VICP Registry Case Source Bundle
Canonical URL: https://vicp-registry.org/case/USCOURTS-cofc-1_21-vv-01231
Package ID: USCOURTS-cofc-1_21-vv-01231
Petitioner: Adwoa Ampofo-Addo
Filed: 2021-04-16
Decided: 2025-07-31
Vaccine: Tdap; MMR; varicella
Vaccination date: 2018-04-17
Condition: MOGAD / acute disseminated encephalomyelitis (ADEM)
Outcome: denied
Award amount USD: 

AI-assisted case summary:
Adwoa Ampofo-Addo, a 37-year-old woman, received a Tdap vaccine on April 17, 2018, and MMR and varicella vaccines on April 24, 2018, as part of her U.S. immigration requirements. She alleged these vaccines caused her to develop myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) and/or MOG-positive acute disseminated encephalomyelitis (ADEM). Petitioner presented with a history of upper respiratory infection symptoms prior to vaccination, and in the weeks following vaccination, she experienced a range of symptoms including fever, headache, urinary issues, abdominal distention, weakness, tremor, and sensory disturbances. She was hospitalized and diagnosed with ADEM post-vaccination, acute renal insufficiency, and an adnexal mass, later also diagnosed with transverse myelitis and anti-MOG positive encephalomyelitis. Petitioner's experts, a neuroimmunologist and an immunologist, proposed that the vaccines triggered her condition through mechanisms like molecular mimicry and inflammasome activation. Respondent's experts, a neurologist and an immunologist, contested the diagnosis, suggesting a post-infectious myelitis was more likely, and argued that the proposed vaccine causation theories were not supported by sufficient scientific evidence. The court found that Petitioner failed to prove by a preponderance of the evidence that the vaccines caused her condition, noting the presence of concurrent illness and the lack of robust scientific support for the proposed causal mechanisms. The petition was denied.

Theory of causation field:
Tdap on April 17, 2018, age 37, followed by MMR and varicella on April 24, 2018, alleged to cause MOG antibody disease/ADEM. DENIED. Petitioner advanced an immune-mediated demyelinating disease theory; respondent disputed theory, sequence, and timing. Special Master Horner denied entitlement on July 31, 2025. Later attorney-fee decision did not change merits outcome.

Public staged source text:

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DOCUMENT 1: USCOURTS-cofc-1_21-vv-01231-1
Date issued/filed: 2025-08-26
Pages: 32
Docket text: PUBLIC DECISION (Originally filed: 07/31/2025) regarding 69 DECISION of Special Master. Signed by Chief Special Master Brian H. Corcoran. (mva) Service on parties made.
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Case 1:21-vv-01231-UNJ Document 70 Filed 08/26/25 Page 1 of 32
In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
No. 21-1231V
* * * * * * * * * * * * * * * * * * * * * * * * *
*
ADWOA AMPOFO-ADDO, * Chief Special Master Corcoran
*
Petitioner, * Filed: July 31, 2025
*
v. *
*
SECRETARY OF HEALTH *
AND HUMAN SERVICES, *
*
Respondent. *
*
* * * * * * * * * * * * * * * * * * * * * * * * *
Maximillian J. Muller, Muller Brazil, LLP, Dresher, PA, for Petitioner.
Rachelle Bishop, U.S. Department of Justice, Washington, DC, for Respondent.
ENTITLEMENT DECISION1
On April 16, 2021, Adwoa Ampofo-Addo filed a petition for compensation under the
National Vaccine Injury Compensation Program (the “Vaccine Program”).2Petitioner alleges that
her receipt of a tetanus, diphtheria, and acellular pertussis (“Tdap”) vaccine on April 17, 2018, as
well as measles-mumps-rubella (“MMR”) and varicella vaccines administered on April 24, 2018,
caused her to suffer myelin oligodendrocyte glycoprotein antibody-associated disease
(“MOGAD”), and/or MOG-positive acute disseminated encephalomyelitis (“ADEM”). See
Amended Petition, dated July 31, 2024 (ECF No. 41).
A two-day Entitlement Hearing was held in Washington, D.C., on November 12–13, 2024.
Having reviewed the record, all expert reports, the medical records, and associated literature, I
hereby find that Petitioner is not entitled to an award of compensation.
1 Under Vaccine Rule 18(b), each party has fourteen (14) days within which to request redaction “of any information
furnished by that party: (1) that is a trade secret or commercial or financial in substance and is privileged or
confidential; or (2) that includes medical files or similar files, the disclosure of which would constitute a clearly
unwarranted invasion of privacy.” Vaccine Rule 18(b). Otherwise, the whole Decision will be available to the public
in its present form. Id.
2 The Vaccine Program comprises Part 2 of the National Childhood Vaccine Injury Act of 1986, Pub. L. No. 99-660,
100 Stat. 3758, codified as amended at 42 U.S.C. §§ 300aa-10 through 34 (2012) [hereinafter “Vaccine Act” or “the
Act”]. Individual section references hereafter will be to § 300aa of the Act (but will omit that statutory prefix).

Case 1:21-vv-01231-UNJ Document 70 Filed 08/26/25 Page 2 of 32
I. Factual Background
Pre-Vaccination History
Petitioner (37 years old when she received the vaccines in question) has a medical history
significant for an ectopic pregnancy in 2017, suspected allergic rhinitis, and migraines. Ex. 5 at
126, 204; Ex. 6 at 9; Ex. 11 at 24–24; Ex. 22 at 52; Ex. 53 at 145. More significantly, the record
establishes that Petitioner was ill in the days before receiving the first vaccine at issue in this case.
Thus, on April 14, 2018, Petitioner went to University Hospitals Twinsburg Urgent Care in
Twinsburg, Ohio (“Twinsburg”) complaining of a cough and congestion that was “not getting
better” after a week (consistent with a similar complaint from several weeks before). Ex. 23 at 117,
118–19. She was instructed to follow up with her primary care provider for treatment of a
“recurrent upper respiratory infection [“URI”] and cough.” Id. at 119.
Vaccination and ER/Urgent Care Visits
Three days after treatment for her URI (now April 17, 2018), Petitioner visited an urgent
care facility for a medical examination, and to obtain lab work needed to fulfill her U.S.
immigration requirements. See generally Ex. 16. She received a Tdap vaccine—and the following
week (April 24, 2018) returned to the same urgent care provider for receipt of MMR and varicella
vaccines. Ex. 1 at 2; Ex. 16 at 16. There are no medical records from the intervening seven days
between the two vaccination events, and no close-in-time evidence of complaints specific to the
vaccines. But in the days and weeks not long after the second vaccine administration event,
Petitioner sought urgent care several times.
For example, on April 27, 2018 (three days after the second vaccination event), Petitioner
went to the University Hospitals Ahuja Medical Center Emergency Department (“Ahuja ED”) in
Beachwood, Ohio, for treatment of sinus congestion, cough, fever, headache, and eye pain. Ex. 23
at 15–30, 50. The records memorializing this ED visit contain no history summary setting forth
how long these symptoms had existed, or when they first manifested. Petitioner was diagnosed
with a sinus headache and prescribed amoxicillin, Sudafed, Mucinex, and Flonase. Id. at 43.
Three days later (April 30, 2018), Petitioner returned to Twinsburg, complaining of
continued fevers, urinary frequency, and delayed menstruation, with her overall ill feeling
unchanged since she had been last seen on April 27th. Ex. 23 at 187. Petitioner’s urine culture
revealed positive human chorionic gonadotropin (evidence of a possible pregnancy3), plus
abnormal protein levels, heightened white blood cells (“WBC”), and bacteria. Id. at 178–79. She
3 “Chorionic gonadotropin can be detected by immunoassay in the maternal urine within days after fertilization and
thus provides the basis for the most commonly used pregnancy tests.” Chorionic Gonadotropin, Dorland’s Medical
Dictionary Online, https://www.dorlandsonline.com/dorland/definition?id=79195 (last visited July 2, 2025).
2

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was diagnosed with acute sinusitis and again discharged. Id. at 191–92.
That same day, however, Petitioner went back to the Ahuja ED reporting more urinary
frequency and urgency, as well as an ongoing headache and congestion. Ex. 23 at 136. A
transabdominal transvaginal ultrasound performed at this time did not confirm a gestational sac in
the uterus, and imaging showed a mass-like area of tissue between the left ovary and the uterus.
Ex. 23 at 34, 144, 146–47. Petitioner was diagnosed with a urinary tract infection and advised to
follow up with obstetrics for repeat evaluation. Id. at 145, 147.
Petitioner returned to the Ahuja ED on May 3, 2018 (now nine days after the second
vaccination event), reporting abdominal distention, lack of bowel movements, urinary frequency,
and a two-day history of nausea and vomiting. Ex. 23 at 236. It was noted that Petitioner had been
diagnosed as pregnant a few days before. Id. A catheter was inserted to “relieve [] [Petitioner’s]
abdominal distention,” but her kidney functioning was deemed significantly worse compared to
her last visit. Id. at 238. Petitioner was admitted with a diagnosis of acute renal insufficiency and
an adnexal mass, and was later transferred to University Hospitals Cleveland Medical Center for
further evaluation. Id. at 238–40, 251; Ex. 21 at 311, 1351.
Hospitalization and Relevant Treatment
At the start of her hospital admission, Ms. Ampofo-Addo reiterated the medical history she
had previously provided other treaters, but also now noted that on April 30, 2018 (six days after
receiving the second set of vaccines at issue), she had found it difficult to empty her bladder, and
also experienced constipation, worsening lower extremity weakness, a noticeable change in her
gait, bilateral feet tingling and pain with light touch, and development of a whole-body tremor.
Ex. 13 at 235, 274, 329. She also noted that she recalled becoming sick the week of April 9, 2018—
prior to her vaccinations—and that the illness arose after a visit from a family member from Ghana.
Id. at 232, 267. Over the first night of her admission Petitioner developed a fever of 102.2 degrees
shortly after administration of Tylenol. Id. at 296.
Petitioner subsequently underwent a brain MRI, which yielded evidence of “patchy areas
of nonspecific abnormal increased signal on the FLAIR and T2 weighted images involving
subcortical white matter and to a lesser degree the cortex within the cerebral hemispheres
bilaterally” with “[a]dditional areas of ill-defined increased signal identified within the thalami
and brainstem.” Ex. 13 at 91. The etiology for these findings, however, was deemed uncertain. Id.
A cervical MRI was also performed at this time, and it revealed “nonspecific vague increased
intramedullary signal on the T2 images overlying the cervical cord.” Id. at 94.
A few days into her hospitalization, Petitioner had a consult in early May 2018 with
Hesham Abboud, M.D., Ph.D., a neuroimmunologist. Ex. 13 at 274–75. Dr. Abboud’s exam
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revealed “slow saccades, pathological hyperreflexia, LUE>RUE rest/postural/action coarse
tremor, reduced vibration sense distally and a positive Romberg’s sign.”4 Id. at 274. Additional
testing provided evidence of pleocytosis with a WBC count of 205, a red blood cell count of 2,
and 35% neutrophils, 35% lymphocytes, and 30% monocytes, as well as signs of high protein at
79 mg/dL and elevated myelin basic protein of 13.7 mcg/L. Id. at 100–35, 330, 333–34, 365, 502.
Petitioner also consulted with allergy and immunology fellow Nancy Joseph, D.O. Id. at 325.
Although Dr. Joseph maintained that an exact etiology for Petitioner’s condition remained
unknown at the time, the normal immunoglobulin values revealed by testing suggested to her that
an immunodeficiency disease was “less likely,” although she allowed for the possibility of an
adverse rection to the rubella component of the MMR vaccine (as had been reported in a prior case
report of which Dr. Joseph was aware). See S. Holt et al., Diffuse Myelitis Associated with Rubella
Vaccination, 2 Br. Med. J. 1037 (1976) (“Holt”) (describing two teenage girls who received rubella
vaccines and developed sensory and motor impairment in their legs, one in four days after
vaccination, and the other two weeks after vaccination).5
Petitioner subsequently began to receive antiviral and antibiotic medications after consult
with the hospital’s infectious disease team. Ex. 13 at 333, 342. Mohamad Yasmin, M.D., noted
that Petitioner’s mental status and lumbar puncture results were inconsistent with bacterial
meningitis, but that “[p]ossible pathology may involve immune response to a preceding infection
or vaccination that cross-reacts with nerve components (molecular mimicry).” Id. Antibiotic and
antiviral coverage were discontinued on May 7th and 8th, respectively, following negative bacterial
cultures, inconsistent findings of bacterial meningitis, and a remaining unidentified etiology. Id. at
399. However, Petitioner’s WBC remained relatively high. Id. at 405.
Petitioner’s condition had noticeably worsened by May 7, 2018. Ex. 13 at 403. She was
tested and later found positive for MOG-IgG antibodies, with titer levels of 1:20 (which
Petitioner’s neurologic expert later deemed a low positive result). Ex. 6 (ECF No. 1-9) at 29; Tr.
at 60. But despite the lack of a clear diagnosis of an immune-mediated illness, her treating
physicians ordered empiric plasmapheresis given the likelihood of an autoimmune process.” Ex.
13 at 369. On May 11, 2018, Petitioner had elevated WBCs of 11.9 with 1.9% immature
granulocytes and increased neutrophils and monocytes, and on May 12, 2018, she had elevated
WBCs of 12. Id. at 499–500. An echovirus lab test also revealed highly abnormal results on May
4 “Romberg Sign” is defined as the “swaying of the body or falling when standing with the feet close together and the
eyes closed; the result of loss of joint position sense, seen in … diseases affecting the posterior columns.” Romberg
Sign, Dorland’s Medical Dictionary Online,
https://www.dorlandsonline.com/dorland/definition?id=106448&searchterm=Romberg+sign (last visited July 29,
2025).
5 Holt was not filed as an exhibit in this case, but it is referenced by Petitioner’s Expert, Dr. Akbari, in his expert
report, as well as in a report prepared by Dr. Forsthuber, and mentioned and cited by Respondent in his Rule 4(c)
Report as well as articles and studies offered by the Respondent. See, e.g., Ex. H at 155; Ex. I at 6; Ex. F Tab 5 at 23.
4

