Dr. Levinson noted that the “localized subcutaneous atrophic changes”
that the case studies in question reported occurred “days to months” after injection. Id. The records
in this case, by contrast, at best supported an onset of symptoms of lipodystrophy no sooner than
approximately eighteen months after vaccination, in December 2013 – far too remote in time, even
if the case reports were embraced as supportive of causation. Id.

        Dr. Levinson’s second report responded to Dr. Shoenfeld’s April 2017 report. See
generally Second Levinson Rep. He took direct issue with Dr. Shoenfeld’s suggestion that the
medical record evidenced significant loss of fat in Ms. Rothenberg’s face sufficient to be deemed
lipodystrophy, noting that this assertion had no support in the records, and that in fact the
dermatologist who evaluated her, Dr. Jorizzo, had made “no findings” suggestive of lipodystrophy
– rather, he proposed that “nutritional deficiencies” were the actual cause of any disparities in her
lower body subcutaneous fat. Id. at 1-2. Dr. Levinson thus disputed Dr. Shoenfeld’s contention
that the record established any lipodystrophy diagnosis, let alone a valid one. Otherwise, Dr.
Levinson reiterated his prior points about the limited value of the specific findings of the case
studies cited, and the fact that Petitioner’s well-documented preexisting health problems were all
more likely explanations for her medical complaints than vaccine-caused lipodystrophy. Id. at 2-
3.




12
  To the extent aluminum contained in the vaccines had anything to do with the adverse reaction, as Dr. Shoenfeld
maintained, case studies offered to support this contention only underscored the fact that the lipodystrophy was a
localized reaction to the site of vaccine administration, since it was in the “surrounding fat” where either traces of
aluminum were observed, or where it would be expected that a reaction to the adjuvant would occur. First Levinson
Rep. at 12; see Ojaimi at 4877 (stating that “aluminum has been suspected to play a role in the development of local
reactions with other vaccines, such as DPT”); Stephan at E133 (noting that aluminum adjuvant is known to cause
aluminum granuloma).
                                                         12
III.   Procedural History and Ruling on Record Arguments

        As noted above, the Petition was filed in July 2015. Thereafter, Ms. Rothenberg began
gathering and filing relevant medical records, although the process had not been completed by the
end of 2015. I eventually asked Respondent to prepare his Rule 4(c) Report based upon the
available record, and he did so in April 2016, asserting that the case was not appropriate for
compensation because, among other things, it required expert support to establish a sufficiently
reliable causation theory. See generally Respondent’s Rule 4(c) Report, dated April 12, 2016 (ECF
No. 23) In particular, Respondent addressed the relevant facts of Ms. Rothenberg’s health history
and its likely relationship to her complaints. Report at 3-4.

        The parties participated in a status conference in May 2016, at which time I set July 29,
2016, as the deadline for filing an expert report. Petitioner asked me to extend that deadline to the
end of September (ECF No. 25), and I did so. That deadline, however, was delayed further, after
Petitioner’s first counsel withdrew from the case in the fall of 2016. But eventually, Petitioner filed
Dr. Shoenfeld’s first expert report in December 2016.

        Several months passed before Respondent filed Dr. Levinson’s first report in April 2017.
Both sides also filed follow-up supplemental reports from each expert. Thereafter, I proposed to
the parties that the matter be resolved on the papers rather than in a hearing, and they accepted my
proposal. To that end, Petitioner filed her brief in support of her claim on September 23, 2017
(ECF No. 53) (“Mot.”), and Respondent filed a memorandum arguing for dismissal of the matter
on November 30, 2017 (ECF No. 57) (“Opp.”).

         Petitioner’s brief included an overview of her medical history before turning to the
elements of a successful Vaccine Act claim as set forth by the Federal Circuit in Althen v. Sec’y of
Health & Human Servs., 418 F.3d 1274 (Fed. Cir. 2005). She maintained that the initial, “can
cause” element was met, asserting that there is “universal acceptance” of the association between
the Tdap vaccine and lipodystrophy. Mot. at 8. Although she emphasized the case studies reporting
localized associations, she noted that there was also support for “systemic” adverse effects, and
that the aluminum adjuvant was suspected to be a source of such effects. Id. at 9, citing Ex. 20-18
(1981 article cataloging local and systemic reactions occurring within 48 hours in recently
vaccinated DTP pediatric patients between 1978-1979), 20-19 (retrospective case report review of
all patients presenting with lipoatrophy following DPT administration between 2000 and 2005 at
three hospitals in New Delhi, India), 20-22 (2014 case report detailing a case of lipoatrophy
following the HPV vaccine). She also reiterated Dr. Shoenfeld’s point that a person like Petitioner
with a known autoimmune condition (her preexisting thyroid problem) was more likely to have
other autoimmune diseases. Id. at 9-10.

