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Since the outbreak of West Nile virus (WNV) in the United States in 1999, the WNV neuroinvasive disease has been increasingly reported with a wide spectrum of neuromuscular manifestations. Case: We submit a case of a 46-year-old male with a history of alcohol abuse, diabetes, hypertension, and hepatitis C who presented with fever, nausea, shortness of breath, and dysphagia. The patient rapidly developed hypercapnic respiratory failure and was found to have WNV meningoencephalitis without obvious neuromuscular weakness. His hospital course was significant for repeated failures of extubation secondary to persistent bulbar weakness eventually requiring tracheotomy.This is a unique case of WNV meningoencephalitis with bulbar palsy without other neuromuscular manifestations resulting in recurrent hypercapnic respiratory failure.