[Question #1977] Herpes Uncertainty Post Testing

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87 months ago

Hi, Here's my situation: In the morning of Dec. 18, I had unprotected oral and vaginal sex with a new partner of unknown herpes status. It was fairly rigorous and I anticipated being moderately sore. By later that evening, I was experiencing some prickling sensation discomfort and what felt like throbbing. By the next morning, I experienced further prickling pain, itchiness, and occasional sharp pain when urinating. I suspected a yeast infection and used Monistat that evening. The next morning, my symptoms had not improved, and when I looked I saw two ulcers on either side of the introitus. I had an appointment that afternoon (approx. 56 hrs post exposure), where the Dr. told me it would be a fast herpes outbreak. She took a culture and a week later that came back negative for both types of HSV; my urine culture was positive for gram-positive bacteria. Negative for all other STDs. Both ulcers resolved within 5 days. However, I showed my mother, who is a retired OB/GYN, photos of the ulcers and she believed it looked like herpes. I had nothing recur until the end of February when, after approx. 4-5 days of daily protected vaginal sex with my long-distance boyfriend, I noticed a fissure in my posterior fourchette. It did not look like the previous ulcers - more like a tear with a little spotted bleeding. I believed it may have been trauma from not having sufficient lubrication/repeated sexual activity. The fissure resolved within 3 days. The same fissure occurred, however, at the end of March - again after repeated sexual activity, and again without an ulcer, just spotted bleeding.

I had a full panel of STD tests done on April 6th. They came back negative for everything except HSV1 (history of cold sores approx. once a year since toddlerhood). I was taking Valtrex at the time of the fissures to prevent oral-genital HSV1 transmission.

 

ELISA results:

HSV1: 47.1 (positive)

HSV2: .0501 (negative)

 

 

I am now going to be seeing my boyfriend again at the end of the month and am concerned about passing something to him, even if we use protection. Is it likely I have HSV2 despite being tested 108 days post symptoms? Could I have contracted HSV1 genitally after having it orally? How would you counsel a patient in my current situation?

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Terri Warren, RN, Nurse Practitioner
86 months ago
It is very UNLIKELY that you would acquire HSV 2 and still test negative at 108 days post exposure.  And it is also extremely unlikely that you would contract HSV 1 genitally after having it orally since childhood. 

here are the thing speaking against you having herpes:

1) your culture from  newly erupted area was negative
2) the symptoms showed up too quickly for it to be herpes
3) you already have HSV 1 orally so getting it genitally would be extremely unlikely

The thing that makes this questionable is your mom's experience as an OB, thinking this might be herpes. 
What did the clinician say who saw you?  Did they think it was herpes?
A herpes western blot is slightly more accurate than the IgG test is you want the best test and the greatest ability to confirm you don't have HSV 2.

Terri
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86 months ago
Hi Terri, 

Thanks for your reply. The clinician who saw me was a PA I hadn't seen before - she said she thought the timeline was too rapid for herpes, but that since the area was raw, she wanted to take a culture to rule it out. She didn't say much beyond that. She prescribed Keflex and Diflucan, both of which I took. At the time, my mom noted that it would be an extremely rapid onset of symptoms and rapid resolution of them (since they were healed in about 5 days), and has since tried to assure me that it's very possible for her to have misdiagnosed me and that I should try and trust the test results. But, she did feel strongly that the lesions looked herpetic at the time. 

Part of me is concerned because I am sort of oddly susceptible to skin issues - I get cold sores with some frequency, have had a couple minor eruptions of herpes zoster on my side over the past couple years, gotten impetigo as an adult 3 times, and various rashes etc., which for whatever reasons makes me believe I'm more susceptible to herpes. 

A couple further questions - thanks in advance!

1) My mom said that she had never seen a case of herpes recur at the posterior fourchette, and doubts that those issues are caused my herpes.  This is especially true given where I had my ulcers initially (not across the fourchette), and because they have a with a  'straight line' from top to bottom of the fourchette look that she says is very common with tears, not herpes ulcers - is that consistent with your experience? 

2) I was wondering if you knew whether it's possible for condom usage (or specific types of condoms) to cause irritation to the posterior fourchette area? I have had irritation after sex before, but nothing like this.  My mom has suggested that it could be related to a recently-diagnosed HPV infection and/or a switch from progesterone-only BC pills to a lower dose progesterone-only IUD - my boyfriend is the only person I have had repeated sex with in a short period of time since switching from estrogen BC pills to progesterone only pills and the IUD. 

3) Would you recommend re-testing by IgG blood test at six months? And if the fourchette tear recurs, would you recommend trying to get a culture? Would it be best to wait for the Western Blot until the 6 month mark?

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Terri Warren, RN, Nurse Practitioner
86 months ago
I have seen recurrences of herpes at posterior fourchette though not often - but are you thinking this is a recurrence?  The straight line presentation speaks against herpes, I think
I seriously doubt that this has anything to do with an HPV diagnosis but a change in birth control pills as you describe cause lead to irritation with sex, yes, and possibly more vulnerability of the tissue to tearing.
I think you've gotten as good an answer as you are going to get with the IgG - your timing is good, and certainly a swab test with any recurrence of this presentation.  Alternatively, you could do the western blot at 16 weeks.

Terri
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86 months ago
Hi Terri, 

Thanks (again) for your speedy response. I will be certain to do a swab test if the fissure recurs - I'm uncertain if I believe it's related to the initial ulcers (i.e. a recurrence of what could be herpes) or something else, but the timing is what's causing me concern. 

In the absence of a recurrence of either the ulcers or the fissure (or in the event of a negative swab test on a recurred fissure), I'm wondering if you could give me some general advice on how I should address this issue going forward. From what I've gathered from your responses, it seems very unlikely that this is herpes: the viral culture from new lesions was negative; ELISA negative for HSV2; relative rarity of recurrence at the fourchette (if that is a recurrence), etc. But I want to ensure that I'm being as personally responsible as I can be, especially for the sake of my current partner. So, a final list of questions:

1) If nothing else recurs (or if a swab test is negative), would you still recommend the Western Blot test, or is it more for my own peace of mind that you suggest it? Another way to put this - do you think my situation requires that I get confirmatory WB testing?

2) Provided my partner has negative labs, would you say that it's safe to have unprotected vaginal sex at this time? 

3) Would you recommend disclosing this history going forward? I already disclose that I have a history of oral HSV1 AND am unsure what exactly I would disclose regarding this situation.

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Terri Warren, RN, Nurse Practitioner
86 months ago
1.  No, I don't think you have to  get a western blot if you can relax about this - it would be more for peace of mind at this time, I think, though I have to tell you that your mom's thought that it looked like herpes does bother me a bit
2.  I think your negative IgG test and negative swab test suggest strongly that you don't have herpes and if all other STI tests are negative, I think it is reasonable to have unprotected sex
3.  I don't think you need to disclose this history, no

I would suggest that you talk about this with your mom - the western blot - don't know if she knows about it, but you could talk to her about it and see if her suspicions are strong enough that she would recommend the blot in spite of the negative IgG.  I think herpes is unlikely here but I also value her thoughts as I'm sure you do too.

Terri
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