Hello doctor, Im a 30y/o male. 1.5 years ago I had a protected sexual encounter with a street pick up CSW from southamerica. Protected oral sex (receiving) and protected vaginal sex. Don't know the kind of condom or status of it as it was given by the hotel lobby.

After the encounter I've had numerous symptoms and situations, and Ive come a long way trying to just think of it all as a coincidence, but lingering symptoms and even new ones are making it pretty hard for me.

Some of the symptoms Ive had include testicles pain, groin pain, pelvic pain, difficulty urinating, urgent urination, split stream, some mild discharge sometimes, and more.

In the past 1.5 years Ive had a lot of tests trying to know if I have an infection or not. Ive had 2 urethral swabs and 2 urine tests for STDs (last one urine test 11 months post exposure) All negative. 

Ive had many HIV and VDRL or RPR tests, all negative. Last HIV 15 months post exposure and last VDRL at 12 months. Also had HIV PCR test at 1 year and also negative.

Recently a few days ago Ive started having some intense pain if my left feet big toe that is sometimes exclusively while urinating. I do feel some mild discomfort during the day but everytime I pee it becomes a very intense pain in my toe tip. Im also feeling some discomfort in my fingers and other toes sometimes but the real intense pain is in my left big toe and it comes while I urinate.

1) Could this be reactive arthritis?

2) Can reactive arthritis just start 1.5 years after exposure?

3) What are the possible complications of long lasting not treated STDs like Chlamydia and Gono?

4) Ive seen that HIV is also a cause of this disease, could it be related? I did have a false positive P24 Antigen test that then was ruled as false because of confirmatory PCR and Western Blot

5) I resumed sex with my partner 6 months post exposure, now Im worry I might had given her an infection. She's been dealing with pelvic pain and frequent urination for a couple of weeks as well.

6) For other reasons (respiratoy infections) Ive had taken 1G Azythro and 10 days of Augmentin in the last year about 6-7 months post exposure. Would this affect anything like the infection or the tests itself?

You describe a very safe sexual exposure with little or no risk of any STD, and certainly none that could explain your symptoms. The bottom line is that none of your symptoms suggests any infection of any kind related to the sexual exposure you are concerned about. More comments below after I address your numbered questions.

1) Nothing in these symptoms or circumstances suggests reactive arthritis (reA).

2) ReA can start at any time, but when triggered by STDs like gonorrhea and chlamydia, typically symptoms would begin within a few weeks.

3) The main complications of gonorrhea or chlamydia involve the genitals like (in males)urethral stricture and epididymitis; rare cases of gonorrhea cause disseminated infection with acute arthritis, and you already know they might trigger ReA. Clearly you have none of these things. Neither of these infections is a plausible cause of any of the symptoms you have described.

4) I am not aware of HIV as a cause of ReA, and in any case you clearly do not have HIV.

5) I am confident you have no STD, or any other infection from your encounter 1.5 yr ago that you could transmit to your current partner. I can't say the cause of her symptoms; if they continue and/or she is concerned, she should see her doctor.

6) There was no need for such treatment, nor would these or any other antibiotics be expected to have any effect on the symptoms you have mentioned. If you had had gonorrhea, chlamydia, nongonococcal urethritis (NGU) or syphilis taking the antibiotics, you would have been cured. Negative tests after the antibiotics prove you were not infected at the time of those tests, but say nothing about prior infection that might have been cured. However, as noted above, you were at little or no risk for any of these infections anyway.

It seems pretty clear that you are linking a sexual experience with very nonspecific symptoms that in fact have nothing to do with that event. Probably 90% of all humans have some or all these symptoms at one time or another. None sound serious. Most important, the combination of low risk at the time, absence of symptoms typical of any STD (almost all of which would have shown up within a couple of weeks, not months or years later), and your negative test results are conclusive evidence against any infection from the sexual exposure on your mind.

I hope these comments are helpful. Let me know if anything isn't clear.

HHH, MD

1) Im a little confused because my fingers and toes hurt, as do my feet and sometimes other joints and I've read this is suggestive of ReA or another other arthritis. Specially the part about urinating making the pain worse, that is very specific to ReA isnt it? My knuckles hurt and the center of my hand as well.

2) Ive been experiencing most of these symptoms since one week post exposure. The fingers and toes, feet pain have just started like one week ago, but all the rest (pain in testicles, pelvic area, difficult urinating,  sometimes clear discharge, and more have been going on non stop for 1.5 years now. Isnt this suggestive of a possible situation after the exposure? Some kind of infection?

