Ida Mosley v. HHS - Td, transverse myelitis (2015)

Ida Mosley was a mental health counselor in Florida when, on the evening of September 6, 2007, she went to the emergency room after pricking her finger on a screw at work. While there, at approximately 11:10 p.m., she received a tetanus toxoid vaccine.

The following day, September 7, she felt unwell and had urinary symptoms. On September 8, she returned to the emergency room in a wheelchair, complaining of body aches, joint aches, fever, and frequent urination, and told the ER staff she had begun feeling sick on September 7.

The emergency room doctors diagnosed a urinary tract infection and prescribed antibiotics. On September 9, Ms.

Mosley returned to the emergency room again, this time complaining of aching all over with weak legs for three days, an inability to urinate, and suprapubic pain radiating down both legs. She was admitted to the hospital.

On September 10, an infectious disease specialist, Dr. Luis Duharte, noted that her presentation was "highly suggestive of adverse reaction to the tetanus toxoid." On September 11, internist Dr.

Miguel Beltre recorded his impression that her condition was "probably reaction to the tetanus toxoid." Her neurologist, Dr. Bridglal Ramkissoon, initially doubted Guillain-Barré syndrome based on normal reflexes, but after a lumbar puncture on September 12 showed elevated protein and pleocytosis — consistent with viral meningitis rather than GBS — and after he noted absent reflexes on September 14, he tentatively diagnosed GBS and transferred her to the intensive care unit.

A second lumbar puncture showed normal protein with continued pleocytosis and a white blood cell count of 33. Tests for absent tibial and peroneal F waves were noted on September 15, and possible diagnoses included GBS, viral meningitis, and acute inflammatory demyelinating polyneuropathy (AIDP).

Ms. Mosley transferred to an inpatient rehabilitation center at Winter Haven Hospital on September 20, where neurologist Dr.

Alain Delgado assessed her with AIDP "with onset dating back to September 7, 2007," and noted her elevated, 100% lymphocytic white blood cell count as "suggesting some sort of viral syndrome." After discharge, her primary care physician, Dr. Audwin Nelson, recorded that Ms.

Mosley was "in the recovery phase of Guillain-Barré syndrome secondary to tetanus toxoid booster." Ms. Mosley never returned to her job as a mental health counselor; she began receiving social security disability benefits in March 2008 and settled a workers' compensation claim in December 2008.

Dr. Ramkissoon later submitted a letter stating that in his opinion the tetanus vaccination had caused her neurological injury through molecular mimicry, "destroy[ing] segments of the myelin sheath around the nerves." Ms.

Mosley filed her petition on October 14, 2008, originally alleging GBS. Her expert, Dr.

William Triggs, a neurologist with a subspecialty in demyelinating disorders, disagreed with the GBS diagnosis and testified that Ms. Mosley had instead suffered an inflammatory lesion of the spinal cord — a partial or mild myelitis — caused by the Td vaccination.

He identified September 9 as the onset of the neurological condition, distinguishing the urinary frequency on September 7 and 8 as symptoms of the urinary tract infection rather than a neurological condition, and explaining that the neurological presentation was urinary retention (inability to empty the bladder), which first appeared on September 9. In a supplemental report, Dr.

Triggs explained that while he had expressed uncertainty at the hearing about molecular mimicry, he did not reject it and considered it "the viable mechanism, more likely than not, at work." The government's expert, Dr. Thomas Leist, testified that the best diagnosis was viral meningoradiculitis — a process between GBS and transverse myelitis.

He testified that Ms. Mosley's bladder symptoms on September 7 and September 8 were not separate events but parts of the same continuous neurological process, making the onset less than twenty-four hours after vaccination — a timeframe he testified was too short for a vaccine-mediated immune response.

He identified the minimum time for a cross-reactive immune response to manifest neurological symptoms as approximately five days. Former Special Master Daria Zane held hearings on July 11 and July 20, 2012, but the case was eventually transferred to Special Master Laura Millman, who issued the entitlement decision on June 23, 2014, denying compensation.

The special master accepted that tetanus vaccine can cause transverse myelitis, satisfying Althen's first prong. However, she found that Ms.

Mosley failed to establish a proximate temporal relationship under Althen's third prong. Relying on Dr.

Leist's opinion, the special master found that Ms. Mosley's neurological symptoms began on September 7, less than twenty-four hours after vaccination.

She noted that Dr. Triggs, while using urinary dysfunction as proof of transverse myelitis, had ignored that urinary dysfunction began on September 7 — the very symptom he identified as signaling a spinal cord lesion at the conus medullaris.

Medical literature, including case reports submitted by petitioner herself, showed onset of transverse myelitis following vaccination ranging from two days to weeks; the Federal Circuit in De Bazan had found an eleven-hour onset interval for a demyelinating disease too short to support causation. The special master's analysis did not mention, address, or weigh the notations or opinions of any of Ms.

Mosley's treating physicians — Drs. Duharte, Beltre, Ramkissoon, Delgado, and Nelson — all of whom had explicitly attributed her neurological condition to the tetanus vaccination.

Judge Kaplan, writing for the Court of Federal Claims, vacated the special master's decision and remanded the case on January 28, 2015. The court held that the special master committed legal error by failing to consider and discuss the opinions of Ms.

Mosley's treating physicians in her causation analysis. The Federal Circuit in Capizzano and Andreu had made clear that treating physicians are typically in the best position to detect a link between vaccination and injury, that their opinions are "quite probative" of causation, and that failure to consider them constitutes reversible error.

The court reasoned that a treating physician's conclusion that a vaccine caused the petitioner's illness implicitly embeds a finding that the onset was within a medically appropriate timeframe — it would be difficult to conceive of a treating physician reaching a causal conclusion while believing the onset interval was medically inappropriate. The government's argument that Capizzano and Andreu confined treating physicians' opinions to the prong-two analysis was rejected; the court found no principled basis for that limitation, and Capizzano itself noted that evidence can overlap to satisfy multiple Althen prongs.

On the Broekelschen issue, the court held that the special master had made no finding that the question of causation turned on whether Ms. Mosley had GBS rather than transverse myelitis, and therefore could not assume that the treating physicians' opinions (which diagnosed GBS) were irrelevant.

The case was remanded for 120 days for the special master to consider and explain the impact of those treating physicians' opinions. Special Master Millman issued an attorneys' fees decision on October 22, 2015, awarding $247,000.00 in attorneys' fees and costs based on the parties' stipulation, payable jointly to Ms.

Mosley and her attorneys at Maglio, Christopher & Toale, PA.