VICP Registry Case Source Bundle
Canonical URL: https://vicp-registry.org/case/USCOURTS-cofc-1_20-vv-00057
Package ID: USCOURTS-cofc-1_20-vv-00057
Petitioner: Josephine Inyang
Filed: 2020-01-17
Decided: 2024-09-05
Vaccine: influenza
Vaccination date: 2017-11-21
Condition: neuromyelitis optica spectrum disorder (NMOSD)
Outcome: entitlement_granted_pending_damages
Award amount USD: 

AI-assisted case summary:
Josephine Inyang alleges that an influenza vaccine administered on November 21, 2017, caused her to suffer from neuromyelitis optica spectrum disorder (NMOSD). The Secretary disputed this, arguing that Ms. Inyang already had undiagnosed NMOSD before vaccination. Ms. Inyang filed her petition on January 17, 2020. Medical records and expert opinions were submitted by both parties. While the parties agreed that Ms. Inyang suffered from NMOSD by December 6, 2017, and that MRIs from December 2017 showed chronic lesions predating the vaccination, they disagreed on whether these lesions were demyelinating. After a hearing with expert testimony from neuroradiologists, the court found it more likely than not that the chronic lesions were demyelinating and consistent with NMOSD, and that Ms. Inyang suffered from NMOSD before her vaccination. Therefore, the court ruled that the vaccine did not cause her NMOSD but may have significantly aggravated it. The case will proceed to discuss potential aggravation. The decision was issued on September 5, 2024.

Theory of causation field:
Off-Table

Public staged source text:

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DOCUMENT 1: USCOURTS-cofc-1_20-vv-00057-0
Date issued/filed: 2024-09-05
Pages: 12
Docket text: PUBLIC ORDER/RULING (Originally filed: 08/08/2024 ) regarding 118 Findings of Fact & Conclusions of Law. Signed by Special Master Christian J. Moran. (ceo) Service on parties made.
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Case 1:20-vv-00057-UNJ Document 122 Filed 09/05/24 Page 1 of 12
In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
* * * * * * * * * * * * * * * * * * * * * *
JOSEPHINE INYANG, *
* No. 20-57V
Petitioner, * Special Master Christian J. Moran
*
v. *
* Filed: August 8, 2024
SECRETARY OF HEALTH *
AND HUMAN SERVICES, *
*
Respondent. *
* * * * * * * * * * * * * * * * * * * * *
Amy A. Senerth, Muller Brazil, LLP, Dresher, PA, for petitioner;
Debra A. Filteau-Begley, United States Dep’t of Justice, Washington, DC, for
respondent.
Finding of Fact1
Josephine Inyang alleges that an influenza vaccine, which was administered
to her on November 21, 2017, caused her to suffer a neurologic problem known as
neuromyelitis optica spectrum disorder (“NMOSD”).2 The Secretary disputes this
1 Because this Finding of Fact contains a reasoned explanation for the action taken in this
case, it must be made publicly accessible and will be posted on the United States Court of
Federal Claims’ website, and/or at
https://www.govinfo.gov/app/collection/uscourts/national/cofc, in accordance with the
E-Government Act of 2002. 44 U.S.C. § 3501 note (2018) (Federal Management and Promotion
of Electronic Government Services). This means the Finding of Fact will be available to anyone
with access to the internet. In accordance with Vaccine Rule 18(b), the parties have 14 days to
identify and move to redact medical or other information, the disclosure of which would
constitute an unwarranted invasion of privacy. Any changes will appear in the document posted
on the website.
2 “Neuromyeltis optica spectrum disorder” or “NMOSD” includes the condition
“neuromyelitis optica” or “NMO.” See Exhibit C-1 (Bruna Garbui Dutra et al., “Neuromyelitis
Optica Spectrum Disorders: Spectrum of MR Imaging Findings and Their Differential

