[Question #5235] New diagnosis of Hsv 1 by culture neg labs ,spouse lab positive for both?

24 months ago
Hello, unfortunately was diagnosed  by a culture of a genital linear erosion positive for hsv1 the only other Dx was yeast  infection.  I thought I cut myself shaving but apparently not , told it was an ulcer, had never had cold sores or any other symptoms,  this is a first outbreak for me .  The last time we had sex ( oral and genital)  was 3 weeks earlier, no obvious sores at that time.   In a monogamous marriage of 10 years, I have not been with anyone else and  he states he has not either. This has been a huge shock for us both. 
I had an STI panel done 13 years ago all negative doubt hsv tested. My spouse had never had testing. He and myself have never had fever blisters. He a year ago had a red penile bump he thought was a pimple or zipper abrasion.  He has had a tooth get infections and had it removed and a graft done the area does get irritated if food gets there he uses a wash then it clears but otherwise no mouth sores.  A few days after  the positive culture myself and my spouse both asked for full STI work up , my  results all are negative including IgG hsv 1 and 2 negative . His results show positive HSV1 IgG 6.26 , positive HSV 2 IgG 1.39 per the doctor told he is positive for both.
Would the fact it’s my first outbreak and testing occurred so soon  be the reason my hsv 1 is negative, and I assume confirms newly infected? Would it support that it was contracted at the encounter 3 weeks earlier?
Do I need to be concerned about hsv 2? I’m worried and don’t want to add that as read it has more outbreaks not wanting to be on suppressive therapy .What sexual precautions do we need to take to prevent that?
Is his positive hsv 2 dx really positive since so low, his Dr told him that he is positive for both  Hsv1 and 2 by those IGG results, is that so? If so should he start preventative treatment? 
On treatment but feeling very overwhelmed. Thanks for your help!

Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
23 months ago
Your IgG could have been negative because this is new infection OR it could be negative because the IgG test misses 30% of HSV 1 infections and you could have had long standing infection.  He clearly is infected with HSV 1 but his HSV 2 is a low positive (1.1 to 3.5) and he needs confirmation of this diagnosis.  This is the guidance of the CDC.  The best confirmatory test is the western blot and I can help you with that at westoverheights.com or you can work with your own doctor, but apparently that doctor does not know that this low positive value should be confirmed.

Here is what the CDC STD treatment guidelines say about this:

Type-Specific Serologic Tests

Both type-specific and type-common antibodies to HSV develop during the first several weeks after infection and persist indefinitely. Accurate type-specific HSV serologic assays are based on the HSV-specific glycoprotein G2 (HSV-2) and glycoprotein G1 (HSV-1). Providers should only request type-specific glycoprotein G (gG)-based serologic assays when serology is performed for their patients (329-331).

Both laboratory-based assays and point-of-care tests that provide results for HSV-2 antibodies from capillary blood or serum during a clinic visit are available. The sensitivities of these glycoprotein G type-specific tests for the detection of HSV-2 antibody vary from 80%–98%; false-negative results might be more frequent at early stages of infection (330,332,333). The most commonly used test, HerpeSelect HSV-2 Elisa might be falsely positive at low index values (1.1–3.5) (334-336). Such low values should be confirmed with another test, such as Biokit or the Western blot (337). The HerpeSelect HSV-2 Immunoblot should not be used for confirmation, because it uses the same antigen as the HSV-2 Elisa. Repeat testing is indicated if recent acquisition of genital herpes is suspected. The HerpeSelect HSV-1 Elisa is insensitive for detection of HSV-1 antibody. IgM testing for HSV 1 or HSV-2 is not useful, because IgM tests are not type-specific and might be positive during recurrent genital or oral episodes of herpes (337).

Because nearly all HSV-2 infections are sexually acquired, the presence of type-specific HSV-2 antibody implies anogenital infection. In this instance, education and counseling appropriate for persons with genital HSV infections should be provided. The presence of HSV-1 antibody alone is more difficult to interpret. Many persons with HSV-1 antibody have oral HSV infection acquired during childhood, which might be asymptomatic. However, acquisition of genital HSV-1 is increasing, and genital HSV-1 also can be asymptomatic (318-321,338). Lack of symptoms in a person who is HSV-1 seropositive does not distinguish anogenital from orolabial or cutaneous infection, and regardless of site of infection, these persons remain at risk for acquiring HSV-2.

