[Question #2305] Syphillis?

98 months ago

I had protected vaginal sex with CSW 11/1/16. On 11/15/16, my gf got vaginal and oral ulcers. She also had swelling of lips and vaginal area. All that resolved by 11/25/16. She now has same symptoms starting today. I got tested for herpes and syphillis on 11/29/16, on 12/13/16, on 3/1/17, and on 6/1/17. All negative results. Note: 12/15/17 GF and I took a 2gram dose of Azithromycin in case it was syphillis. I never had symptoms other than rash in genital area in mid November. Could Azithromycin have cause negative RPR for March and June tests? Possible we have syphillis?

98 months ago

Sorry a few additions/edits to my initial question. Date Azithromycin was taken 12/15/16. Tests have been all negative except for HSV-1. Possible GF symptoms are those? Not sure if I always had HSV-1. I do sometimes get a pimple/ulcer on inner thigh by groin but seems it's more bc of friction - been going on for years. My GF also had symptoms of fever, fatigue, headaches. I got tested through third party anonymous testing 10 panel and got checked for trich as well. If I had syphillis, I would be positive on RPR even with treatment on 12/15/16, correct? Possible that azithro cured me but not her, and I could re acquire from her? Just stressed, what could it be, is it STD? THANK YOU SO MUCH in advance!

H. Hunter Handsfield, MD

98 months ago

Welcome to the forum. Thanks for your question.

To first deal with your primary concern, syphilis: First, syphilis is rare in female sex workers in the US, where the large majority of syphilis in recent years has been in men who have sex with men. Second, "ulcers" (plural) plus both oral and vaginal sites suggests that your partner had several ulcers, not one or two, right? Initial syphilis almost always causes only a single lesion, the chancre; somtimes two of them at once; very rarely any more than that. Also, syphilitic chancres generally are painless, and would not cause genital or lip swelling. Third, your partner's onset of symptoms was too soon: if you had acquired syphilis, it would be at least 2-3 weeks before you could transmit it to another partner; and that partner's symptoms wouldn't appear before 2 weeks after exposure. In other words, 14 days from your exposure to her symptoms is not compatible with syphilis. Fourth, azithromycin or other antibiotics could not allow infection to proceed but not result in a positive blood test.

So you can dismiss syphilis. For sure it's not the problem here.

However, from your description, I am very suspicious your partner acquired herpes, regardless of the reported negative HSV tests. What HSV tests were negative on the 4 dates mentioned? And yet you say also say your tests were "all negative except for HSV1". What kind of test was that? When was it done? Were your girlfriend's genital or oral ulcers testing for HSV, by culture or PCR? Has she had an HSV blood test?

I doubt your recurrent "pimple/ulcer on inner thigh" is herpes. But that doesn't mean you don't have it, either oral or genital. If you have had a positive blood test for HSV1, then the odds are you have oral herpes (whether or not you have ever had obvious cold sores or fever blisters), and you could have infected your partner, probably by both kissing (the oral lesions) and oral sex (her genital ulcers and swelling). It further sounds like she might now be having her first recurrent outbreak.

If you and your partner have herpes, my guess is that you didn't get it from the CSW exposure last November. However, this judgment will depend on answering my several questions above. Also, if your girlfriend didn't have HSV culture or PCR from her ulcers in November, she should see a doctor immediately (within the next day or two) to have them re-tested during her current symptoms.

I look forward to helping more, if you would like, after you have filled in the many gaps in the story.

Best wishes-- HHH, MD

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98 months ago

Dr. Handsfield, thanks again, it's an honor to get your advice. I think this is my last reply allowed, so I will try to clarify well. All four of my tests were negative for everything except the HSV-1, which came back positive all 4 times. It was an IGG, type-specific AB test for both HSV-1 and HSV-2. Specifically it states "this assay utilizes recombinant type-specific antigens to differentiate HSV-1 from HSV-2 infections. As for my GF, she just had a culture and blood test done on 11/24/16 - when ulcers were resolving. Her practitioner admitted that culture may not be accurate bc of timing. I'm not sure of any other details on her test. And all she was told was culture was negative but blood test was positive for herpes but it wasn't testing specificity for type 1 or type 2. But would my 4 negative HSV-2 blood tests without question rule out HSV-2 for myself (Dates mentioned in first post). I know syphillis is ruled out :) but just to clarify, would a treated/cured case of syphillis still show up as positive on RPR 4-6 months after one acquires it? If it's type 1 Herpes after all, I guess she acquired it recently, correct? Since she never had similar symptoms in past 7 years prior. I am 100% positive she has been monogamous with me. PS I've only been with GF last 7 months, never plan on cheating again EVER. If I didn't answer everything, will gladly pay to submit another question to continue - your expertise brings a good deal of peace of mind! Thanks!

98 months ago

Re-read my post, when I said "PS: I've only been with GF last 7 months, never plan on cheating again EVER." I may have caused confusion. My intent was to say I've been faithful to her for past 7 months since that encounter with CSW. I had been with a few other women in past (2013-2015), always protected vaginal sex. 2 episodes of unprotected oral sex where I was receiving the oral sex. In any case, I've been with GF since 2010 and she has never had genital symptoms like she had recently in November and June. She admits to having cold sores occasionally. Goodnight and thank you, will patiently await your reply.

H. Hunter Handsfield, MD

98 months ago

Thanks for the additional information. I wasn't misled by your PS comment.

If a syphilis blood test isn't positive by 6 weeks, it will never be positive later. If treatment (e.g. azithromycin) aborts syphilis before infection takes hold, the blood test never becomes positive. There is no point in any more RPRs or other syphilis tests. And as I said above, there was never any realistic chance that syphilis is the cause of your gf's problems.

