[Question #2932] Symptoms have me worried

96 months ago

Hi Dr's HHH and Hook -

I'll get straight to the point:

10/13 unprotected prolonged, vigorous cunnilingus and protected vaginal intercourse with a new partner. Same thing on 10/25

10/26 I had a painful lymph node pop up under my jaw/neck line. No fever. 10/29 extreme dizziness and continued pain in lymph node. Save my PCP on 10/30 and he rx'd augmentin 875 mg 2x a day for 7 days for suspected ear infection. 11/3 back to the Dr. and tested for strep and flu - both negative and switched me to a z pack. (could the augmentin have caused false negative for strep?). Wanted to test me for mono but I've already had mono, and I understand you can only get it once.

Questions:

1. My sore throat persists, as do my tender lymph nodes and low grade fever. It tends to "break" at night while I'm sleeping. This has me concerned over ARS. Do the pattern of my symptoms follow those of ARS? The reason I'm so nervous is because everything seems to point to either mono or HIV and I've already had mono. Could another virus be responsible for these odd symptoms?

2. Could my sore throat be do to HSV 1/2?

3. I've always thought unprotected cunnilingus to be a "safe sex" activity but now my mind is going crazy. Brass tacks - do I have anything to be concerned over? If this was an STD (gonn/chlam) of the throat would the antibiotics likely take care of it? My main concern is obviously ARS/HIV.

96 months ago

Sorry, forgot to mention what prompted my visit back to the Dr. on 11/3 was a second, very tender lymph node popped up on the other side of my jaw, accompanied by very sore throat and fever on 11/2.

H. Hunter Handsfield, MD

96 months ago

Welcome to the forum. Thanks for your question and your confidence in our services.

3) Going first to question 3, cunnilingus indeed is a very safe sexual activity, with low risk for all STDs and zero risk for some. As for "brass tacks", your symptoms are much more consistent with a garden variety, non-STD upper respiratory infection than for any STD. The problem conceivably could nonetheless be related to the sexual exposure described: being close enough for sex of any kind obviously carries potential for transmission of colds and related viruses; and some viruses (e.g. adenovirus) can involve both the genital and upper respiratory tracts. However, your symptoms came up quite late for them to be related to that event. Almost all such viral infections would show up within 3-5 days, not almost 2 weeks later.

1) While some STDs are theoretically possible from the event described, but oral gonorrhea and chlamydia rarely cause symptoms at all; and if symptomatic, would also usually show up within a few days. Also, the antibiotics you had would have promptly cured either of these. (They also would have aborted syphilis, but that's even more unlikely based on both the exposure and your symptoms.)

As for HIV, your symptoms could go along with it, but HIV has never been proved (or to my knowledge even suspected) to have been acquired through cunnilingus, and unless your new partner is at special risk for HIV (injection drug use, immigrant from an HIV endemic part of the world, etc), it is exceedingly unlikely she has HIV. On average, well under 1 in 1,000 sexually active women in the US have HIV. Also these symptoms, without fever and/or generalized skin rash, don't fit well with acute HIV. I agree mono also could fit, and would recommend testing for it -- even though I agree that repeat infections are rare. Finally, HIV doesn't cause only a few tender nodes in one area of the body; typically they are painless and all over the body, e.g. armpits, groin, etc in addition to the neck area.

2) Herpes? Of all STDs, this probably is the most likely -- but here too the time duration is against it. Initial symptoms can be delayed as long as 2 weeks, but that's uncommon; and herpes rarely if ever causes sore throat or lymph node inflammation without also causing multiple painful open sores in the mouth and/or throat -- not the sort of symptom you would miss. That said, I think you should be tested for it. If indeed it's herpes, either HSV1 or HSV2 could be responsible, acquired by kissing or by cunnilingus, respectively. (But if you've had oral herpes yourself, you're immune to a new HSV1 infection.)