Type-specific HSV serologic assays might be useful in the following scenarios: 1) recurrent genital symptoms or atypical symptoms with negative HSV PCR or culture; 2) clinical diagnosis of genital herpes without laboratory confirmation; and 3) a patient whose partner has genital herpes. HSV serologic testing should be considered for persons presenting for an STD evaluation (especially for those persons with multiple sex partners), persons with HIV infection, and MSM at increased risk for HIV acquisition. Screening for HSV-1 and HSV-2 in the general population is not indicated.

He is not vulnerable to your HSV 1 as he already has HSV 1.  I think you are in better shape than you think you are!


Terri

---
23 months ago
Thanks Terri,  for your reply ! 
Could  my lesion culture from my current primary outbreak that showed genital hsv1 missed hsv2.? For myself after this primary outbreak heals would I just need episodic treatment for new OB? But again both my IgG are negative at this point . I assume we need to eventually find out where his hsv1 is by culture of any outbreak? 
Should my spouse start suppression therapy that his Dr recommended before getting another test to confirm the hsv2 or would that cause the follow up test to be inaccurate? Are precautions  recommended to keep Me  from getting  Hsv 2 if truly positive from him until the confirmative test is done and  results are back.
My spouse states he doesn’t think he has ever  had an outbreak (but has  had the symptoms I described in the original question . ) He is aware the hsv1 IgG means he is hsv1 positive. He had a follow up today with his physician and no his physician does not seem knowledgeable on HSV or retesting his physician is contacting quest about what test was done and the fail rate and their recommendation even though my spouse asked for western blot follow up testing , then the Dr stated he would ask Quest for recommendations. He informed his Dr of cdc recommendations. 
I’m on day  8 of 10 day Rx with Valacyclovir 1g bid but still with open sore and enlarged red area on labial fold, is a 10 day course usually enough to  get over a primary outbreak? 
 Thanks Terri for your help!
 


Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
23 months ago
No, once it is typed, that should be the accurate answer. 
and Yes, the way to know where your husband is infected is by swabbing any outbreaks, either oral or genital.
Taking antivirals now is not an issue IF he has not been recently infected.
I believe that your husband may have contacted me today to arrange the blot but I'm not sure as I don't know who either of you are but the story sounds familiar.
You may need a refill of your prescription - that is common and not a worry.
And yes, it is likely you will need only episodic therapy.

Terri
---
23 months ago
Thanks Terri for your help, his physician is not informed on herpes and it has been frustrating . I have not seen my Dr , I was Diagnosed in clinic as my physician was off but I follow up with my PCP next week. So you giving us some information and answers has been so helpful!

If we ever feel the need for a local specialist is it an infectious disease physician or what specialty is usually most informed ?

I think my spouse is going to go with the western blot,  I do believe it was him that reached out. I think he is good going through you, he is wanting to get that low positive clarified. It seems  his only concern is finding somewhere to get it drawn as he doesn’t believe his physician office will do the blood draw. So he is wanting to ask his Dr , are there any labs that will normally draw the blood - quest, lab Corp etc?


Since I now am positive  with genital hsv1 and my IgG negative  with no history of cold sores in either of us and since we don’t know the location of his hsv1 would I also be able to be exposed in another area if his is oral by him kissing any area? Is it possible to be infected with the same type in other locations ?
Thank you again , you providing us with accurate information and answering concerns has really helped us with coping and understanding this diagnosis!

Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
23 months ago
You know, the specialty doesn't seem to matter much with herpes.  I've heard absolutely awful inaccurate advice from ID docs and dermatologist and OB's and GP's.  And I've also heard some great advice from these specialties.  I think it just depends on whether the clinician has done any recent updating on herpes. 
You know I should add that your IgG could be negative for HSV 1 because it is missing an old infection, in addition to the possibility that this is a new infection and you have not yet made antibody.
We like to use anylabtestnow locations for blood draws but I have other labs I use as well if there are none in your area.  Sometimes people have to drive a ways to get this done.  quest and labcorp will not draw for this, no. 
While it is possible to be infected at more than one location, that happens both at the same time rather than getting it in one place and then years later getting it somewhere else.

Terri
---
23 months ago
Thanks Terri, sounds like  he is going to search for the closest any lab test now contact to confirm they will draw then proceed with you. To clarify then that it can’t be transferred other than at original time of transmission to another location- I had read don’t touch the sores as possible to spread ( I was looking at when cleansing), is that not true?
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
23 months ago
Once the virus is well established (4 months) it is highly unlikely you would transfer this to a new location on your body.  It's fine to touch the sores if you should wash your hands for 20 seconds with warm water and soap and then stop.

Terri
---