                                                  13
        Regarding the second prong, Petitioner made additional first prong arguments, referencing
the mechanisms that Dr. Shoenfeld had proposed for how a vaccine might set into motion a
biologic process resulting in lipodystrophy. In particular, she maintained that “defects in the
complement system” are understood to be an aspect of lipodystrophy’s pathogenesis, and also link
the condition to autoimmunity (given autoantibodies believed to be related to complement system
defects associated with lipodystrophy). Mot. at 11-12. But she otherwise did not offer much in the
way of explanation for how the theory she proposed was reflected in her actual experience, as set
forth by the medical record.

        Finally, Petitioner proposed that the timeframe in which her alleged lipodystrophy
developed was medically acceptable. Noting the existence of case study reports that supported an
onset of lipodystrophy within four to eight weeks of vaccination or injection (given the studies that
focused on non-vaccine injections), she maintained that her “first complaint about increasing pain
in her joints” represented onset of the alleged condition, and that its occurrence (at her September
14, 2012 doctor’s visit) approximately seven weeks after vaccination was medically reasonable.
Mot. at 13, 17.

        Respondent’s brief argued for the claim’s dismissal. With respect to the first prong,
Respondent stressed the fact that the majority of literature offered by Petitioner dealt with localized
injection or vaccine responses, rather than the systemic effects complained of in this case. Opp. at
9. He also disputed how much weight could be given to the presumption that an individual
suffering from one autoimmune condition (like Petitioner’s thyroid problem) would necessarily
experience a different one. Id. at 10. And Respondent challenged the scientific adequacy of Dr.
Shoenfeld’s theory that aluminum-based adjuvants in vaccines can initiate autoimmune reactions.
Id. at 11.13

         Regarding the “did cause” prong, Respondent noted that Petitioner’s testing did not reveal
any complement abnormalities, and thus the facts of this case were inconsistent with a large aspect
of her theory. Opp. at 10. Respondent also reviewed the medical record, pointing out the lack of
treater support for a lipodystrophy diagnosis as well as the lack of support for the conclusion that
in fact Petitioner did suffer from this condition. Id. at 2-3, 6-8. And Respondent attacked the
adequacy of Petitioner’s Althen prong three showing, noting that (a) the alleged four to eight week
timeframe for onset of an autoimmune condition after receipt of several vaccines relevant to

13
   Although Dr. Shoenfeld did not define in formal terms this component of his theory, in other cases it has been
classified as “autoimmune syndrome induced by adjuvants,” or “ASIA.” Similar ASIA theories, however, have
repeatedly been found to be unpersuasive by other special masters because the theory has been deemed too preliminary
or unreliable given present science. See, e.g., Rowan v. Sec’y of Health & Human Servs., No. 10-272V, 2014 WL
7465661 (Fed. Cl. Spec. Mstr. Dec. 8, 2014); mot. for review den’d, 2015 WL 3562409 (Fed. Cl. 2015); D’Angiolini
v. Sec’y of Health & Human Servs., No 99-578V, 2014 WL 1678145 (Fed. Cl. Spec. Mstr. Mar. 27, 2014), mot. for
review den’d, 122 Fed. Cl. 86 (2015), aff’d, 645 F. App’x 1002 (Fed. Cir. 2016).
                                                        14
Petitioner’s scientific proof, including that relating to the Tdap vaccine ,was far longer than what
reliable science recognized to be reasonable, and (b) in fact the first instance in the record that
could conceivably be deemed onset of anything approaching lipodystrophy was from Petitioner’s
October 24, 2012 visit with Dr. Honig (at which time she first expressed the view that her
vaccination could have caused an injury) – 13 weeks after vaccination, and hence too long even
under Petitioner’s own proposed timeframe. Id. at 12-13.