So all things considered, I am very confident this isn't HIV/ARS. As just noted, I'm less certain about herpes -- I think it is a fairly distant possibility, but not impossible. Probably this is unrelated to the sexual exposures described. However, if your partner also has been experiencing a similar illness, that would support a shared non-STD viral infection. Have you spoken with her about all this? Including any past history of either oral or genital herpes?

What to do now? I would go ahead with the mono test, and would also suggest HIV testing -- not because I think it likely at all, but because it's on your mind and I doubt you'll rest easy until it has been ruled out. You're at a point now when a standard antigen-antibody test ("4th generation" test) would detect 90-95% of new infections. Also a repeat evaluation by your doctor, to include careful inspection of your mouth and throat for ulcers you might not have noticed, and (with or without ulcers) a throat swab to test for an HSV DNA test. You might consider printing out this thread as a framework for discussion with your doctor.

I'll be interested to hear all this shakes out. In the meantime, I hope this information has been helpful. Let me know if anything isn't clear.

HHH, MD

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96 months ago

Thank you Dr HHH.

Given the low risk nature of my exposure for HIV, are my symptoms the reason you recommend testing? Or is it simply to put my mind at ease?

Regarding HSV - I do have sores in my throat . However I frequently get canker sores in my throat - so I can’t tell if that’s what these are. I will call my PCP tomorrow to see if he can take a closer look at my throat and possibly swab the sores. I forgot to mention there is some blood in my mucus - not sure if this changes anything.

Thx for the help

H. Hunter Handsfield, MD

96 months ago

The blood doesn't mean much to me, but the ulcers do. Canker sores usually are in the front of the mouth or cheeks. If true ulcers in back of the throat, my concern for herpes is quite a bit higher. I would recommend PCR (i.e. DNA) testing for HSV even if your doctor doesn't confirm the ulcers. Also, assure that he orders virus type if HSV is identified. (It's important for prognosis for future outbreaks and prevention, but a step often skipped by labs or providers who don't understand the important clinical differences between HSV1 and 2.) For sure do it tomorrow or even today if possible. Also ask your doctor to send blood for type specific HSV antibodies; if PCR is negative, initial infection can also be documented by early negative antibody testing followed by a positive test a few weeks later (i.e. looking for seroconversion, a term your doctor will understand). Also direct that only IgG antibody testing be done; the sometimes automatic IgM test is never reliable, often misleading, and always best skipped. Finally, you and your PCP should discuss starting you on an anti-herpes drug like valacylovir, especially if throat ulcers are seen. Benefit is maximized by the earliest possible treatment and the drugs are entirely benign, with essentially no side effects, so there's no downside in starting treatment if you don't have herpes or before confirming the diagnosis.

HIV testing is mostly for reassurance; for all the reasons above, it's very unlikely. Still, the chance isn't zero and testing is easy. And HIV testing should be automatic in anyone being evaluated for any STD. Finally, if you do have a new HSV infection, it would elevate the chance of catching HIV at the same time, if exposed. Still, it's extremely unlikely; this is not the main issue that should be on your mind.

By the way, I misread part of your initial question. My replies above refer to the delay from the first exposure 10/13, but I missed your comment about repeat exposure 10/25. However, it doesn't change my assessment. Just as nearly 2 weeks is too long for many STD symptoms, 1 day is much too soon for any of them. Either way, the second event can be disregarded as a source of your symptoms.

Finally, you definitely should go ahead with a conversation with your partner about your symptoms and whether she has ever had genital or oral herpes, or unexplained sores at either site.

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96 months ago

Dr HHH

I went to the PCP today. He looked at my lip and diagnosed angular Chelitis and coated tongue (probably from the antibiotics). He examined my throat and said it looked neither like mono and the lesions were not herpes ulcers. He did see yeast and rxd mouthwash to abate. As I mentioned previously I often have canker sores on the back of my throat. I have for years. If they are in fact herpes sores, does this mean this wasn’t my initial infection?

He also ordered a CBC which was normal. Not sure that means anything. After returning home my fever suddenly spiked to 103. He had me come back in to do a chest scan (waiting results). Not sure why as I’m not coughing . Kinda scares me...