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13, 2018—1:80 (normal range <1:10) for echovirus 7 and 30—although subsequent histories or
summaries from the remainder of Petitioner’s treatment course do not document further
consideration of these findings and their significance. Id. at 125. Petitioner underwent a total of
five cycles of plasmapheresis and two days of IVIG treatment between May 8 to May 18, 2018—
both of which were deemed to have helped ameliorate Petitioner’s condition. Id. at 539, 569.
Diagnosis and Subsequent Treatment
On May 18, 2018, and after slightly more than two weeks as a hospital in-patient, Petitioner
was discharged to an acute in-patient rehabilitation center with the final diagnoses of ADEM post-
vaccination, acute urinary retention, and unspecified abnormal involuntary movements. Ex. 13 at
557, 567. At discharge, she exhibited a mild full-body and resting bilateral hand tremor, full
strength, intact sensation, subjective numbness in her left foot without loss of sensation on exam,
intermittent chest tightness complaints, and the ability to walk with assistance. Id. at 568–69. Some
lab work results that might have shed further light on the etiology of her condition remained
outstanding as of discharge.6 Petitioner was advised to follow up with an obstetrician, urology,
and Dr. Abboud. Id. at 570. For approximately a week in mid-May 2018, Petitioner received in-
patient physical therapy (“PT”) and occupational therapy (“OT”) at Beachwood Rehabilitation
Hospital. See generally Ex. 17.
A few days later (May 22, 2018), Petitioner saw Dr. Harold Mars, a neurologist,
complaining of “a tight band-like sensation about the waist,” which corresponded to a T6–T8
sensory level. Ex. 13 at 31. Upon examination, Dr. Mars noted Petitioner possessed diffusely
hyperactive deep tendon reflexes and a sensory level at T6–T8, concluding that her condition was
“predominantly transverse myelitis [“TM”].” Id. at 32. Although Dr. Mars was unable to exclude
other demyelinating disorders at that time, he did note that TM with brain lesions could reflect an
“autoimmune response to vaccine received a few weeks previously.” Id. He recommended that
Petitioner undergo continued brain and spine MRIs in order to monitor for recurrent disease
(consistent with a protocol to watch for multiple sclerosis). Id. Petitioner was at this time noted,
however, to have significantly improved since her in-patient rehab stay, and could not transfer
independently, walk independently for more than 150 feet, and climb stairs. Id. at 328–30.
Petitioner had a follow-up appointment with Dr. Abboud on June 4, 2018. Ex. 20 at 25.
She exhibited decreased sensation in her left lower extremity, but her exam was otherwise
unremarkable. Id. at 28. After reviewing Petitioner’s extensive testing results, Dr. Abboud
recommended additional MOG antibody testing, another brain and cervical MRI, and PT and OT.
Id. at 42. Dr. Abboud proposed that if Petitioner’s antibodies remained positive, or the MRI
6 These lab testing categories include Listeria IgG, Mayo CDS1 panel for demyelinating diseases, JCV with IgG
antibody, echovirus antibody, Strep pneumococcal IgG antibody, and coxsackie, rubella, and echovirus. Ex. 13 at 569-
70.
5

