[Question #1514] Conflicting results need second opinion please

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86 months ago

Hi all, I have been helped out by Terri Warren already on her website and just hoping to get a second opinion here from the Docs.  Thank you so much for your help thus far Terri.  I will more than likely pursue the WB but just for piece of mind wanted to hear some other opinions as well!

My testing results:

Partner A 3 protected encounters Feb-April 2015

Feb 6 2015 HSV1:equivocal HSV2: neg

July 8 2015 HSV1: pos; HSV2: neg

No sex May, June, or July

Partner B 8 encounters (4 protected 4 unprotected) Aug-Nov 2015

June 22,  2016 HSV1: pos; HSV2: neg

No sex Dec, Jan, Feb, March, April

Partner C Several encounters ALL with protection from May 2016-present

July 15, 2016 rash/ulcers on right buttocks

July 22, 2016 positive culture (not typed) but MD told me shingles

August 24, 2016 HSV1: pos; HSV2: equivocal

Dec 8, 2016 HSV1: 1.13; HSV2: 4.28

Dec 9, 2016 Biokit was NEGATIVE

Dec 15, 2016 HSV1: 1.13; HSV2: 3.65

Since July OB, I have not had a recurrence of obvious ulcers or bumps in that same area.  I have had pretty consistently every few weeks with little break in between: occasional thigh tingling, painless pimple like bumps (that leave dark scars) scattered on different parts of my buttocks (1-6 at a time), low back (1), torso near rib cage (2), anterior thigh/hips (2) but I do have a history of back and butt acne so it's confusing .  I don't know the status of any of my partners.  I do know that partner C (current bf) gets cold sores.  We still have protected sex.  Been trying to figure out the likelihood of getting this from Partner B vs Partner C.  Also the likelihood of a false positive at 4.28, then 3.65 is low but would you suggest more testing?  I guess the negative Biokit threw me off.  The MD who gave me the results said I likely have HSV1 (which is what Terri thought until I got the equivocal HSV2 result)  Please let me know your thoughts on my conflicting results. Thanks!

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86 months ago
Sorry just correcting a mistake below...the last HSV1 value dropped to 0.93 (thanks)
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H. Hunter Handsfield, MD
86 months ago
Welcome to the forum. Thanks for your question. In addition to the information you provided, I've had a communication from Terri about your situation.

Direct detection of HSV in a swab specimen -- typically by polymerase chain reaction (PCR) or culture -- always overrules blood test results. So you can be confident you have genital herpes, almost certainlly caused by HSV2. There is no culture test for varicella zoster virus (VZV, shingles virus), so there is some miscommunication with your former doctor, or s/he may not fully understand HSV/VZV testing. A positive culture test must be for HSV. Too bad the virus wasn't typed, but as already noted, it was much more likely HSV2 than HSV1.

Your blood test result also support HSV2 infection, and the timing of those results is consistent with an HSV2 infection acquired about the time of your positive culture: equivocal (consistent with early infection) 8/24/16, 5 weeks after the positive culture, then becoming unequivocally positive in the repeat tests December 8 and 15. Biokit is an inherently less reliable test; that negative result on 12/9 was false. Your HSV2 antibody numerical results of 4.28 and 3.65 are not "low" at all, but very solidly in the definite positive range.

Probably you also have HSV1, but that predates your genital herpes. Most likely it goes back to childhood, and probably is oral, although there is no way to know for sure unless and until you have an oral outbreak consistent with HSV1 (cold sore, fever blister). The HSV1 blood tests are inherently unstable and less reliable than those for HSV2. It is quite common for people with longstanding HSV1 infections to have intermittently positive resuls as you have had. And in fact, this goes along with the apparent mild nature of your initial HSV2 infection and perhaps lack of symptomatic outbreaks since then. Prior HSV1 tends to make initial HSV2 infections less severe than they otherwise would be.

The most atypical aspect of your story is that the outbreak tested by culture sounds more like a recurrent than initial HSV2 infection. Recurrences sometimes occur on the buttocks, thighs, etc, whereas initial HSV2 infections usually are directly on the genitals. But exceptions occur -- and if you didn't acquire HSV2 immediately at that time, you surely acquired sometime in the preceding weeks. This suggestsyou likely were infected during one of the encounters from May to July 2016, despite condom protection.

