[Question #1006] Could this be genital HSV 1/2?

50 months ago

Dear experts,

Please see below chronology, followed by question. Please note that throughout period, I was taking curcumin 500mg twice daily, Ashwagandha 300mg twice daily, and Omega 3 1000mg once daily. Please note as well that I am a thalassemia minor. I had one cold sore as a child.

June 23 (night): protected receptive anal intercourse with lubricant

June 24 (early morning – 5 hours later): brief (5 minute) unprotected receptive anal intercourse without lubricant; no ejaculation; partner claims to be HSV- as of Jan 2016; no visible blisters/ulcers on partner

July 6: minor itchiness in anal area; 1.5/10 itchiness level

July 13: diagnosed with gonorrhea from June 8 throat swab in routine test; urine test negative. Received ceftriaxone injection and 1g of azithromycin same day. Anal itchiness continues at same level.

July 16-17: international flight; missed night of sleep; feel fatigued; itchiness continues. Rigorous exercise on July 17 (despite no sleep)

July 18: results for HIV, Hep B, syphilis, chlamydia, and gonorrhea all negative from Jun 8 blood/urine sample

July 20: anal itchiness intensifies to 2.5/10; red patches appear briefly on inner foreskin of penis, but disappear completely within 5 hours after application of coconut oil and turmeric powder; no fever; general fatigue

July 21: see family medicine physician; conducts anal scope and inspects genital area; sees no clinical evidence for genital herpes (no lesions/ulcers); attributes short duration of penile redness to skin irritation; no fever

July 22-26: erratic (fluctuates throughout day) muscle/joint soreness through pelvic area and legs, including, buttocks, thighs, glutes, quads; occasionally knees and shoulders; soreness intensifies from 2.5/10 to 4/10 over 4 days; no visible lesions, though anal area raw and itchy (no redness); occasional discomfort at tip of urethra when urinating (minor – 1/10); muscle twitching all throughout body periodically (~100 times in the day), but concentrated in pelvic area; no fever

July 26 (afternoon): see physician at STD clinic; finds no sores/lesions and concludes not herpes

July 26 (evening): tiny pimple-like bump (0.7mm diameter) appears on left side of perineum; no pain/feeling, and no surrounding skin redness; only noticed through detailed inspection with mirror; in hairy part of perineum (not middle)

July 28-29: skin rawness in middle perineum (not near bump); no change in bump on left side of perineum (shape, size, type);

July 30: rawness 70% improved; no change in perineum bump; muscle soreness and twitches 80% improved

Could this be genital HSV 1/2?

 

 

Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
50 months ago
You don't mention whether you have actually had any HSV 2 testing done recently - do you know where you started in June with herpes?  We already know you have HSV 1 from your cold sore history.
Your risk would most likely be the brief unprotected anal encounter and a single encounter, though not zero risk, is lower risk, statistically.  The symptoms that you describe are also not consistent with what I would expect from herpes.   The only real exception is your description of skin rawness on the perineum - did the doc see this?