IV.    Relevant Legal Standards

       A.      Petitioner’s Overall Burden in Vaccine Program Cases

         To receive compensation in the Vaccine Program, 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 the vaccinations in question within a statutorily prescribed period of time
or, in the alternative, (2) that her illnesses were actually caused by a vaccine (a “Non-Table
Injury”). See Sections 13(a)(1)(A), 11(c)(1), and 14(a), as amended by 42 C.F.R. § 100.3; §
11(c)(1)(C)(ii)(I); see also Moberly v. Sec’y of Health & Human Servs., 592 F.3d 1315, 1321 (Fed.
Cir. 2010); Capizzano v. Sec’y of Health & Human Servs., 440 F.3d 1317, 1320 (Fed. Cir. 2006).
In this case, Petitioner does not assert a Table claim.

         For both Table and Non-Table claims, Vaccine Program petitioners bear a “preponderance
of the evidence” burden of proof. Section 13(1)(a). That is, a petitioner must offer evidence that
leads 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.” Moberly, 592 F.3d at 1322 n.2; see also Snowbank Enter. v. United States, 6 Cl. Ct.
476, 486 (1984) (mere conjecture or speculation is insufficient under a preponderance standard).
Proof of medical certainty is not required. Bunting v. Sec’y of Health & Human Servs., 931 F.2d
867, 873 (Fed. Cir. 1991). In particular, a petitioner must demonstrate that the vaccine was “not
only [the] but-for cause of the injury but also a substantial factor in bringing about the injury.”
Moberly, 592 F.3d at 1321 (quoting Shyface v. Sec’y of Health & Human Servs., 165 F.3d 1344,
1352-53 (Fed. Cir. 1999)); Pafford v. Sec’y of Health & Human Servs., 451 F.3d 1352, 1355 (Fed.
Cir. 2006). A petitioner may not receive a Vaccine Program award based solely on her assertions;
rather, the petition must be supported by either medical records or by the opinion of a competent
physician. Section 13(a)(1).

        In attempting to establish entitlement to a Vaccine Program award of compensation for a
Non-Table claim, a petitioner must satisfy all three of the elements established by the Federal
Circuit in Althen: “(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;
                                                  15
and (3) a showing of a proximate temporal relationship between vaccination and injury.” Althen,
418 F.3d at 1278.

        Each of the Althen prongs requires a different showing. Under Althen prong one, petitioners
must provide a “reputable medical theory,” demonstrating that the vaccine received can cause the
type of injury alleged. Pafford, 451 F.3d at 1355-56 (citations omitted). To satisfy this prong, a
petitioner’s theory must be based on a “sound and reliable medical or scientific explanation.”
Knudsen v. Sec’y of Health & Human Servs., 35 F.3d 543, 548 (Fed. Cir. 1994). Such a theory
must only be “legally probable, not medically or scientifically certain.” Id. at 549.

        Petitioners may satisfy the first Althen prong without resort to medical literature,
epidemiological studies, demonstration of a specific mechanism, or a generally accepted medical
theory. Andreu v. Sec’y of Health & Human Servs., 569 F.3d 1367, 1378-79 (Fed. Cir. 2009) (citing
Capizzano, 440 F.3d at 1325-26). Special masters, despite their expertise, are not empowered by
statute to conclusively resolve what are essentially thorny scientific and medical questions, and
thus scientific evidence offered to establish Althen prong one is viewed “not through the lens of
the laboratorian, but instead from the vantage point of the Vaccine Act’s preponderant evidence
standard.” Id. at 1380. Accordingly, special masters must take care not to increase the burden
placed on petitioners in offering a scientific theory linking vaccine to injury. Contreras v. Sec’y of
Health & Human Servs., 121 Fed. Cl. 230, 245 (2015) (“[p]lausibility . . . in many cases may be
enough to satisfy Althen prong one” (emphasis in original)), rev’d on other grounds, 844 F.3d
1363 (Fed. Cir. 2017). But this does not negate or reduce a petitioner’s ultimate burden to establish
her overall entitlement to damages by preponderant evidence. W.C. v. Sec’y of Health & Human
Servs., 704 F.3d 1352, 1356 (Fed. Cir. 2013) (citations omitted).

