[Question #1422] HSV Diagnosis? IgG vs. Western Blot?

46 months ago
Thank u for your time and kindness. Although i agree that this topic is 'taking up too much space' in my head, I do think I will be able to move on (without concern for an obsessive-compulsive issue), once I've gathered and processed a bit more information. I thank u again for your kindness, and just ask for a little more continued patience as I work thru some of my questions...

As I've read up on HSV, it seems that it can present in a variety of fashions & locations. This has made me a bit paranoid about my acne, as I find myself wondering if each "zit" could possibly be HSV. I do get a fair amount of acne on my chin & around my mouth. Although the "sores" I've had up til now have all been inside my mouth, yesterday I felt a bump on the outside, at the corner of my mouth. I'm sorry to be gross, but today I can see that there is some white pus in the center of the bump. 

Although this bump looks a lot like my typical acne, I am concerned because it does seem to involve the edge of the lip ever so slightly. I was going to go in to get it swabbed for PCR, but I wanted to ask a question first: 

*Since I had run out of OTC topical zit cream, when I noticed this bump yesterday I started applying dabs of hand sanitizer (70% ethyl alcohol). I did that several times yesterday and once this morning. Could this affect the results of a PCR swab? In other words, could the ethyl alcohol have destroyed enough virus to cause a false negative? Or, since there is visible "pus" in the lesion, could I expect there to be enough virus still to test positive if in fact it is HSV?
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
46 months ago
Usually herpes doesn't have pus in the lesions, far more often, clear or slightly cloudy fluid.  Pus is more likely a zit.  The hand sanitizer might well influence a PCR swab if taken close to the time of application of the sanitizer.  If there is visible pus that can be swabbed, then I think this is not as much of an issue at all.

Terri
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46 months ago
Thank you. Unfortunately my regular doc's office was closed, so I went to an urgent care where I had been previously. The MD declined to swab the lesion bc he said it was a zit and that in a case like this clinical observation was sufficient and why waste a $200 test. I am not very assertive in these types of situations, and I did not insist, which of course I now regret. 

In regards to HSV cropping up on different areas of the body... Since I was a teenager, I can recall occasionally getting what I assumed were pimples on my buttocks. I still get them occasionally as an adult. They are red, raised, and slightly uncomfortable if pressed. They do not usually have any noticeable fluid or pus, though sometimes they do. Sometimes they can take several weeks or even a month to go away. Can you give me any direction as to how to distinguish whether these could be HSV? Or is it impossible to say without having them swabbed for PCR?

Thank you. 
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
46 months ago
I would say that 99% of my patients get zits on the bottoms from time to time.  Herpes lesions truly are different from zits in that they are water filled and usually tender.  They usually come in groups on the buttocks and are very noticeable and uncomfortable.  I doubt that you would mix them up.  it's good the doc in the urgent care clinic felt strongly it was a zit - then it probably was.

Terri
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45 months ago
Thank you. I don't want to seem as though I can't accept good news - in fact I would be so happy to be done with all this. I really don't want to sound like a negative person. It's just that it's hard to make sense of these docs. This urgent care doc, for example, was one of the original providers who told me back in 2015 that his clinical exam was totally sufficient and that my mouth lesion WAS HSV. He did a swab in 2015 just to appease me, but he was very emphatic when he told me that even if it came back negative, that was probably just because the lesion was too small. Well the swab in 2015 did come back negative (it was a NAAT), but I didn't put too much stock in that result since the doc had seemed so down on it. So now I guess it's just hard for me to trust him when I went back this last time and he's telling me how sensitive the swab in 2015 was, and that there's no need to do a swab this time because his clinical exam is sufficient. I just... I don't know how to make sense of this. At least one of his clinical exams clearly was incorrect, and he's told me both that the NAAT is not super sensitive for a small lesion and then again that it is. I don't know...