Case 1:20-vv-00057-UNJ Document 122 Filed 09/05/24 Page 2 of 12
allegation on several grounds, including an argument that Ms. Inyang suffered
from an undiagnosed NMOSD before she received the vaccination.
I. Procedural History
Ms. Inyang started this case by filing her petition on January 17, 2020. She
submitted various medical records, which included reports about MRIs. The
Secretary denied that Ms. Inyang was entitled to compensation. Resp’t’s Rep.,
filed Dec. 4, 2020.
After multiple enlargements of time, Ms. Inyang supported her claim with a
report from Lawrence Steinman, a neurologist who has frequently assisted
petitioners seeking compensation in the Vaccine Program. Exhibit 18. Dr.
Steinman opined that Ms. Inyang suffered from NMO and the flu vaccination
caused it. Citing the National Institute of Neurological Disorders and Stroke
website, Dr. Steinman described NMO as an autoimmune disease of the central
nervous system predominantly affecting the optic nerves and spinal cord. Id. at 12.
He explained that NMO develops when the immune system attacks healthy cells
and proteins, most often in the spinal cord and eyes. Abnormal autoantibodies
bind to the protein aquaporin-4, which activates other components of the immune
system, resulting in inflammation and cell damage. Id. at 13. Those with NMO
develop optic neuritis and transverse myelitis. Id. at 12. As part of this opinion,
Dr. Steinman asserted that the onset of Ms. Inyang’s NMO was “somewhere
between Dec. 1 and Dec. 4.” Id. at 33. Dr. Steinman did not specify in this section
of his report what evidence supported his opinion regarding this onset. See id.
The Secretary opposed Dr. Steinman’s opinion with an opinion from
Michael Wilson, who is also a neurologist. Exhibit A. Although Dr. Wilson
agreed with the diagnosis of NMOSD, Dr. Wilson disagreed with other parts of Dr.
Steinman’s report. Dr. Wilson maintained that Ms. Inyang was suffering from
NMOSD before she was vaccinated for two reasons. First, Ms. Inyang reported
severe headaches on the date of vaccination. Exhibit A at 7-8, citing Exhibit 2 at
82. Second, the MRIs that Ms. Inyang had shortly after the vaccination revealed
non-enhanced lesions, meaning the lesions were “present before her vaccination.”
Id. at 8.
Diagnosis," 38(1) Radiographis 169 (2018)) at 3. The experts and the parties appear to use
NMOSD and NMO interchangeably.
2

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In the ensuing status conference, the parties discussed when Ms. Inyang
developed NMOSD. She proposed obtaining the actual images of her MRIs and
asking someone to review them. Ms. Inyang was uncertain as to whether she
would ask Dr. Steinman to review the MRI images.
After Ms. Inyang obtained images from most MRIs and after multiple
enlargements of time, she presented a report from a neuroradiologist, David
Wilson. Dr. Wilson agreed that the MRIs from December 2017 showed that Ms.
Inyang suffered from NMOSD at that time. Exhibit 45. However, he contended
that the images did not confirm the presence of a demyelinating condition before
the vaccination. Dr. Wilson proposed that in 2017, Ms. Inyang suffered from a
different condition, cerebral small vessel disease (“cSVC”). Id. at 3. He described
cSVC as “the narrowing and/or obstruction of small vessels in the brain causing
hemorrhages, and a characteristic distribution of white matter abnormalities.” Id.
In response to an opinion from a neuroradiologist, the Secretary retained
another neuroradiologist, William B. Zucconi. Dr. Zucconi stated that the presence
of non-enhancing lesions on the December 6, 2017 MRI meant that the lesions pre-
dated the November 21, 2017 vaccination. Exhibit A at 8-9. Dr. Zucconi further
opined that the lesions detected in the December 2017 MRIs were consistent with
NMOSD.
The parties were asked whether they wanted to proceed to a hearing. Order,
issued Jan. 4, 2024. They decided to proceed to a hearing during which only the
neuroradiologists would testify. During the January 17, 2024 status conference,
Ms. Inyang also stated that she received more MRI images and was attempting to
obtain another MRI image. Accordingly, she was given 60 days to submit a report
from Dr. Wilson. Order, issued Jan. 19, 2024.
After 60 days had passed, Ms. Inyang requested additional time. However,
she did not establish good cause for enlarging the deadline. Order, issued Mar. 20,
2024.
The Secretary’s expert, Dr. Zucconi, reviewed the images from the more
recently obtained MRIs. He disclosed his opinion about their significance.
Exhibit E.
3

