[Question #1824] Best clinic or physician to resolve the issues

42 months ago
Last possible exposure in 2002. Since then noticed painful to touch ulcers most reminiscent of herpes. One episode of sepsis due to Klebsiella (cultured)needing iv antibiotics. Two more episodes of moderate UTI treated with cipro and doxy.
In the last 3 months two episodes of severe urethritis after wet dreams.  Last episode particularly troublesome because persistent urethritis treated empirically with azithromycin and suprax. Have symptoms with   meatitis with redness and quite bothersome.  First stream urine  tested for all possible organisms chlamydia, gn, mycoplasma and many others which are possible(PCR), all neg  Other cultures negative. NOT tested for syphylis yet. Treated with Levaquin for about three weeks (current) but not resolving. 
Question what next, where best to go  to get resolution and definitive treatment even if I have to travel away from home.  The symptoms affect my lifestyle and travel and worried about strictures. Could this be HSV only? Do I need to tested for syphylis Have BPH and take Tamsulosin.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
42 months ago
Welcome to the forum. Thanks for your question.

This is obvioiusly a clinically complex situation, and neither this nor any other online source can provide specific diagnostic or treatment advice. Presumably "last exposure" refers to high risk sexual activity, but it happened 15 years ago -- strongly suggesting that most of the ongoing problems are likely not due to any STD. It also seems you have been getting relatively sophisticated care, given the diagnostic tests you mention plus the treatments that have been tried. Some of the symptoms described are rather peculiar. For example, ejaculation (whether an involuntary night dream or in overt sexual activity) cannot cause urethritis.

Genital herpes is the one STD that is apparently on your mind, that might explain some if not all your ongoing symptoms, and yet you say nothing about diagnostic tests or attempted treatments. Surely in all the tests you had, HSV must have been included, so I assume you have had negative culture and/or PCR tests from your recurrent genital ulcers and/or your urethra during episodes of recurrent urethritis. Proper evaluation also would have included type-specific HSV antibody blood tests. What did these show? Presumably anti-herpetic treatment also would have been tried, e.g. acyclovir, valacyclovir, etc.

Syphilis testing also should always be part of the evaluation of anyone with unexplained symptoms and any past sexual history even remotely suspicious for being high risk for STD, and I am amazed that you say this hasn't been done. That said, at least some of the many treatments you have had would have covered syphilis, including azithromycin, cefixime (Suprax), and probably the antibiotics (perhaps given IV?) for Klebsiella sepsis. So a syphilis blood test predictably would be negative; or if positive, probably would reflect distant past infection, not explaining your current problems.

In all this, you ask three specific questions:  Could this be genital herpes? Many of these problems could be due to frequent reactivation of HSV, but not if you have been tested with consistently negative results. Should you be tested for syphilis? Yes, but the result probably won't be helpful in sorting out your current symptoms. Finally, in the title of your quesiton you ask what sort of specialist or clinic to see. I would recommend you see an infectious diseases specialist or, ideally, one who specializes in STDs; or a clinic specializing in sexual health and genitourinary medicine, e.g. a public health STD clinic or Planned Parenthood clinic in the US, or an NHS GUM clinic if you happen to be in the UK; or their equivalents in many countries.

I'll be happy to comment further if you would like to fill in the missing gaps, especially about HSV testing and treatment.

HHH, MD

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42 months ago
Tested neg for HSV only on urine, no blood test. Could it be false negative. Did not have suppression therapy for hsv.
Yes I did have I/V late generation cephalosporins and amino glycosides for Klebsiella for positive blood and urine cultures in hospital.  I am seriously thinking of traveling to get your formal medical  consultation and help and will try and call your office for guidance.
I was thinking of reservoir of infection prostrate or epididymis which gets manifested after ejaculation as I did get quite sick after first episode.
One mistake one time in otherwise unblemished lifestyle and behavior and feel a deep sense of regret and I worry about it.

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
42 months ago
I've never heard of testing urine for HSV and I would not trust the netative result. You should have a blood test for HSV; make sure it's a type specific IgG test that accurately distinguishes HSV1 from HSV2. And the next time you have an episode of urethritis (especailly with meatitis) or genital ulcers/sores, get tested promptly (within 1-2 days, if possible) with a PCR test for HSV. You could start suppressive treatment for herpes, with daily valacyclovir or acyclovir; if there is then a substantial reduction in frequency and severity of urethritis etc, it would tend to confirm herpes as the cause. If you do that, however, it will reduce the chance of confirming the diagnosis by PCR (although it would have no efffect on blood testing for HSV antibody). These are things to address with an STD or GUM specialist.

If it's herpes, and if the first episodes began 3-10 days after that sexual exposure back in 2002, that probably was the source. Otherwise, you cannot know the source and may never know for sure.

Acute bacterial prostatitis could have been a source of Klebsiella sepsis. However, prostatitis is an unlikely explantion for the recurring symptoms you have had. This probably was an entirely separate problem from your recurrent urethritis and perhaps gential ulcers. (I don't clearly understand whether or not you have had recurrent ulcers, or only urethritis with meatitis.)

The IV cephalosporins definitely would have eradicated syphilis if you had it. So would doxycycline, which I forgot to mention previously.

I no longer have an active clinic and do not see patients in person. In any case, I am confident you can find other sources of care equally competent as I am to diagnose and manage this problem. But if you'll tell me where you are (country, city) I might be able to recommend potential sources for excellent care.


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H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
42 months ago
I asked Terri Warren, moderator of our herpes forum, to glance at this discussion. She agrees with my opinions and recommendations. If you would like, she is available for personal consultation, which can include all the lab testing you need -- inluding providing specimen collection materials so you can provide PCR specimens when you have new symptoms. Her service is available world wide, in case you're not in the US or Europe. Go to westoverheights.com and click on the link to set up a video conference. Terri is a world class herpes expert and her telemedicine services are excellent; I highly recommend it.

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