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imaging revealed new lesions, then long-term immunosuppressive therapy would need to be
considered for treatment of “presumed NMO.”7 Id. Petitioner was now diagnosed with “anti-MOG
positive post-vaccination encephalomyelitis vs NMOSD.” Id.
Later that same June, Petitioner began outpatient PT and OT. She reported at this time that
she had resumed the majority of her activities of daily living. Ex. 4 at 16. Her therapist documented
some positive upper body motor neurological findings, but overall Petitioner’s “movement quality,
balance, and strength are virtually normal.” Id. at 8. Petitioner attended three visits, after which
she was discharged with “excellent gains in strength, balance, and vestibular-ocular function.” Id.
at 16. She further noted that she was “90–95 percent recovered” and that she had regained “95
percent of her strength.” Id. at 16–19.
Petitioner returned to Dr. Abboud on August 9, 2018. Ex. 20 at 15–24. Repeat MRIs,
completed on June 20, 2018, revealed “near complete resolution of the abnormal signal in the brain
and cord.” Id. at 18–22, 23. Dr. Abboud deemed Petitioner to be “doing great,” with a residual
mild and tolerable “cold feeling in her right leg and some vibration feeling in the left hip.” Id. at
15. His diagnosis remained “anti MOG positive post-vaccination encephalomyelitis vs. NMOSD.”
Id.
Since the summer of 2018, Petitioner has experienced no significant regression or relapse
in her health—and support for the MOGAD diagnosis considered in this case is variable. For
example, in November 2018, Petitioner underwent Aquaporin 4 and MOG antibody testing, but
the results were now negative. Ex. 6 at 37–38; Ex. 20 at 49. At a follow-up visit that December
with Dr. Abboud, it was proposed that these results (coupled with her improved physical condition)
supported the conclusion that her April–May 2018 illness was “a one-time event related to
vaccination” and “more consistent with monophasic post-vaccinal demyelination.” Ex. 20 at 14.
Dr. Abboud also stated that no additional follow up would be needed should her repeat brain MRI
in June 2019 was negative. Id. In the following two to three years, Petitioner has intermittently
sought treatment for neurologic concerns, but physical exams and testing have not revealed any
concerning evidence of an ongoing disease process.
II. Witness Testimony
A. Fact Witness – Ms. Ampofo-Addo
Ms. Ampofo-Addo was the only fact witness to testify at the hearing. See generally Tr. at
7 Neuromyelitis Optica is defined as a “demyelination of the optic nerve and the spinal cord . . . marked by diminution
of vision and possibly blindness, flaccid paralysis of the extremities, and sensory and genitourinary disturbances.”
Neuromyelitis Optica, Dorland’s Medical Dictionary Online,
https://www.dorlandsonline.com/dorland/definition?id=92610&searchterm=neuromyelitis+optica (last visited July 2,
2025).
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5–54. She began her testimony describing her pre-vaccination medical history. Id. at 11. The only
major issue she had experienced was an ectopic pregnancy that occurred in 2017. Tr. at 11. She
also had ongoing sinus problems, including nasal congestion and an itchy throat, and she was
diagnosed with a dust allergy. Id. Three days before receiving the Tdap vaccine, Petitioner went
to urgent care to seek treatment for a cold and cough that had “lingered” longer than a usual illness.
Id. at 13.
Petitioner received the Tdap vaccine on April 17, 2018, followed by the MMR and varicella
vaccines on April 24th. Tr. at 14. She received these vaccines as part of her application for
permanent residency in the United States. Id. She remembers thinking it was “unusual” to receive
two vaccines at once, but does mention any pain or other symptoms after receiving these vaccines.
Id. at 15. Three days after she received the MMR and varicella vaccines, Petitioner experienced
sinus congestion, cough, fever, headache, and eye pain. Id. Six days after she received the MMR
and varicella vaccines, Petitioner recalled that she still had a headache, in addition to other
symptoms such as difficulty urinating and fever. Id. at 16. At that time, it was determined that
Petitioner was pregnant. Id. at 17.
On May 3, 2018, Petitioner went to the Ahuja ED. Tr. at 18–19. She testified that she was
suffering from abdominal distention, lack of bowel movements, difficulty urinating, nausea, and
vomiting. Id. at 19. At that time, a foley catheter was inserted to relieve Petitioner’s abdominal
distention. Id. Petitioner explained that her doctor was concerned about the functioning of her
kidneys, so she was transferred to the Cleveland Clinic. Id. at 20. She recalled that on the day of
the transfer, she began to experience a full body tremor, lower extremity weakness, bilateral
tingling and numbness in the feet, pain with light touch, and difficulty walking. Id. at 21–22.
Petitioner testified that she was “in so much pain [that she] couldn’t explain or know where the
pain was coming from,” and that the “upper part” of her body was shaking. Id. at 22–23.
Once admitted to the Cleveland Clinic, Petitioner’s symptoms worsened. Petitioner
testified that after four days in the hospital, she could no longer walk due to the pain and numbness
in her feet. Tr. at 26. She began to experience tremors in her hands that prevented her from dressing
herself or doing “anything that a normal person could… do for themselves.” Id. Petitioner recalled
that while she was in the hospital, Dr. Joseph posited that her symptoms may be a result of an
adverse reaction to the vaccines. Id. at 28–29. Petitioner testified that the treatments of
plasmapheresis and IVIG began to work, and she regained feeling and mobility. Id. at 29. At some
point during her stay at the clinic, Petitioner experienced a miscarriage. Id. at 30. Petitioner was
discharged from the Cleveland Clinic to Beachwood Rehab Hospital, where she spent a week
doing physical and occupational therapy. Id. at 31. Petitioner recalled that her mobility had
improved between her stay at the Cleveland Clinic and her time at Beachwood, though she had not
regained full mobility and continued outpatient physical therapy through the summer. Id. at 32–
34.
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Petitioner experienced a “band-like” sensation of tightness around her upper trunk and
tinging and pain in her lower extremities that continued after being released from the hospital. Tr.
at 33. She recalled that Dr. Abboud told her that she had tested positive for the anti-MOG antibody
and prescribed Gabapentin, which Petitioner took until her nerve pain ceased. Id at 33–34. Two
months after receiving her vaccines, Petitioner reported migraines and blurry vision that is
ongoing. Id. at 35.
Petitioner recalled seeing Dr. Abboud again four months after her vaccinations, and he
requested that she be tested again for the anti-MOG antibody. Tr. at 36. On November 16, 2018,
Petitioner tested negative for the anti-MOG antibody. Id. at 38–39. Petitioner remembered Dr.
Abboud telling her that because of her negative test results, her symptoms from earlier that year
were likely a “one-time event related to vaccination.” Id. at 39. Petitioner explained that Dr.
Abboud told her to avoid live vaccines if possible so that she did not have an “adverse reaction.”
Id. at 38.
Petitioner became pregnant and gave birth to her first child in August 2019. Tr. at 38. In
June 2020, Petitioner saw a new neurologist reporting coldness and tinging in her lower left
extremity that had been continuous since her hospitalization in 2018. Id. at 41. Petitioner returned
to the neurologist in July 2022 and reiterated her concerns about sensory symptoms in her legs and
migraines. Petitioner stated that she is seeing a therapist to help process her trauma surrounding
the hospitalization and continued symptoms. Id. at 43–44. Petitioner testified that her symptoms
impacted her daily life, including her ability to work, engage in recreation, volunteer, and interact
with her family. Id. at 45–46.
On cross-examination, Petitioner acknowledged that a family member had visited her from
Ghana around the time she first became sick. Tr. at 50-51. She denied records indicating that this
individual had been sick, but acknowledged the individual may at least have had a cold. Id. at 51.
B. Petitioner’s Experts
1. Dr. Syed Rizvi – Dr. Rizvi, a neuroimmunologist, prepared two written
reports for the Petitioner and testified at trial. Report, dated April 11, 2023, filed as Ex. 30-1 (ECF
No. 29-2) (“First Rizvi Rep.”); Report, dated October 4, 2023, filed as Ex. 46-1 (ECF No. 31-2)
(“Second Rizvi Rep.”). He proposed that the Tdap, MMR, and varicella vaccines that Petitioner
received likely played a significant role in the development of Petitioner’s MOGAD. Tr. at 59.
Dr. Rizvi is a neuroimmunologist in academic practice at Brown Neurology, and Professor
of Clinical Neurology at the Alpert Medical School of Brown University. First Rizvi Rep. at 1. He
routinely cares for patients with a wide variety of autoimmune conditions, such as
ADEM/MOGAD and multiple sclerosis. Id. Dr. Rizvi received his medical degree from Dow
Medical School in Karachi, Pakistan. Curriculum Vitae, dated April 25, 2023, filed as Ex. 31-1
(ECF No. 29-3) (“Rizvi CV”) at 1. He is board certified by the American Board of Psychiatry and
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Neurology to practice neurology in the state of Rhode Island. Id. Dr. Rizvi also received fellowship
training in multiple sclerosis and clinical neuroimmunology in 2000. First Rizvi Rep. at 1. He
previously taught neurology at Stony Brook University Hospital before accepting a position at the
Alpert Medical School. Id. at 2. He has acted a principal investigator in over twenty-five clinical
trials, authored over twenty journal articles in his field, and continues his clinical practice today.
Id. at 1–8.
Dr. Rizvi began his testimony by describing MOGAD as a newly-identified classification
for an autoimmune disease in which the body’s immune system attacks MOG proteins found in
the myelin sheath covering central nervous system (“CNS”) nerves, causing demyelination and
inflammation. Tr. at 60. Although the exact etiology of MOGAD is unknown, it is generally
thought to occur after an infection or, more rarely, a vaccination. Id. at 60–61. Dr. Rizvi discussed
the diagnostic criteria for MOGAD, opining that Petitioner’s “core clinical demyelinating event”
was myelitis or ADEM. Id. at 66.
Dr. Rizvi acknowledged that Petitioner’s antibody titer levels (as first tested on May 7,
2018) were not by themselves high enough to support a diagnosis of MOGAD. Tr. at 63–64; Ex.
6 (ECF No. 1-9) at 29. But he opined that, when combined with her negative test for aquaporin
antibodies and her supporting MRI features of longitudinally extensive myelitis and multifocal
brain lesions, the results pointed toward MOGAD. Id. at 64–65; Rizvi First Rep. at 6 (citing B.
Banwell et al., Diagnosis of Myelin Oliogdendrocyte Glycoprotein Antibody-Associated Disease:
International MOGAD Panel Proposed Criteria, 22 Lancet Neurol. 268, 276 Fig. 3 (2023), filed
as Ex. 49 (ECF No. 52-2) (“Banwell”)). In addition, Petitioner’s ongoing symptoms were
consistent with her diagnosis (other than her tremors). Tr. at 99, 115. And he maintained that the
timing of the onset of Petitioner’s symptoms after her vaccinations was consistent with studies of
other patients that developed similar disorders. Id. at 101.
Dr. Rizvi went on explain his causation theory connecting Petitioner’s vaccinations to her
MOGAD. Tr. at 78. He opined that Petitioner’s vaccinations triggered the production of MOG
antibodies through a process known as molecular mimicry, in which “there is a sharing of antigen
between… the host and the pathogen, epitope sharing, so that what happens is when your immune
system gets activated, there is… a mechanism where it’s attacking both certain parts of the host
and the pathogen.” Id. at 79. In Petitioner’s case, Dr. Rizvi believed that via molecular mimicry,
“certain components of her central nervous system were attacked as well.” Id. Petitioner’s
exposure to vaccines, combined with her pregnancy and possible genetic predisposition to
autoimmune disorders, produced her “abnormal immune response resulting in autoimmunity and
MOGAD.” Id. at 81. Dr. Rizvi later acknowledged, however, that there was nothing in Petitioner’s
medical records to suggest a predisposition or genetic susceptibility to autoimmunity. Id. at 130.
He also did not specify anything about the nature of the cross-reactivity between any of the
vaccines that Petitioner received and the MOG protein. Id. at 131.
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Dr. Rizvi further sought to rebut the contention of Respondent’s experts that Petitioner’s
MOGAD was caused by a possible preceding viral infection (reflecting a para-infectious myelitis,
as Dr. Roos opined). Tr. at 82, 472–73. He concluded instead, based on Petitioner’s medical
records, that (as seemed to be the view of Petitioner’s treating physician) her pre-vaccination
symptoms were likely bacterial in origin. Id. at 84. In Dr. Rizvi’s view, Petitioner did not
demonstrate symptoms of a viral infection during her various pre-vaccination presentations—he
would have expected someone with a “significant viral illness” to show “more flu-like symptoms”
and have “a lot more congestion.” Id. at 85. Dr. Rizvi also confirmed that Petitioner’s neurological
symptoms began around April 30th, six days after her second vaccination event. Id. at 87. He found
it significant that four of Petitioner’s treating physicians, including an immunologist, two
infectious disease specialists, and a neurologist, all allowed for the possibility that Petitioner’s
symptoms could be connected to her recent vaccinations. Id. at 90–93. However, Dr. Rizvi did
later acknowledge that most cases of MOGAD are post-infectious. Id. at 470. And he could identify
no large-scale studies connecting MOGAD to vaccination. Id. at 132.
Dr. Rizvi similarly sought to undermine the argument that an echovirus infection (as
evidenced by Petitioner’s moderately elevated antibody titers for echovirus-7 and echovirus-30
after her hospitalization) explained her MOGAD. Tr. at 93. Due to a lack of repeat testing to show
the change in antibodies over time, he could not determine the time frame in which Petitioner had
likely experienced an active echovirus infection. Id. at 94. Petitioner also did not show specific
clinical symptoms of echovirus, and thus “in the absence of real typical clinical presentation,”
physicians would tend to discount such test results as not meaningful. Id. at 96. He later admitted,
however, that Petitioner’s treating physicians never ruled out echovirus as a cause of her
symptoms, and that he could not himself rule out echovirus given Petitioner’s positive titers. Id. at
126, 480.
Dr. Rizvi addressed an error in his first expert report, where he stated that Petitioner was
treated with steroids while in the hospital. Rizvi First Rep. at 4. According to the case report
specifically written about Petitioner, she was never treated with steroids. N. Kumar et al., Case
Report: Postvaccination Anti–Myelin Oligodendrocyte Glycoprotein Neuromyelitis Optica
Spectrum Disorder, 22 Int. J. MS Care 85, 87 (2020), filed as Ex. 43 (ECF No. 29-15) (“Kumar”).
Dr. Rizvi acknowledged the error, and stated that while most MOGAD patients are treated with
steroids, Petitioner’s treating physicians likely did not likely do so due to her pregnancy. Id. at
130.
2. Omid Akbari, Ph.D. – Dr. Akbari is an immunologist, and he both testified
on Petitioner’s behalf and prepared two written reports. Report, dated Oct. 3, 2023, filed as Ex.
50-1 (ECF No. 31-6) (“First Akbari Rep.”); Report, dated May 16, 2024, filed as Ex. 92-1 (ECF
No. 38-2) (“Second Akbari Rep.”). He posited that Petitioner’s immune response to the MMR
vaccine triggered her ADEM and MOGAD via multiple mechanisms, including inflammasome
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activation8 and then adaptive immune response-driven molecular mimicry. First Akbari Rep. at
24.
Dr. Akbari is both a director and professor of Immunology at the University of Southern
California Keck School of Medicine. First Akbari Rep. at 2; Curriculum Vitae, dated Oct. 13,
2023, filed as Ex. 51-1 (ECF No. 31-7) (“Akbari CV”) at 2. He received both his bachelor’s and
master’s degrees from University College London before receiving a Ph.D. in cellular and
molecular immunology from the Nation Institute for Medical Research in London, England.
Akbari CV at 1. Afterwards, he completed a postdoctoral fellowship at Stanford University. Id.
Dr. Akbari worked as an assistant professor at the Children’s Hospital of Boston before joining
the faculty of the Keck School of Medicine in 2008. Id. He has and continues to serve on the
editorial board of several journals, and he has numerous publications in the field of immunology
research. Id. at 5–7. His research largely focuses on analyzing “cytokines and inflammation with
the focus specifically on dysregulated immune responses.” First Akbari Ret. at 2. Dr. Akbari is not
a medical doctor, however, and does not diagnose or treat patients with neurological diseases in a
clinical setting.
Dr. Akbari began his testimony by describing how vaccines can trigger the body’s immune
system, particularly the mechanism through which vaccines activate inflammasomes that trigger
inflammatory responses and enhance immune response. Tr. at 154–56. He testified that molecular
mimicry, which he described as the process through which foreign antigens closely resembling the
body’s own proteins “confuse the immune system,” “causing it to mistakenly attack the body’s
own tissue,” was the likely mechanism through which Petitioner’s vaccinations caused her
MOGAD. Id. at 156–61. While Dr. Akbari acknowledged that he did not cite any peer-reviewed
literature about molecular mimicry in his expert report, he affirmed the existence of such literature.
Id. at 200.
He also discussed the activation of the inflammasome. While the scientific community is
still working towards a complete understanding of the innate immune response to vaccinations, it
is well established that all effective vaccines must induce an inflammasome response. Tr. at 155–
56. Dr. Akbari proposed that antigenic elements in the MMR and Tdap vaccines could infect host
immune cells and lead to inflammasome activation—which in turn would lead to the production
of cytokines and encourage subsequent inflammation. First Akbari Rep. at 15; see also Second
Akbari Rep. at 2 (citing B. Pulendran & R. Ahmed, Immunological Mechanisms of Vaccination,
12 Nat. Immunol. 509 (2011), filed as Ex. 93 (ECF No. 38-3) (“Pulendran & Ahmed”) (discussing
8 The inflammasome is “a complex of cryopyrin, caspase-1, and other proteins, found in phagocytic cells and related
to the body's system of innate immunity. Assembly of the inflammasome leads to activation of caspase-1 and resultant
cleavage and activation of interleukins IL-1ß and IL 18 in the inflammatory response.” Inflammasome, Dorland's
Medical Dictionary Online,
https://www.dorlandsonline.com/dorland/definition?id=25203&searchterm=inflammasome (last visited July 22,
2025).
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the mechanisms of vaccine induced immunity); E. Latz et al., Activation and Regulation of the
Inflammasomes, 13 Nat. Rev. Immunol. 397 (2013), filed as Ex. 94 (ECF No. 38-4) (reviewing
the biologic mechanisms that facilitate inflammasome-mediated immune response)).
Dr. Akbari offered three ways the MMR vaccine could activate the inflammasome. First,
the viral components of the MMR vaccine are recognized by Pattern Recognition Receptors on
immune cells and activate the inflammasome. Second Akbari Rep at 2. Second, the MMR vaccine
can induce the production of reactive oxygen species that leads to the release of mitochondrial
DNA from damaged cells, which then activates the inflammasome. Id. Third, that intracellular
sensors of viral RNA (contained in the vaccine) can trigger downstream signaling pathways
leading to inflammasome assembly. Id. at 2–3.
After the inflammasome response, an adaptive immune response—in which the immune
system learns to recognize and react to foreign antigens—is activated. First Akbari Rep. at 7. It is
at this point that pieces of foreign antigens would need to migrate to the lymph nodes in order to
interact with B and T cells. Id. Dr. Akbari emphasized the subsequent role of regulatory and
effector T cells in triggering Petitioner’s ADEM. Tr. at 208. In his opinion, an imbalance in the
types of T cells in the body can cause different ailments. In particular, Dr. Akbari proposed that
“if the T effector [cells start to increase beyond] a usual number” and start to “dominate” the Tregs,
“then the T effectors can cause autoimmunity” such as ADEM. Id. Dr. Akbari testified that there
is a direct causal link between vaccination, T cell imbalance, and ADEM based on the Petitioner’s
likely genetic predisposition to certain autoimmune diseases. Id. at 210–211. While he
acknowledged a lack of peer-reviewed research that demonstrates a causation beyond correlation
connecting these conditions, Dr. Akbari maintained that his theory is “very viable.” Id. at 210.
Dr. Akbari mentioned that some of the circumstances surrounding Petitioner’s vaccination,
including Petitioner’s pregnancy and the fact that she received three vaccines in a short time frame,
may have contributed to the development of her ADEM and/or MOGAD. Tr. at 165, 189.
However, he could not commit to the opinion that all three vaccines were necessary to trigger her
ADEM. Id. at 225–26. Additionally, Dr. Akbari briefly touched on Petitioner’s elevated echovirus
titers, agreeing with Dr. Rizvi that he would not consider test results revealing a single elevated
titer to be clinically significant (“one titer doesn’t mean anything”). Id. at 186.
Notably, Dr. Akbari did not identify anything specific about the nature of the proposed
cross-reactivity in this case. Thus, although the MOG antibody would presumably be driving the
disease process at issue, he provided no direct testimony as to how the vaccines at issue would
cause the production of this autoantibody, whether due to mimicking similarity between vaccine
components and the MOG protein in self-tissues or via some other mechanism. At most, he
referenced a case study where the authors found amino acid sequence similarities between two T-
cell epitopes of tetanus toxoid and MOG-specific T cells in MS patients. A. Virupakshaiah et. al.,
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Life-Threatening MOG Antibody-Associated Hemorrhagic ADEM With Elevated CSF IL-6¸ 11
Neurol. Neuroimmunol. Neuroinflamm. 1, (2024), filed as Ex. 120 (ECF No. 55-3)
(“Virupakshaiah”). But he did not address the low expect values for each of these similarities, nor
challenge the veracity of the results of homologic research performed by Respondent’s
immunologic expert (which did not find sufficient homology between the relevant vaccine
components and self-structures to find cross-reactivity likely). See Analysis of Dr. Forsthuber’s
BLAST Search Results, dated Nov. 21, 2024, filed as Ex. K. (ECF No. 54-1) (“Forsthuber
BLAST”) at 3–4.9
C. Respondent’s Experts
1. Dr. Karen L. Roos – Dr. Roos, a neurologist, filed two reports for
Respondent and testified at the hearing. Report, dated July 27, 2023, filed as Ex. A (ECF No. 30-
1) (“First Roos Rep.”); Report, dated January 22, 2024, filed as Ex. E (ECF No. 35-1) (“Second
Roos Rep.”). Dr. Roos opined that the Petitioner was misdiagnosed, and likely suffered from a
postinfectious/parainfectious myelitis with a mild encephalitis component that was fully resolved
in three months, rather than MOGAD. First Roos Rep. at 10.
Dr. Roos is a board-certified neurologist specializing in infectious diseases and serves as
the John and Nancy Nelson Professor Emerita of Neurology at the Indiana University School of
Medicine, where she has taught neurology since 1985. Curriculum Vitae, filed as Ex. B (ECF No.
30-11) (“Roos CV”). She obtained her undergraduate degree from the University of Pittsburgh,
and her medical degree from the Drexel University School of Medicine. Id at 1. She then completed
her residency in neurology and training in electroencephalography at the University of Virginia
Medical Center. Id. She has over 40 years of experience in treating patients with neurological
disorders with a specialization in neurological infectious diseases. First Roos Rep. at 1. She has
authored or edited six textbooks and has published 250 manuscripts relating to neurology. Id.
While Dr. Roos conceded that she had never diagnosed anyone with MOGAD, she has treated
over 160 para- and postinfectious myelitis patients. Tr. at 333, 360.
Dr. Roos contended at the outset that, in her view, ADEM was not a reasonable diagnosis
for Petitioner’s symptoms. Tr. at 258. Rather, the medical record established that Petitioner had
experienced a systemic infectious disease prior to her vaccinations which likely caused a myelitis
(inflammation of the spinal cord), resulting in her neurological symptoms. Id. Dr. Roos noted that
Petitioner’s CSF cell count was greater than 50, when one would expect a lower count for an
9 According to its own website, the “Basic Local Alignment Search Tool” (BLAST) “finds regions of local similarity
between sequences. The program compares nucleotide or protein sequences to sequence databases and calculates the
statistical significance of matches. BLAST can be used to infer functional and evolutionary relationships between
sequences as well as help identify members of gene families.” See https://blast.ncbi.nlm.nih.gov/Blast.cgi (last visited
July 29, 2025). It is common in the Program for immunology experts to utilize BLAST searches when arguing about
whether a vaccine’s protein components mimic self-structures.
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ADEM diagnosis. Id. at 262. Petitioner also had not reported experiencing encephalopathy, nor
did she demonstrate any decreased level of consciousness, which is “really important” for a
diagnosis of ADEM. Id. at 263. As such, Dr. Roos would “find it difficult” to diagnose Petitioner
with ADEM. Id. (in addition, even if ADEM were a fair diagnosis given the record, Dr. Roos
opined, it was more likely attributable to an infectious process. Dr. Roos reiterated Dr. Rizvi’s
concession that 95% of ADEM cases follow an antecedent infection, adding that every case of
ADEM that she had ever seen had been triggered by an antecedent infection. Id. at 265, 268).
Dr. Roos pointed out other aspects of the record that suggested Petitioner’s neurologic
symptoms, however properly diagnosed, had an infectious origin. She noted, for example, that
Petitioner’s choice to go to urgent care on April 14, 2018 (hence prior to her first vaccination) for
her cough and congestion established that such symptoms were more severe than what would be
associated with her allergic rhinitis. Tr. at 269–70. In fact, Dr. Roos characterized Petitioner’s
complaints of cough, cold, congestion, fever, and headaches as most likely evidence of a viral
infection. Id. at 271–72. And later on, Petitioner’s “moderately elevated” echovirus-7 and
echovirus-30 titers (1:80), in combination with her symptoms of infection, suggested a specific
explanation for her condition: an echovirus infection. Id. at 266–67. Echovirus-30 is neurovirulent,
meaning that it infects the CNS, and is much more common in adults than ADEM. Id. at 276–77.
It also is not a “latent” virus, so Petitioner’s positive serology result was consistent with a current
or recent infection. Id. at 278–79. And as Petitioner’s treating physicians were seemingly unaware
of her echovirus titer results, their presence was never factored into her diagnosis. Id. at 326.
Dr. Roos also took issue with Dr. Rizvi’s opinion that Petitioner either had MOGAD or
MOG-positive ADEM. Tr. at 280. In particular, Petitioner did not meet the diagnostic criteria
necessary for MOGAD. Id. at 289. Petitioner’s “low-positive” MOG antibody titer of 1:20 (as
identified on testing performed on May 7, 2018) is “seen in many para and postinfectious
neurological disorders,” and was lower than what one would expect for a MOGAD patient. Id. at
282–83; Ex. 6 at 29. And Petitioner’s treating neurologist did not identify any of the “classic and
expected neuroimaging abnormalities of MOG” from Petitioner’s brain MRI. Id. at 285. Thus,
Petitioner’s clinical presentation was inconsistent with MOGAD—especially in light of the low
antibody titers. Id. at 288.
Most damming to Dr. Rizvi’s theory, according to Dr. Roos, was his failure to exclude
alternative diagnoses before settling on MOGAD—a required element of the relevant diagnostic
criteria. Tr. at 292; Banwell at 9 fig. 3. And the case report that was written about Petitioner’s
treatment, Kumar, was also not proof that the diagnosis was correct, especially since the report’s
conclusions were unreliable (and also given the low weight case reports should receive generally
as evidence of causation). Tr. at 294–95. In Dr. Roos’s opinion, the tests chosen and written about
by the physicians “tilted [the conclusion] toward what they wanted it to be.” Id. at 297. In general,
Dr. Roos felt that causation could “not depend on case reports and case series,” as case reports can
be “swayed” to fit a physician’s theory. Id. at 299.
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Dr. Roos concluded her testimony by discussing multiple studies regarding the connection
between vaccines and ADEM. Tr. at 300. In particular, she cited a long-term prospective study
which found no increase in the risk of ADEM after many common vaccinations, including those
received by Petitioner. Id. at 310; Y. Chen et al., Vaccines and the Risk of Acute Disseminated
Encephalomyelitis, 36 Vaccine 3733, 3733–39 (2018), filed as Ex. I (ECF No. 44-2) (“Chen”) (no
increase in the risk of ADEM after administration of the Hepatitis B, influenza, polio (live),
diphtheria, pertussis (acellular), tetanus, measles, mumps, rubella, Japanese Encephalitis,
meningitis, hepatitis a, varicella, and rabies vaccines).
2. Dr. Thomas Forsthuber – Dr. Forsthuber is an immunologist (although also
a medical doctor, unlike Dr. Akbari), and he prepared three written reports in this case and testified
for Respondent. Report, dated July 27, 2023, filed as Ex. C (ECF No. 30-12) (“First Forsthuber
Rep.”); Report, dated February 1, 2024, filed as Ex. F (ECF No. 36-1) (“Second Forsthuber Rep.”);
Report, dated July 30, 2024, filed as Ex. G (ECF No. 42-1) (“Third Forsthuber Rep.”).
Dr. Forsthuber is a Professor of Immunology at the University of Texas at San Antonio
and an Adjunct Professor of Microbiology & Immunology at the University of Texas Health
Sciences Center in San Antonio. First Forsthuber Rep. at 1. He received his M.D. from the
University of Tübingen in Germany and completed his residency in pathology at University
Hospitals Cleveland. Curriculum Vitae, dated July 28, 2023, filed as Ex. D (ECF No. 30-34)
(“Forsthuber CV”) at 2. He is board certified in anatomical and clinical pathology by the American
Board of Pathology. Id. Dr. Forsthuber has over twenty-five years of experience in immunology
and has published over one hundred scholarly publications, reviews, and book chapters in his field.
First Forsthuber Rep. at 1; Forsthuber CV at 21–38. His research focuses on immunology, multiple
sclerosis, and autoimmune heart disease. First Forsthuber Rep. at 1. Dr. Forsthuber does not
currently treat patients, however, and has never treated a patient with encephalomyelitis. Id. at 2.
Dr. Forsthuber began his testimony by criticizing the first component of Dr. Rizvi’s
mechanistic theory: vaccine activation of the inflammasome. Tr. at 383. While a vaccination might
instigate some level of inflammasome activation at the site of the injection, Dr. Forsthuber saw
“no reason that a vaccination in the arm should lead to an inflammasome activation in the brain.”
Id. at 384–85. Additionally, while the activation of inflammasomes is the “first step in a cascade”
of immune system activation that could “eventually lead to molecular mimicry,” there is “no direct
link” between inflammasomes and an adaptive process of autoimmune cross-reactivity due to
molecular mimicry. Id. at 387.
Dr. Forsthuber next discussed the link that Dr. Akbari emphasized between the
inflammasomes and the production of cytokines, particularly interleukin-1 (IL-1), and the role
those cytokines would putatively play in impacting T cell regulation of the immune response. Tr.
at 395. Although he acknowledged that cytokine levels could be impacted by vaccines and
infections alike, “the levels of cytokines that you see after infection are typically much, much
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higher than what you see after vaccination.” Id. at 397. As a result, an infection would “absolutely”
induce more inflammatory cytokines than even the receipt of multiple vaccinations, as the small
number of cytokines produced by a vaccination are “short-lived, 24 to 48 hours,” whereas those
produced by an infection are generated for days or weeks. Id. at 399.
Dr. Forsthuber went on to consider the next element of Dr. Akbari’s theory, which
proposed that interference with regulatory T cells (“Treg”) could encourage ADEM. Tr. at 388.
While Tregs do “play a role in in preventing excessive immune activation,” there is “no direct role
for regulatory T cells” in the pathogenesis of ADEM. Id. at 391. Because even a small number of
T cells can prevent autoimmunity, the kind of massive disruption of T cells required to render them
ineffective (and hence resulting in the “breaking” of immune tolerance) would involve a
“cataclysmic event.” Id. at 393–94. Dr. Forsthuber also pointed out that Dr. Akbari had failed to
explain how a dysregulation in T cells would trigger ADEM specifically, rather than produce other
autoimmune disorders. Id. at 393. And existing medical literature “debunks the claim that
vaccination … somehow alters the T regulatory cell balance.” Id. at 400; A. de Wolf et al.,
Regulatory T Cell Frequencies and Phenotypes Following Anti-Viral Vaccination, 12 PLoS ONE
6 (2017), filed as Ex. G Tab 1 (ECF No. 42-2) (“de Wolf”) (finding that vaccines with a “safe
profile” had minimal and insignificant impact on the homeostasis of Treg cells).
Dr. Forsthuber then criticized the theory of molecular mimicry and its application to this
case. Tr. at 401. In his opinion, there are “very few examples where molecular mimicry [as casual
of an autoimmune injury] has been robustly supported by the evidence.” Id. at 402. Further, none
of the evidentiary elements required to corroborate molecular mimicry as causal of a disease
(epidemiological evidence, sequence or structural similarity between pathogens and self-antigens,
and cross-reactivity) had been demonstrated to support a link between ADEM and vaccination. Id.
at 403. In his opinion, “the literature on MMR vaccine, varicella vaccine and Tdap vaccine is pretty
clear that there is no… robust support that [they cause] ADEM or MOGAD,” or that the receipt of
multiple vaccinations in a short period of time would make someone more likely to develop
ADEM. Id. at 404, 409.
In addition, Dr. Forsthuber found no significant similarity between the amino acid
sequences of tetanus and MOG, as allegedly supported by Virupakshaiah. Forsthuber Blast at 3–
4. Instead, what Dr. Forsthuber found from his own search was that Virupakshaiah’s authors had
erred in their analysis because the E values of the two regions did not match up to the E values of
his BLAST results. Id. In addition, the authors of the study expanded the BLAST search parameters
beyond the standard settings, which allowed the inclusion of insignificant sequence alignments.
Id. Dr. Forsthuber’s own analysis of the proposed sequences resulted in no matches or significant
sequence alignments between the amino acid sequences of tetanus and MOG. Id.
While Dr. Forsthuber did not commit to echovirus as a specific cause of the Patient’s
ADEM, he did agree with Dr. Roos that an upper respiratory infection of an unspecified nature
was the most likely trigger of Petitioner’s illness. Tr. at 432. In fact, he was conflicted as to whether
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any vaccine could cause a neurological disease. Id. at 447. He stressed that Petitioner’s treating
physicians did not do a thorough infectious disease workup to rule out alternative causations.
Finaly, he opined that Petitioner’s existing conditions of pregnancy and an upper respiratory
infection would not increase her susceptibility to an adverse reaction to vaccination. Id. at 455.
III. Procedural History
Respondent filed his Rule 4(c) Report contesting Petitioner’s right to compensation on
November 30, 2022. See Report, dated Nov. 30, 2022 (ECF No. 28). Thereafter, the process of
obtaining expert reports began, with the final report from Dr. Forsthuber filed in July 2024. The
parties submitted pre-hearing briefs and a two-day Entitlement Hearing took place in November
2024. After the Entitlement Hearing, the Respondent submitted medical literature and findings
mentioned at the hearing.10 In addition, both parties indicated their desire to, and later submitted,
post hearing briefs. Petitioner’s Post Hearing Brief, dated Feb. 6, 2025 (ECF No. 63) (“Br.”);
Respondent’s Post Hearing Brief, dated Feb. 6, 2025 (ECF No. 62) (“Opp.”).
IV. Applicable Legal Standards
A. Petitioner’s Overall Burden in Vaccine Program Cases
To receive compensation in the Vaccine Program, a petitioner must prove either: (1) that
he suffered a “Table Injury”—i.e., an injury falling within the Vaccine Injury Table—
corresponding to one of the vaccinations in question within a statutorily prescribed period of time
or, in the alternative, (2) that his illnesses were actually caused by a vaccine (a “Non-Table
Injury”). See Sections 13(a)(1)(A), 11(c)(1), and 14(a), as amended by 42 C.F.R. § 100.3; §
11(c)(1)(C)(ii)(I); see also Moberly v. Sec’y of Health & Hum. Servs., 592 F.3d 1315, 1321 (Fed.
Cir. 2010); Capizzano v. Sec’y of Health & Hum. Servs., 440 F.3d 1317, 1320 (Fed. Cir. 2006).11
There is no Table claim for vaccine-caused MOGAD or ADEM.
For both Table and Non-Table claims, Vaccine Program petitioners bear a “preponderance
of the evidence” burden of proof. Section 13(1)(a). That is, a petitioner must offer evidence that
10 See generally Forsthuber BLAST; M. Varrin-Doyer et. al., MOG Transmembrane and Cytoplasmic Domains
Contain High Stimulatory T-cell Epitopes in MS, 2 NEUROL. NEUROIMMUNOL. NEUROINFLAMM. 1 (2014), filed as Ex.
L (ECF No. 54-2); R. Weissert, et. al. High Immunogenicity of Intracellular Myelin Oligodendrocyte Glycoprotein
Epitopes, 169 J. IMMUNOL. 548 (2022), filed as Ex. M (ECF No. 54-3); Supp. App. to B. Banwell, et. al., Diagnosis
of Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease: International MOGAD Panel Proposed
Criteria, 22 LANCET NEUROL. 268 (2023), filed as Ex. N (ECF No. 54-4).
11 Decisions of special masters (some of which I reference in this ruling) constitute persuasive but not binding
authority. Hanlon v. Sec’y of Health & Hum. Servs., 40 Fed. Cl. 625, 630 (1998). By contrast, Federal Circuit rulings
concerning legal issues are binding on special masters. Guillory v. Sec’y of Health & Hum. Servs., 59 Fed. Cl. 121,
124 (2003), aff’d 104 F. Appx. 712 (Fed. Cir. 2004); see also Spooner v. Sec’y of Health & Hum. Servs., No. 13-159V,
2014 WL 504728, at *7 n.12 (Fed. Cl. Spec. Mstr. Jan. 16, 2014).
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leads the “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, 592 F.3d at 1322 n.2; see also Snowbank Enter. v. United States, 6 Cl. Ct.
476, 486 (1984) (mere conjecture or speculation is insufficient under a preponderance standard).
Proof of medical certainty is not required. Bunting v. Sec’y of Health & Hum. Servs., 931 F.2d 867,
873 (Fed. Cir. 1991). In particular, a petitioner must demonstrate that the vaccine was “not only
[the] but-for cause of the injury but also a substantial factor in bringing about the injury.” Moberly,
592 F.3d at 1321 (quoting Shyface v. Sec’y of Health & Hum. Servs., 165 F.3d 1344, 1352–53
(Fed. Cir. 1999); Pafford v. Sec’y of Health & Hum. Servs., 451 F.3d 1352, 1355 (Fed. Cir. 2006).
A petitioner may not receive a Vaccine Program award based solely on his assertions; rather, the
petition must be supported by either medical records or by the opinion of a competent physician.
Section 13(a)(1).
In attempting to establish entitlement to a Vaccine Program award of compensation for a
Non-Table claim, a petitioner must satisfy all three of the elements established by the Federal
Circuit in Althen v. Sec'y of Health & Hum. Servs., 418 F.3d 1274, 1278 (Fed. Cir. 2005): “(1) a
medical theory causally connecting the vaccination and the injury; (2) a logical sequence of cause
and effect showing that the vaccination was the reason for the injury; and (3) a showing of
proximate temporal relationship between vaccination and injury.”
Each of the Althen prongs requires a different showing. Under Althen prong one, petitioners
must provide a “reputable medical theory,” demonstrating that the vaccine received can cause the
type of injury alleged. Pafford, 451 F.3d at 1355–56 (citations omitted). To satisfy this prong, a
petitioner’s theory must be based on a “sound and reliable medical or scientific explanation.”
Knudsen v. Sec’y of Health & Hum. Servs., 35 F.3d 543, 548 (Fed. Cir. 1994). Such a theory must
only be “legally probable, not medically or scientifically certain.” Id. at 549.
Petitioners may satisfy the first Althen prong without resort to medical literature,
epidemiological studies, demonstration of a specific mechanism, or even a generally accepted
medical theory. Andreu ex rel. Andreu v. Sec'y of Dep't of Health & Hum. Servs., 569 F.3d 1367,
1378–79 (Fed. Cir. 2009) (citing Capizzano, 440 F.3d at 1325–26). Special masters, despite their
expertise, are not empowered by statute to conclusively resolve what are essentially thorny
scientific and medical questions, and thus scientific evidence offered to establish Althen prong one
is viewed “not through the lens of the laboratorian, but instead from the vantage point of the
Vaccine Act’s preponderant evidence standard.” Id. at 1380. Accordingly, special masters must
take care not to increase the burden placed on petitioners in offering a scientific theory linking
vaccine to injury. Contreras v. Sec'y of Dep't of Health & Hum. Servs., 121 Fed. Cl. 230, 245 (Fed.
Cl. May 6, 2015).
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In discussing the evidentiary standard applicable to the first Althen prong, the Federal
Circuit has consistently rejected the contention that it can be satisfied merely by establishing the
proposed causal theory’s scientific or medical plausibility. See Kalajdzic v. Sec’y of Health &
Hum. Servs., No. 2023-1321, 2024 WL 3064398, at *2 (Fed. Cir. June 20, 2024) (arguments “for
a less than preponderance standard” deemed “plainly inconsistent with our precedent” (citing
Moberly, 592 F.3d at 1322)); Boatmon v. Sec’y of Health & Hum. Servs., 941 F.3d 1351, 1359
(Fed. Cir. 2019); see also Howard v. Sec'y of Health & Hum. Servs., 2023 WL 4117370, at *4
(Fed. Cl. May 18, 2023) (“[t]he standard has been preponderance for nearly four decades”), aff’d,
2024 WL 2873301 (Fed. Cir. June 7, 2024) (unpublished). And petitioners always have the
ultimate burden of establishing their overall Vaccine Act claim with preponderant evidence. W.C.
v. Sec’y of Health & Hum. Servs., 704 F.3d 1352, 1356 (Fed. Cir. 2013) (citations omitted); Tarsell
v. United States, 133 Fed. Cl. 782, 793 (2017) (noting that Moberly “addresses the petitioner’s
overall burden of proving causation-in-fact under the Vaccine Act” by a preponderance standard).
The second Althen prong requires proof of a logical sequence of cause and effect, usually
supported by facts derived from a petitioner’s medical records. Althen, 418 F.3d at 1278; Andreu,
569 F.3d at 1375–77; Capizzano, 440 F.3d at 1326; Grant v. Sec’y of Health & Hum. Servs., 956
F.2d 1144, 1148 (Fed. Cir. 1992). In establishing that a vaccine “did cause” injury, the opinions
and views of the injured party’s treating physicians are entitled to some weight. Andreu, 569 F.3d
at 1367; Capizzano, 440 F.3d at 1326 (“medical records and medical opinion testimony are favored
in vaccine cases, as treating physicians are likely to be in the best position to determine whether a
‘logical sequence of cause and effect show[s] that the vaccination was the reason for the injury’”)
(quoting Althen, 418 F.3d at 1280). Medical records are generally viewed as particularly
trustworthy evidence, since they are created contemporaneously with the treatment of the patient.
Cucuras v. Sec’y of Health & Hum. Servs., 993 F.2d 1525, 1528 (Fed. Cir. 1993).
Medical records and statements of a treating physician, however, do not per se bind the
special master to adopt the conclusions of such an individual, even if they must be considered and
carefully evaluated. Section 13(b)(1) (providing that “[a]ny such diagnosis, conclusion, judgment,
test result, report, or summary shall not be binding on the special master or court”); Snyder v. Sec’y
of Health & Hum. Servs., 88 Fed. Cl. 706, 746 n.67 (2009) (“there is nothing . . . that mandates
that the testimony of a treating physician is sacrosanct—that it must be accepted in its entirety and
cannot be rebutted”). As with expert testimony offered to establish a theory of causation, the
opinions or diagnoses of treating physicians are only as trustworthy as the reasonableness of their
suppositions or bases. The views of treating physicians should be weighed against other, contrary
evidence also present in the record—including conflicting opinions among such individuals.
Hibbard v. Sec’y of Health & Hum. Servs., 100 Fed. Cl. 742, 749 (2011) (not arbitrary or capricious
for special master to weigh competing treating physicians’ conclusions against each other), aff’d,
698 F.3d 1355 (Fed. Cir. 2012); Veryzer v. Sec’y of Dept. of Health & Hum. Servs., No. 06-522V,
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2011 WL 1935813, at *17 (Fed. Cl. Spec. Mstr. Apr. 29, 2011), mot. for review den’d, 100 Fed.
Cl. 344, 356 (2011), aff’d without opinion, 475 F. Appx. 765 (Fed. Cir. 2012).
The third Althen prong requires establishing a “proximate temporal relationship” between
the vaccination and the injury alleged. Althen, 418 F.3d at 1281. That term has been equated to the
phrase “medically-acceptable temporal relationship.” Id. A petitioner must offer “preponderant
proof that the onset of symptoms occurred within a timeframe which, given the medical
understanding of the disorder’s etiology, it is medically acceptable to infer causation.” de Bazan v.
Sec’y of Health & Hum. Servs., 539 F.3d 1347, 1352 (Fed. Cir. 2008). The explanation for what is
a medically acceptable timeframe must align with the theory of how the relevant vaccine can cause
an injury (Althen prong one’s requirement). Id. at 1352; Shapiro v. Sec’y of Health & Hum. Servs.,
101 Fed. Cl. 532, 542 (2011), recons. den’d after remand, 105 Fed. Cl. 353 (2012), aff’d mem.,
503 F. Appx. 952 (Fed. Cir. 2013); Koehn v. Sec’y of Health & Hum. Servs., No. 11-355V, 2013
WL 3214877 (Fed. Cl. Spec. Mstr. May 30, 2013), mot. for rev. den’d (Fed. Cl. Dec. 3, 2013),
aff’d, 773 F.3d 1239 (Fed. Cir. 2014).
B. Legal Standards Governing Factual Determinations
The process for making determinations in Vaccine Program cases regarding factual issues
begins with consideration of the medical records. Section 11(c)(2). The special master is required
to consider “all [ ] relevant medical and scientific evidence contained in the record,” including
“any diagnosis, conclusion, medical judgment, or autopsy or coroner's report which is contained
in the record regarding the nature, causation, and aggravation of the petitioner's illness, disability,
injury, condition, or death,” as well as the “results of any diagnostic or evaluative test which are
contained in the record and the summaries and conclusions.” Section 13(b)(1)(A). The special
master is then required to weigh the evidence presented, including contemporaneous medical
records and testimony. See Burns v. Sec'y of Health & Hum. Servs., 3 F.3d 415, 417 (Fed. Cir.
1993) (determining that it is within the special master's discretion to determine whether to afford
greater weight to contemporaneous medical records than to other evidence, such as oral testimony
surrounding the events in question that was given at a later date, provided that such determination
is evidenced by a rational determination).
As noted by the Federal Circuit, “[m]edical records, in general, warrant consideration as
trustworthy evidence.” Cucuras, 993 F.2d at 1528; Doe/70 v. Sec'y of Health & Hum. Servs., 95
Fed. Cl. 598, 608 (2010) (“[g]iven the inconsistencies between petitioner's testimony and his
contemporaneous medical records, the special master's decision to rely on petitioner's medical
records was rational and consistent with applicable law”), aff'd, Rickett v. Sec'y of Health & Hum.
Servs., 468 F. App’x 952 (Fed. Cir. 2011) (non-precedential opinion). A series of linked
propositions explains why such records deserve some weight: (i) sick people visit medical
professionals; (ii) sick people attempt to honestly report their health problems to those
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professionals; and (iii) medical professionals record what they are told or observe when examining
their patients in as accurate a manner as possible, so that they are aware of enough relevant facts
to make appropriate treatment decisions. Sanchez v. Sec'y of Health & Hum. Servs., No. 11–685V,
2013 WL 1880825, at *2 (Fed. Cl. Spec. Mstr. Apr. 10, 2013); Cucuras v. Sec'y of Health & Hum.
Servs., 26 Cl. Ct. 537, 543 (1992), aff'd, 993 F.2d at 1525 (Fed. Cir. 1993) (“[i]t strains reason to
conclude that petitioners would fail to accurately report the onset of their daughter's symptoms”).
Accordingly, if the medical records are clear, consistent, and complete, then they should
be afforded substantial weight. Lowrie v. Sec'y of Health & Hum. Servs., No. 03–1585V, 2005 WL
6117475, at *20 (Fed. Cl. Spec. Mstr. Dec. 12, 2005). Indeed, contemporaneous medical records
are often found to be deserving of greater evidentiary weight than oral testimony—especially
where such testimony conflicts with the record evidence. Cucuras, 993 F.2d at 1528; see also
Murphy v. Sec'y of Health & Hum. Servs., 23 Cl. Ct. 726, 733 (1991), aff'd per curiam, 968 F.2d
1226 (Fed. Cir. 1992), cert. den'd, Murphy v. Sullivan, 506 U.S. 974 (1992) (citing United States
v. United States Gypsum Co., 333 U.S. 364, 396 (1947) (“[i]t has generally been held that oral
testimony which is in conflict with contemporaneous documents is entitled to little evidentiary
weight.”)).
However, the Federal Circuit has also noted that there is no formal “presumption” that
records are accurate or superior on their face to other forms of evidence. Kirby v. Sec’y of Health
& Hum. Servs., 997 F.3d 1378, 1383 (Fed. Cir. 2021). There are certainly situations in which
compelling oral or written testimony (provided in the form of an affidavit or declaration) may be
more persuasive than written records, such as where records are deemed to be incomplete or
inaccurate. Campbell v. Sec'y of Health & Hum. Servs., 69 Fed. Cl. 775, 779 (2006) (“like any
norm based upon common sense and experience, this rule should not be treated as an absolute and
must yield where the factual predicates for its application are weak or lacking”); Lowrie, 2005 WL
6117475, at *19 (“[w]ritten records which are, themselves, inconsistent, should be accorded less
deference than those which are internally consistent”) (quoting Murphy, 23 Cl. Ct. at 733)).
Ultimately, a determination regarding a witness's credibility is needed when determining the
weight that such testimony should be afforded. Andreu, 569 F.3d at 1379; Bradley v. Sec'y of
Health & Hum. Servs., 991 F.2d 1570, 1575 (Fed. Cir. 1993).
When witness testimony is offered to overcome the presumption of accuracy afforded to
contemporaneous medical records, such testimony must be “consistent, clear, cogent, and
compelling.” Sanchez, 2013 WL 1880825, at *3 (citing Blutstein v. Sec'y of Health & Hum. Servs.,
No. 90–2808V, 1998 WL 408611, at *5 (Fed. Cl. Spec. Mstr. June 30, 1998)). In determining the
accuracy and completeness of medical records, the Court of Federal Claims has listed four possible
explanations for inconsistencies between contemporaneously created medical records and later
testimony: (1) a person's failure to recount to the medical professional everything that happened
during the relevant time period; (2) the medical professional's failure to document everything
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reported to her or him; (3) a person's faulty recollection of the events when presenting testimony;
or (4) a person's purposeful recounting of symptoms that did not exist. La Londe v. Sec'y of Health
& Hum. Servs., 110 Fed. Cl. 184, 203–04 (2013), aff'd, 746 F.3d 1334 (Fed. Cir. 2014). In making
a determination regarding whether to afford greater weight to contemporaneous medical records
or other evidence, such as testimony at hearing, there must be evidence that this decision was the
result of a rational determination. Burns, 3 F.3d at 417.
C. Analysis of Expert Testimony
Establishing a sound and reliable medical theory often requires a petitioner to present
expert testimony in support of his claim. Lampe v. Sec’y of Health & Hum. Servs., 219 F.3d 1357,
1361 (Fed. Cir. 2000). Vaccine Program expert testimony is usually evaluated according to the
factors for analyzing scientific reliability set forth in Daubert v. Merrell Dow Pharm., Inc., 509
U.S. 579, 594–96 (1993). See Cedillo v. Sec’y of Health & Hum. Servs., 617 F.3d 1328, 1339 (Fed.
Cir. 2010) (citing Terran v. Sec’y of Health & Hum. Servs., 195 F.3d 1302, 1316 (Fed. Cir. 1999).
Under Daubert, the factors for analyzing the reliability of testimony are:
(1) whether a theory or technique can be (and has been) tested; (2) whether the
theory or technique has been subjected to peer review and publication; (3) whether
there is a known or potential rate of error and whether there are standards for
controlling the error; and (4) whether the theory or technique enjoys general
acceptance within a relevant scientific community.
Terran, 195 F.3d at 1316 n.2 (citing Daubert, 509 U.S. at 592–95).
In the Vaccine Program the Daubert factors play a slightly different role than they do when
applied in other federal judicial settings, like the district courts. Typically, Daubert factors are
employed by judges (in the performance of their evidentiary gatekeeper roles) to exclude evidence
that is unreliable or could confuse a jury. By contrast, in Vaccine Program cases these factors are
used in the weighing of the reliability of scientific evidence proffered. Davis v. Sec'y of Health &
Hum. Servs., 94 Fed. Cl. 53, 66–67 (2010) (“uniquely in this Circuit, the Daubert factors have been
employed also as an acceptable evidentiary-gauging tool with respect to persuasiveness of expert
testimony already admitted”). The flexible use of the Daubert factors to evaluate the
persuasiveness and reliability of expert testimony has routinely been upheld. See, e.g., Snyder, 88
Fed. Cl. at 742–45. In this matter (as in numerous other Vaccine Program cases), Daubert has not
been employed at the threshold, to determine what evidence should be admitted, but instead to
determine whether expert testimony offered is reliable and/or persuasive.
Respondent frequently offers one or more experts in order to rebut a petitioner’s case.
Where both sides offer expert testimony, a special master's decision may be “based on the
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credibility of the experts and the relative persuasiveness of their competing theories.” Broekelschen
v. Sec'y of Health & Hum. Servs., 618 F.3d 1339, 1347 (Fed. Cir. 2010) (citing Lampe, 219 F.3d
at 1362). However, nothing requires the acceptance of an expert's conclusion “connected to
existing data only by the ipse dixit of the expert,” especially if “there is simply too great an
analytical gap between the data and the opinion proffered.” Snyder, 88 Fed. Cl. at 743 (quoting
Gen. Elec. Co. v. Joiner, 522 U.S. 146 (1997)); see also Isaac v. Sec'y of Health & Hum. Servs.,
No. 08–601V, 2012 WL 3609993, at *17 (Fed. Cl. Spec. Mstr. July 30, 2012), mot. for review
den'd, 108 Fed. Cl. 743 (2013), aff'd, 540 F. App’x. 999 (Fed. Cir. 2013) (citing Cedillo, 617 F.3d
at 1339). Weighing the relative persuasiveness of competing expert testimony, based on a
particular expert's credibility, is part of the overall reliability analysis to which special masters
must subject expert testimony in Vaccine Program cases. Moberly, 592 F.3d at 1325–26
(“[a]ssessments as to the reliability of expert testimony often turn on credibility determinations”);
see also Porter v. Sec'y of Health & Hum. Servs., 663 F.3d 1242, 1250 (Fed. Cir. 2011) (“this court
has unambiguously explained that special masters are expected to consider the credibility of expert
witnesses in evaluating petitions for compensation under the Vaccine Act”).
D. Consideration of Medical Literature
Both parties filed numerous items of medical and scientific literature in this case, but not
all such items factor into the outcome of this decision. While I have reviewed all the medical
literature submitted in this case, I discuss only those articles that are most relevant to my
determination and/or are central to Petitioner’s case—just as I have not exhaustively discussed
every individual medical record filed. Moriarty v. Sec’y of Health & Hum. Servs., No. 2015–5072,
2016 WL 1358616, at *5 (Fed. Cir. Apr. 6, 2016) (“[w]e generally presume that a special master
considered the relevant record evidence even though he does not explicitly reference such evidence
in his decision”) (citation omitted); see also Paterek v. Sec’y of Health & Hum. Servs., 527 F.
App’x 875, 884 (Fed. Cir. 2013) (“[f]inding certain information not relevant does not lead to—and
likely undermines—the conclusion that it was not considered”).
ANALYSIS
I. MOGAD and Program Treatment of it as a Vaccine Injury
MOGAD is a rare, antibody-mediated inflammatory demyelinating disorder of the CNS
that presents in a variety of ways—including optic neuritis, ADEM, and TM. E. Sechi et al., Myelin
Oligodendrocyte Glycoprotein Antibody-Associated Disease (MOGAD): A Review of Clinical and
MRI Features, Diagnosis, and Management, 13 Front Neurol. June 17, 2022, at 2–3, filed as Ex.
C Tab 14 (ECF No. 30-25) (“Sechi”); Tr. at 59–60. It occurs when MOG autoantibodies mistakenly
attack MOG proteins on oligodendrocytes (the cells responsible for the creation of myelin in the
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CNS), leading to nerve demyelination, and then to the clinical symptoms of the disorders
associated with MOGAD (like ADEM). Sechi at 3. Significantly, and as acknowledged in this
case, the MOG antibody itself has not been proven to be pathogenic—hence the name “MOG-
antibody-associated disease (MOGAD).” Tr. at 60, 172 (emphasis added). MOGAD’s exact
etiology is unknown, although it is generally thought to occur after an infection or, more rarely,
after a vaccination. Tr. at 60–61.
Medical science has only recently identified the MOG autoantibodies and observed their
potential relationship to the kinds of CSN-oriented demyelinating injuries that characterize
MOGAD. Accordingly, there are few Program cases addressing MOGAD as a vaccine injury.
Petitioners have been successful, however, in demonstrating the anti-MOG antibody was vaccine-
induced, causing an individual to experience a CNS demyelinating injury. See, e.g., White v. Sec'y
of Health & Hum. Servs., No. 15-1521V, 2019 WL 7563239 (Fed. Cl. Spec. Mstr. Dec. 19, 2019)
(HPV vaccine caused anti-MOG antibody-mediated TM). I have also so found. Hock v. Sec'y of
Health & Hum. Servs., No. 21-945V, 2024 WL 3826125 (Fed. Cl. July 12, 2024) (holding
Petitioner satisfied his burden of proof for his claim that the influenza vaccine caused his
MOGAD); L.C. v. Sec'y of Health & Hum. Servs., No. 17-722V, 2021 WL 3630315 (Fed. Cl. July
2, 2021) (finding Tdap vaccine caused MOGAD in a minor).
I note, however (and as reflected in my own decisions involving MOGAD), that there is a
paucity of scientific understanding of this new diagnostic classification—and hence that the
showing deemed preponderant in cases involving MOGAD was still somewhat limited. See, e.g.,
L.C., 2021 WL 3630315 at *17–19; Hock, 2024 WL 3826125 at *19–20. For example, in Hock, I
found the Petitioner satisfied causation because despite the somewhat-underwhelming evidence
applicable to causation, Respondent did not sufficiently rebut the factors suggesting Petitioner’s
showing was preponderantly established. 2024 WL 3826125, at 20–22.
Thus, while there is nascent Program recognition that vaccination might play a role in the
propagation of these MOG antibodies, the question is far from resolved. It cannot be said based on
the paltry number of decisions that the Program favors a vaccine-MOGAD connection. And, as I
have indicated before, I am not otherwise prepared to find in favor for all petitioners that bring
forward MOGAD claims post-vaccination, just because the injury involves demyelination and/or
is believed in part to be associated with certain autoimmune neuroinflammatory conditions. See,
Hock, 2024 WL 3826125, at *19. This is especially so given that MOGAD-specific literature
remains limited12 (likely related to the fact that widespread commercial testing for the
autoantibody only became available in the past decade). The understanding of MOGAD will
evolve as medical science continues to study this disease—and this in turn ensures variability in
12 Dr. Rizvi conceded that there are no large epidemiological studies focusing on MOGAD. First Rizvi Rep. at 5.
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how Vaccine Act cases involving this injury are resolved, with the individual evidentiary showings
made from one case to the other most dispositive.
II. Petitioner Has Not Carried Her Althen Burden of Proof13
A. Prong One
Petitioner contends that that the Tdap, MMR, and/or Varicella vaccine can cause MOG-
positive ADEM or MOGAD. In support, Dr. Akbari (Petitioner’s primary expert on the
immunologic issues relevant to causation) offered a lengthy, multi-step theory that requires the
vaccines in question to impact every step of the immune process in order to reach the conclusion
that the vaccines caused the Petitioner’s injury.
I am familiar with the contours of the theory Dr. Akbari has espoused (which implicates
the inflammasome and its impact on the innate response, and then goes on to propose a role for
the putatively-causal vaccine to affect Treg cells and the adaptive immune response in producing
cross-reactive autoantibodies). I have actually heard him personally propose it before—but I
deemed the theory unreliable and insufficiently corroborated by independent scientific or medical
evidence. Efron v. Sec'y of Health & Hum. Servs., No. 20-1405V, 2025 WL 408219, at *21 (Fed.
Cl. Spec. Mstr. Jan. 2, 2025) (denying entitlement to petitioner who could not show by a
preponderance of the evidence that his anhidrosis could be vaccine-caused; noting that Dr.
Akbari’s causal theory lacked sufficient evidence to support it).
The theory was no better substantiated in this matter. First, Petitioner has failed to show a
causal connection between inflammasome activation and ADEM or MOGAD. The literature
offered does not support the conclusion that vaccines pathologically impact inflammasome
stimulation. For example, Pulendran & Ahmed does not state that the MMR vaccine triggers
inflammasome activation. At best (and only with respect to the Tdap vaccine), it references other
studies that have demonstrated that alum (an adjuvant contained in some vaccines) impacts the
function of the inflammasome, but the article concedes that the process is poorly understood.
Pulendran & Ahmed at 4. Dr. Forsthuber offered a study that confirms how little is known about
the impact of alum adjuvant-containing vaccines on the inflammasome. H. Hogenesch, Mechanism
of Immunopotentiation and Safety of Aluminum Adjuvants, 3 Front Immunol. 406 (2013), filed as
Ex. G Tab 4 (ECF No. 42-5). And Dr. Akbari otherwise did not corroborate the larger connection
between vaccine-induced inflammasome activation and ADEM or MOGAD—and therefore his
arguments about its initial, critical role in what follows amount to trying to “spin” an acknowledged
feature of the innate immune system response into something pathologic.
13 I address herein only the Althen prongs relevant to my analysis, since all three prongs must be met to obtain
entitlement. Dobrydnev v. Sec'y of Health & Hum. Servs., 566 F. App'x 976, 979 (Fed. Cir. 2014).
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Second, Dr. Akbari failed to explain how innate immune cell activation at the injection site
would cause any kind of immune cells to travel from the periphery of the body to the CNS. In
reaction, Dr. Forsthuber offered more compelling evidence that vaccine-induced inflammasome
activation is localized, and any elevation in the presence of pro-inflammatory cytokines is still far
below the number of cytokines expected to influence Tregs, or trigger ADEM or MOGAD. Tr. at
399–400 (discussing de Wolf).
Dr. Akbari’s contentions about the negative impact of Treg cells in promoting autoimmune
diseases were also not persuasively tied to vaccination. This component of his theory posited that
the dysregulation of these cells prevents them from successfully suppressing autoimmune reactions
resulting in disease. But he has not specified how those cells become dysregulated by
vaccination—resorting instead to the conclusory reasoning that vaccines can cause dysregulation
in those with a genetic predisposition (without also establishing what Petitioner’s genetic
propensity was, let alone offering sufficient evidence that Treg cells are critical to the pathogenesis
of ADEM and other autoimmune diseases—even if immune tolerance breakdown plays some role
in such conditions). Tr. at 209; First Akbari Rep. at 12. And Dr. Forsthuber (again) effectively
rebutted such points, offering evidence that vaccines and infections could actually increase the
number of Tregs (and thus prove to be encouraging of immune resistance to autoimmune
reactions). Second Forsthuber Supp. Rep. at 9 (citing K. Mills, Designer Adjuvants for Enhancing
the Efficacy of Infectious Disease and Cancer Vaccines Based on Suppression of Regulatory T
Cell Induction, 122 Immunol. Lett. 108 (2009), filed as Ex. G Tab 9 (ECF No. 42-10), at 110.
Otherwise, little in the way of more specific evidence that the vaccines at issue have been
shown to spur the immune system to create MOG-antibodies via molecular mimicry has been
offered. And Petitioner’s experts did not successfully identify possible sequences or similar
homologic structures between components of the vaccines and the MOG protein. Dr. Rizvi offers
support for molecular mimicry between vaccines and CNS diseases unrelated to what the Petitioner
experienced, while failing to identify a vaccine or vaccine component that could cause ADEM or
MOGAD. Tr. 131:2–16. Dr. Akbari also failed to identify any homologies or structural sequences
between the MOG-antibody and the varicella or MMR vaccines, and dismissed the need for a
structural or sequential homology. Second Akbari Rep. at 9–10. While this kind of showing is not
required of claimants, their experts often spend a great deal of time hoping to substantiate it
anyway. See, e.g., A.T. v. Sec'y of Health & Hum. Servs., No. 16-393V, 2021 WL 6495241, at
*23–25 (Fed. Cl. Dec. 17, 2021); L.R. v. Sec'y of Health & Hum. Servs., No. 16-922V, 2024 WL
1912575, at *18–21 (Fed. Cl. Mar. 28, 2024).
At most, Dr. Akbari referenced the Virupakshaiah case study as establishing sequence
homology between tetanus toxoid protein components and the MOG-protein. But its authors did
not conclude that Tdap vaccine had a causal role in the development of MOGAD, and merely
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identified two T-cell epitopes of tetanus toxoid that share an amino acid sequence with MOG-
specific T cells in MS patients. Virupakshaiah at 5. This is not enough of a basis upon which to
conclude that a tetanus-containing vaccine will likely lead to a cross-reactive process mediated by
autoantibodies and resulting in MOGAD. By contrast, Dr. Forsthuber found no significant
similarity between the amino acid sequence of TT and MOG based upon his own searches.
Forsthuber Blast at 3–4. While I do not give great weight to BLAST searches as a general matter
(since a showing of homology alone is never enough to prove causation),14 it is telling in this case
that Petitioner’s immunology expert made little effort to establish homology—while Respondent’s
expert offered reliable evidence, based on his own review (and one which he was qualified to
conduct), to refute its likelihood.
Molecular mimicry is in this case (as in many others) invoked as the mechanistic “skeleton
key” that unlocks how an autoimmune disease process may have occurred. But it has not been
fleshed out with sufficient corroborative evidence specific to the vaccines at issue or to MOGAD,
and thus alone does not carry the day for Petitioner on the issue of causation. McKown v. Sec'y of
Health & Hum. Servs., No. 15-1451V, 2019 WL 4072113, at *50 (Fed. Cl. Spec. Mstr. July 15,
2019) (explaining that “merely chanting the magic words ‘molecular mimicry’ in a Vaccine Act
case does not render a causation theory scientifically reliable, absent additional evidence
specifically tying the mechanism to the injury and/or vaccine in question” (emphasis omitted));
Forrest v. Sec’y of Health & Hum. Servs., No. 14-1046V, 2019 WL 925495, at *3 (Fed. Cl. Spec.
Mstr. Jan. 28, 2019), (“[A] simple invocation of the term ‘molecular mimicry’ does not carry a
petitioner’s burden of proof. As explained by the Court of Federal Claims, ‘Without any empirical
evidence that the theory actually applies to the [vaccine and the disease in question], the first prong
of Althen would be rendered meaningless.’” (quoting Caves v. HHS, 100 Fed. Cl. 119, 135 (2011),
aff’d, 463 F. App’x 932 (Fed. Cir. 2012) (per curiam)).
At bottom, Dr. Akbari’s theory seeks to accomplish what many other unsuccessful
claimants attempt: describe expected ways in which vaccines impact the immune system, and then
convert that into a narrative of an aberrant process resulting in illness. But a theory that requires
the vaccine to impact the immune system at so many points (stimulating the production of
cytokines, defeating the immune system’s self-regulating safeguards, and then encouraging an
aberrant adaptive immune response due to the creation of cross-reacting MOG autoantibodies)
cannot be found to have met the “more likely than not” standard unless its various subcomponents
14 Indeed, I have found for Petitioners in MOGAD cases even where they did not show structural or sequential
homologies between a vaccine and the MOG-protein. See, e.g., Hock, 2024 WL 3826125; L.C., 2021 WL 3630315.
But I did so because of MOGAD’s novelty as a diagnosis, the fact that the vaccines at issue had a history of being
associated with comparable CNS demyelinating diseases, and because both parties had agreed that the “relevant cross-
reactive process herein is ‘more complicated than simple amino acid sequence homology.’” Hock, 2024 WL 3826125;
L.C., 2021 WL 3630315, at *19.
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have preponderant support. Here, they do not.15 And Dr. Akbari’s opinion was soundly rebutted
by Dr. Forsthuber, a very qualified immunologist who provided cogent testimony. I ultimately
found Dr. Forsthuber far more persuasive on the causation question than Dr. Akbari. It is well-
recognized in the Program that special masters are not compelled to accept the ipse dixit of experts
at face value. Snyder, 88 Fed. Cl. at 743 (quoting Gen. Elec. Co., 522 U.S. at 146). And in this
case, the overall balance of evidence favored Respondent, even if Dr. Akbari possessed sufficient
personal expertise on immunologic matters to propose a causation opinion.
I thus do not find that the “can cause” prong was established, given the mix of evidence
and testimony presented in this case. This is not to say that “the door is closed” (from the
Program’s standpoint) on the question of whether MOGAD could be vaccine-associated. The
subject is very much under study at this time—and as more medical and scientific evidence is
generated on the topic, it will likely become easier to ascertain in Vaccine Act cases the strength
of the putative vaccine association. But it certainly cannot be presumed that MOGAD is likely
vaccine caused, in some or all circumstances. Rather, the discovery of the MOG antibody raises
questions about its role in propagating disease, as well as its origins—and as science evaluates the
matter, it is likely that vaccine injury cases involving MOGAD will continue to turn on the strength
of evidence offered in the case at hand.
B. Prong Two
As revealed from the discussion of the trial testimony, Respondent challenges Petitioner’s
MOGAD diagnosis. Opp. at 15–16. He contends that Petitioner has not provided sufficient
evidence, in the form of supporting clinical or MRI features, to establish MOGAD, especially
given the low-positive MOG antibody titer levels revealed in testing. Id. at 16–17.
Respondent’s arguments have independent support. For example, authority establishes that
a low positive MOG-IgG test must usually be supplemented with evidence of both a negative
AQP4-IgG test and at least one supporting clinical or MRI feature to satisfy the MOGAD diagnosis
requirement. Banwell at 9 Fig. 3. Here, however, although Petitioner did obtain a negative AQP4-
IgG test, the MRI results were not sufficient to confirm MOGAD. Ex. 13 at 290–91. And Dr. Roos
15 I give relatively little weight to Kumar—the case study specific to the Petitioner herself. It is factually accurate, but
it observes consistently the limitations of its findings, which are largely based on the temporal relationship to
vaccination (and it notes other associations between vaccination and diseases featuring demyelination, like MOGAD,
are also temporal only). Kumar at 87. It relies largely on other case reports or series to reach its conclusions. Id. at 90.
It seems to assume that vaccination’s aberrant impact was heightened by Petitioner’s concurrent pregnancy and illness.
Id. at 89. And most significantly, it is foundationally difficult to find probative a case report written about the relevant
petitioner—since the speculation it raises about causation is the very subject of this matter, and numerous items of
reliable evidence pro and con were offered. To find a petitioner-specific case report to be worthy of evidentiary weight
(e.g., to rule that “a case report about a petitioner’s adverse vaccine reaction supports her contention that she had an
adverse vaccine reaction”), I would require additional corroborative evidence that the case report’s speculation was
later shown to be more than that.
28