So in summary:  You have genital herpes, almost certainly HSV2; and probably HSV1, most likely a distant past infection, probably oral, perhaps since childhood. You don't need any more testing for either HSV1 or HSV2. (But one possible exception:  if you ever develop either a genital area, buttock, or oral outbreak consistent with herpes, a prompt PCR test -- within a couple of days -- could be considered, if you want further confirmation of the diagnosis. If so, for sure insist on typing for HSV1 vs 2 if positive.)

Your current sex partner needs to be informed of your HSV2 infection. He should be tested. It sounds like there's a good chance his HSV2 result will be positive, since he may have been the source of your infection. If so, it's good news in a way:  if allready infected, the two of you need take no precautions to protect him. If his HSV2 result is negative, however, the two of you should jointly decide what prevention steps to take. Options include suppressive treatment by you, consistent condoms, and avoidance of sex in event you have a symptomatic outbreak. (Some couples just let nature take its course and don't worry much about it. But that's part of the discussion you would need to have as a couple.)

Perhaps this isn't entirely what you were hoping to hear, but I hope these comments have been helpful. Let me know if anything isn't clear.

Best regards--  HHH, MD
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86 months ago

First of all thank you and Terri for collaborating and being so compassionate and kind in your responses.  This is a very difficult time for me as I have been very cautious with my sexual encounters (aside from the few times with partner B) and have finally found someone that I want to be with and hopefully marry.  But oh boy the luck of catching this at my age 33, not married and not children is just a huge disappoint, especially since I used protection.  I do have a few more questions.

1. How common are false negatives on the Bikoit test?  So I should just throw that result out of my mind?2. I get tingling, but do you think the pimple like bumps I described could be HSV? Could they be considered an outbreak?  If so how contagious are they?  Like if they were on my buttocks and I had sex could Partner C (assuming he is not the source) have gotten it from me?

3. So essentially Terri has explained that at 7.5 months the HSV IGG is 93-95% accurate.  So 5-7% scares a bit into the WHAT IFS, which I know you don't like to deal with often.  But you mentioning that my July OB seemed more like a reoccurrence scares me.  If Partner C turns out to be positive is it possible to have gotten this from Partner B (esp since there were 4 times we didn't use protection) and had delayed seroconversion with no noticeable symptoms and then passed it on to partner C?  What is the likelihood of this?  Or do you feel it is more likely I missed the genital symptoms from May-July and then had the buttocks OB?  And why am I not having true ulcers like the first OB, just pimple like bumps? could that be unrelated to HSV?  Have you seen that before, an OB with ulcers then subsequent ones look like pimples?  At the time of the OB in July I had muscle soreness/twitching and night sweats.

4. Also when I first had the OB Partner C said he tested in April clean, but he knows that they will on test for HSV if you don't show symptoms.  He stated he did not have any symptoms of it.  Recently I've noticed him scratching his genital area and thighs quite often, I don't know if I'm just paying attention too much or if this possibly a sign he may have it.  I noticed a bit in July but seems to be progressively more scratching in the last few months (Nov-Dec).  Also he had one single bump not on his penis but on the area we call the mons pubis for women (looked like a pimple with yellow pus inside).  And a single bump on his buttocks that I did not see.  But he did not seem concerned.  Assuming I got this from him, Is it possible that he could have caught HSV near the time we were first having sex and then did not show symptoms until after my OB in July?

5. How does a woman contract HSV with condom use? Would the man most certainty have to have it on the base of his shaft (where the condom may not reach)?  Could he be asymptomatic when passing it to me, then have symptoms months after?

Thanks just trying to cover a lot of questions he may have when I have to tell him this sad news!  2016 has been the worst year ever! Thanks again!

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H. Hunter Handsfield, MD
86 months ago
1) I can't sey exactly how common it is for Biokit to give false negative results. But it happens, and it clearly happened to you. It wouldn't be surprising if a later test someday would become positive, but I see no need for it.

3) Terri's "93-95% accurate" statement refers to sensitivity, i.e. that 93-95% of people with HSV2 have positive results by that time. That statistic is irrelevant when the test is positive. Your positive result is secure. You need to avoid the temptation to look at each individual test by itself. My conclusion you have HSV2 is based on a combination of factors:  your symptoms, the positive lesion test for HSV, three different blood test results (despite the false negative Biokit), and the specific timing of all of those. Could any one of these be wrongly interpreted? Maybe. Is there any chance that they ALL gave misleading results? No way.