3) Is it possible that all my tests have been wrong? 2 urethral swabs and 2 urine tests. For one of these swabs the doctor actually did a DRE and white discharge came out and he took the sample with that. Does this help or affect the test in any way?

4) Ive also been having a lot of skin irritations and kind of rashes and pimples, way more than usual. Ive taken RPR and VDRL tests almost monthly for all this time the last time was 11 months post exposure. Also took a FTA-ABS test like 9 months post exposure. Could any of this be a manifestation of an undiagnosed syphilis?

5) Just to clarify I didnt take the antibiotics for any of these, I had them prescribed for upper respiratory infections. Does 1 dose of 1g of azythro and 10 days of amoxicilin would have been enough to cover all this STis you mention? 

6) How exactly does "self cured" gono and chlamydia work? Is this just for asymptomatic patients or all patients? I literally waited 6 months post exposure to get back to having sex with my partner. During that time I testes multiple times and had the antibiotics mentioned.

3) The tests you had are conclusive. You have been over tested; it's time to stop. There is no chance they are wrong, especially done twice. Expressing prostate fluid for one of the tests is equally valid as urethral swab, but no more so.

4) You're looking at entirely normal human life; none of this sounds abnormal, regardless of frequency and how much the symptoms bother you. Also see the comments below.

5) The reason for the antibiotics makes no difference on their effect on testing. And yes those doses would have been effective against any bacterial STD you might have had.

6) Most infections are entirely cured by the immune system. Antibiotics speed cure and prevent complications, but throughout human history before antibiotics most people with pneumonia, diphtheria, staph infection, gonorrhea and a hundred others survived without complications. Some infections persist (TB, syphilis, herpes, and many more) but most of these are still controlled by the immune system to an extent that they do little harm. For gonorrhea, most infections in males are cleared entirely by the immune system within a couple of months.  You waited far too long to not have sex at home, especially with your negative test results. Even if you had never tested and had not taken the antibiotics, it would have been safe for your partner after a couple of months. On top of which, you had an exposure that was essentially risk free at the start!

Your symptoms:  I could use your story to teach med students and residents about anxiety or stress magnifying trivial symptoms or normal body sensations, which otherwise would be ignored or maybe not even noticed. If there is a connection with the sexual exposure a few months ago, it is psychological -- the result of your emotional reaction to a sexual event (and a sexual decision) that you now regret. For sure no infection of any kind is involved, and that includes reactive arthritis. If your symptoms continue and/or you remain concerned, see a physician you trust and then follow her advice, which might include professional counseling. For sure stop any testing (and if you can, any worry) about any infection from the sexual exposure described.

1) Is there any other condition or joint pain that would get worse while urinating that is not ReA? The pain that gets worse is the big toe left foot.

2) Assuming none of my symptoms are actually typical of ReA, what symptoms would make a doctor concerned about this condition?

3) The antibiotics I mentioned were taken 6 and 7 months post exposure, does this changes your assessment of possible cure on possible undiagnosed infections?

4) For the past 2 days Ive been having irritated eye (just one eye, the left one) Its red, goes away for a few minutes but comes back to red frequently and it just feels weird, watery and cloudy. Could this be the start of a pink eye? Another symptom of ReA? Ive never had pink eye before so I dont know how it feels like and how does it start and developes

General pain on fingers, toes, foot sole, bridge, instep, ankle.

5) With all these information Ive been giving during our interaction, would you say I coud be 100% sure Im not infected with any STI and Im not putting me or my partner in danger?

Thanks

1. Joint pain with urination is most consistent with a psychological origin; see my comments above.

2. Disabling back pain; red and swollen knee, ankle, other large joints; joints red and swollen, not merely painful; inflamed eyes; typical skin rash.

3. Your antibiotics make no difference in any ay

4. This sort of eye discomfort doesn't suggest the sort of ocular problems common with ReA

5. Yes, I am completely confident you have no STI.

That completes the two follow-up exchanges included with each question and so ends this thread. If despite this reasoned, science based advice you remain obsessed with the possibility of ReA, I suggest you consult with a rheumatologist (arthritis specialist). I am confident s/he will confirm no ReA, but conceivably would test you for the genetic profile called HLA B27. If that's negative, it would rule out ReA. That said, I remain confident your symptoms are entirely psychological in origin and probably related to conflicts over a sexual decision you regret. But I do hope this discussion has been helpful.