Dr. Steinman concurred with the ALE diagnosis and agreed that the second HPV vaccination was the etiologic trigger for A.M.'s ALE. Tr. at 134-35. Both experts also agreed that A.M. likely had a susceptibility to an autoimmune disease, in that she suffered from a previous autoimmune disorder, idiopathic thrombocytopenic purpura23 ("ITP"), when she was eight years old. Tr. at 378-79; Pet. Ex. 25 at 6; Pet. Ex. 34 at 6. All experts, including Dr. Venkatesan, agreed that a prior autoimmune disorder may make a patient more susceptible to a subsequent one. Tr. at 350.
Dr. Blitshteyn acknowledged that some of the more typical presentations of ALE, mainly the short-term memory and behavioral deficits, were not initially noticed in A.M.'s case; rather, she opined that these deficits were overshadowed by her rapidly developing severe seizure disorder. Tr. at 59. In this regard, as A.M. went straight into severe seizures and became unresponsive shortly after being admitted, Dr. Blitshteyn opined that A.M.'s treating physicians did not have an opportunity to notice these memory and behavioral changes. Tr. at 59-60. She does state, however, that shortly after A.M. came out of her coma, her treating physicians did in fact notice significant memory deficits and behavioral changes. Id. Dr. Venkatesan agreed that once the seizures began, it would have been very "difficult to ascertain whether there were any memory changes or personality changes." Tr. at 356.