        The second Althen prong requires proof of a logical sequence of cause and effect, usually
supported by facts derived from a petitioner’s medical records. Althen, 418 F.3d at 1278; Andreu,
569 F.3d at 1375-77; Capizzano, 440 F.3d at 1326; Grant v. Sec’y of Health & Human Servs., 956
F.2d 1144, 1148 (Fed. Cir. 1992). In establishing that a vaccine “did cause” injury, the opinions
and views of the injured party’s treating physicians are entitled to some weight. Andreu, 569 F.3d
at 1367; Capizzano, 440 F.3d at 1326 (“medical records and medical opinion testimony are favored
in vaccine cases, as treating physicians are likely to be in the best position to determine whether a
‘logical sequence of cause and effect show[s] that the vaccination was the reason for the injury’”)
(quoting Althen, 418 F.3d at 1280). Medical records are generally viewed as particularly
trustworthy evidence, since they are created contemporaneously with the treatment of the patient.
Cucuras v. Sec’y of Health & Human Servs., 993 F.2d 1525, 1528 (Fed. Cir. 1993).

       However, medical records and/or statements of a treating physician’s views do not per se
bind the special master to adopt the conclusions of such an individual, even if they must be
                                                 16
considered and carefully evaluated. Section 13(b)(1) (providing that “[a]ny such diagnosis,
conclusion, judgment, test result, report, or summary shall not be binding on the special master or
court”); Snyder v. Sec’y of Health & Human Servs., 88 Fed. Cl. 706, 746 n.67 (2009) (“there is
nothing . . . that mandates that the testimony of a treating physician is sacrosanct – that it must be
accepted in its entirety and cannot be rebutted”). As with expert testimony offered to establish a
theory of causation, the opinions or diagnoses of treating physicians are only as trustworthy as the
reasonableness of their suppositions or bases. The views of treating physicians should also be
weighed against other, contrary evidence also present in the record – including conflicting opinions
among such individuals. Hibbard v. Sec’y of Health & Human Servs., 100 Fed. Cl. 742, 749 (2011)
(not arbitrary or capricious for special master to weigh competing treating physicians’ conclusions
against each other), aff'd, 698 F.3d 1355 (Fed. Cir. 2012); Caves v. Sec’y of Dep't of Health &
Human Servs., 100 Fed. Cl. 119, 136 (2011), aff'd, 463 F. App'x 932 (Fed. Cir. 2012); Veryzer v.
Sec’y of Health & Human Servs., No. 06-522V, 2011 WL 1935813, at *17 (Fed. Cl. Spec. Mstr.
Apr. 29, 2011), mot. for review den’d, 100 Fed. Cl. 344, 356 (2011), aff’d without opinion, 475
Fed. App’x 765 (Fed. Cir. 2012).

        The third Althen prong requires establishing a “proximate temporal relationship” between
the vaccination and the injury alleged. Althen, 418 F.3d at 1281. That term has been equated to the
phrase “medically-acceptable temporal relationship.” Id. A petitioner must offer “preponderant
proof that the onset of symptoms occurred within a timeframe which, given the medical
understanding of the disorder’s etiology, it is medically acceptable to infer causation.” Bazan v.
Sec'y of Health & Human Servs., 539 F.3d 1347, 1352 (Fed. Cir. 2008). The explanation for what
is a medically acceptable timeframe must also coincide with the theory of how the relevant vaccine
can cause an injury (Althen prong one’s requirement). Id. at 1352; Shapiro v. Sec’y of Health &
Human Servs., 101 Fed. Cl. 532, 542 (2011), recons. den’d after remand, 105 Fed. Cl. 353 (2012),
aff’d mem., 2013 WL 1896173 (Fed. Cir. 2013); Koehn v. Sec’y of Health & Human Servs., No.
11-355V, 2013 WL 3214877 (Fed. Cl. Spec. Mstr. May 30, 2013), mot. for review den’d (Fed. Cl.
Dec. 3, 2013), aff’d, 773 F.3d 1239 (Fed. Cir. 2014).

       B.      Law Governing Analysis of Fact Evidence

        The process for making determinations in Vaccine Program cases regarding factual issues
begins with consideration of the medical records. Section 11(c)(2). The special master is required
to consider “all [] relevant medical and scientific evidence contained in the record,” including “any
diagnosis, conclusion, medical judgment, or autopsy or coroner’s report which is contained in the
record regarding the nature, causation, and aggravation of the petitioner’s illness, disability, injury,
condition, or death,” as well as “the results of any diagnostic or evaluative test which are contained
in the record and the summaries and conclusions.” Section 13(b)(1)(A). The special master is then
required to weigh the evidence presented, including contemporaneous medical records and
                                                  17
testimony. See Burns v. Sec’y of Health & Human Servs., 3 F.3d 415, 417 (Fed. Cir. 1993) (it is
within the special master’s discretion to determine whether to afford greater weight to
contemporaneous medical records than to other evidence, such as oral testimony surrounding the
events in question that was given at a later date, provided that such a determination is evidenced
by a rational determination).