Case 1:20-vv-00057-UNJ Document 122 Filed 09/05/24 Page 4 of 12
A hearing was held on August 2, 2024, during which Dr. David Wilson3 and
Dr. Zucconi appeared in person. (The undersigned appreciates the experts’
willingness to travel.) Both Dr. Wilson and Dr. Zucconi have testified in the
Vaccine Program relatively infrequently. Despite (or because of) this
inexperience, both Dr. Wilson and Dr. Zucconi made favorable impressions. Each
presented their opinions respectfully and noted that he often agreed with his
counterpart. Dr. Wilson and Dr. Zucconi acknowledged the limits of their
knowledge. This humbleness enhanced the credibility of both witnesses.4
II. Events in Ms. Inyang’s Life5
A. Before Vaccination and Vaccination
Ms. Inyang was born in 1961 in Cameroon. Exhibit 3 at 901, 903, Exhibit
12 (affidavit) ¶ 1. She worked as a social worker in that country as well as in the
United States. She had stopped working as a social worker by the time of the
allegedly causal vaccination. Exhibit 2 at 83-86. Although not employed, Ms.
Inyang volunteered for church. Exhibit 12 at ¶ 2.
In 2010, Ms. Inyang underwent an MRI without contrast, although the
reason for the MRI is not abundantly clear. Regardless, during the litigation, Ms.
Inyang obtained the MRI images from 2010. According to Dr. Zucconi, the May
7, 2010 MRI shows “abnormal white matter signal hyperintensity in the deep and
periatrial regions of the posterior cerebral hemispheres, in the same anatomic
3 Unless otherwise specified, all further references to “Dr. Wilson” refer to
neuroradiologist Dr. David Wilson, not neurologist Dr. Michael Wilson.
4 In accordance with the Federal Circuit stated that special masters should not make
credibility assessments to determine the strength of an expert’s testimony, Andreu v. Sec’y of
Health & Hum. Servs., 569 F.3d 1367, 1379 (Fed. Cir. 2009), the undersigned does not
determine that Dr. Wilson or Dr. Zucconi were more credible based upon their demeanors.
Nevertheless, the undersigned commends the trial presentation of the Secretary’s attorney for
carefully showing how Dr. Zucconi derived his opinions from MRI images presented on direct
examination.
5 Due to the agreement about the diagnosis of NMOSD, Ms. Inyang’s medical history is
summarized. Although this finding does not memorialize all the details, the medical records
have been reviewed. Information about Ms. Inyang’s medical history is summarized in the
Amended Petition, filed Mar. 21, 2024, and Respondent’s Report at 6-8. See also Exhibit 18
(Dr. Steinman’s report) at 8-12; Exhibit A (Dr. Michael Wilson’s report) at 3-4.
4