I'm even more convinced she has HSV1, both genital and oral. Almost certainly not HSV2. However, she should still be tested by PCR during this outbreak to confirm the diagnosis and virus type. If for some reason that can't be done, or if it is done and negative, she should have another HSV blood test, this time making sure it's a type specific test to distinguish HSV1 from HSV2. Either way, I predict a positive result for HSV1. (I don't understand the business about her blood test not telling HSV1 vs HSV2. The routine HSV blood tests these days almost always are type specific and the virus type should be obvious from the lab report -- unless for some reason her doctor specifically requested a non-type-specific test.)

Your exposure was more risky for HSV1 (unprotected oral) than for HSV2 (protected vaginal). However, it's still not very likely you acquired it at that time. Your HSV1 IgG could have become positive as soon as 2 weeks after catching it, but that would be unusual; generally it takes 3+ weeks. Also, you had no genital symptoms to suggest new herpes in the days following that exposure. So it's most likely you have a longstanding infection, probably oral, which likely was the source of your girlfriend's infection. Her symptoms are very typical for a primary infection, i.e. first exposure to the virus. In other words, my best judgment is that she indeed has newly acquired herpes, both genital and oral; and that your commercial sex exposure has nothing to do with it.

Two other facts may help you (and your gf) to understand all this: 1) Over half of all new genital herpes cases are caused by HSV1, not HSV2. 2) Many (perhaps most) new genital herpes occurs in committed couples, without implication for outside sexual exposures, for exactly the reason that seems most likely in your case: one partner is infected unknowingly, and transmission occurs (randomly) often months or years after the relationship starts. In other words, with no implication that either partner has had other partners recently.

As you anticipated, that concludes this thread. If you have other questions about it -- and especially if your partner develops a positive test, either blood or PCR -- I would suggest you ask a new question, which would be answered by Terri Warren.

I hope the discussion has been helpful.

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H. Hunter Handsfield, MD

98 months ago

I decided to leave this open to ask you one more thing. I might have misunderstood the dates of your HSV1 test results. It looks like your first test was 11/29/16, i.e. 4 weeks after the CSW exposure. Right? If you have the lab reports, tell me the numerical results for your positive HSV1 tests 11/29, 12/13, 3/1, and 6/1. They might give a clue as to whether you were infected during that exposure.---

98 months ago

Thanks Dr. Handsfield! Well, I have only the results for the November and June tests, I cannot locate the two tests in between. The November test shows an HSV-1 level at 30.8 and the June test shows level at 33.0. Those were the first and fourth test, over 6 months apart. Does that provide any further clue, apologies I can't locate the other two. While I have the chance here, two last questions :) Do my 4 negative HSV-2 tests completely rule out HSV-2 for me, then? And secondly, I know you get slot of paranoia here and I'm feeding into it a bit here, but one last thing on syphillis. Is it potentially possible that when I took Azithromycin after 6 weeks post-exposure (already tested negative for syphillis twice by then at 4 weeks and 6 weeks), that I could have been cured. But perhaps girlfriend did not get cured, could she give it back to me now. She doesn't have it though, right :)? You said it would take very minimum 4 weeks from time I was exposed to syphillis for her to present symptoms? And she had systemic issues, fever, fatigue, swelling, ulcers (oral and vaginal), etc. On this occasion, she also had swelling in her palms and soles of feet (not rash but swelling). Both episodes when she was symptomatic, she had had extreme vaginal swelling and burning, hard to even walk for her. Okay, THANK YOU SO MUCH! You all are really the best!

98 months ago

Oh and one last thing, I've read it's not likely for a person to be symptomatic for both oral and genital with only one HSV type. Meaning not likely to have type 1 for both oral and genital, or type 2 for both oral and genital. I'll just be happy to know that I didn't give her type 2 herpes, if that's a safe conclusion with my 4 negative blood tests? Type 1 just isn't as taboo. You all are a great service and your are an amazing resource, keep up the great work Doctor!

98 months ago

And before this is closed :) one more thought, could it be HPV? If so, is there a diagnostic test and treatment for that? That's it I promise - no more questions.

H. Hunter Handsfield, MD

98 months ago

Syphilis: No, there is no realistic chance of the scenario you outline. You could not have infected your gf before your test became positive. Why are you so laser-focused on syphilis? Do your best to stop worrying about it.

I don't know what to make of your gf's painful swellings of palms and soles. But this doesn't change my overall assessment and recommendations.

Herpes: First, you misunderstood something you read. I think the business about bein symptomatic for both oral and genital must have been referring to recurrent herpes. But for the initial infection, which is what you partner apparently had, it's not at all rare to have it at both sites, if both were exposed -- in this case, probably by your both kissing and performing oral sex on her.

Finally, those blood test results suggest you probably were infected before the commercial sex exposure. There's no way to know for sure, but that's the best bet. You probably have an oral infection and infected your partner.

That completes this thread. If you have further questions about herpes, feel free to post a new question, which would be answered by Terri.

Thanks for the thanks about our services. I'm glad to have helped.

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H. Hunter Handsfield, MD

98 months ago

I forgot to answer your qeustion about HSV2. Almost certainly not, since your blood tests are negative and you are confident she hasn't had other partners. Assuming your partner has herpes, almost certainly it's HSV1.

You're overthinking all this. You truly can dismiss both syphilis and HSV2. I suggest you take the time to very carefully read every word of all my replies above, which pretty well explain everything.

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