[Question #1668] 13 year old daughter IgM positive

43 months ago

I am a nurse who worked at the STD clinic years ago, so I am somewhat familiar with STD's.  My 13 year old, honor roll, sports playing daughter, who does not have a boyfriend told me while I was out of town on business that she had developed vaginal ulcers on 1/13/17.  She did not want her sister or Grandmother who was caring for her to take her to the MD so she suffered (very painful, could not urinate) until 1/20/17 when she saw the NP at a local OB/GYN office.  The NP thought based on clinic exam, she had Herpes.  Started her on Acylovir 5x per day- she only took for 1 day as (mistake number 1)  because we initially we were told tests negative due to cultures (so she stopped taking it) and later told us positive due to blood tests.  Today, 12 days later ulcers are nearly healed.

Test results

HSV Type 1 AB IGG , S <0.91

HSV Type 2 AB IGG, S <0.91

HSV vaginal cultures for HSV1 and HSV2 negative

HSV AB IgM 3.19

(side note gonorrhoeae and chlamydia neg)

I have seen your video

http://www.ashasexualhealth.org/stdsstis/herpes/herpes-testing/


My provider said "it does not matter what type, we are treating the same".  When I told her the internet says IgM has false positives, she did not believe me.  I have grilled my daughter up and down and she denies sex, honestly I don't when she would have had sex, but want to be the Mom with her head in the sand, but I believe her.


Based upon your video.  You would have never tested IgM and likely found her results as negative.  Do I need to prove that this provider is wrong by doing a DNA test or Western Blot?  Do it for my peace of mind and put this to bed?  Do it to confirm IgM was wrong?  Please provide your expert medical opinion.


Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
43 months ago
What an unfortunate circumstance this is.  I wonder why she didn't want anyone to take her to the doctor?  When you talk to her about if she's had sex, are you including oral sex in that discussion? 

If you and she are certain she has not no sexual contact of any kind, then this has to be something else, right?  And the trick will be sorting out what it was.  It could be bacterial or even fungal, though less likely fungal. 

The IgM is a terrible test, many many false positives, but not every single time, so it's hard to sort that out.  The CDC says never to use an IgM test, so I think perhaps your provider is not up on the latest recommendations for herpes testing.  Having said that, we would expect the IgG tests to be negative this early, if indeed she does have herpes.  A test done later, perhaps 8-12 weeks, would be more accurate by far.  I think if I were you I might make my daughter aware that follow up testing will help sort out what is going on.  If she has been sexually active in some way, this might encourage her to disclose this to you.  I'm not saying she is, by any means, just putting that thought out there.

This is truly puzzling.  If she gets it again, I would strongly encourage you to take her to a provider that will do a PCR swab test vs a culture = culture misses many infections compared to PCR.

It is not necessary to do the western blot at this time.  That, like the IgG test, looks for antibody and that can take a while to develop so testing now will not be helpful

Terri
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43 months ago

We have talked to my daughter at length.  We have talked about sex, oral sex, abusive situations, cold sores (she does not have, has not had in the past and does not know anyone with a cold sore), touching...  I have told her we would get a 2nd opinion, but science is science- the tests will still be the same if she has had sex, so if she has had sex, I have asked her to not put herself, and I through all this and also the financial burden that it would bare on our family.  She continues to deny having sex.

She has told me when a girl at school had "hickies" and when some were drinking...she is typically very open to me.

On the drive to the NP, I prepared her before the visit with the NP what it was going to be like, what a pelvic exam was going to be and that they are likely going to think she has Herpes.

As a nurse, I have scoured the internet trying to figure this out.  I failed to mention that she also had a "viral type illness" which she stayed home from school on 1/11/17 (just prior to break out).    Consistent with a HSV break out, but also Acute Genital Ulcers.

A few studies I have found that also show this.  It appears to be rare.  I am reluctant to see other providers as I am not sure who?  Her pediatrician is not well versed on this topic either and has not been less than helpful as well.  I am really not sure which way to turn. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3912377/#!po=68.3333

http://jamanetwork.com/journals/jamadermatology/fullarticle/711867


Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
43 months ago
Let's assume that she has not been sexually active for now.  You seem like a very open mom, one who is able to communicate clearly with her daughter. 
I agree that the articles that you mention provide some other explanations for the genital ulcer disease -there are also other viral infections that are possible.  Your description of another viral type illness prior to the genital ulcers suggest a possible viral cause for these ulcers as well.  But I think at this point, it would be hard to sort that one out with any accuracy. 
Are the ulcers gone now?  If they are gone for now, I think there are a few ways to approach this situation now. 
The first would be to just wait and see what happens next - perhaps nothing will happen, let's hope so, and it will be an unexplained incident in the past of your family.
The second would be to redo the IgG herpes antibody test down the road a ways - at 6 weeks from any new herpes infection, 70% of those who are going to become positive will be positive by then. 
As her mom, what would you like to do next here?
I would say that if she gets the ulcers again, you might want to consider seeing a dermatologist when they are fresh. 
This has to be a challenging time for your family, my heart goes out to both you and your daughter as you work through this puzzling health problem

Terri

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43 months ago

Ulcers are gone now.

