[Question #212] HSV 1 or Strep B
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107 months ago
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Here is the background information before I ask the questions.
Had intercourse with two different men, Guy A and B. I had been with Guy A regularly before. Guy B is the only one to perform oral. Two weeks later, I had intercourse with Guy A again. The next day I found it very painful to urinate. When examining myself, I did not see any sores. When I went to the doctor (3 days after the last intercourse session) she first gave me a urine sample which was positive for Strep B. She then did an exam and diagnosed it was herpes. She took a viral culture, which came back negative, and blood work which came back positive for HSV 1 at 3.02 igg (Negative for HSV2). She then said this meant it was a past infection since the number was so high. I later examined myself again and saw one white canker sore looking thing one one side, close to the vaginal opening. I went back 90 days later and it was still negative for HSV 2 but still positive for HSV 1.
1. Do you think this is herpes or the Strep B? Or possibly something else? I understand this could be a recurrent outbreak if it was a past infection, but aren't the first outbreaks generally the worst? I've never experienced anything like that before.
2. If it is a past infection, and I've been with Guy A for awhile, unprotected, and he has yet to have symptoms, is it safe to assume he hasn't gotten it from me? Or could possibly already have HSV 1 (I know a lot of people do).
3. From my understanding, genital to genital HSV 1 is quite rare. Am I under obligation to disclose to future partners? My only problem with this is that people with oral HSV 1 never disclose, so why should we? Especially if we shed even less if we have it genitally.
I look forward to any answers. I have not approached Guy 1 about being tested because I don't want to pass on this burden of knowing ones HSV 1 positive status. If it isn't going to effect him, or if he has it already, I would rather leave him with ignorant bliss.
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Terri Warren, RN, Nurse Practitioner
107 months ago
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So you were diagnosed by examination with herpes so there must have been ulcers that looked like herpes to your doctor. And three months later, it was still positive for HSV 1 and negative for HSV 2. Have you had any discussion with either A or B about their herpes status? Do you know if either of them have been tested for herpes?
1. I think it is possible the group B strep could have been a finding unrelated to the symptoms that you are describing, kind of an incidental finding. The finding of HSV 1 positivity may or may not even be related to the genital sore. Have you ever in your life had a cold sore on your lip or in your nose? It is possible that the lesion is HSV 1 and the culture (which turns out to be insensitive compared to it's sister test PCR) missed it. This would be especially predictable if this is a recurrent infection, not your first one. Virus is cleared from recurrent lesions more rapidly than with new infection lesions. Even if you have not really noticed something like this before, it could still be a recurrence of HSV 1. But the thing about a positive HSV 1 antibody test is that it doesn't tell us where in your body the infection is, only that you have it.
2. He could already have HSV 1, yes. About 56% of the US population between 14-49 have HSV 1 already. Again, has any testing been done?
3. Actually, new genital HSV 1 is now more common than new genital HSV 2. So not uncommon. But your question about disclosure is a common one from people with HSV 1 and I can tell you that experts even do not agree about this. Genital HSV 1 does shed less frequently than oral HSV 1, true. My bigger concern about not disclosing an HSV 1 infection to a sex partner is if the relationship moves to a more serious level and this has not been disclosed previously it can become an issue of trust more than virus itself. And also, HSV 1 can be transmitted sexually though not often (we have most certainly seen it at our clinic) and that would not be good either from a medical, ethical or legal point of view.
So let's recap - we don't know if your genital lesion was HSV 1 or not. While I have seen strep isolated from ulcerative lesions (yes, I have) in the genital area, the most common cause of genital ulcers in the US is HSV. If you ever get another one (and if it is HSV 1 it won't be for a while), please have it swab tested preferably using PCR, not culture. It is likely that you don't have HSV 2 given the negative antibody test at 90 days. There is about a 2% chance that the blood antibody test (I"m assuming it is IgG, not IgM) missed an HSV 2 infection. Check and be sure it is an IgG test, OK? While I know it is difficult to raise this issue with others, it may be the only way to get more clarity on this issue. It is not an easy question that you ask. Please feel free to follow up with your extra questions so we can work on this more fully.
Terri
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1. I think it is possible the group B strep could have been a finding unrelated to the symptoms that you are describing, kind of an incidental finding. The finding of HSV 1 positivity may or may not even be related to the genital sore. Have you ever in your life had a cold sore on your lip or in your nose? It is possible that the lesion is HSV 1 and the culture (which turns out to be insensitive compared to it's sister test PCR) missed it. This would be especially predictable if this is a recurrent infection, not your first one. Virus is cleared from recurrent lesions more rapidly than with new infection lesions. Even if you have not really noticed something like this before, it could still be a recurrence of HSV 1. But the thing about a positive HSV 1 antibody test is that it doesn't tell us where in your body the infection is, only that you have it.