Terri
---
50 months ago
Thanks for the opinion.
I have not had HSV-2 testing. My doctor said to wait until three months post-exposure to avoid false results.
To clarify, I felt the rawness in the perineum for about two days (July 28-29), and it is gone now; but during that time, I inspected the area at least ten times times, and there was no visible redness. I felt it, though it wasn't visible. I also live in a very hot, humid country, and had generalized itching (with no redness) around the whole genital area, though I would describe the perinium feeling more as minor rawness than itchiness.
I should also mention that I took two doses of Valtrex -- 1g on the night of June 20th, and 1g on the morning of the 21st. This was before any of the muscle symptoms, and before I had seen a doctor about the symptoms. The anal itchiness by itself (as well as the fleeting red patches on the inner foreskin) were enough to convince me that I potentially had genital herpes, so I took the two doses to prevent a full primary outbreak. But after seeing my doctor the same afternoon (on the 21st), who said there was no clinical evidence for herpes, I stopped the Valtrex and haven't taken it since. The doctor said my night time dose of Valtrex on the 20th (the night before the appointment) would not have made the red patches on my penis go away completely within 5 hours, before my morning dose. That's why he attributed the foreskin redness that I saw to skin irritation (or possibly a yeast infection, though he said that wasn't likely).
Also, I've checked the small bump on the perineum again (which I've had for 5 days now), and it doesn't seem to be changing. There is still no feeling on the bump (although I've had sore buttocks muscles today), and it does not appear to be getting bigger, smaller, or changing color.
If the perineum bump were herpes-related as part of a primary outbreak, is it possible that is could be there for 4 days without blistering? Could herpes bumps just go away gradually, without turning into blisters, bursting, then scabbing? Or would you expect it to grow, burst, and scab eventually? It's behaving more like a painless pimple at the moment.
Also, would a PCR swab on the tiny perinium bump be able to pick up HSV just from the skin? Or would the bump have to be leaking fluid or have ulcered for the swab to pick up anything?
Finally, what is the likelihood of reinfection with HSV-1 in the genital area? I realize it's low, but could that explain the lack of apparent lesions, but strong extended prodrome-symptoms in the area (i.e. because my body might already have HSV-1 antibodies)?
I realize that each individual symptom doesn't strongly suggest herpes, but I'm primarily concerned because of the cluster of symptoms (which admittedly did not accur all at once, but which have been unfolding over 2.5 weeks). I've been told that a primary outbreak would be painful and noticeable, and have read (in posts by HHH on medhelp.com) that atypical herpes genital outbreaks, though possible, are often more 'typical' on closer inspection. Still, I am concerned, as no doctor has been able to give me another viable explanation for the combination of symptoms.
Thanks again for the opinion.
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
50 months ago
When you said "rawness" I thought there was visible rawness, but since not, then I'm not worried about that anymore.
Yes, if the bump was herpes,I would expect some kind of progression into something else - herpes lesions don't just stay a bump. 
The likelihood of HSV 1 genitally is extremely remote indeed.
It's too bad you didn't get a baseline antibody test because now, if you test positive, you don't know if it is new or old infection.  Perhaps it doesn't matter to you anyway. 
The itchiness could most certainly be fungal, fits very well with what you are describing actually.

Terri
---
50 months ago
Thanks, Terri. Final follow-up questions:
1) Could a PCR swab on the bump pick up on HSV 1/2 even if the blister has not bursted, ulcered, or leaked fluid? In other words, is PCR testing sensitive enough to pick up HSV from just the skin surface of the bump?
2) What is the likelihood of a primary outbreak without any visible lesions (i.e. just skin itchiness, rawness without redness, bad muscle/joint pains in the pelvis/thighs, and minor irritation at the tip of urethra)? Could the lesions be subclinical (i.e. not visible to a naked eye)? Is that possible?
3) Could the two doses of Valtrex on June 20-21 (10 days ago) have prevented any visible lesions, even if I were infected?
3) Could a fungal/bacterial infection cause the pelvic-area muscle/joint pains and the fatigue?
Many thanks.
50 months ago
Sorry, Terri, I added a fifth question below:

1) Could a PCR swab on the bump pick up on HSV 1/2 even if the blister has not bursted, ulcered, or leaked fluid? In other words, is PCR testing sensitive enough to pick up HSV from just the skin surface of the bump?
2) What is the likelihood of a primary outbreak without any visible lesions (i.e. just skin itchiness, rawness without redness, bad muscle/joint pains in the pelvis/thighs, and minor irritation at the tip of urethra)? Could the lesions be subclinical (i.e. not visible to a naked eye)? Is that possible?
3) Could the two doses of Valtrex on June 20-21 (10 days ago) have prevented any visible lesions, even if I were infected?
4) Could a fungal/bacterial infection cause the pelvic-area muscle/joint pains and the fatigue?
5) In your expert opinion, given everything I've told you, if the bump that I mentioned goes away without developing (increasing in size, bursting, scabbing), and no other lesions appear, and the symptoms gradually fade, can I safely rule out genital herpes as a potential cause of these symptoms?
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
50 months ago
1. Yes, the PCR can be positive from perfectly normal looking skin if the virus is present. 
2.  Unusual but not completely impossible that this would be a true primary outbreak - you are watching carefully and I think you would be very aware if you had more symptoms.  Most people who miss a primary infection are people who 1) already have HSV 1 infection and the antibody to HSV 1 keeps HSV 2 symptoms well under control or 2) confuse the symptoms with something else.
3.  Not if it was primary herpes, no - not enough medicine to prevent a full blow outbreak of new herpes
4.  That's hard to say but not likely.  My guess is that the joint pains and fatigue are not related to the bump
5.  I do think you can, but that's an opinion, not fact.

Terri
---