[Question #285] Fear of ARS or Gonorrheal Pharyngitis

106 months ago

Background: HSV-2 positive since 2007, never any outbreak of any kind; highly discriminate of sexual partners; only give oral sex, never anal sex

Situation: Oct 28 - I provided oral sex to a young very fit uncut guy, unknown to me but re-assured me multiple times he was completely clean and HIV negative. He did have an orgasm but did not ejaculate in my mouth and there was no anal sex. Nov 17 - I provided oral sex to an 18 year old cut guy, again, very fit and he reassured me he was clean and HIV negative. He did ejaculate in my mouth and I swallowed. Neither of these men had any visible lesions or discharge. Nov 20 - I began to have painful swallowing on the left side of my throat. As the day progressed, I was running a low grade fever of about 99.5-101 and felt achy with the fever. My fever spiked to about 102 the next morning and the lymph node on the left side was tender and enlarged. No other symptoms. I went to urgent care and was diagnosed with likely strep throat (despite the rapid strep test being negative) as the physician felt that I had 3 of the 4 criteria for strep throat (left tonsil swollen with white exudate spots) and you can often get a false negative. I started Amoxicillin (875mg @ 2x/day for 10 days) on Friday and I started a course of Valtrex (500 mg @2x/day for 3 days). By Saturday late morning, I had normal temp of 97.5 and my pain on swallowing was significantly improved. By Sunday, for the most part, my symptoms were near resolved, just very faint tenderness on swallowing and the node swelling appears down.

Questions: 1) How likely is this HIV and ARS? The sequelae and timing are uncanny and frightening! 2) Can this be gonorrheal pharyngitis? 3) Could this be herpetic pharyngitis triggered by HSV-2 given that I did not have a positive rapid strep test?

H. Hunter Handsfield, MD

106 months ago

Welcome to the forum. Thanks for your question.

Congratulations for a sober, thoughtful approach to your sexuality, an in going out of your way to protect your partners from your apparent HSV2 infection. (More about that below.)

I really don't think you have much to worry about. Almost certainly your symptoms were not due to ARS, herpes, or gonorrhea. It's much more likely you have just had a garden variety, everyday viral pharyngitis.

First, it is exceedingly unlikely you caught HIV from the exposures described. Penile to oral HIV transmission is rare and it seems unlikely your partners were infected. Second, symptoms are just about the wrost way to judge whether or not anyone has a new HIV infection. Too many things, far more common, cause the same symptoms as ARS. Third, longstanding herpes is not known to cause pharyngitis. Fourth, the vast majority (90-95%) of pharyngeal (throat) gonorrhea causes no symptoms at all.

Even in people with "likely strep throat" based on examination, most in fact have viral infections, so your negative strep test isn't a surprise. Probably your symptoms cleared up on their own, not because of either the amoxicillin or valacyclovir. The time course of improvement is entirely consisteng with a viral infection and in fact too fast for the drugs to have helped. Neither strep nor herpes symptoms is likely have cleared so rapidly on either treatment. As for timing of your symptoms, I would remind you that any time you are close enough to someone to have sex, you are susceptible not only to STDs but to any day to day virus your partner(s) may have. Or you could have been infected by any other person in your environment in the few days before onset of symptoms. And viral infections are hundreds of times more common than HIV or ARS, even in people at risk for having or catching HIV.

I think those comments pretty well cover your questions, but to be explicit: 1) Almost certainly this isn't ARS. In addition to the points above, ARS doesn't clear this fast, minimum 7 days or so. But if you want even more security, you could be tested for HIV in the next few weeks. 2) Pharyngeal gonorrhea can't be excluded unless you were tested for it. But it is very unlikely. But it's too late now to test. Although amoxicillin isn't the usual recommended treatment, it would cure most cases and a negative test would be meaningless. But a positive test of course would be significant. 3) Discussed above. If you indeed have HSV2, that cannot be the cause of your pharyngitis. If you were exposed to HSV1, conceivably that could be the cause -- but as already discussed, herpes wouldn't improve so fast, even with valacyclovir. Also, nonprimary first HSV infections (i.e. if you caught HSV1 on top of prior HSV2) rarely cause such prominent symptosm or fever.

Turning back to your opening comments: Are you sure about your past HSV2 blood test result? If you scan this forum's herpes questions, you'll see lots of discussions about low positive HSV2 results that are false. Given your lack of symptoms, you might want to confirm your past result, incuding the HSV2 antibody numerical value.

I hope these comments have helped. Best wishes and stay safe-- HHH, MD

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106 months ago

Thanks Dr. Handsfield. This helps me tremendously. Just a follow-up question - if pharyngeal gonorrhea can't be exlcuded, albeit unlikely, and I can't get tested for it now, how do I know if I have (had it)? Will other symptoms now evolve if it was pharyngeal gonorrhea? If all of my pharyngitis symptoms have resolved, and if it was pharyngeal gonorrhea, am I still contagious and therefore to refrain from giving anyone oral sex and if so, how long? Sorry for the follow-up questions but as you can imagine, a bit anxious.

H. Hunter Handsfield, MD

106 months ago

You could be tested in a couple of weeks. It would have to be a throat swab, requiring professional exam and specimen collection, and with a request to test for gonorrhea. (A routine throat swab would not be tested for gonorrhea without a specific request.) If negative, it will show you don't have pharyngeal gonorreha at that time. However, there will be no way to know whether you never had it or were infected but cured with amoxicillin.

OTOH, you could just forget it. Pharyngeal gonorrhea clears up on its own within 3 months, without treatment; and is uncommonly transmitted to partners. The likelihood of symptoms or complications in the meantime is low. So really not something to worry much about. If somehow I were in your circumstance, I wouldn't change my sexual behavior.

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106 months ago

You have been very helpful. Thank you. So just one last F/U question - if I had pharyngeal gonorrhea, the course of amoxicillin that the doctor prescribed for strep throat (875 mg BID for 10 days) could cure any gonorrhea of the throat?

H. Hunter Handsfield, MD

106 months ago

About 80% of gonorrhea would be cured with amoxicillin in that dose. The other 20% are resistant to it and would not be cured.

That concludes the permitted two follow-ups on each thread, so it will now be closed. I recommend against any further testing for gonorrhea or anything else.

Best wishes and stay safe.

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