Exposure :

I performed oral sex on a woman(22yrs old) who was menstruating. I discovered this very early on; within two minutes and abruptly stopped. Prior to that and after there was heavy kissing. She also performed oral sex on me with no ejaculation (circumcised heterosexual male). No intercourse, however her bodily fluids were on my hands and in my mouth.

Four days post exposure: 

I noticed one swollen lymph node and a very mild burning sensation in my throat, so I went to a doctor. He gave me a one time injection of Cefaxone and four Azithromycin tablets to consume all at once. The next three days I had upset stomach, nausea and a mild headache. 

Nine days post exposure:

I developed a small sore (not circular) on my tongue that was flat with white edge and red centre that had a burning sensation. I returned to the doctor and he said it didn’t resemble herpes and thought it could have been thrush caused by the heavy dose of antibiotics and prescribed me Nystatin oral(4 times per day/ 5ml). He also told me std tests for gonorrhoea and chlamydia were negative. He swabbed the sore on my tongue to test for syphilis and drew blood to test for HIV to put my mind at rest. This sore changed shapes a few times and went away within 6 days.

I still have one slightly swollen lymph node that seems to stay the same size. It doesn’t hurt, but it’s clearly swollen. Both blood and swab tests for Syhilis and HIV were negative, however run only 11 days post exposure.

What is my real risk for HIV?

What is my real risk for Syphilis?

What is causing this lymph node to remain swollen?  

Can my stress/anxiety be causing anything here?

I’m thinking of flying to the US next week for an HIV RNA test(not available in Canada); how accurate will this be 6weeks(42 days) post exposure?

My stress levels are through the roof the last four to five weeks ... please help!

Thank you

You and perhaps your doctor may have overreactted to a low risk situation. You were at zero risk for HIV from this event, for all practical purposes. First, the likelihood any particular 22 yo female in Canada has HIV is well under 1 chance in a thousand, and that includes most of the highest risk women you can think of. Second, there has never been a proved/reported case of HIV transmission by cunnilingus, whether or not menstruating.Third, blood contains no more HIV than vaginal fluid -- whatever low risk there might have been was no higher because of the blood contact. (Swallowing blood is actually pretty low risk for HIV, believe it or not.) There also have been no reported cases of HIV transmission by fellatio, i.e. mouth to penis, so that part of the exposure also was risk free.

As for other STDs, the risks depend on your partner's sexual lifestyle, which you say nothing about. If that or other factors like social context (e.g. bar pick-up vs friend met at work) suggest high risk, then evaluation and maybe treatment for other STDs may have been warranted -- although most likely my clinic would not have treated you without waiting for test results. In any case, I'm glad to hear you were tested for gonorrhea and chlamydia. If your partner had oral gonorrhea, there was modest risk of penile infection from oral sex. Chlamydia was zero risk or close to it (chlamydia doesn't readily infect the oral cavity and is rarely transmitted by oral sex). Cunnilingus carries little or no risk for either of these STDs. Presumably you had a throat swab for gonorrhea, right? (Urine/urethral testing cannot detect oral infection.) In any case, you have been treated appropriately (if unnecessarily) for chlamydia and gonorrhea and can now put those out of your mind.

I can't imagine what "swab test" for syphilis was done. I am unaware of any such tests approved and used routinely for infections in the mouth. A single superficial oral sore isn't typical for herpes (i.e. I agree with your doctor), but I cannot say it is impossible. As a guess, your "lymph node" (if that's what's actually causing your jaw [?] pain) is the result of the oral sore, whatever is causing it. In any case, having had both ceftriaxone and azithromycin, it is impossible you have syphilis and there is no point in testing for it again:  those antibiotics would have aborted any brewing infection and prevent any future test positivity.

I strongly recommend against taking the time, spending the money, or devoting any emotional energy to HIV testing in the US or anywhere else. For sure this situation does not warrant HIV PCR testing. (It is nonsense that such tests are not available in Canada. Some of the best research on their use in early HIV diagnosis has come from Vancouver, Toronoto, Montreal, and elsewhere in Canada, and such tests are routinely used nationwide. But perhaps there is a policy against their routine use in situations like yours. I wish we had such a policy in the US!)

Those comment cover all your specific questions, I believe. You really needn't be worried about HIV or any other STD from the exposure described.

I hope these comments are helpful. Let me know if anything isn't clear.

HHH, MD

I should have been clearer. I live in Canada, however my exposure was in Tel Aviv, Israel. It was a 22yr girl I met casually at a club. I cannot contact her and her status is unknown. A single lymph node in my neck has remained swollen 6days post exposure to this day(almost 3.5weeks!) . 

All standard tests for syphilis and HIV, in both the US and Canada, are conclusive any time 6 or more week after teh last possible exposure.

If you remain so stressed and anxious after the reasoned, science based reassurance you have had -- on this forum for sure and probably from your own doctor(s) -- consider professional counseling. This is not normal mentation in this situation and suggested an underlying emotional issue that is not likely to go away even with absolutely conclusiive testing. I suggest it from compassion, not criticism.

Perhaps you'd also like to know that in the 14 years I have been doing this and my previous online forum, with thousands of questions like yours, not one person turned out to have actually caught HIV. You won't be the first. If and when it happens, it will be a real HIV risk, not a trivially risky event like yours.

Do your best to suck it up and move on.