Case 1:20-vv-00057-UNJ Document 122 Filed 09/05/24 Page 5 of 12
location demonstrated to undergo demyelination at future time points.” Exhibit E
at 1.
Other potentially relevant medical history includes a history of hypertension,
obesity, and prediabetes. Exhibit 2 at 5-6, 83-84. Both Dr. Wilson and Dr. Zucconi
testified that these traits predisposed Ms. Inyang to developing a small vessel
disease.
Ms. Inyang sought care from her primary care physician, Michael Reiner, on
November 21, 2017. She related that over the past two weeks, she has had “a
fleeting kind of discomfort which occurs in her left frontal region, thinking that
might be associated with a lot of reading that she does.” Exhibit 2 at 82. Dr.
Reiner assessed her as having “tension type headache, probably related to eye
strain.” Id. at 86. Dr. Reiner also gave her the flu vaccine.
B. Within One Month of the Vaccination
Ms. Inyang returned to Dr. Reiner’s office ten days later. She reported
“back pain after twisting, carrying groceries in the house.” Exhibit 2 at 94 (Dec. 1,
2017). Dr. Reiner assessed her with a lumbosacral neuromuscular strain. Id. at 98.
Ms. Inyang saw Dr. Reiner again on December 4, 2017. She stated that on
December 1, 2017, she had developed numbness extending down from her waist.
The numbness had not extended to her chest. Exhibit 2 at 106. Dr. Reiner was
concerned that she was suffering from a spinal cord stroke, transverse myelitis, or
Guillain-Barré syndrome. He referred her to a neurologist and possible admission
to the hospital. Id. at 110.
Later the same day, Ms. Inyang sought care in an emergency room. She
recounted her history of numbness and pain, which had started in her left leg and
now was present in both legs. Exhibit 3 at 1223. Ms. Inyang underwent MRIs of
her spine, which revealed a lesion from C3 to T9. Id. at 1309-11. She was
assessed with transverse myelitis and admitted to the hospital. Id. at 1226.
A neurologist, Irfan Altafullah, ordered additional testing. A test for an
aquaporin 4 (“AQP4”) antibody was positive. Exhibit 3 at 1296. The presence of
an AQP4 antibody means that the person is likely to suffer from NMOSD. Exhibit
18 (Dr. Steinman) at 12; Exhibit A (Dr. Michael Wilson) at 4.
Ms. Inyang underwent a brain MRI on December 6, 2017. The radiologist
who interpreted this imaging in 2017, Brian Larkin, identified chronic lacunar
5

Case 1:20-vv-00057-UNJ Document 122 Filed 09/05/24 Page 6 of 12
infarcts. Exhibit 3 at 1305. As Dr. Zucconi explained at the hearing, an infarct is a
lesion due to impaired flow of oxygen. See also Dorland's Illustrated Medical
Dictionary at 934 (32nd ed. 2012)
As discussed extensively below, the neuroradiologists the parties retained
also interpreted this imaging. Dr. Wilson and Dr. Zucconi agreed that the lesions
were chronic. Exhibit 45 at 3; Exhibit C at 7. However, they disputed whether the
chronic lesions were evidence of demyelination.
Following administration of high dose steroids, Ms. Inyang improved. She
was discharged from the hospital on December 7, 2017 to inpatient rehabilitation.
Exhibit 3 at 1270. Her discharge diagnosis was neuromyelitis optica.
During inpatient rehabilitation, Ms. Inyang improved but then developed
memory and cognitive processing issues. Exhibit 3 at 939-40. This decline led to
more investigation, including another brain MRI, which was performed on
December 18, 2017. Exhibit 3 at 822. Again, Dr. Wilson and Dr. Zucconi
reviewed this imaging and, again, had some agreements and some disagreements
as discussed below.
Ms. Inyang ultimately was discharged home on December 21, 2017. Exhibit
3 at 819. Her diagnosis was NMO.
C. Treatment and Imaging Starting in 2018
Since her diagnosis, Ms. Inyang has continued to suffer from NMOSD. See
Exhibit 12 (affidavit) ¶ 12. The ebbs and flows of her disease course generally do
not contribute to determining when Ms. Inyang started suffering from NMOSD as
the parties are relying upon neuroradiologists, who have based their opinions on
successive MRIs that are discussed below.
Date Location Cite Interpretation
2/4/2018 Cervical spine 5 at 54; 16 at 112 marked improvement
4/20/2018 Lumbar spine 3 at 442 marked improvement
4/20/2018 Thoracic spine 3 at 442 marked improvement
6

