[Question #2165] HSV concern post testing window

46 months ago

Scenario:  17 weeks ago – protected intercourse with CSW, unprotected cuntillingus, extremely high anxiety exposure to date (17 weeks), all other STI/STD tests negative at 1, 6, and 12 weeks


Scale: Yes = reason to believe infection,

No = reason to believe test results


Yes – 1 week to 7 weeks chills

Yes – 5 days post exposure penis sore, possible mild clear discharge, no pain with urination, increased urination, 3 hard bumps appeared on middle of pelvis 2 inches apart from each other (popped them with blood releasing and yellowish head popped from one of them) maybe popped something prior to the blister stage.  These were sore for several days but I did press hard on each.

No – Applied diaper cream to the tip of penis and the pain went away the next day

Yes – 5 to 8 after muscle soreness in the right upper buttocks almost like I bumped into something and sore soles of my feet.

No – No fever

No -  Negative urine test for white blood cells at 5 days

Yes – 7 week positive IGM test for 1&2 w/reflex (1.20H range less than 1.20) 

No – 7 week negative IGG test 1&2

Yes – 7 week, itching on genitals and several pimple like spots

No – Shaved genitals at 6 weeks, and had spot PCR RNA cultured with negative results at 7 weeks

No – 7 week negative IGG 1&2, 10 week negative IGG 1&2

Yes – 8 weeks pinching in but cheeks small pimple a few days later on butt (never cultured)

No – 8 weeks red line up but crack (PCR RNA cultured with negative results) visited dermatologist and he said it is likely from running prescribed hydro cream and it went away in a few days.

Yes – Sore lower back from 7 weeks to 17 weeks, along with hip pains

No – Started running every day and I was 275lbs and ran up to 2mls, already have lower back problems.  Aleeve does relieve symptoms.

Yes – 7 weeks to 17 weeks periodical pinched in genitals (all over but mostly testicals) and pinching on buttocks but not spot specific.

No – itching started to resolve and shaved again at 8 weeks at 9 weeks itching started again 

Yes – 11 weeks pinching in buttocks and shortly afterwards small red spot appeared on both sided of buttocks (pencil eraser size), very mild itching, went away in 3 to 4 days, no scabbing but possible oozing.  Penis tip sore again (went away over night with diaper cream)

No – 11 weeks PCR DNA tested spots but was only able to rub swab on them the following day.  Negative results

No – 12 weeks Quest IGG 1&2 negative, Labcorp 2 negative, 12 week WB negative 1&2

Yes – 12 weeks, penis sore and periodic pinching in genitals

No – 13 week pimple on pelvis PCR RNA cultured and negative result

Yes – 14 to 16 weeks periodic pinching in testicles

No – Quest IGG 1&2 negative at 16 weeks

Yes – 16.5 weeks pinching in butt cheek and 6 to 8 small little pencil eraser spot appeared in different section of butt cheeks.  Went away after 2 days with no scabbing.

17 weeks now what do I do, as I’m so confused can I truly trust the HSV 2 IGG test when it’s only 92% accurate.  If my HSV 1 is negative by WB then does that mean my 7 week IGM is more conclusive because there is less likelihood to cross react?  Am I having a continuous outbreak because I’m not making antibodies?  I’m really concerned, please offer direction…As I have not been with my wife in 4 plus months and I don’t know what to do.


H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
46 months ago
Welcome back to the forum. But sorry to see you remain concerned about herpes despite the reassuring replies you had from Terri. Although she normally replies to all herpes related questions, we had an email exchange and thought you might benefit from hearing someone else.

All your "yes" statements is not a "yes" at all. None argue strongly in favor of genital herpes. The single exception might be the symptoms 5 days after exposure, but all the "no" statements conclusively overrule the "yes" ones. Terri told you how unreliable the IgM tests are; a positive result, without corroboration from other evidence, is meaningless. There are no data on how to interpret a chaning IgM result, but the most likely explanation by far is that the first result was a garden-variety false positive and that the second (negative) result is accurate.

There is no such thing as a "continuous outbreak" of genital herpes. With rare if any exceptions, the initial outbreak doesn't last more than 2-3 weeks, symptoms of recurrnet herpes are intermittent, lasting no more than 2 weeks, not less than 4 weeks apart, and with absolutely no symptoms between those outbreaks. There simply is nothing in your ongoing symptoms that suggests you have genital herpes. And while the blood tests are not perfect, you have had a number of negative results with reliable tests, not counting the IgM tests which should never have been done.

As for "don't know what to do" with regard to sex with your wife:  Start having sex with her right now!  You definitely do not have herpes and will not put her at risk. It is time to suck it up and move on. (Terri and I always agree with one another -- but I'm the more blunt one, as you can tell.)