Case 1:21-vv-01231-UNJ Document 70 Filed 08/26/25 Page 29 of 32
noted other aspects of Petitioner’s presentation that were not clinically consistent with ADEM (a
form of how MOGAD might present). Tr. at 258–63.16
But even assuming that Petitioner’s MOGAD diagnosis was correct, she has failed to carry
her burden of preponderantly establishing that the vaccines she received “did cause” that injury.
To begin, the record lacks evidence that Petitioner experienced any kind of reaction from
the vaccines. Tr. at 15. Petitioner was clearly experiencing infectious symptoms during the
timeframe in which she was vaccinated, but these cannot be linked to the vaccines (and they do
not reflect the kinds of symptoms often viewed as vaccination-associated “malaise”). And there is
no evidence that would establish the presence of vaccine-associated inflammation (which Dr.
Akbari’s theory of inflammasome stimulation would require for corroboration).
This leads to the second, and more compelling, evidentiary factor militating against a
finding of causation: the Petitioner’s obvious URI symptoms. The etiology of those symptoms
cannot be ascertained on this record. But their existence and severity is plain. Thus, the record
clearly shows that (a) Petitioner was very ill, with little improvement, for a week or more prior to
her receipt of the Tdap vaccine, and (b) she experienced comparable, recurrent symptoms a few
days after the second vaccination event on April 27, 2018. Ex. 23 at 117–19, Ex. 23 at 15–30, 50;
see also Tr. at 14. Only by April 30th did she begin to report symptoms that could be reflective of
a neurologic condition (urinary frequency and urgency)—and while this occurred post-
vaccination, it was also in the wake of her confirmed URI treatment on two occasions.17 And she
admitted in her testimony (as corroborated by record proof) that her illnesses predated
vaccination—and there is other proof suggesting Petitioner told contemporaneous treaters that she
might have become ill after being exposed to a relative who had traveled from abroad (although
she disputes how ill this individual actually was).
All of the foregoing supports the conclusion that both before and then during the time
Petitioner was vaccinated, she was also ill with some kind of infectious process. And an infection
16 The evidence far more strongly preponderates against the conclusion that Petitioner experienced ADEM, since (as
Dr. Roos opined) the Petitioner’s symptoms did not align with recognized diagnostic criteria. First Roos Rep. at 8.
The Petitioner experienced several weeks of URI symptoms that developed after visiting her sick relative, test results
showed “abnormally high echovirus” titers, Petitioner’s physicians did not have an explanation for her coagulopathy—
which is reported in echovirus 7 infections, negative subsequent anti-MOG antibody test results during the “acute
period” of the affliction, and testing and post-hospitalization neurological testing and provider visits shows that her
symptoms abated approximately three months from her onset—meaning she did not experience a neurological deficit
lasting at least six months. Id. at 8–9.
17 The record also reveals that some of Petitioner’s symptoms as of April 30, 2018, could be attributable to an ectopic
pregnancy. See Ex. 21 at 288; Ex. 23 at 191–92. However, this does not appear to have played a role in her subsequent
illness, and I deem arguments by Drs. Rizvi or Akbari that Petitioner’s pregnant condition was an aspect of her course
later to be speculative.
29