Case 1:20-vv-00057-UNJ Document 122 Filed 09/05/24 Page 7 of 12
In October 2018, Ms. Inyang sought a second opinion from doctors at the
Mayo Clinic, where she was seen by a neuroimmunologist, Oliver Tobin. Exhibit
7 at 7. In considering an appropriate medication for Ms. Inyang’s pain, Dr. Tobin
ordered additional MRIs. Id. at 10.
This set of MRIs on her brain and spine was performed on October 31, 2018
and “did not indicate any new lesions.” Id. at 10. In this context, a
neuroradiologist at Mayo Clinic, Dr. Erickson, compared the recent set of MRIs to
the previous MRIs. Dr. Erickson interpreted the December 2017 MRIs as showing
lesions “along the right lateral ventricle [that] have the more typical Dawson's
finger appearance and would be consistent with demyelinating disease, and by
report she has NMO. Abnormal T2 signal areas consistent with chronic
demyelinating disease.”
The retained experts disputed the Mayo Clinic’s interpretation of the
December 2017 MRIs. Dr. Zucconi agreed that Ms. Inyang’s MRI’s showed a
“Dawson’s finger.” Exhibit C at 6. However, Dr. Wilson disagreed, maintaining
that the December 2017 MRIs are “weak evidence of demyelinating injury in a
patient with clear sCVD.” Exhibit 45 at 7.6
Ms. Inyang underwent additional MRIs:
Date Location Cite Interpretation
9/16/2020 Cervical 16 at 22 “No cervical cord abnormality. No
spine atrophy or abnormal enhancement.”
“Mild cervical disc degeneration.
Right-sided facet arthropathy at C3-4.
No significant narrowing of the spinal
canal or neural foramina./’
6 The original pair of retained experts contribute relatively little to evaluating the Mayo
Clinic’s reinterpretation of the December 2017 MRIs. Dr. Steinman noted the MRIs from
October 2018, but Dr. Steinman did not discuss the commentary about Dawson’s fingers and
demyelination. Exhibit 18 at 12. Dr. Michael Wilson, who did not have the MRIs imaging
available for review, credited the Mayo Clinic’s reinterpretation. Exhibit A at 4.
7

Case 1:20-vv-00057-UNJ Document 122 Filed 09/05/24 Page 8 of 12
Date Location Cite Interpretation
9/16/2020 Thoracic 16 at 24 “Intramedullary signal abnormality
spine along the upper thoracic spinal cord,
not apparently changed since October
2018. This is compatible with
inflammatory myelitis. No new level
of involvement, cord atrophy, or
abnormal enhancement.”
12/20/2020 Cervical 14 at 66, 69, 72 acute disease
spine
12/20/2020 Thoracic 14 at 66, 69, 72 acute disease
spine
12/20/2020 Brain 14 at 66, 69, 72 “Increase in the deep white matter T2
hyperintense lesions near the atria of
both lateral ventricles since the 2017
MRI. Partial enhancement of the white
matter lesions adjacent to the atrium of
the right lateral ventricle is compatible
with acute
inflammation/demyelination.”
The significance of the December 20, 2020 MRI is another point of
disagreement between Dr. Wilson and Dr. Zucconi. They agree that the December
20, 2020 MRI shows demyelination in the area where a lesion was detected in
2017. Exhibit 45 at 6; Exhibit C at 7. Dr. Zucconi reasons that because Ms.
Inyang developed a demyelinating lesion at this location in 2020, it is likely that
the 2017 lesions was also demyelinating. Exhibit C at 7-8. In contrast, Dr. Wilson
asserts that “new demyelinating injury in this location in 2020 does not imply that
injury at the same location observed in 2017 is of demyelinating origin.” Exhibit
45 at 6.
The remaining MRIs do not meaningfully contribute to determining whether
Ms. Inyang suffered from NMOSD before her vaccination.
8