4) Here too, don't look for soft clues. He needs to be tested. It's not worth ruminating about until he does so. I'm not going to speculate about his symptoms reported second hand.

5) Properly used condoms are probably around 90% effective against HSV2 for any single exposure, in the absence of symptoms in the infected partner. But 10% transmission risk isn't trivial, and over time, condoms are only about 50% protective. That is, among couples in which one person has HSV2, who take no precautions other than condom use, the frequency of transmission in condom users is about half that in non-users. As you suggest, it is generally believed that transmission occurs because of skin contact above areas convered by male condoms. Also, during sex, the penis may slide inside the condom, perhaps working infected material up to the condom rim. And indeed, most transmissions occur from partners without symptoms -- either no symptoms at all, or at least none at the time of transmission.

It sounds like you have a solid relationship with a partner who is already alerted to the herpes concern and hasn't freaked out yet. Probably he won't when you get into the details of your results. In any case, I hope he responds favorably to the calm, reasoned discussion you will have with him.

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86 months ago

Thank you for your prompt responses and patience.  I have a few more questions as this is still devastating to me and I just want clarity.  I promise to be out of your hair after that unless some odd scenario arises with his results.

1. Regarding the sensitivity I was just referring to the 93-95% sensitivity at 7.5 months after Partner B..... meaning that the chances of getting it from him could be deducted to be 5-7% correct?  It's just this small percentage change leaves me a bit uneasy.  In your experience how many people that were healthy and not taking antivirals took longer than 6 months to seroconvert.  Teri stated that she has not had this happen with ANY of her patients. 

2. I'm feeling some type of anxiety  now and I know that my partner will likely deny he has it or had it first and I just want to be able to answer his questions.  Since we haven't discussed the issue much since my equivocal result I feel very guilty and sad that there is still a slight chance I may had this first and passed it on to him.  At this point now that I have it there is nothing I can change, but I would feel much better if I got it from him unknowingly, than if I had it all this time and was confused with all this testing and misinformation from my MD, passing it on to him when I could have prevented him from getting it! I know there is no 100% guarantee but I guess overall  since you say I'm definitely positive for HSV2 would you be more inclined to think I got it from Partner B (condoms 50%) and seroconverted later than normal  or Partner C despite condom use 100% of the time?  Obviously had sex more frequently and more times with Partner C.  Partner B was like 2 times each month (aug, sep, oct, nov).  Teri still seems to think I got it from Partner C?  Do you feel the same?

3.  If I had already gotten this from Partner B (7.5 months prior to neg IGG, 8.5 prior to equivocal, and 13 months prior to confirmed positive) would you expect the IGG levels to go from Neg to equiovocal to positive as they did over this time period? Or would delayed seroconversion typically go from negative straight to positive?  Would my index number be higher if I had gotten it 13 months ago? Or does the testing and time frames almost surely leading you to think I got it from Partner C?

4.  Any suggestions on how to bring this up since we haven't talked much about it since the equivocal result? Or any resources you have for having this type of talk with a partner?  I'm really nervous especially with the Holidays season approaching I feel depressed that this is something I have to bring up during such a happy time!

Please excuse any reduancy but I think mainly for me now is trying to sort out which partner gave this to me.  I know it can't be 100% sure but if your feelings are similar to Teri's I will feel more relieved.  Thanks!

Thank you for all of your help!!!!!!

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H. Hunter Handsfield, MD
86 months ago
You are seriously over-analyzing and overthinking all aspects of this.

1) I do not understand this reasoning and do not agree with it. Once again, you are laser focused on one aspect of the evidence for or against herpes, i.e. a blood test. Exposure, symptoms, multiple tests, inherent risks (e.g. condom use), and other factors have their influences as well.

2,3) There's no mystery here. You caught it from someone with whom you had sex in the several weeks prior to your positive HSV culture test. Your timeline above suggests it had to be C. Catching it from B does not fit with this timelines provided either in your original question above or in this follow-up question.

4) I've already suggested a calm, reasoned discussion with your partner, but can't go farther than that. Terri is an expert in this aspect of herpes. If you discussed partner notification in your previous discussion on her forum, I you should follow that advice.

That completes the two follow-ups and replies included with each new question, and so ends this thread. Please do not start a new question on this forum concerning the same exposures, symptoms, and herpes diagnosis. Repeated same-topic questions are discouraged. Thanks for your understanding.