[Question #1595] Lingering Questions and Test Results

44 months ago
Doctors, 

Good evening. I had a few questions regarding test results and reconciling some symptoms. I have had a fair amount of partners in my past, though I have been married for the past 7 years and only with my wife. 

Prior to my wife, I have frequently been concerned with STD's, specifically those that are for life. I have complete confidence in HIV and Syphillis testing, but struggle with seeing that HSV testing is not definite. I have never had lesions or anything concerning on my penis, but have had single red bumps/pimples/infected hair follicles in the "boxer short area." I have had shingles after the loss of a close friend and prior to being sexually active, so I believe I have a good understanding of a "typical" case in regards to water blisters, rupturing and the pain.

Late last week I noticed a red pimple on my thigh, parallel to where my penis hangs. It hasn't been really painful, other than when I foolishly "popped" it. It bled some and is now purple and tender, notably when I tough it or my jeans rub against it. I plucked 3-4 hairs from the perimeter of the area, two of which stung a bit more than the others. It definitely feels "under" the skin. 

1.) In the fall, I had a similar bump on my scrotum and was worried so I had igg tests and had my prescriber order Western Blot. All was negative. My wife had igg a few years back, and it was negative other than HSV 1. Would you consider this conclusive?

2.) Assuming I am in fact negative for HSV 1/2, if it were Herpes would my outbreak be more memorable, even though I've had shingles? Would Herpes bleed? 

3.) I took Valtrex over 3 years ago after Shingles recurrence due to a severe immune suppression, would it be safe to say it has left my system and would not impact my testing?

Many thanks for this tremendous service and a Happy 2017 to you.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
44 months ago
Welcome. Thanks for your question.

Before I go to your questions, a few comments about genital herpes. Recurrent outbreaks are rarely something to be confused with pimples. Recurrent herpes doesn't occur in random locations, even in the "boxer shorts" area. With only infrequent exceptions, each outbreak is similar to the previous one; occurs in more or less the same location (within an inch or so) each time; appears as a cluster of superficial blisters; and occur an average of 2-6 times a year. Random pimples almost never are herpes. And from your description, I see no reason to suspect the pimple on your thigh was herpes. As for reliability of HSV blood tests, they miss a fair proportion of HSV1 infections, but a negative result of HSV2 is highly reliable in ruling out infection with that virus. 

Second, your shingles had nothing to do with loss of your friend. Shingles occurs from time to time even in young people (my son had it at age 13), and is not triggered by stress, anxiety, etc. This episode says nothing about the likelihood you have genital herpes or what symptoms you would have if you did.

1) Your negative blood test shows you don't have HSV2, and I've already explained why these symptoms don't suggest herpes.

2) Herpes wouldn't bleed. Believe it or not, I didn't read ahead and look at this question before my comment above about shingles and herpes:  but I hit the nail on the head. There is no relationship or interaction between shingles and herpes simplex virus (HSV) infections.

3) I'm curious what sort of "severe immune suppression" you had that was believed to trigger another herpes zoster outbreak. In any case, even if you were taking valacyclovir (Valtrex) at the same time you were tested, the drug has absolutely no effect on the HSV blood tests. It certainly has no effect three years later.

Bottom line:  Your negative HSV blood test is convincing evidence you don't have HSV2, and your symptoms are not suggestive of it. You can be confident you don't have it and never did. 

Thanks for your kind words about our services. Let me know if anything isn't clear.

HHH, MD

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44 months ago
Dr. Handsfield,

This is very helpful, thank you. I always believed that shingles could be brought on by stress. To answer your question, I was hospitalized with cancer and coming off of chemo with shingles recurrence and took Valtrex until they were gone. So, I've been off it for 3+years. 

That is reassuring that HSV would not bleed. 

Is there any research about why the ~1% who do not test positive on WB never do? Or igg for that matter? I know that the internet is dangerous, but there seem to be multiple people on Honeycomb who have never tested positive via WB or igg. 

Those that never test positive but have a positive swab, are they usually "typical" outbreaks? Though recurrent outbreaks can be anywhere in the groin area, are they most often multiple lesions on the penis? I ask because my two pimples were singular in areas where hair grows and could have been infected follicles I irritated with my mutalation. Even with that, they have felt "below" the skin vs. "on" the skin. 

