[Question #106] Oral transmission of HSV2?

39 months ago
Hi -- About 6 weeks ago I was with a female CSW in New York.  We had protected vaginal and anal intercourse, but she performed unprotected oral sex on me, including analingus.  A couple weeks later, I developed itching and redness in my butt crack area lasting roughly a week, which may have been caused by chafing while running, but also got me concerned about HSV2 (years ago, I tested positive for HSV1).  After checking with a mirror, I did not see or feel any lesions, blisters or crusting. My question is -- how likely is oral transmission of HSV2 to a man receiving oral sex, and do my symptoms sound like herpes?  Should I be tested for HSV2 and/or refrain from unprotected sex with my wife?
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
39 months ago
A couple of weeks later is a long time for incubation of a new HSV 2 infection - statistics suggest that almost all new cases of HSV 2 show up with symptoms (if symptoms are going to be present) within 2 to 10 days, the average being 5.5 days.  I'm not saying that a longer incubation can't happen but it is unlikely.  Since you have HSV 1, if you did acquire HSV 2, your symptoms would likely be more subtle, if you had any symptoms, as the HSV 1 antibody offers some protection against major symptoms, though likely not against infection itself.  Having said all of that, acquiring HSV 2 from someone's mouth is rare.  First, HSV 2 doesn't like the mouth much and rarely presents there.  I have certainly seen people with brand new HSV 2 infection have symptoms in both the mouth and genital area - they had intercourse with and gave oral sex to the same person with HSV 2 infection.  But even when people do have HSV 2 orally, it rarely activates - again, it doesn't like the mouth.  Studies by Dr. Anna Wald suggest that activation of oral HSV 2 happens on about 1% of day in people who have oral HSV 2 who are HIV negative.  That means if someone has HSV 2 orally and are HIV negative, then they give off virus about 3 days out of a year from their mouth. 

I think another thing to remember is that you could acquire other things from the mouth of people - staph, strep, etc, that are normal for their mouth but might not be normal for your anus.

Your contact was a single contact - how likely would it be that you would receive oral sex from first someone who has HSV 2 and then second, someone who is actually shedding HSV 2 from their mouth on that particular day?  I think it is extremely unlikely. 

You could test after about 12 weeks with the ELISA IgG antibody test if you want to.  I honestly cannot guide you about sex with your wife - I've given you my opinion about the risk being very low but I cannot be in the position of advising you about how to implement that information in your own situation.  Some people who say "OK, the risk is low, I'm going to start having sex with my wife now".  Others, who are more risk adverse, would say they aren't going to do that until after a 12 week test.  And there are those in between.  That will be your call. 

Terri
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39 months ago
Thanks for your response.  One quick follow-up -- would you expect HSV2 to present as redness and itching that comes and goes over several weeks, or would noticeable sores / blisters need to be present to suggest HSV?  In my case, the itching / redness has been intermittent, lasting between a week and a day or two each time.  The first episode, a couple weeks after my CSW encounter that now was almost two months ago, was the most noticeable and persistent.  Thanks very much.
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
39 months ago
You know, while it is possible that herpes could only present as redness, usually we do see other things, including small but visible breaks in the skin when a person or clinician is looking very carefully.  The fact that your redness and itching has been lasting a while and has been intermittent doesn't really suggest herpes though I couldn't say it is impossible.  But let's go back to the initial event that is concerning for you- acquiring HSV 2 from receiving oral sex.  That is a pretty darn low risk probability for getting herpes.  We need to look at the entire package here - the risk of the initial encounter and then for you symptoms - that came very late in terms of how herpes would normally present.  Are you planning to test again for HSV 2 at some point?

Terri
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39 months ago
Thanks.  I do plan to retest at 12 weeks out from exposure as you suggest (I'm assuming that a HerpesSelect antibody test is the right one to take, but please let me know if you recommend something different).  Right now I'm at about 8 weeks. The symptoms I've experienced typically occur after I go on a long run and last for a few days afterward.  This seems to make chafing the most logical explanation, but I've read that chafing can trigger a herpes outbreak, and that has me a concerned.  Since I need to wait a month for accurate testing, I'd really appreciate your further thoughts.
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
39 months ago
I'm guessing that chafing is a more accurate explanation for your symptoms, honestly.  I have not, in 33 years of practice, seen someone acquire HSV 2 genitally from receiving oral sex.  I'm not saying it is impossible but I do think it is unlikely.  And the face that your symptoms get worse after a long run?  Really suggest chafing to me.

Terri
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39 months ago
A quick update - my symptoms (redness and itching/burning) improved almost completely within a day of applying zinc oxide cream, so that the symptoms are essentially gone just over two days after they emerged this time.  Would you expect HSV symptoms to respond that way?  With this information taken together, what's your advice about testing?  I've read a lot about ambiguous or false negative results.  Thanks!
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
39 months ago
I think improvement of symptoms that quickly does suggest a cause other than herpes but of course I can't be certain you don't have herpes.  About 5.5% of results test in the ambiguous range for positive (1.1 to 3.5).  Of those half are false positives.  So I don't hesitate to test because the false positive and ambiguous because 95% of the time, we get a clear answer, positive or negative.  And western blots can be ordered for those with low index values.  Not everyone shares this opinion, however.

Terri
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