Time for you to move on without worry. Best wishes--  HHH, MD

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46 months ago
Dr. H, thank for the response I have all of this uncertainty because of my hip and back pain, and because it feels like I have something zapping my testicles and butt cheeks throughout the day.  Additionally, I know that the HSV 2 gig test misses 8% of time.  After speaking to the folks at the UofW Virology Research Center they said my testing is conclusive but if I want be 100% then waiting 6 months to 12 months would be needed.  I'm just confused as by definition conclusive means 100%.  Where is there a variance from this definition respectfully to hsv testing and why doesn't the CDC have conclusive testing times for hsv as they do for so many other tests relative std/sti's...You mentioned my igm on the previous response and spoke to a 2nd negative igm test, that was not the case for me as I never took another igm.  I've done igg testing after that test per Terri's advice.  Should I have taken another igm to see if it would have been negative.  With this statement and with my testing out to 16 weeks w/ 12 week negative WB can you conclusively say I am negative?  Would you offer the same advice to a person closer to you?  I only ask because I've had weird things going on over the last four months in my genitals that have never happened before and that in and of itself makes me question that the testing window is not adequate.  Thank you for everything the forum does and please do not look into my response as a challenge to the professional authorities of the site but only of major concern as the stakes are so high for me.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
46 months ago
Contrary to what you think you have learned somewhere, herpes is not a cause of hip and back pain, or of "zapping" sensations (testicular, butt cheeks, or anywhere else). Herpes outbreaks can be preceded by neurological symptoms, which could include these symptoms, but such symptoms only precede overt outbreaks and are limited in duration (no more than 2-3 days before an outbreak). See my comments above about continuous symptoms never being caused by herpes. Most likely you have seen websites or other information that simply list symptoms, which may include back pain, tingling sensations, etc. However, as you may have found, those sites often do not provide the context that I just did, the importance of the pattern of occurrence as well as symptoms themselves, etc. In my 40+ years in the STD business, I have had many, many patients with complaints like yours and not one turned out to have herpes as the cause.

Therefore, there is nothing in your current symptoms that hints at herpes. As I said above, the initial occurrence of new genital sores a few days after a sexual exposure is the only thing you mention that is consistent with herpes, but all other information argues strongly against it. I would say the combination of lack of onging symptoms consistent with herpes, plus the negative test results you have had, I am 100% confident you do not have HSV2 or genital herpes. No more testinbg is necessary and you should continue sexual relations with any or all partner(s) as you normally would, with no worry you could transmit HSV2 to them. 

As for the HSV2 test missing up to 8% of infections, that sounds too high to me. In the real world, we almost never see anyone with proved HSV2 (far less than 8%) with negative IgG testing, and especially not also with negative WB results. In any case, my conclusion you don't have HSV2 is not based only on the test result, but on all the information available. There simply is no realistic chance you have herpes and you should move on with confidence in that. And yes, I would say exactly the same thing to my adult children, or to any family member (which, in fact, I have done).

Does that help settle things for you?

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46 months ago
Is this correct that 10% to 15% for hsv1 and 5% to 10% for hsv2 never produce igg traceable antibodies by either test herpes select or WB.  I just received my 16 week seuroconvetsion WB panel and it was negative.  Now I'm questioning it because of my constant hip pain and my on again / off again genital prickling feelings.  Please offer details as there is so much conflicting feedback.  Terri mentions 9 non detectable but positive in 33 years, how many folks have been blood tested negatively but never went on to have a culture done.  There is so much mentioned about the WB be the "gold standard"  and 99.6% reliability but there is no data published to support the number for accuracy.  Lastly,  the IGM has had some published testing back 10 plus years ago where is showed to be reliable, and the testing was done by Anna Wald has that testing since been debunked?  How do we know so many IGM tests are false positive if we are so cavelier with diagnosis w/in the medical sector of non-std specialist.  I know the three professionals on the forum are well schooled in the understanding of hsv, and while each of you mentioned the herpes handbook to testing is the best we have.  Is it really certain in my case if there is up to a 15% that I'm not producing anti bodies?
Avatar universal
Symptoms of Herpes with no Antibodies
Hi Doctor, 

I received oral sex from a guy about 7 months ago, and developed a paper cut-like lesion below my clitoris within 2 weeks.  The same lesion (in the same location) has reappeared a total of 4 times over the last 7 months.  Each time, the lesion lasts for about 3 days and then is followed by intense itching on my inner labia for a few weeks.  (The itching is not coming from the same spot as my lesion, and only begins after the lesion has healed.)  I got tested with the HerpesSelect IgG tests for both HSV 1 and 2 at 3 months and 7 months post-exposure, and everything came out negative both times.  I’ve also been tested for all other STDs, yeast, and bacteria, all of which were also negative.  I have not had the opportunity to do an HSV culture, but hope to do so if the lesion comes back again.  So my questions for you are: 

1. Does this sound like it could be herpes? 

2. What are the chances that I am one of those rare people who has herpes but doesn’t develop HSV antibodies?  What percent of people with HSV 1 or HSV 2 in the genital area don’t develop antibodies? 