Many thanks, not meaning to be redundant. 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
44 months ago
Thanks for the additional clinical information. I'm very glad to hear you're doing so well after your cancer diagnosis and treatment.

I'm unaware of any data that attribute herpes zoster outbreaks to stress. Of course, almost all medical conditions sometimes garner such claims on the internet:  we all have stressful events in our lives (it's part of being alive and human), ado so virtually every person with a new health problem can look back see a link with a stressful event. However, immune supression from cancer or chemotherapy for sure trigger HZ outbreaks, undoubtedly explaining your second episode of shingles. But still, none of this has any bearing on the likelihood you have genital herpes.

Indeed the internet is "dangerous" for the reason you state. And others:  anybody can write anything they want. My bet is the many (most? nearly all?) those who claim they have herpes with negative WB don't in fact have herpes; or they have HSV1, for which blood tests in general, including WB, miss many infections (unlike HSV2, for which it is rare). And even for those cases that are real, i.e. true herpes with negative blood tests, remember that the internet selectively attracts exceptions to the rule:  the far more common persons with herpes confirmed by WB or other blood tests have no reason to tell those results.

Don't focus only on the possibilty of a false negative test. My judgment you don't have genital herpes is not based only on your blood test results. It also stems from a sexual lifestyle that actually doesn't sound especially risky for herpes or other STDs (people with histories like yours are a dime a dozen, and most don't get HSV2); and that none of the pimples or other symptoms you describe sound like herpes. Any one of these aspects (risk history, symptoms, blood tests) could break either way. But the odds that all three would do so are very small. In other words, the chance you have genital herpes is far, far less than the 1% figure for false negative HSV antibody tests.

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44 months ago
Dr. Handsfield,

Thank you for your very detailed reponse and this all makes sense. I have also read that Terri Warren has only seen 9 patients over 30+ years not test positive on WB. I'm assuming that is over tens of thousands of folks, so very rare like you said.

Just a few last questions and then I will be on my way. 

1.) When patients have confused HSV with pimples or folliculities, are the majority of those multiple lesions? I ask since I have only had singular lesions.

2.) Even with "atypical" outbreaks (which I realize in hindsight are actually typical) do patients experience the life cycle of blisters, sores/open ulcer, scab, etc? Other than my mutilation, my spot has not really changed appearance. 

3.) I see a lot of data on how long initial outbreaks last, but how long do recurrent OB's last? My spot has been there about a week. 

4.) Though recurrent outbreaks can be anywhere in the boxer short area, are they most often on the penis vs. an area like the thigh?  I understand initial outbreaks are typically on the penis due to the necessary friction for the virus to take hold, but curious with your clinical expertise if most recurrences are also on penis. 

Again, many thanks and not trying to be redundant or ask foolish questions.

The work you all do is tremendous, I will be adding ASHA to my list of organizations to support. Have a terrific 2017. 
44 months ago
Apologies, mean to include re: history I've likely had 15-20 partners, but outside of 3 or 4, they have been one time condom protected encounters of college females. 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
44 months ago
1) I don't know the answer to this.

2) Closely observed herpetic lesions usually go through all stages, but there are exceptions. Perhaps most commonly, lesions that don't progress beyond a red bump.

3) Typical recurrent HSV outbreaks usually last 10-14 days from onset to complete healing; although the acute, inflammatory phase (until improvement begins) is as short as 1-2 days. Once there is a break in the skin from any cause -- think of cuts, scrapes that bleed, minor burns, etc -- it takes at least 7-8 days to completely heal. That healing time comprises most of the time for recurrent herpes lesions, from start to finish.

4) Yes, the large majority of recurrent GH outbreaks involve the penis in men (or anus if exposed). I can't say the proportion that are non-genital on thighs, buttocks, etc, but I would say roughly 10% max.

Thanks for the thanks. That completes the two follow-up questions and comments included with each thread and so concludes this one. Do your best to move on with confidence you don't have either genital or oral herpes.

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