As her Mom, what do want to do?  I think what the best course of action is follow your advice.   If we have IgG retested approximately March 1 (this will just over 6 weeks from break out 1/13/17).  You said 70% of those will test positive at 6 weeks.  If she were to wait longer is that better or have better accuracy?  I do not want to go through any unclear results again.

If she has another breakout- see derm. Make sure they do PCR swab test vs a culture .

Then, my question is what provider to do IgG testing?  Obviously her current NP is not educated on the most recent guidelines.  She reviewed these with the MD in her office she told me, so either is he...  I just do not want to go to any provider because I do not want them to automatically assume HSV.  Infectious disease?  FP? A STD clinic at the county? I just don't know and really am discouraged with current provider.  If the current provider followed CDC's guidelines, and not tested IgM, we would think negative test now.  I also I do not want to go in to provider and educate them or be "that Mom" and say "the internet says"...  but I may have to. 

Can you provide me with link with CDC's guidelines that say do not use IgM testing?  I could not find that.  Because I likely will need to provide that to whoever she sees.

Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
43 months ago
Here is the link to the STD treatment guidelines where the IgM is discussed:  https://www.cdc.gov/std/tg2015/herpes.htm.  The CDC is a pretty good reference, right?
You can order the test yourself online without seeing a provider - they will send you to a reputable lab to have bloods drawn and remember no IgM - only IgG for both HSV 1 and 2.
I am going to leave this open for one more response from you if you want to make one.
Terri 
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43 months ago

When I worked at a local health dept, the CDC is who was referenced.  The link from the CDC you provided states "Providers should only request type-specific glycoprotein G (gG)-based serologic assays when serology is performed for their patients" and also states "IgM testing for HSV 1 or HSV-2 is not useful, because IgM tests are not type-specific and might be positive during recurrent genital or oral episodes of herpes"  But it does not specifically address the false positives, which I wish it did.

So researching more, sleeping on this over night, I think if what I have read and absorbed, she could very easily have HSV.  Can you confirm that my summary is correct.

- The IgG likely will not be positive if this is acute outbreak. (consistent with her lab being neg)- if you have stats for me that would be great.  You said, in 6 weeks 70% of IgG are positive.  Is waiting 12 weeks better- what % of those are positive?

-IgM is typically used to demonstrate acute illness, but with herpes, this does not always happen and sometimes the IgM is positive later when the IgG becomes positive.  Sometimes the IgM can be positive much later after exposure.  And lastly, what I am praying for her case, that there are false positives sometimes.  But my original thinking of her IgG was negative, the IgM shouldn't have been ran, the NP didn't know what she is doing,she is in the clear, why do this to ourselves---is not really a good theory, because of her CLINICAL symptoms of vaginal ulcerations- correct?  So that is why to be sure, she needs retested for IgG.

-Her sisters- they share everything.  Not typically underware, but I can't say that it hasn't happened.  Do I need to worry about them sharing underware or bathing suits?

-If the IgG is positive later, she still does not admit to sex, then what do I do?  Send to a child psychologist? Counseling?  See what they can get out of her? 

I really want to believe her, but I realize that this very easily could be HSV.

Then, on to my MD to get anti-anxiety meds to get me through until March.  Thank you for your assistance and expertise with all of this information.

PS- I tried to get a online evisit with you on West Over clinic, waited several hours yesterday, it never worked. 


 


Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
43 months ago
Yes, the results of the testing will be more reliable at 12 weeks - the majority of people who are going to be positive will be positive by then.
In my experience,  and this is anecdotal but based on 33 years of experience with herpes testing, the IgM is falsely positive about 7 out of 10 times, or maybe even 8 out of 10 times.  It just isn't virus specific and it causes such trouble for people when clinicians order it - just makes me so upset to others so upset by this lousy test. The third largest lab in the country took it off of their testing option list because it is so poor.  
Yes, I think retesting with IgG is valuable in this situation just as one of the attempts that can be done to get to the bottom of this puzzle. 
If the IgG is positive, then it's probably time to sit and down and explain what that means - she went from negative to positive indicating new infection.  I don't think she needs to see anyone at that point if you and she can talk about this openly.  I suppose if she continues to deny any sexual contact at that point, then a visit with a counselor would be beneficial because you will KNOW that she was just recently infected due to documented seroconversion.   However, the other thing that runs through my head, and I hate to even raise it, but could she have been molested by any adults in her life? 
I would be happy to talk with you  - here's what happened yesterday.  I do video consults on Tuesday mornings only unless by emergency appointment.  There is a place where I can click a button that says I'm in or I'm out of the office - after Tuesday's consults I forgot to push the button for out of the office.  I'm so sorry you had to wait for me!  Late in the day I got a call from Herb at evisit and told me you had been trying (didn't know it was THIS you).  Please forgive the error

Terri
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