Case 1:20-vv-00057-UNJ Document 122 Filed 09/05/24 Page 9 of 12
III. Standards for Adjudication7
A petitioner is required to establish her case by a preponderance of the
evidence. 42 U.S.C. § 300aa–13(1)(a). The preponderance of the evidence standard
requires a “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 v. Sec’y of Health & Hum.
Servs., 592 F.3d 1315, 1322 n.2 (Fed. Cir. 2010) (citations omitted). Proof of
medical certainty is not required. Bunting v. Sec’y of Health & Hum. Servs., 931
F.2d 867, 873 (Fed. Cir. 1991).
Distinguishing between “preponderant evidence” and “medical certainty” is
important because a special master should not impose an evidentiary burden that is
too high. Andreu v. Sec’y of Health & Hum. Servs., 569 F.3d 1367, 1379-80 (Fed.
Cir. 2009) (reversing special master's decision that petitioners were not entitled to
compensation); see also Lampe v. Sec’y of Health & Hum. Servs., 219 F.3d 1357
(Fed. Cir. 2000); Hodges v. Sec’y of Health & Hum. Servs., 9 F.3d 958, 961 (Fed.
Cir. 1993) (disagreeing with dissenting judge's contention that the special master
confused preponderance of the evidence with medical certainty).
Here, although the parties agree with the diagnosis of NMOSD, they dispute
whether Ms. Inyang was suffering from NMOSD on the date of vaccination.
Although Ms. Inyang was diagnosed as suffering from NMOSD after the
vaccination, the date of diagnosis does not always determine the date of onset. See
Rocha v. Sec’y of Health & Hum. Servs., No. 16-241V, 2024 WL 752787, at *33
(Fed. Cl. Spec. Mstr. Feb. 1, 2024) (stating “As a matter of logic, a doctor's
detection of a disease does not establish the date the disease began" and citing
appellate cases affirming findings regarding date of onset).
IV. Analysis
Preliminarily, basic areas of agreement should be set forth. The parties
agree:
• Ms. Inyang suffered from NMOSD by December 6, 2017. Exhibit 45
at 7 (Dr. Wilson); Exhibit C at 8 (Dr. Zucconi).
7 This Finding is being issued before the release of the transcript.
9

Case 1:20-vv-00057-UNJ Document 122 Filed 09/05/24 Page 10 of 12
• Ms. Inyang’s spinal MRIs from December 4, 2017 are consistent with
NMOSD;
• Ms. Inyang’s brain MRIs from December 2017 show chronic lesions
that are of such age that they must have existed before the November
21, 2017 vaccination.8
Despite those agreements, Dr. Wilson and Dr. Zucconi disagree on a
question critical to whether Ms. Inyang may establish that the flu vaccine caused
her NMOSD. This critical question is whether the chronic lesions detected on the
December 2017 MRIs are evidence of a demyelinating injury. A fact hearing was
held on August 2, 2024 for the experts to testify about and annotate the MRI
images.
As previously stated, both experts were credible, in part, because they did
not exaggerate their knowledge. For example, Dr. Zucconi admitted that he could
not say that Ms. Inyang suffered from NMO before her vaccination “definitively.”
Yet, he could say---and did say---that it was more likely than not that the lesions
on the two brain MRIs from December 2017 were demyelinating. Dr. Wilson’s
opinion to the contrary does not prevent a finding of fact crediting Dr. Zucconi’s
opinion. See Doe 11 v. Sec’y of Health & Hum. Servs., 601 F.3d 1349, 1355 (Fed.
Cir. 2010) (noting that conflicting evidence does not mean a special master’s
finding is arbitrary).
Dr. Zucconi’s opinion that Ms. Inyang began suffering from NMOSD before
the vaccination is credited for several reasons. First, the 2017 brain MRIs revealed
lesions in four different areas of the brain. Dr. Wilson and Dr. Zucconi agreed that
these four areas correspond to areas where AQP4 is highly expressed and,
therefore, are common places for lesions in people with NMOSD. Dr. Wilson is
not wrong, as a matter of theory, to say that people might develop infarcts in these
same regions. However, it seems unlikely that all four lesions developed in areas
with AQP4 expression without any being demyelinating. See W.C. v. Sec’y of
Health & Hum. Servs., 704 F.3d 1352, 1358 (Fed. Cir. 2013) (ruling that a special
8 This agreement about the chronicity of the December 2017 brain lesions avoids any
controversy over how long lesions enhance. For information about the duration of enhancement,
see W.C. v. Sec'y of Health & Human Servs., No. 07-456V, 2011 WL 4537877, at *6-7 (Fed. Cl.
Spec. Mstr. Feb. 22, 2011) (discussing Cotton article), mot. for rev. denied on relevant grounds,
100 Fed. Cl. 440, 451 (2011), aff'd, 704 F.3d 1352, 1359-60 (Fed. Cir. 2013).
10

