Compensation Entitlement–Overlap Syndrome caused by Flu Vaccine
Rodd v. HHS, (Fed. Cl. Spec. Mstr. Nov. 13, 2015) (Gowen, SM)
Respondent primarily defended the case on the basis that Petitioner had symptoms within one day of his vaccination, which would be too soon for an autoimmune reaction. However, Petitioner had two distinct problems, carpal tunnel syndrome, and polymyositis/polyarthralgia, and only the former manifested one day after vaccination.
Petitioner’s expert, Dr. Byers, explained that the Petitioner likely had a developing but asymptomatic carpal tunnel syndrome at the time that he received the flu shot, related to employment. The additional inflammation caused by the innate response to the flu shot made it symptomatic. Specifically, cytokines released by the flu vaccine, in particular, IL-1 and IL-2, caused inflammation and entrapment of the median nerve, which caused it to become symptomatic in the carpal tunnel. The fact that Petitioner’s symptoms of numbness and tingling in the thumbs and fingers were relieved by the carpal tunnel release surgery provided confirmation of the diagnosis of carpal tunnel, as did the Tinel’s test.
Respondent’s expert did agree that the Physician’s Desk Reference says that transient myopathies are common after vaccines and that it is possible that they may have an impact on a pre-existent condition like carpal tunnel. However, he maintained that Petitioner’s initial symptoms were not carpal tunnel, but rather the initial manifestation of his autoimmune disorder. The special master disagreed, finding that the initial symptoms were carpal tunnel and that Petitioner had provided a persuasive explanation of how the vaccine caused it to manifest.
Both experts agreed that Petitioner later developed polyarthritis, polyarthralgia, and polymyositis, or an overlap syndrome. These symptoms began several weeks after the flu vaccine. Dr. Byers offered several mechanisms by which the flu vaccine could cause polyarthritis and polymyositis: molecular mimicry, bystander activation, antigenic spreading, and cryptotope production, which would be the unmasking of an antigen that the body had not seen before. She thought that the latter three mechanisms were more likely than molecular mimicry to be the cause of Mr. Rodd’s disease.
The court found that Dr. Byers’ testimony was more consistent and more persuasive than Respondent’s expert, in that she provided a cogent explanation for both the early-onset carpal tunnel syndrome and the subsequently occurring overlap or anti-synthetase syndrome. Further, her testimony was consistent with multiple treating physicians, including a neurologist and two rheumatologists—one a specialist in myositis.
With regard to timing, the experts agreed that four days to several weeks was necessary for the B cell and T cell adaptive responses to occur. The only issue with respect to timing was whether the initial symptoms one day after the vaccine were part of the autoimmune disorder, and the special master determined they were not.