Case 1:21-vv-01231-UNJ Document 70 Filed 08/26/25 Page 30 of 32
could be causal of MOGAD, as literature filed in this case allows. See Sechi at 13; Banwell at 5
(stating that infectious episodes—mostly respiratory—often preceded ADEM, which is a
presentation of MOGAD). If so, this undermines Petitioner’s contention that the vaccines she
received were also a substantial factor in causing her MOGAD.18 And her experts did not
adequately diminish the significance of this evidence. Of course, claimants need not affirmatively
exclude all alternative factors that could explain an alleged vaccine injury. Efron, 2025 WL
408219, at *22 (citing M.R. v. Sec'y of Health & Hum. Servs., No. 16-1024V, 2023 WL 4936727,
at *30 (Fed. Cl. Spec. Mstr. June 30, 2023)). But they have some obligation to grapple with the
record when it establishes the existence of such countervailing factors—and Petitioner failed here
to do so.
There is also the proof of an echovirus infection as the possible causal infection.
Respondent has made some reasonable points about echovirus—how it could be consistent with
Petitioner’s symptoms, the fact that she did test positive for it, that it can be neurovirulent, and the
fact that the timing of the testing result did not preclude the possibility that such an infection
existed at the time of Petitioner’s onset of MOGAD-like symptoms. In response, Petitioner’s
experts unpersuasively denied the significance of testing confirming the presence of echovirus
(while simultaneously calling upon me to find the very low titer levels of MOG antibodies revealed
by testing to be strong evidence of vaccine causation). First Rizvi Rep. at 10; Second Akbari Rep.
at 23. Dr. Rizvi in fact acknowledged the possibility of echovirus as the cause—and although he
argued that echovirus is more common in children, and that he was unaware of evidence supporting
a connection with MOGAD, the evidence associating vaccines with MOGAD is not all that much
more robust. First Rizvi Rep. at 10; Second Rizvi Rep. at 3.
The fact that Petitioner herein was unquestionably ill at the time of vaccination
distinguishes this case from the other MOGAD cases I have decided where causation was found.
In L.C.¸ for example, a child’s neurologic symptoms occurred a few weeks after vaccination, but
in a context of general good health, with far less direct evidence that the child had been previously
sick. L.C., 2021 WL 3630315, at *1. The evidence that the Hock petitioner was experiencing some
kind of intercurrent infection in the weeks prior to vaccination was a bit stronger, but that Petitioner
had largely recovered by the time he received the flu vaccine (which this Petitioner was not
administered). Hock, 2024 WL 3826125, at *21. I deemed this kind of evidence too inconclusive
to give significant weight in those cases. But in this matter, the evidence of a preexisting,
concurrent illness is substantially greater.
Petitioner can point to instances in the record where treaters allowed for the possibility of
18 Petitioner has argued that she can still prevail even if other factors (the echovirus infection, her intercurrent illness,
etc.) were partially causal, because claimants only need show that a vaccine was a “substantial factor” and “but for”
cause of their injury. Petitioner’s Pre-Hearing Brief, dated Aug. 12, 2024 (ECF No. 43) at 30 (citing Shyface, 165 F.3d
at 1352); Br. at 25. But that only holds if I first had found that the vaccines at issue could cause MOGAD—and I do
not so find in this case (nor have Respondent’s experts conceded vaccine causation).
30

