Ligia Gairdo v. HHS - Pneumococcal, shoulder injury related to vaccine administration (SIRVA) (2024)

Ligia Gairdo, a 65-year-old woman, filed a petition on August 22, 2018, alleging that she suffered a shoulder injury related to vaccine administration (SIRVA) after receiving a pneumococcal vaccination on August 20, 2015. Petitioner was represented by Ramon Rodriguez, III, of Sands Anderson, PC, and the respondent was represented by Austin Joel Egan of the U.S.

Department of Justice. Special Master Daniel T.

Horner issued the decision on September 20, 2024. Petitioner claimed entitlement to compensation under the National Childhood Vaccine Injury Act, alleging a "Table Injury" or, alternatively, that the vaccination was the cause-in-fact of her injury.

The Vaccine Injury Table lists SIRVA as a compensable injury if it occurs within 48 hours of vaccine administration and meets specific criteria, including no prior history of shoulder pain or dysfunction that would explain the symptoms, timely onset of pain, limitation of pain and reduced range of motion to the affected shoulder, and no other condition explaining the symptoms. Alternatively, to prove causation-in-fact, a petitioner must demonstrate a medical theory connecting the vaccination and injury, a logical sequence of cause and effect, and a proximate temporal relationship.

Petitioner's medical records from August 26, 2015, indicated a reaction to the vaccination including fever, fatigue, myalgias, and localized swelling and erythema of the left arm, diagnosed as cellulitis and an allergic reaction. Petitioner was treated empirically with antibiotics and prednisone.

Subsequent medical records from September 2015 through early 2017 documented complaints of neck pain, cervical strain, cervical muscle pain, and generalized body pain, which petitioner suspected was fibromyalgia. Petitioner also had a history of lower back pain.

The medical records from this period did not consistently document left shoulder dysfunction or pain. Petitioner's physical therapy in September and October 2015 was for her neck, and she was discharged having met her goals.

In February 2017, petitioner presented with left arm pain, reporting a fall on her elbow while bathing her mother, which resulted in a posterior lateral force through her shoulder. She reported inability to abduct her arm and significant pain.

An MRI in February 2017 showed a partial tear of the supraspinatus tendon and degenerative disease. An orthopedist diagnosed cervical spondylosis, glenohumeral arthritis, and cervical radiculopathy, noting extensive spondylosis on cervical spine x-ray and deeming the rotator cuff tear low grade.

Petitioner underwent shoulder surgery in January 2021, which found degenerative changes but an intact rotator cuff. Petitioner testified that her health was excellent prior to vaccination and that she had no prior pain.

She denied having fibromyalgia or osteoarthritis. However, her testimony was found to be inconsistent with contemporaneous medical records, which documented prior back pain, suspicion of fibromyalgia at the time of vaccination, and a fall in February 2017 that she initially denied or mischaracterized.

Her husband, Rafael Gil, also testified, but his recollection of events was inconsistent, and he incorrectly asserted that doctors misrecorded the fall. Petitioner's sister, Yolanda Evans, and granddaughter, Marai Gairdo, testified, as did her daughter, Mary Gairdo.

Marai Gairdo's testimony suggested shoulder pain began significantly after the fall, and Ms. Evans's testimony was not detailed regarding the timeline.

Mary Gairdo's affidavit noted miscommunication due to language barriers and a belated realization of the extent of her mother's shoulder pain. Petitioner's expert, Daniel Carr, M.D., opined that the vaccination contributed to the fall due to persistent shoulder pain and weakness.

Respondent's expert, Paul Cagle, M.D., was critical of Dr. Carr's review and the proposed mechanism of injury.

Special Master Horner found that the contemporaneous medical records were clear and consistent in showing that petitioner had an initial, limited vaccine reaction (cellulitis) that resolved within weeks, and that her shoulder pain and dysfunction began after the February 2017 fall. The Special Master noted that petitioner's own handwritten intake form from February 2017 explicitly stated the onset of left shoulder pain was due to a fall.

The Special Master found petitioner's testimony unreliable due to inconsistencies with medical records and her own prior statements, and found the testimony of other witnesses lacked the clarity and consistency needed to overcome the weight of the contemporaneous medical records. The Special Master concluded that there was not a preponderance of the evidence to establish that the vaccination caused any shoulder injury prior to the fall.

Therefore, the petition was dismissed.