        Medical records that are created contemporaneously with the events they describe are
presumed to be accurate and “complete” (i.e., presenting all relevant information on a patient’s
health problems). Cucuras, 993 F.2d at 1528; Doe/70 v. Sec’y of Health & Human Servs., 95 Fed.
Cl. 598, 608 (2010) (“[g]iven the inconsistencies between petitioner’s testimony and his
contemporaneous medical records, the special master’s decision to rely on petitioner’s medical
records was rational and consistent with applicable law”), aff’d, Rickett v. Sec’y of Health &
Human Servs., 468 F. App’x 952 (Fed. Cir. 2011) (non-precedential opinion). This presumption is
based on the linked propositions that (i) sick people visit medical professionals; (ii) sick people
honestly report their health problems to those professionals; and (iii) medical professionals record
what they are told or observe when examining their patients in as accurate a manner as possible,
so that they are aware of enough relevant facts to make appropriate treatment decisions. Sanchez
v. Sec’y of Health & Human Servs., No. 11-685V, 2013 WL 1880825, at *2 (Fed. Cl. Spec. Mstr.
Apr. 10, 2013); Cucuras v. Sec'y of Health & Human Servs., 26 Cl. Ct. 537, 543 (1992), aff'd, 993
F.2d 1525 (Fed. Cir. 1993) (“[i]t strains reason to conclude that petitioners would fail to accurately
report the onset of their daughter’s symptoms. It is equally unlikely that pediatric neurologists,
who are trained in taking medical histories concerning the onset of neurologically significant
symptoms, would consistently but erroneously report the onset of seizures a week after they in fact
occurred”).

        Accordingly, if the medical records are clear, consistent, and complete, then they should
be afforded substantial weight. Lowrie v. Sec’y of Health & Human Servs., No. 03-1585V, 2005
WL 6117475, at *20 (Fed. Cl. Spec. Mstr. Dec. 12, 2005). Indeed, contemporaneously medical
records are generally found to be deserving of greater evidentiary weight than oral testimony –
especially where such testimony conflicts with the record evidence. Cucuras, 993 F.2d at 1528;
see also Murphy v. Sec’y of Health & Human Servs., 23 Cl. Ct. 726, 733 (1991), aff'd, 968 F.2d
1226 (Fed. Cir.), cert. den’d, Murphy v. Sullivan, 506 U.S. 974 (1992) (citing United States v.
United States Gypsum Co., 333 U.S. 364, 396 (1947) (“[i]t has generally been held that oral
testimony which is in conflict with contemporaneous documents is entitled to little evidentiary
weight.”)).

       However, there are situations in which compelling oral testimony may be more persuasive
than written records, such as where records are deemed to be incomplete or inaccurate. Campbell
v. Sec’y of Health & Human Servs., 69 Fed. Cl. 775, 779 (2006) (“like any norm based upon
                                                 18
common sense and experience, this rule should not be treated as an absolute and must yield where
the factual predicates for its application are weak or lacking”); Lowrie, 2005 WL 6117475, at *19
(“[w]ritten records which are, themselves, inconsistent, should be accorded less deference than
those which are internally consistent”) (quoting Murphy v. Sec’y of Health & Human Servs., 23
Cl. Ct. 726, 733 (1991), aff'd per curiam, 968 F.2d 1226 (Fed. Cir. 1992)). Ultimately, a
determination regarding a witness’s credibility is needed when determining the weight that such
testimony should be afforded. Andreu, 569 F.3d at 1379; Bradley v. Sec’y of Health & Human
Servs., 991 F.2d 1570, 1575 (Fed. Cir. 1993).

       C.      Analysis of Expert Testimony

        Establishing a sound and reliable medical theory often requires a petitioner to present
expert testimony in support of his claim. Lampe v. Sec’y of Health & Human Servs., 219 F.3d
1357, 1361 (Fed. Cir. 2000). Vaccine Program expert testimony is usually evaluated according to
the factors for analyzing scientific reliability set forth in Daubert v. Merrell Dow Pharm., Inc., 509
U.S. 579, 594-96 (1993). See Cedillo v. Sec’y of Health & Human Servs., 617 F.3d 1328, 1339
(Fed. Cir. 2010) (citing Terran v. Sec’y of Health & Human Servs., 195 F.3d 1302, 1316 (Fed. Cir.
1999)). “The Daubert factors for analyzing the reliability of testimony are: (1) whether a theory or
technique can be (and has been) tested; (2) whether the theory or technique has been subjected to
peer review and publication; (3) whether there is a known or potential rate of error and whether
there are standards for controlling the error; and (4) whether the theory or technique enjoys general
acceptance within a relevant scientific community.” Terran, 195 F.3d at 1316 n.2 (citing Daubert,
509 U.S. at 592-95).