3. I plan on getting pregnant in the near future.  If I am indeed someone who has herpes but does not develop antibodies, am I going to risk passing this on to my baby, since I won’t be able to pass the antibodies to the baby? 

Thanks for your help, 
Sally 
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8 Answers
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239123 tn?1267651214
Welcome back to the forum.  I reviewed the discussion you had with Dr. Hook 5 months ago and agree with his opinions and advice. 

It is possible to have atypical symptoms, and it is possible to have HSV with persistently negative blood tests, and it is possible to have such frequently recurrent herpes due to HSV-1.  (HSV-2 is out of the picture since your exposure was by oral sex.)  But for all these factors to all have such an atypical outcomes is statistically impossible for all practical purposes. 

When it is said recurrent HSV outbreaks are usually in the same location each time, it generally means within an inch or so.  Herpes rarely recurs repeatedly at exactly the same spot; that fact suggests something other than herpes.  Also, herpes doesn't cause itching except at the site(s) of herpes lesions.  And herpes rarely recurs as frequently as you describe; even HSV-2 doesn't often occur as often as once a month, and for HSV-1 it is extremely rare.  To your specific questions: 

1) For the reasons just described, your symptoms are highly atypical for herpes. 

2) Around 5-15% of people don't develop measurable antibodies -- 5-10% for HSV-2 and 10-15% for HSV-1.  But you must not focus on just these percentages.  The judgment you don't have genital herpes is based on a combination of all the factors you describe -- the nature of the exposure, you symptoms, and your test results.  Taken together, these factors provide virtually 100% assurance you don't have it. 

3) There should be no herpes-related worries about pregnancy.  Even if against all odds you actually have it, the risk of transmission to a baby is very low in recurrent herpes.  The high risk of neonatal herpes comes when a woman acquires HSV toward the end of pregnancy. 

If you want still further reassurance, you could follow through with your plan for an HSV test from your clitoral lesion if and when it appears again.  I'm not recommending this, but if you do it, try to have a PCR test rather than culture, if available from your doctor or clinic, and needs to be done within 24 hours of onset of the lesion.  You can expect a negative result.  In the meantime, continue to work with your provider(s) about other causes of your symptoms. 

Regards--  HHH, MD
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Avatar universal
Thank you so much for your response Dr. Hansfield, I really appreciate your help.  I just have one additional question.  You stated that HSV 2 is out of the picture because my exposure was through oral sex. But would it have been possible for my partner to have had HSV 2 orally if he contracted it from someone while performing oral sex on them?  Thanks again, 

Sally
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239123 tn?1267651214
Oral HSV-2 can happen but it is quite rare; and when present, viral shedding is rare so transmission is uncommon.  In 30+ years in the STD business, I have never seen nor heard of a patient who acquired genital HSV-2 through oral sex.
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Avatar universal
Thank You!
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Avatar universal
Hi Dr. Hansfield, 

Would the 5-15% of antibodies that may be undetectable by herpeselect be detected by the western blot?  In other words, does the western blot test for additional antibodies besides the IgG antibodies tested for by herpeselect? 

Thanks
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239123 tn?1267651214
The few people with HSV-2 with negative blood tests usually have negative results both by IgG and Western blot.  But this is irrelevant to your situation.  The totality of evidence proves you don't have it.  Re-read my replies above and concentrate on them.  Then try to stop obsessing about herpes. 

That will be all for this thread.  I won't have any further comments or advice.
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Avatar universal
Hello Dr. Hansfield, 

I know that this discussion was closed some time ago, but I wanted to let you know that I got the western blot done and it came back positive for HSV 1 and negative for HSV 2.  I did this just 2 weeks after a HerpesSelect test that came back negative for both types.  I called the people at the University of Washington and they informed me that I should trust the results, as the western blot is more reliable than HerpesSelect and that the HerpesSelect test has a significant false negative rate for HSV 1.  Even though I don't have the IgG antibodies that the HerpesSelect test looks for, I had some type of HSV 1 antibody that the western blot was able to detect.  I also am confident that the infection is genital because I have never had a cold sore or any oral symptoms ever in my life. 

Given this information, I was wondering if you could please answer a couple of questions for me.   

