Jennifer Hibbard v. HHS - Influenza, dysautonomia (2011)

Jennifer Hibbard was born on February 17, 1962. Before receiving a trivalent influenza vaccine on November 1, 2003, she was a first-grade teacher at Beechwood Knoll Elementary School in Quincy, Massachusetts, and led an active and generally healthy life.

She had a fainting episode on May 27, 2003, which her primary care physician, Dr. Amy Schoenbaum, attributed to mild dehydration.

Seven days after the vaccination, on November 8, 2003, Ms. Hibbard became severely ill while chaperoning two students on a school shopping trip.

She experienced nausea, sweating, flushing, chills, dizziness, near-fainting, and light sensitivity severe enough to cause her to cut the trip short. Her condition did not improve in the weeks that followed.

After initial antibiotics proved unhelpful, she visited the emergency room at Brigham and Women's Hospital on December 12, 2003, where Dr. Schoenbaum raised the possibility of Guillain-Barré syndrome, but a normal neurological exam made that diagnosis "unlikely." An ambulance brought Ms.

Hibbard back to the hospital the following day, where an extensive workup was performed but yielded no clear diagnosis; doctors recommended a psychiatric evaluation. A psychiatrist found no mood or anxiety disorder.

Over the following months, Ms. Hibbard saw approximately twenty different physicians, including specialists in infectious diseases, endocrinology, metabolism, and neurology.

Most were unable to reach a definitive diagnosis. Dr.

Kenneth Gorson, a Guillain-Barré expert at St. Elizabeth's Medical Center, noted in June 2004 that while it was "certainly possible that she developed a modest dysautonomic neuropathy" following the vaccination, he was "hesitant to confirm an autonomic element to her disorder without more objective data." Autonomic testing performed in June 2004 showed a normal Valsalva maneuver but an abnormal tilt table test with postural orthostatic tachycardia syndrome (POTS) and pathological sympathetic adrenergic function.

Dr. Roy Freeman noted that POTS may indicate a mild or early autonomic neuropathy but is a "nonspecific finding." Dr.

Peter Novak, another neurologist, assessed Ms. Hibbard in September 2004 and found her tilt table test abnormal again, concluding that his findings were "suggestive of autonomic neuropathy affecting predominantly sympathetic fibers," though he noted that "relationship to flu shots remains, however, unclear." A November 2005 evaluation by Dr.

Russell Chin — including EMG, nerve conduction studies, and skin biopsies for small fiber neuropathy — produced entirely normal results. Dr.

Novak's records over time shifted in terminology from "autonomic neuropathy" (2004) to "autonomic dysfunction" (2005–06) to "dysautonomia" (2007–09) without explanation. Ms.

Hibbard was forced to leave teaching and could only return part-time in 2008. Ms.

Hibbard filed her petition on June 28, 2007, claiming that the flu vaccination caused her to suffer a demyelinating neurological injury. Petitioner's expert, Dr.

Thomas Morgan, a board-certified neurologist and independent medical examiner, opined that she had sustained a post-flu-vaccine immunization autonomic neuropathy resulting from molecular mimicry — the vaccine had caused her immune system to attack normal sympathetic nerve tissue, causing autonomic neuropathy that manifested as dysautonomia and POTS. Respondent's expert, Dr.

Vinay Chaudhry, a professor of neurology at Johns Hopkins with subspecialty certifications in neuromuscular diseases and electrodiagnostic medicine, found no unifying diagnosis in Ms. Hibbard's extensive medical records and no causal link between the flu vaccine and her symptoms.

He emphasized that the objective testing she had undergone showed mostly normal results. Special Master Moran held hearings in August 2009 and February 2010 and issued his decision on April 12, 2011.

The special master found that Ms. Hibbard suffered from POTS, a type of dysautonomia, but that a preponderance of the evidence did not support a finding that she had autonomic neuropathy — actual damage to the autonomic nerves.

He preferred Dr. Chaudhry's opinion because it was grounded in the objective testing results, which were mostly normal.

While many of Ms. Hibbard's treating physicians had mentioned autonomic neuropathy as a possibility, they had done so without objective test support, and several physicians were uncertain or inconclusive.

POTS and dysautonomia indicate a malfunction of the autonomic nerves but do not necessarily signify damage to those nerves. Because Ms.

Hibbard's entire causation theory required autonomic neuropathy as the essential intermediate link between the flu vaccine and her dysautonomia — vaccine → molecular mimicry → autonomic neuropathy → dysautonomia/POTS — the special master concluded that without a finding of autonomic neuropathy, "the remainder of her case ceases to be logical," and denied compensation without completing the Althen analysis. Judge Wheeler, writing for the Court of Federal Claims on August 24, 2011, denied the motion for review and affirmed the special master's decision.

The court held that the special master's diagnosis-first approach was proper. Although Ms.

Hibbard argued that Broekelschen should be confined to cases involving two competing diagnoses with different etiologies, the court found that Broekelschen's principle applies here because autonomic neuropathy was the essential intermediate link in Ms. Hibbard's own causation theory, without which there was no logical sequence of cause and effect satisfying Althen's second prong.

The special master had not committed legal error by deciding the case on the preliminary question of autonomic neuropathy rather than conducting a complete Althen analysis. The special master's factual determination that Ms.

Hibbard did not have autonomic neuropathy was supported by the record: the objective testing was mostly normal, Dr. Chaudhry's reliance on that testing was reasonable, and the court was not permitted to reweigh the evidence or second-guess the special master's credibility determination.