Case 1:21-vv-01231-UNJ Document 70 Filed 08/26/25 Page 31 of 32
vaccine causation. While such views are entitled to some evidentiary weight, they are not per se
controlling of the outcome. Al-Uffi v. Sec'y of Health & Hum. Servs., No. 13-956V, 2017 WL
1713113, at *13 (Fed. Cl. Spec. Mstr. Feb. 22, 2017). In addition, some of these opinions appear
to have reflected speculation or reliance on unreliable case studies. For example, Dr. Abboud noted
that Petitioner’s symptoms could be related to a demyelinating process, including ADEM post-
vaccinal demyelination, or an atypical CNS infection. Ex. 21 at 327–28. But this observation
seemed to reflect reasoned speculation based on timing between onset and receipt of vaccines,
rather than an informed interpretation of the overall record (including Petitioner’s illness
throughout the time of her vaccination). Dr. Joseph also proposed that Petitioner’s symptoms could
reflect an adverse reaction to the rubella compound of the MMR vaccine. Ex. 21 at 368. But she
relied expressly on Holt - an outdated case report that does not involve MOGAD at all. Tr. at 62.
Dr. Yasmin provided a bit more substantiation for his view of a possible vaccination
association. See Ex. 13 at 399. But he hypothesized that either an infection or a vaccination cross-
reacted with a nerve component via molecular mimicry to cause Petitioner’s condition. Id. That
view is consistent with the opinions offered by Petitioner’s experts—and does not exclude the
possibility of a solely-viral cause (something Petitioner did test positive for—findings reached
after Dr. Yasmin expressed this view).19 It otherwise is not strong support for the conclusion that
vaccine and infection acted synergistically to cause Petitioner’s MOGAD—especially since I am
finding it not preponderantly demonstrated that any of the vaccines Petitioner received can cause
it.
What remains is the fact that Petitioner’s most likely neurologic symptoms arose within
two weeks of her first vaccination event. But as the Circuit has stated, “neither a mere showing of
a proximate temporal relationship between vaccination and injury, nor a simplistic elimination of
other potential causes of the injury suffices, without more, to meet the burden of showing actual
causation.” Althen, 418 F.3d 1274 at 1278 (citing Grant, 956 F.2d at 1149). Petitioner has not met
that burden. Despite the fairly robust evidence that Petitioner was ill before and around the time
of her vaccinations, I cannot on this record identify what explanation for Petitioner's general
complaints has the most preponderant support (and I do not ever purport to diagnose the cause of
any Program claimant's injury in performing my duties as a special master). But the overall
murkiness of this evidentiary balance prevents a finding that one, or a combination, of Petitioner’s
vaccines were likely a substantial factor in causing MOGAD.
19 Dr. Yasmin expressed his view on May 7, 2018, but Petitioner’s test results showing abnormally high echovirus
antibody levels were reported later, on May 13, 2018. ECF 14-2 at 135, 399.
31