2. He could already have HSV 1, yes. About 56% of the US population between 14-49 have HSV 1 already. Again, has any testing been done?
3. Actually, new genital HSV 1 is now more common than new genital HSV 2. So not uncommon. But your question about disclosure is a common one from people with HSV 1 and I can tell you that experts even do not agree about this. Genital HSV 1 does shed less frequently than oral HSV 1, true. My bigger concern about not disclosing an HSV 1 infection to a sex partner is if the relationship moves to a more serious level and this has not been disclosed previously it can become an issue of trust more than virus itself. And also, HSV 1 can be transmitted sexually though not often (we have most certainly seen it at our clinic) and that would not be good either from a medical, ethical or legal point of view.
So let's recap - we don't know if your genital lesion was HSV 1 or not. While I have seen strep isolated from ulcerative lesions (yes, I have) in the genital area, the most common cause of genital ulcers in the US is HSV. If you ever get another one (and if it is HSV 1 it won't be for a while), please have it swab tested preferably using PCR, not culture. It is likely that you don't have HSV 2 given the negative antibody test at 90 days. There is about a 2% chance that the blood antibody test (I"m assuming it is IgG, not IgM) missed an HSV 2 infection. Check and be sure it is an IgG test, OK? While I know it is difficult to raise this issue with others, it may be the only way to get more clarity on this issue. It is not an easy question that you ask. Please feel free to follow up with your extra questions so we can work on this more fully.
Terri
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107 months ago
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I have not discussed with either Guy A or B because, as I mentioned, even if they do have HSV 1 I would almost rather leave them not knowing since it is such a hard thing to process.
The only sore I ever remember having was a blister on the inside of my lower lip kind of recently, but that is when I started Invisalign and heard that can be common. It was gone with not sore in less than a day. Also to note, there was not scabbing or scar left where I saw that white canker looking thing. It just disappeared.
The test was IGG, I made sure after reading how pointless IgMs can be. I'm not entirely sure if it was a culture or PCR test, I just know she swabbed the area and it came back negative.
I understand the Strep B might be a long shot, but she mentioned it so I thought I would do.
I also understand genital HSV 1 is becoming more and more common, I was more curious about the transmission. That, I heard, is rare. That almost all genital HSV 1 comes from someone with oral HSV 1, not genital. But you said you have seen it in your clinic? I've read other posts with other doctors saying they've never seen it. (but still admitting it could happen)
Besides all of this, should I be taking antiviral meds? Would this help with transmission?
Thank you for your response about disclosure. The thing is, from what I've read about STD testing is that they don't include herpes because you can't tell where it is and would just worry some people. So I just don't know want to worry Guy A if I don't have to.
(Thanks for your help with all of this)
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Terri Warren, RN, Nurse Practitioner
107 months ago
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If you are having sex with someone who does have HSV 1, then you taking daily therapy would like reduce the risk of transmission though we do not have statistics on how much exactly as we do with HSV 2.
Yes, we have seen people acquire HSV 1 from having intercourse with someone who has it but I would say perhaps 4 people in 33 years have been in that situation, where they have new HSV 1 infection (no antibody) and only had intercourse, no oral sex. Not too many, but huge numbers from oral sex, for sure. I see many herpes patients every day so it might be logical that would I see a bit more of that.
While it is correct that you cannot know where HSV 1 if someone has never had a cold sore and tests positive for HSV 1, if you are HSV 2 positive, we and the CDC in the 2015 STD treatment guidelines say we should assume it is genital as we know that the vast majority of people who test antibody positive for HSV 2 shed virus form the genital tract if they participate in daily home swabbing studies looking for virus.
The CDC also says in this 2015 guidelines that herpes testing should be considered for those undergoing STD testing or if they have symptoms that they cannot explain by another disease or condition (an ulcer that is swab test negative qualifies). I think your test was completely appropriate in this circumstance.
Terri
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Yes, we have seen people acquire HSV 1 from having intercourse with someone who has it but I would say perhaps 4 people in 33 years have been in that situation, where they have new HSV 1 infection (no antibody) and only had intercourse, no oral sex. Not too many, but huge numbers from oral sex, for sure. I see many herpes patients every day so it might be logical that would I see a bit more of that.
While it is correct that you cannot know where HSV 1 if someone has never had a cold sore and tests positive for HSV 1, if you are HSV 2 positive, we and the CDC in the 2015 STD treatment guidelines say we should assume it is genital as we know that the vast majority of people who test antibody positive for HSV 2 shed virus form the genital tract if they participate in daily home swabbing studies looking for virus.
The CDC also says in this 2015 guidelines that herpes testing should be considered for those undergoing STD testing or if they have symptoms that they cannot explain by another disease or condition (an ulcer that is swab test negative qualifies). I think your test was completely appropriate in this circumstance.
Terri
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