Case Presentation: A 20 year-old female presented to the emergency department with a one-week history of fever, neck swelling, and sore throat. A rapid streptococcal antigen screen was negative, and she was diagnosed with viral upper respiratory tract infection and discharged home from the ED. She followed up with her primary care provider and physical exam revealed bilateral tonsillar exudates and cervical adenopathy. A rapid mononucleosis test was negative and CT neck only confirmed cervical adenopathy. She was given a prescription for amoxicillin-clavulanate, prednisone, and received intramuscular penicillin. Two days later, the patient returned to the ED when her symptoms progressed with oral ulcers on her tongue, buccal mucosa and lips, as well as “blacking out” while in the shower and waking up with new lower extremity weakness.Physical exam was notable for oral ulcers on her lips, tongue, and buccal mucosa, cervical adenopathy, and 4 out of 5 strength in bilateral lower extremities with diminished sensation, but intact reflexes. Her legs were visibly shaking with strength testing, and she was unable to stand due to weakness. An MRI and lumbar puncture were obtained. The MRI L-spine showed no acute pathology and cerebrospinal fluid had 0 nucleated cells, 17 mg/dL protein, 58 mg/dL glucose. Her oral ulcer tested positive for HSV-1 by PCR, and her serum was positive for HSV-1 IgM. She was diagnosed with primary HSV-1 gingivostomatitis with associated acute inflammatory demyelinating polyneuropathy (AIDP), also known as Guillan-Barre Syndrome (GBS). Neurology suspected that her CSF was normal as it was very early in her disease presentation. She was started on acyclovir and intravenous immunoglobulin (IVIG) with rapid recovery of her weakness. She followed up with neurology three months post-discharge and only had mild residual right lower extremity weakness and sensory loss.

Discussion: While generalized fatigue and “weakness” are common symptoms presented to clinicians in the setting of acute illness, it is important to keep the whole clinical picture in mind and establish whether a patient has fatigue or new focal weakness. While AIDP/GBS is uncommon, occurring in about 0.62-2.66 per 100,000 person years[4], it does carry a risk of mortality as high as 5%[5]. Of established cases of AIDP/GBS, approximately two-thirds are associated with a preceding infection, one of the more common infections being Campylobacter jejuni enteritis[1]. GBS has also been associated with several different viral infections including HIV, influenza A and B, cytomegalovirus, Epstein-Barr virus, and acute hepatitis A infection[1,2,3,5], and even more uncommonly, HSV infections[1,2]. This presentation for primary HSV-1 infection is atypical in due to majority of these infections are asymptomatic and HSV infection is an uncommon precipitator for AIDP/GBS as majority of adults in the United States are seropositive for HSV-1. With early treatment and rehabilitation evaluation during her hospitalization, this patient was able to be discharged home.

Conclusions: When patients report feeling fatigued or “weak” in the setting of acute illness, it is important to establish if they have fatigue or new genuine weakness in the setting of a viral infection, as this could actually be a presentation of AIDP/GBS. Although rare, AIDP/GBS is a progressive condition that can be debilitating, or even fatal if untreated.