         The Daubert factors play a slightly different role in Vaccine Program cases than they do
when applied in other federal judicial fora (such as the district courts). Daubert factors are usually
employed by judges (in the performance of their evidentiary gatekeeper roles) to exclude evidence
that is unreliable and/or could confuse a jury. In Vaccine Program cases, by contrast, these factors
are used in the weighing of the reliability of scientific evidence proffered. Davis v. Sec’y of Health
& Human Servs., 94 Fed. Cl. 53, 66-67 (2010) (“uniquely in this Circuit, the Daubert factors have
been employed also as an acceptable evidentiary-gauging tool with respect to persuasiveness of
expert testimony already admitted”). The flexible use of the Daubert factors to evaluate the
persuasiveness and reliability of expert testimony has routinely been upheld. See, e.g., Snyder, 88
Fed. Cl. at 742-45. In this matter (as in numerous other Vaccine Program cases), Daubert has not
been employed at the threshold, to determine what evidence should be admitted, but instead to
determine whether expert testimony offered is reliable and/or persuasive.

       Respondent frequently offers one or more experts of her own in order to rebut a petitioner’s
case. Where both sides offer expert testimony, a special master’s decision may be “based on the
                                                 19
credibility of the experts and the relative persuasiveness of their competing theories.”
Broekelschen v. Sec’y of Health & Human Servs., 618 F.3d 1339, 1347 (Fed. Cir. 2010) (citing
Lampe, 219 F.3d at 1362). However, nothing requires the acceptance of an expert’s conclusion
“connected to existing data only by the ipse dixit of the expert,” especially if “there is simply too
great an analytical gap between the data and the opinion proffered.” Snyder, 88 Fed. Cl. at 743
(quoting Gen. Elec. Co. v. Joiner, 522 U.S. 146 (1997)); see also Isaac v. Sec’y of Health & Human
Servs., No. 08-601V, 2012 WL 3609993, at *17 (Fed. Cl. Spec. Mstr. July 30, 2012), mot. for
review den’d, 108 Fed. Cl. 743 (2013), aff’d, 540 Fed. App’x 999 (Fed. Cir. 2013) (citing Cedillo,
617 F.3d at 1339).

        Weighing the relative persuasiveness of competing expert testimony, based on a particular
expert’s credibility, is part of the overall reliability analysis to which special masters must subject
expert testimony in Vaccine Program cases. Moberly, 592 F.3d at 1325-26 (“[a]ssessments as to
the reliability of expert testimony often turn on credibility determinations”); see also Porter v.
Sec’y of Health & Human Servs., 663 F.3d 1242, 1250 (Fed. Cir. 2011) (“this court has
unambiguously explained that special masters are expected to consider the credibility of expert
witnesses in evaluating petitions for compensation under the Vaccine Act”). It is in the exercise of
my duties as a special master to weigh competing expert testimony. Copenhaver v. Sec’y of Health
& Human Servs., 129 Fed. Cl. 176, 183 (2016) (“Special Masters may use their discretion in
weighing expert testimony, and case law supports that discretion”).

        In determining whether a particular expert’s testimony was reliable or credible, I may
consider whether the expert offers an opinion that exceeds his training or competence. Walton v.
Sec’y of Health & Human Servs., No. 04-503V, 2007 WL 1467307, at *17-18 (Fed. Cl. Spec. Mstr.
Apr. 30, 2007) (otolaryngologist not well suited to testify about disciplines other than her own
specialty). While (in keeping with the liberality with which evidence offered in Vaccine Program
cases is treated) I heard and have considered all of the testimony of the experts offered at the
entitlement hearing, I may properly evaluate, and give appropriate weight to, whether certain
testimony is beyond a particular expert’s purview. See, e.g., King v. Sec’y of Health & Human
Servs., No. 03-584V, 2010 WL 892296, at *78-79 (Fed. Cl. Spec. Mstr. Mar. 12, 2010)
(petitioner’s expert far less qualified to offer opinion on general causation issues pertaining to
autism than specific issues pertaining to the petitioner’s actual medical history, given the nature of
the expert’s qualifications).