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master’s crediting of one expert’s testimony about chronicity of MRI was not
arbitrary).
Next, the evolution of lesions is more consistent with a single disease
process. Dr. Wilson and Dr. Zucconi agreed that the 2020 MRI revealed an acute
demyelinating lesion in Ms. Inyang’s left medulla. This location is also the
location of a small lesion seen on the first MRI in December 2017 and faintly seen
on the second MRI in December 2017. Dr. Zucconi reasons persuasively that it
would seem unlikely for one person to have an infarct in one part of the brain and
then develop demyelination in the same spot three years later. Dr. Wilson’s
alternative view---essentially that the similar location but different etiology was
simply coincidental---is less persuasive.
Third, there is relatively little persuasive evidence that Ms. Inyang suffers
from small vessel disease. In Dr. Zucconi’s first report, he identified the ways
small vessel disease typically appears on imaging. Exhibit C at 5, citing exhibit C-
7 (Aowei Lv et al., “Dawson’s Fingers in Cerebral Small Vessel Disease,” 11
Front. Neurol. 669 (2020)). At the hearing, Dr. Wilson agreed that these features
are typical. Dr. Zucconi also asserted that Ms. Inyang’s MRIs did not reveal these
features. Exhibit C at 5. Again, Dr. Wilson agreed.
Furthermore, no treating doctor appears to have diagnosed Ms. Inyang with
small vessel disease.
The expert Ms. Inyang retained, Dr. Steinman, stated that Ms. Inyang
“clearly” had “neuromyelitis optica.” Exhibit 18 at 12. Dr. Steinman does not
suggest that she also suffered from a small vessel disease. See id.
None of these factors is dispositive by itself. But, collectively, these factors
preponderate in favor of a finding that Ms. Inyang suffered from an undiagnosed
case of NMOSD before she was vaccinated on November 21, 2017.
Because Ms. Inyang suffered from NMOSD before the vaccination, she
cannot claim that the flu vaccine caused her condition. Locane v. Sec’y of Health
& Hum. Servs., 685 F.3d 1375, 1381 (Fed. Cir. 2012). Ms. Inyang, however, may
continue with her claim that the flu vaccine significantly aggravated her NMOSD.
A status conference will be held to discuss this topic.
11

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V. Conclusion
The evidence preponderates in support of a finding that the chronic lesions
on Ms. Inyang’s brain MRIs from December 2017 were demyelinating.
The parties are directed to provide this order to any expert whom they retain.
A status conference is set, sua sponte, for Wednesday, August 28, 2024 at
10:00 A.M. Petitioner should be prepared to discuss potential next steps.
IT IS SO ORDERED.
s/Christian J. Moran
Christian J. Moran
Special Master
12