Case 1:21-vv-01231-UNJ Document 70 Filed 08/26/25 Page 32 of 32
CONCLUSION
Despite the uncertainty still surrounding MOGAD, I can determine in this case—and based
on the evidence before me—that Petitioner did not carry her preponderant burden of showing
causation. I am therefore compelled to deny compensation.
In the absence of a motion for review filed pursuant to RCFC Appendix B, the Clerk of the
Court SHALL ENTER JUDGMENT in accordance with the terms of this Decision.20
IT IS SO ORDERED.
/s/ Brian H. Corcoran
Brian H. Corcoran
Chief Special Master
20 Pursuant to Vaccine Rule 11(a), the parties may expedite entry of judgment if (jointly or separately) they file notices
renouncing their right to seek review.
32

================================================================================
DOCUMENT 2: USCOURTS-cofc-1_21-vv-01231-cl-extra-11243375
Date issued/filed: 2026-01-20
Pages: 1
Docket text: Supplementary opinion from CourtListener cluster 10776788
--------------------------------------------------------------------------------
                 In the United States Court of Federal Claims
                                     OFFICE OF SPECIAL MASTERS
                                             No. 21-1231V

*************************
                            *
ADWOA AMPOFO-ADDO,          *
                            *
                Petitioner, *                                             Filed: December 17, 2025
                            *
          v.                *
                            *
SECRETARY OF HEALTH AND     *
HUMAN SERVICES,             *
                            *
                Respondent. *
                            *
*************************

Maximillian J. Muller, Muller Brazil, LLP, Dresher, PA, for Petitioner.

Rachelle Bishop, U.S. Department of Justice, Washington, DC, for Respondent.

                        DECISION GRANTING IN PART MOTION FOR
                      FINAL AWARD OF ATTORNEY’S FEES AND COSTS 1

         On April 16, 2021, Adwoa Ampofo-Addo filed a petition for compensation under the National
Vaccine Injury Compensation Program (the “Vaccine Program”). 2 Petitioner alleged that her receipt
of a tetanus, diphtheria, and acellular pertussis vaccine on April 17, 2018, as well as measles-mumps-
rubella and varicella vaccines administered on April 24, 2018, caused her to suffer myelin
oligodendrocyte glycoprotein antibody-associated disease (“MOGAD”), and/or MOG-positive acute
disseminated encephalomyelitis. See Amended Petition, dated July 31, 2024 (ECF No. 41). A two-day
hearing was held on November 12, 2024, and I subsequently issued a decision denying entitlement.
Decision, dated July 31, 2025 (ECF No. 69).

1
  This Decision will be posted on the United States Court of Federal Claims’ website in accordance with the E-
Government Act of 2002, 44 U.S.C. § 3501 (2012). This means the Decision will be available to anyone with access
to the internet. As provided by 42 U.S.C. § 300aa-12(d)(4)(B), however, the parties may object to the published
Decision’s inclusion of certain kinds of confidential information. Specifically, under Vaccine Rule 18(b), each party
has fourteen (14) days within which to request redaction “of any information furnished by that party: (1) that is a trade
secret or commercial or financial in substance and is privileged or confidential; or (2) that includes medical files or
similar files, the disclosure of which would constitute a clearly unwarranted invasion of privacy.” Vaccine Rule 18(b).
Otherwise, the entire Decision will be available to the public in its current form. Id.
2
 The Vaccine Program comprises Part 2 of the National Childhood Vaccine Injury Act of 1986, Pub. L. No. 99-660,
100 Stat. 3758, codified as amended, 42 U.S.C. §§ 300aa-10 through 34 (2012) [hereinafter “The Program” or
“Program”]. Individual section references hereafter will be to Section 300aa of the Act.
        Petitioner previously obtained an interim award of fees and costs after the hearing, although I
deferred ruling on costs related to her expert, Omid Akbari, Ph.D. Motion for Interim Attorney’s Fees
and Costs, dated Dec. 27, 2024 (ECF No. 60) (“Interim Fees Mot.”); Interim Fees Decision, dated Feb.
27, 2025 (ECF No. 65). Petitioner has now sought her final award of fees and costs, seeking
compensation for expenses incurred since filing her Interim Fee Request plus Dr. Akbari’s total fees
and costs for his work on the matter. Final Application for Attorney’s Fees and Costs, dated Oct. 21,
2025 (ECF No. 73) (“Final Fees Mot.”). In total, Petitioner is seeking $66,211.00, comprised of
$4,336.00 in attorney’s fees and $61,875.00 in costs.