        D.      Consideration of Medical Literature

        Both parties filed medical and scientific literature in this case, including some articles (such
as those discussing molecular mimicry and protein sequences in vaccines) that do not factor into
the outcome of this decision. I have reviewed all of the medical literature submitted in this case,
                                                  20
but I only discuss those articles that are most relevant to my determination and/or are central to
Petitioners’ case – just as I have not exhaustively discussed every individual medical record filed.
Moriarty v. Sec’y of Health & Human Servs., No. 2015-5072, 2016 WL 1358616, at *5 (Fed. Cir.
Apr. 6, 2016) (“[w]e generally presume that a special master considered the relevant record
evidence even though he does not explicitly reference such evidence in his decision”) (citation
omitted); see also Paterek v. v. Sec’y of Health & Human Servs., 527 F. App’x 875, 884 (Fed. Cir.
2013) (“[f]inding certain information not relevant does not lead to — and likely undermines —
the conclusion that it was not considered”).

       E.      Ruling on the Record

         The parties accepted my proposal to determine entitlement based on written submissions
and evidentiary filings, including both side’s expert reports, rather than by holding a hearing. The
Vaccine Act and Rules not only contemplate but encourage special masters to decide petitions on
the papers where (in the exercise of their discretion) they conclude that doing so will properly and
fairly resolve the case. Section 12(d)(2)(D); Vaccine Rule 8(d). The decision to rule on the record
in lieu of hearing has been affirmed on appeal. See Hooker v. Sec’y of Health & Human Servs.,
No. 02-472V, 2016 WL 3456435, at *21 n.19 (Fed. Cl. Spec. Mstr. May 19, 2016) (citing
numerous cases where special masters decided on the papers in lieu of hearing and that decision
was upheld). I am simply not required to hold a hearing in every matter, no matter the preferences
of the parties. Hovey v. Sec’y of Health & Human Servs., 38 Fed. Cl. 397, 402-03 (1997) (special
master acted within his discretion in denying evidentiary hearing); Burns, 3 F.3d at 417; Murphy
v. Sec’y of Health & Human Servs., No. 90-882V, 1991 WL 71500, at *2 (Ct. Cl. Spec. Mstr. Apr.
19, 1991).

                                           ANALYSIS

       I am addressing the Althen prongs in order of their significance to my determination, rather
than consistent with their sequential presentation in the Federal Circuit’s decision.

       A.      Althen Prong Two

        Assuming for sake of argument that Petitioner could establish that the Tdap vaccine can
cause lipodystrophy, I would still be unable to conclude (based on the records filed in this case)
that the vaccine likely caused Petitioner’s lipodystrophy – because it does not appear she suffered
from that condition (or any vaccine-caused injury at all). The failure to establish a claimed injury
can be fatal to a petitioner’s claim. See, e.g., Lombardi v. Sec’y of Health & Human Servs., 656
F.3d 1343, 1353 (Fed. Cir. 2011).

                                                21
        First, nowhere in the record is there clear evidence that Petitioner was in fact ever
diagnosed with lipodystrophy. Rather, there is evidence that Petitioner so informed treaters, and
they dutifully wrote it down as if true, in an effort to capture accurately all facts potentially relevant
to her treatment. But Program petitioners cannot establish a diagnosis simply by citing to records
in which they informed physicians of a diagnosis that the evidence does not corroborate - any more
than they can prevail in a case simply based on their own averments. See Castaldi v. Sec’y of
Health & Human Servs., No. 09-300V, 2014 WL 3749749, at *11 (Fed. Cl. Spec. Mstr. June 25,
2014) (“the records of treating physicians can be questioned and the weight afforded to them
depends on whether the physician is noting her own observations or merely recording statements
made by the patient.”), aff’d, 119 Fed. Cl. 407 (2014).

        Second, the record does not contain sufficient evidence from which it could be concluded
that Petitioner more likely than not did have lipodystrophy, regardless of whether she was so
diagnosed. Rather, the record better supports the conclusion that her longstanding medical
problems, characterized by osteomalacia and/or post-gastric bypass surgery sequelae, better
explain the complained-of symptoms herein. The treaters most competent to weigh in on the topic
of lipodystrophy, such as Dr. Jorizzo, never made any conclusions about her complaints that could
be deemed consistent with lipodystrophy in a meaningful sense.