1.  I had 5 recurrences of genital HSV-1 during the past year (the first year after my exposure.)  Is it likely that I will continue to have such frequent recurrences for the next couple of years?  I know that the rate of genital HSV-1 in future years usually drops off, but the recurrence rate during the first year is also generally very low, which mine was not. 

2.  Do you think that the fact that I do not have IgG antibodies, but instead have some other type of antibody is the reason for my increased rate of recurrence? 

3.  I know you said the risk of neonatal herpes is low, but does the fact that I do not have IgG antibodies change that at all, and should I be concerned during pregnancy? 

Thank you for your continued help during this time.  I know this is a long post but I just found out about my HSV positive status today and wanted some answers to help with my concerns. 

Sally 
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239123 tn?1267651214
Thanks for the follow-up.  For the reasons in my original reply, I continue to believe herpes probably is not the cause of your recurrent genital lesions.  It is more likely that, like half the population, your positive HSV-1 test is the result of an unrecognized oral infection, probably in childhood. 

However, I could be wrong.  There are two ways that might sort it out.  First, do what I already suggested -- see a health care provider immediately (within a day) of the next time the lesion recurs, so it can be tested directly for HSV.  I predict that even you do this several times, there will be no positive results.  Second, ask your doctor for a prescription for an antiherpes drug like valacyclovir (Valtrex).  If you take such treatement daily and your lesions stop recurring, it will suggest I am wrong and you really have genital herpes.  If it makes no difference, it will confirm my belief against herpes.  (However, I suggest you not try the second strategy right away.  Try the first strategy until recurrent lesions have been tested at least 2-3 times.) 

You have a misunderstanding of the HSV blood tests.  Western blot detects IgG antibody.  Your negative HerpeSelect test does not mean you don't make IgG antibody to HSV-1; it means only that HerpeSelect didn't pick it up.  That is the case in 10-15% of HSV-1 infections (and about 5% of those with HSV-2).  To your specific questions: 

1) If you indeed having herpes episodes, it is not possible to predict the frequenty of future outbreaks.  There are no data on the natural course in patients with unusually frequent outbreaks of genital HSV-1. 

2) There are no known differences in outbreak frequency in people with or without false negative blood test results.  Probably it makes no difference. 

3) Similarly, your negative HerpeSelect test results probably have no bearing on the risk of transmission to a baby during delivery.  However, I do agree that if and when you become pregnant in the future, you should definitely inform your obstetrician of this problem (whether or not genital HSV-1 is confirmed); s/he will know how to go about preventing transmission. 

I'll be interested to hear more if and when your lesion(s) have been tested for HSV and/or you have tried suppressive antiherpes theraoy.
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H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
46 months ago
Our conclusion you don't have herpes is based not only on the blood test results, but the overall information provided:  your exposure, lack of symptoms that suggest herpes, plus the blood test. The HSV1 blood test misses even more than you say, closer to 30% according to the latest research (on which Terri Warren was one of the investigators). However, HSV2 testing misses fewer than you state, probably only 1-2%. I disagree with your statement about HSV IgM testing being reliable:  I am unaware of any valid scientific studies that came to that conclusion.

Regardless of all that, my overall assessment is that there is no realistic chance you have genital herpes. Thus, there is nowhere near a 15% chance you are infected but just don't produce anti-HSV antibodies. Do your best to go forward without worry about herpes. If your symptoms continue and are truly bothersome, continue to work with your doctors on the cause and treatment. They are not due to herpes or any other infection from the sexual encounter described above.

That finishes the two follow-up comments and replies included with each question, and so concludes this thread. Please note the forum does not permit repeated questions on the same topic or exposure. This will have to be your last one; future new questions about this exposure, testing, and your fears about herpes or other STDs from that event will be deleted without reply and without refund of the posting fee. This policy is based on compassion, not criticism, and is designed to reduce temptations to keep paying for questions with obvious answers. In addition, experience shows that continued answers tend to prolong users' anxieties rather than reducing them. Finally, such questions have little educational value for other users, one of the forum's main purposes. I trust you will understand.


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46 months ago
Dr. H thanks for adding perspective from your professional standpoint and your thoughts on my chances of being positive.  I'm a stats guy so if you say that a percentage will never make antibodies I use that number as my gospel.  With that number being as high as 15% (referencing your post from years ago) that scares the heck out of me because it is such a high probability for fals negative results.  Lastly and I won't post again but just to clarify are you saying that even with Western Blot testing HSV1 is missed 30% or more of the time?  
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
46 months ago
Since your risk of infection and absence of symptoms indicate you almost certainly didn't catch herpes, the probability that your result is false pos is far less than 30%. You don't have it. Believe it and move on.---