As for the girl, she is 23 and tested neg for hiv/chlam/gonn in July. She is very permiscuous but uses protection (she says). Not sure about hsv.

The more I read the more I’m convinced I have pharyngitis hsv - wouldn’t that be more likely than mono? The only thing that has me scratching my head is the slow onset of symptoms (they were very similar to my first bout with mono). It took a week before I developed a fever/sore throat after my initial node. Could it be hsv 1? Or is it likely 2 based on severity.

All of that said - what is your advice? Should I demand he culture the sores? He’s not keen on taking my advice. Or should I test privately?

I’m obviously most concerned about hiv, but the oral hsv 1/2 risk seems quite realistic . I’m starting to panic to be honest. Thanks for your help.

H. Hunter Handsfield, MD

96 months ago

It is true that your symptoms started later and are evolving somewhat more slowly than typical for initial herpes. But they are within the normal range and it seems to be a best bet. There is no difference between HSV1 and 2 in severity, speed of onset, or anything else. So far, there is no way to distinguish between them: assuming you and your partner kissed (HSV1 risk) as well as cunnilingus (HSV2).

I'm still not convinced this is herpes, but I do think it's a good bet -- certainly more so than I indicated in my first reply. You definitely should insist on a throat swab (for PCR, i.e. DNA testing, not culture -- but culture is acceptable if it's the only test offered by the lab your doctor's office uses. Also have the blood tests as I indicated above. If your doctor continues to demur, I would repeat my advice above to print out this thread as a framework to discuss it; or see another doctor. (Not sure what you mean by "test privately". Testing services can be found online for the blood antibody test, but maybe not easily for a throat swab PCR -- and self collection of good throat specimens can be difficult.)

Finally, as for HIV, it remains very unlikely; as I said, there have not been any proved cases transmitted by kissing or cunnilingus. However, I also would test you for it. It's not too soon for a nearly conclusive test: anybody with HIV symptoms for more than a week has a positive result with a standard antigen-antibody ("4th generation") blood test. A negative result will be conclusive that you don't have it.

Normally threads are closed after two follow-up comments and replies, but I'm going to leave this open. But not for general advice -- hoping you have an HSV test and also wait for the result, and can also report how you're feeling in a week or so.

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96 months ago

Dr HHH

Thanks again for your in depth reply.

I’m feeling much better today and I spoke to the girl. She said she had an ear infection with a swollen lymph node about 2 weeks after we got together (exactly how my symptoms started), so I’m now thinking we are sharing a non std virus - that I likely started?

Anyway, my pcp is out of town and my throat has largely improved so I’m not sure how effective a swab would be at this point. Would you recommend testing with igg tests in a few weeks to rule out hsv 1/2?

Also , my anxiety was killing me regarding hiv so I broke down and took an oraquick swab test. It was negative. I know this isn’t as accurate as a lab based antibody test but is it a good indication I’m negative? I can have a lab based test through quest tomorrow if you advise.

If I need to pay to post a second question I’m happy to do so, as I know this reply is only around hiv test results and not hsv .

H. Hunter Handsfield, MD

96 months ago

I still think herpes is and was a reasonable possibility, despite your partner's ear infection history. Initial oral herpes, like most viral pharyngitis, naturally resolves over this time frame. But I agree that since you're improving, it is opional whether you want to pursue herpes diagnosis any further. You can always face that if or when you have symptoms that suggest a recurrent oral area outbreak. In any case, since you're apparently set in not evaluating it further at thist time, I won't have any further comments.

There is no need for you to start a new thread, assuming your HIV test is negative, as almost certainly it will be. In that case, Dr. Hook or I would have nothing more to say except "Yep, negative. You don't have it." That will be the case no matter what symptoms you might still have -- the HIV tests overrule any and all exposures and symptoms. So I would suggest not spending your money on a 100% predictable response!

Best wishes and stay safe-- HHH, MD

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