       Respondent reacted to the fees request on November 4, 2025. See Response, dated Nov. 4,
 2025 (ECF No. 74) (“Resp.”). Respondent defers to my discretion as to whether the statutory
 requirements for an award of attorney’s fees and costs are met in this case, and if so, the
 calculation of the amount to be awarded. Resp. at 2, 9. Petitioners elected to not file a Reply.

      For the reasons set forth below, I hereby GRANT IN PART Petitioners’ motion in part,
 awarding fees and costs in the total amount of $49,336.00.


                                             ANALYSIS

 I.      Petitioner’s Claim had Reasonable Basis

        Although the Vaccine Act only guarantees a fees award to successful petitioners, a special
master may also award fees and costs in an unsuccessful case if: (1) the “petition was brought in
good faith”; and (2) “there was a reasonable basis for the claim for which the petition was brought.”
Section 15(e)(1). I have in prior decisions set forth at length the criteria to be applied when
determining if a claim possessed “reasonable basis” sufficient for a fees award. See, e.g., Sterling
v. Sec’y of Health & Hum. Servs., No. 16-551V, 2020 WL 549443, at *4 (Fed. Cl. Spec. Mstr. Jan.
3, 2020). Importantly, establishing reasonable basis does not automatically entitle an unsuccessful
claimant to fees, but is instead a threshold obligation; fees can still thereafter be limited, if
unreasonable, or even denied entirely.

        A claim’s reasonable basis must be demonstrated through some objective evidentiary
showing. Cottingham v. Sec’y of Health & Hum. Servs., 971 F.3d 1337, 1344 (Fed. Cir. 2020)
(citing Simmons v. Sec’y of Health & Hum. Servs., 875 F.3d 632, 635 (Fed. Cir. 2017)). This
objective inquiry is focused on the claim—counsel’s conduct is irrelevant (although it may
bulwark good faith). Simmons, 875 F.3d at 635. In addition, reasonable basis inquiries are not
static—they evaluate not only what was known at the time the petition was filed, but also take
into account what is learned about the evidentiary support for the claim as the matter progresses.
Perreira v. Sec’y of Health & Hum. Servs., 33 F.3d 1375, 1377 (Fed. Cir. 1994) (upholding the

                                                  2
finding that a reasonable basis for petitioners’ claims ceased to exist once they had reviewed their
expert's opinion, which consisted entirely of unsupported speculation). As a result, a claim can
“lose” reasonable basis over time.

        The standard for finding the existence of reasonable basis is lesser (and thus inherently
 easier to satisfy) than the preponderant standard applied when assessing entitlement, as cases
 that fail can still have sufficient objective grounding for a fees award. Braun v. Sec’y of Health
 & Hum. Servs., 144 Fed. Cl. 72, 77 (2019). The Court of Federal Claims has affirmed that
 “[r]easonable basis is a standard that petitioners, at least generally, meet by submitting
 evidence.” Chuisano v. Sec’y of Health & Hum. Servs., 116 Fed. Cl. 276, 287 (Fed. Cl. 2014)
 (internal quotations omitted) (affirming special master). The factual basis and medical support
 for the claim is among the evidence that should be considered. Carter v. Sec’y of Health & Hum.
 Servs., 132 Fed. Cl. 372, 378 (Fed. Cl. 2017). Under the Vaccine Act, special masters have
 “maximum discretion” in applying the reasonable basis standard. See, e.g., Silva v. Sec’y of
 Health & Hum. Servs., 108 Fed. Cl. 401, 401–02 (Fed. Cl. 2012).

        Although Petitioner’s claim was ultimately unsuccessful, I find that there was sufficient
 objective basis to entitle her to a fees and costs award. There was record evidence that Petitioner
 experienced a variety of symptoms after the relevant vaccines. In addition, theories that an
 individual’s MOGAD could have been vaccine-caused are very much legitimate; the Program
 certainly has not at this point reached a consensus on the validity of this particular vaccine injury.
 I also note that I previously awarded interim fees based upon the claim, and nothing from a fact
 standpoint changed in the matter as it proceeded that would justify a finding that reasonable basis
 ceased to exist once the matter was fully resolved.

       Thus (and in light of the exceedingly lenient standard that governs reasonable basis
 determinations), a final award of fees and costs in this matter is permissible. And because I find
 no reason otherwise to deny a fees award, I will allow one herein.

 II.     Calculation of Fees

         A.    Hourly Rates

       Determining the appropriate amount of the fees award is a two-part process. The first part
involves application of the lodestar method—“multiplying the number of hours reasonably
expended on the litigation times a reasonable hourly rate.” Avera v. Sec’y of Health & Hum. Servs.,
515 F.3d 1343, 1347–48 (Fed. Cir. 2008) (quoting Blum v. Stenson, 465 U.S. 886, 888 (1984)).
The second part involves adjusting the lodestar calculation up or down to take relevant factors into
consideration. Id. at 1348. This standard for calculating a fee award is considered applicable in
most cases where a fee award is authorized by federal statute. Hensley v. Eckerhart, 461 U.S. 424,


                                                   3
429–37 (1983).

        An attorney’s reasonable hourly rate is determined by the “forum rule,” which bases the
proper hourly rate to be awarded on the forum in which the relevant court sits (Washington, D.C.,
for Vaccine Act cases), except where an attorney’s work was not performed in the forum and there
is a substantial difference in rates (the so-called “Davis” exception”). Avera, 515 F.3d at 1348
(citing Davis Cty. Solid Waste Mgmt. & Energy Recovery Special Serv. Dist. v. U.S. Envtl. Prot.
Agency, 169 F.3d 755, 758 (D.C. Cir. 1999)). A 2015 decision established the hourly rate ranges
for attorneys with different levels of experience who are entitled to the forum rate in the Vaccine
Program. See McCulloch v. Sec’y of Health & Hum. Servs., No. 09-293V, 2015 WL 5634323, at
*19 (Fed. Cl. Spec. Mstr. Sept. 1, 2015).

       Petitioner requests the following rates for her attorneys and support staff, based on the
years work was performed:

                 Max Muller          Erik Pavlacsek              Tereza               Alexandria
                 (Attorney)           (Paralegal)               Pavlacsek               Munoz
                                                               (Paralegal)            (Paralegal)
 2025            $475.00                 $170.00                 $180.00                $125.00
 Rate
Final Fees. Mot. at 7.

        Mr. Muller and his colleagues practice in Dresher, Pennsylvania—a jurisdiction that has
been deemed “in forum,” entitling them to rates commensurate with what was established in
McCulloch. See Le v. Sec’y of Health & Hum. Servs., No. 16-1078V, 2023 WL 2054467 (Fed.
Cl. Spec. Mstr. Feb. 17, 2023). The rates requested for Mr. Muller and his colleagues (including
newly requested 2025 rates) are also consistent with what has previously been awarded, based on
the attorneys’ work and experience in the Program, and are otherwise in accordance with the
Office of Special Masters’ fee schedule. 3 Hock v. Sec’y of Health & Hum. Servs., No. 21-945V,
2024 WL 5349129, at *2 (Fed. Cl. Spec. Mstr. Dec. 16, 2024). I thus find no cause to reduce
them in this instance. And I deem the time devoted to the matter to be reasonable. I will therefore
award all fees requested without adjustment.

    III.   Calculation of Attorney’s Costs

       Just as they are required to establish the reasonableness of requested fees, petitioners must
also demonstrate that requested litigation costs are reasonable. Presault v. United States, 52 Fed.
Cl. 667, 670 (2002). Reasonable costs include the costs of obtaining medical records and expert

3
  OSM Attorneys’ Forum Hourly Rate Fee Schedule, https://www.uscfc.uscourts.gov/osm-attorneys-forum-hourly-
rate-fee-schedules (last visited Dec. 16, 2025).

                                                    4
time incurred while working on a case. Fester v. Sec’y of Health & Hum. Servs., No.10-243V, 2013
WL 5367670, at *16 (Fed. Cl. Spec. Mstr. Aug. 27, 2013). When petitioners fail to substantiate a
cost item, such as by not providing appropriate documentation to explain the basis for a particular
cost, special masters have refrained from paying the cost at issue. See, e.g., Gardner-Cook v. Sec’y
of Health & Hum. Servs., No. 99-480V, 2005 WL 6122520, at *4 (Fed. Cl. Spec. Mstr. June 30,
2005).

        The sole cost element to be resolved is what reimbursement should be provided for the work
of Dr. Akbari. Petitioner requests $61,875.00, reflecting 112.5 hours of work performed by Dr.
Akbari at a rate of $550.00 per hour. Final Fees Mot. at 10–15. Dr. Akbari has, however, been
consistently been awarded a rate of $500.00 per hour for his work in the Vaccine Program. See,
e.g., Cogan v. Sec'y of Health & Hum. Servs., No. 21-1847V, 2025 WL 2505545, at *5 (Fed. Cl.
Spec. Mstr. July 24, 2025) (reducing Dr. Akbari’s hourly rate to $500 an hour based after listing
cases in which Dr. Akbari has previously been awarded $500.00 per hour). While I am not averse
in future cases to awarding Dr. Akbari a higher hourly rate, the work he performed on this matter
occurred while his rate was lower. Accordingly, the rate to be awarded herein will be reduced to
$500.00 per hour.

        Additionally, I find that a reduction in hours is necessary. Fees for experts are subject to
the same reasonableness standard as fees for attorneys. See Baker v. Sec'y of Health & Hum. Servs.,
99-653V, 2005 WL 589431, at *1 (Fed. Cl. Spec. Mstr. Feb. 24, 2005); Rochester v. United States,
18 Cl. Ct. 379, 387 (1989) (stating that services that are “primarily of a secretarial or clerical nature
... should be considered as normal overhead office costs included within the attorneys’ fee rates”).
And my review of the billing records lead me to conclude that some of the time spent on this case
by Dr. Akbari was excessive, and hence unreasonable.

        In particular, Dr. Akbari has billed 112.5 hours for work devoted to this case. See Final
Fees Mot. at 10–15. This includes time spent downloading exhibits and references, preparing
billing statements, and reviewing medical literature, among other things. See Final Fees Mot. at
10–15. But several of Dr. Akbari's billing entries are for administrative tasks, which are not
compensable in the Vaccine Program. For example, Dr. Akbari billed roughly 9 hours of
administrative tasks like downloading and highlighting PDFs, submitting his report, and preparing
his statement of hours. 4 Dr. Akbari has previously been warned against billing for such tasks and
has had his hours reduced for such offenses. See e.g., Cogan, 2025 WL 2505545, at *6; Williams
v. Sec'y of Health & Hum. Servs., No. 19-1269V, 2024 WL 1253768, at *4 (Fed. Cl. Spec. Mstr.
Feb. 28, 2024); Walters v. Sec'y of Health & Hum. Servs., No. 15-1380V, 2022 WL 1077311, at
*6 (Fed. Cl. Spec. Mstr. Feb 23, 2022).

       More broadly, Dr. Akbari’s hours are excessive for the work performed in this case. An
expert may be compensated only for the number of hours reasonably expended. King v. Sec'y of

4
    See billing entries dated: 9/24/2023; 9/27/2023; 9/29/2023; 10/3/2023; 5/15/2024; 5/16/2024; 11/10/2024.

                                                           5
Health & Hum. Servs., No. 03-584V, 2010 WL 5470787, at *4 (Fed. Cl. Spec. Mstr. Dec. 13, 2010)
(indicating that counsel had a “duty to ‘monitor the expert's overall fees to ensure that the fees
remain reasonable.”); Griffin & Dickson v. United States, 21 Cl. Ct. 1, 11 (1990) (“[t]he special
master is within his discretion in reducing hours that are duplicative, padded, spent on unrelated
matters, or not ‘reasonably expended.’”). Other special masters have also previously reduced Dr.
Akbari's hours for excessive time spent reviewing medical literature. See Walters, 2021 WL
3928993, at *7–8 (deducting 20% of Dr. Akbari's billed hours for excessive time spent reviewing
medical literature); Reinhardt v. Sec'y of Health & Hum. Servs., No 17-1257V, 2021 WL 2373818,
at *5 (Fed. Cl. Spec. Mstr. Apr. 22, 2021) (deducting 20% of Dr. Akbari's billed hours for excessive
time spent). Dr. Akbari billed 43.3 hours for reviewing literature. 5

        Here, the kind of “rough justice” that is appropriate when rendering fees decisions in the
Vaccine Program counsels me to make a single, across-the-board percentage reduction. deduct Dr.
Akbari’s requested time by 20%, for a total reduction of 22.5 hours. 6 With Dr. Akbari’s reduction
in hours and hourly rate taken into consideration, I will award a total of $45,000.00 for costs
associated with Dr. Akbari’s work on this case. 7



                                                  CONCLUSION

        Based on the foregoing, I GRANT IN PART Petitioner’s Motion for Final Award of
Attorney’s Fees and Costs. Petitioner is awarded a total amount of $49,336.00, reflecting $4,336.00
in attorney’s fees and $45,000.00 in costs, to be paid through an ACH deposit to Petitioner’s
counsel’s IOLTA account for prompt disbursement.

          In the absence of a motion for review filed pursuant to RCFC Appendix B, the Clerk of the
    Court SHALL ENTER JUDGMENT in accordance with the terms of this Decision. 8

      IT IS SO ORDERED.

                                                                          /s/ Brian H. Corcoran
                                                                          Brian H. Corcoran
                                                                          Chief Special Master


5
 See billing entries dated: 08/19/2023; 08/21/2023–08/23/2023; 09/2/2023; 09/5/2023; 09/9/2023; 09/12/2023;
4/11/2024; 4/15/2024; 4/17/2024; 4/19/2024; 4/22/2024; 4/24/2024; 4/27/2024; 4/29/2024.
6
    Calculated by: 112.5 hours x (20% ÷ 100) = 90 hours
7
    Calculated by: 90 hours x $500/hour = $45,000.00
8
 Pursuant to Vaccine Rule 11(a), the parties may expedite entry of judgment if (jointly or separately) they file notices
renouncing their right to seek review.

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