        In addition, the record also does not support the conclusion that in the months after Ms.
Rothenberg’s vaccination, she was experiencing any kind of vaccine-caused injury. No test results
of any kind can be credibly pointed to in this case that would establish an undercurrent of
autoimmunity of the kind often seen in other Program cases, such as inflammation. While ample
medical records were filed in this case, they provide thin to no support for the conclusion that
Petitioner was experiencing an autoimmune process in the many months between the July 2012
vaccination and the first time the term “lipodystrophy” appears in a medical record, or that she was
undergoing some kind of underlying, at times subclinical, pathologic process.

        The overall impression left by my review of the medical records filed in this case is that
Petitioner is a person burdened with chronic health problems who received a vaccination, and then
thereafter continued to experience such health problems – but not the precise injury alleged, and
in fact nothing that could otherwise be persuasively deemed vaccine-related. The Tdap vaccine
does not appear more likely than not to have had anything at all to do with the continuation of
Petitioner’s underlying problems and symptoms, and therefore Petitioner’s claim lacks
preponderant evidence sufficient for an entitlement award based on the “did cause” component of
the Althen test.




                                                   22
       B.      Althen Prong Three

         The record in this case, as interpreted by Dr. Shoenfeld’s causation theory, does not support
the conclusion that Petitioner’s injury (assuming that it was lipodystrophy) occurred in a medically
acceptable timeframe. I note preliminarily that it is extremely difficult even to say when
Petitioner’s lipodystrophy could be deemed to have begun. The term was not used in any records
before December 2013, although Petitioner did visit treaters two months before (October 2013)
complaining of skin issues that could arguably be related. Even so, the earlier October date is 15
months after vaccination – far too long to be medically acceptable, as Dr. Levinson argued, even
if the few case studies that might connect certain vaccines to lipodystrophy are deemed persuasive.

        Moreover, in the period between vaccination and October 2013, the record is replete with
instances in which Petitioner sought medical treatment for a variety of medical conditions. But
none of these treatment occasions have been shown to have any relationship to her later complaints
that she had lipodystrophy, nor has Petitioner referenced any medical test results from the period
that arguably could bulwark the timeframe as medically acceptable. Without evidence that
Petitioner was experiencing symptoms over a long period of time that ultimately manifested as
true lipodystrophy, I cannot conclude under such circumstances that a period in excess of a year
post-vaccination is reasonable – and Dr. Shoenfeld otherwise did not persuasively establish that it
would take such time for an autoimmune-caused lipodystrophy to occur.

       C.      Althen Prong One

        Petitioner has not offered sufficient evidence to meet her burden of establishing a reliable
theory for how a flu vaccine could cause lipodystrophy. As Dr. Levinson admitted, there is some
evidence that lipodystrophy could be autoimmune in character when occurring in a localized
fashion, i.e., near the place of the vaccine’s administration. However, although Dr. Shoenfeld has
expertise with respect to autoimmune diseases broadly, he lacks specific competence as to the
alleged injury at issue to persuasively establish how it could be caused by vaccination. To the
extent Petitioner offered reliable evidence associating other kinds of injections or vaccines with
lipodystrophy (more often than not in the form of case studies that do not merit much weight on
their face), that evidence suggests that the injury would be limited to the site of the vaccine’s
administration – not what is alleged herein. The evidence offered to support one possible
mechanism, via aluminum in the vaccine used as an adjuvant, was particularly weak and reflects
a causation component that has not won favor in other Program cases, as noted above.

       Even if I found, however, that Petitioner had established sufficient reliable evidence to
support this Althen prong, Petitioner’s claim would still founder on her inability to establish (a)

                                                 23
that she ever experienced lipodystrophy, or (b) that in her case the Tdap vaccine caused
lipodystrophy in a medically acceptable timeframe.


                                                  CONCLUSION

       Petitioner has not successfully carried her burden of proof, and therefore entitlement is
DENIED. Pursuant to RCFC Appendix B, the clerk of the court SHALL ENTER JUDGMENT
in accordance with the terms of this decision.14

                                                       IT IS SO ORDERED.

                                                       s/ Brian H. Corcoran
                                                       Brian H. Corcoran
                                                       Special Master




14
  Pursuant to Vaccine Rule 11(a), the parties may expedite entry of judgment if (jointly or separately) they file notices
renouncing their right to seek review.
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