I had another lesion, possibly more acne, crop up yesterday near the vermillion border. I went in today and the NP at my doc's office swabbed it for PCR. I told her that I'd been applying salicylic acid to it, but she said that wouldn't affect the PCR. After she did the swab, I went to clean up in the restroom and found that there was clearly some of the acne gel still on the lesion (I could feel the gel as I rinsed with my finger tips over the area). I went back and told the NP, but she still said that that wouldn't affect the PCR because the salicylic acid is not antiviral, per se. Would you agree?
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
45 months ago
I honestly don't know what that particular gel would do to a PCR swab - it isn't antiviral, that's correct, but what impact it might have anyway isn't completely clear to me.  I would suggest that if you are having lip lesions that you want to have swabbed next time don't get that gel anywhere near them so you can get the most accurate results possible.
in terms of what the urgent are doctor said to you and your struggle with this:  The CDC clearly states that physical exam alone is insufficient to diagnose herpes as many mistakes are make when using physical exam only as a diagnostic tool.  I know that his words are sticking with you and I certainly don't know if he's right or not but I guess your only option now is to continue to try and have lesions swabbed as they come up.   

Terri
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45 months ago
Thank you. Yes, I agree at this point all I can do is try to get the lesions swabbed as they come up. I wish I hadn't put the acne gel on that last one, but I was feeling indecisive - wanting to believe the urgent care doc that it was just a zit, wanting to be optimistic, etc. Yet still not entirely convinced. Live and learn, I suppose. At any rate, the PCR that my regular doc's office did did come back negative. So that's good news. I don't know if the acne gel influenced that result, but either way I supposed it's good to have a negative result. 

If it's alright, I'd like to run some scenarios by you, to gather your opinion as to how many of these concerns that I have are excessive amd need to be let go of, and/or whether any of them represent good due diligence. 

1. If I did have oral herpes, are there any precautions I should I take in terms of brushing my teeth in the same restroom as the rest of the family? Specifically, I have an electric toothbrush as well as a partial denture that I take out and brush to keep clean.  I'm sure some of my saliva/toothpaste gets sprayed around a bit during this process. ***If I have an active cold sore, could my family pick up HSV through any of that saliva/toothpaste landing on their toothbrushes sitting on the countertop, or through it landing on the toilet seat/toilet paper next to the sink? ***What if my kids drop their toothbrushes into the sink after I have recently brushed? ***I suppose it would be excessive and unnecessary to change my shirt after brushing my teeth?

2. I read something on the CDC's website about 60-80% ethyl alcohol being an effective agent against HSV (destroys it within 10 seconds): 

https://www.cdc.gov/hicpac/Disinfection_Sterilization/6_0disinfection.html 

This seems to tell me that hand sanitizer at that concentration would be just as good as washing my hands in terms of preventing HSV transmission. Does that sound reasonable to you?

Thank you. 


45 months ago
P.S. I meant to mention that I've taken your advice/expertise to heart in regards to not worrying so much about laundry and pillows and the like. I'm much more comfortable with sharing pillows with the kids once again and also with sticking to the basics in terms of washing the laundry. It's nice to be able to let go of those concerns, and I look forward to your reply in regards to what I realize are probably silly concerns regarding tooth-brushing, so that I may let go of those as well and move on with life as usual. 

Also, I followed your advice and read up a bit on PubMed about the Western Blot and how it is used as the standard against which the sensitivity of  other serology tests for HSV are judged. I think I understand better now, and I did go forward with ordering the Western Blot kit. Thank you for the information that you shared on that subject. 
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
45 months ago
The things you describe around oral hygiene are NOT a concern for transmission of oral herpes to your family members, no.
Yes, hand sanitizer is what we professional use between patients unless there is visual contamination (blood, stool, etc) in which case we wash hands of course. 
I'm so very very pleased to hear that you are doing better with the laundry, that's a big step forward for you, I think.   And glad you are going to do the western blot.  Now the trick will be letting the results be the final word on your worries, if you can.  You sound much much better already, though.  Great job getting on top of some of those worries.

Terri
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