[Question #5851] Much more new concerning HSV2 symptom

19 months ago

I posted a question a few weeks ago freaking out over a new red spot on my penis, but the consensus was it was probably nothing. I have a new much more concerning symptom and I am convinced I have herpes and my life is over (disclaimer I have severe OCD over contracting herpes)

To summarize:

I have oral HSV-1.

Last encounter with girl I was dating was 22 days ago. We had 4 total encounters, all protected. I found out she is very promiscuous and has multiple partners off of Tinder. She said she was "tested for everything" regularly but history shows no evidence of HSV tests. She denies any history of blisters or sores. I was taking 500mg daily Valtrex at this time (to prevent oral outbreak and because I thought it couldn't hurt lower my chances of getting type 2).

20 days ago she said she had a "yeast infection" and it hurt. My mind started racing. This apparently went away quickly with an OTC treatment and she said she gets them a few times a year.

19 days ago I developed tingling in both lower legs and feet, feet almost felt like burning. This comes and goes and has continued to come and go since then. Sometimes feels like pulses of 'buzzing' in my toes. I have it right now.

18 days ago developed painless red spot on corona of penis. Increased Valtrex to 1000mg. Red spot faded to purple and has remained this way since. I also had a stiff neck for a few hours.

16 days ago I stopped taking Valtrex completely. I had focal muscle aches on the inside of both thighs for about a day.I continued to freak out and obsess during this time. I also had a brief 2-3 hour episode of tingling over my entire upper pubic area.

7-8 days ago I developed sore thighs. Same individual muscle on both sides. Felt like I had been doing squats the day before but I have not been exercising. These muscle aches seem to jump around to different individual muscles over the past few days. Mostly anterior muscles but also come lower leg/calf aching. Deep muscle aching. Skin not sensitive to the touch but continued weird tingling in lower legs and feet. I’ve had occasional headaches over the past 2 weeks but have been extraordinarily stressed. Not eating, sleeping, etc.

6 days ago. Some brief anal itching. Something felt kind of off on the right side. Couldn’t feel anything with my finger. I had diarrhea around this time.

5 days ago. Had pain in front of anus. I’ve had prior surgery and cautery for warts 10 years ago so often get some tears and things. Didn’t think much since I’m used to my perianal area being sensitive to wiping, etc.

4 days ago. Pain continued. Tender to the touch. Took multiple pictures and could see there was a small round (single) ulcer just in front of the anus on the right where the perineum begins. No vesicles but absolutely a clear ulcer with moist red center. The skin on the right side of the perineum and perianal area is all red and looks irritated almost like diaper rash but doesn’t hurt at all. No other bumps.

2 days ago. Went to urgent care and had it swabbed and antibody tests taken. Doc couldn’t see it at first then said, yeah I guess it is an ulcer when he swabbed it and it got angry.

Today. Finally doesn’t really sting when you touch it like it did. No crust I can see but gray/yellow layer forming over it.

 

I am beside myself. Is there any chance this ulcer and ongoing muscle aching/tingling is anything other than herpes? Can I believe the swab test if it comes back negative? Can stool from a single diarrhea episode irritate the area and cause a tender ulcer like that if not cleaned well enough?

I had no anal contact during sex although she touched below the scrotum with her finger once or twice. Would my prior surgery make that area a prime area of entry? Does this make any sense? Would the Valtrex have delayed the initial presentation?

The partner before her was 3 months ago. Unprotected sex twice and protected probably 8 times. Was also taking Valtrex with her. She told me she “was clean.” Is this a first recurrence from her?

Please help.

Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
19 months ago
The ulcer could certainly be other things like a small fissure.  If you went right in and had the swab test and it is negative, you should feel reassured, yes.  Diarrhea would be unlikely to cause an ulceration
it isn't possible to know if this was herpes or not without 1) the swab result and 2) an antibody test when sufficient time has passed for antibody to be made - I would test no sooner than 6 weeks from the incident for a preliminary result.
"I am convinced I have herpes and my life is over".  That doesn't make sense to me.  People live very well with herpes and their lives are not over.  Are they happy about it?  Probably not but they go on to live full and meaningful lives.

Terri

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19 months ago
Thanks for your response. I understand you can't tell me I definitely don't have herpes without test results. I will update you in a couple of days when these come in.
I am just curious if what I am describing ever resembles anything like you've seen in your practice in terms of a first outbreak or first recognized recurrence.

I was taking Valtrex at the time of the encounter and experienced bilateral lower leg and feet tingling and burning feelings 3 days later. The Valtrex was stopped 5 days post-encounter and I've taken none since. This comes and goes but it is now 24 days post encounter and I am still experiencing this. Do you ever see this with herpes?

The focal muscle aches occurred last week in the lower anterior thigh, again in both legs. This was 2-3 weeks post encounter. Do you ever see this? I have read that nerve symptoms tend to be on one side and go down the back of the upper leg in the sacral distribution. I never had this. My symptoms are on both sides, on the lower legs, and in the lumbar nerve distribution.
I have not had any fever/chills and have not had any swollen lymph nodes. I have had some mild headaches. No photophobia. No nausea, no bowel symptoms. Loss of appetite and weight loss, yes, but I attribute that to my severe stress over this.

When a man uses a condom and contracts herpes, will the initial outbreak always occur on an area the condom wasn't covering or does it still typically occur on the penis shaft/glans? I have red that perianal herpes lesions are unusual in men who don't have anal sex.

And what is your opinion on the timing of all this? The perianal ulcer appeared about 16-17 days post-encounter. Although again, I was taking Valtrex the first few days. I've read the initial lesion usually presents within 3-5 days and almost never beyond 10 days. Does that mean this is more likely a first recurrence than an initial infection?

Today, the lesion basically doesn't hurt at all to touch, and when I photographed it, I can barely even tell where it is. There is no crusting or scabbing, the mucosa/skin just seems to have returned to normal and there's just a tiny area where you can still see an exposed red cut where it hasn't healed yet. The anus itself was initially red and the most of the right side of the perineum was red and there was just this tiny, maybe 1 cm circular ulcer (basically just looked like an area where the skin was missing, not scalloped out or anything) obviously painful to touch. But strangely all that red skin in the perianal and right-sided perineal area didn't burn, itch, or hurt to touch. It just looked angry but felt normal. So basically this thing stuck around for less than a week and all of the surrounding redness died down. Could this have been a yeast infection? The girlfriend did say she had a "yeast infection" 2 days after the encounter. Will a yeast infection ever cause a small ulcer in a much larger area of erythema? I have been told that I  had some mild fungal growth in the anal region many years ago even though I never had itchniess and was given Ketoconazole, which I never used.

The internet is scary because it says a perianal ulceration/erosion is almost always herpes. I don't think it's a fissure because it was more circular than linear and anterior. It was at 1'oclock, maybe 1 cm in diameter, and 1-2 cm from the anal verge.

I know this is a very weird cluster of symptoms, but I just want to get your opinion on how the timing, the location, the duration, and the leg symptoms all fit together and whether this sounds typical or more unusual for herpes. If I had seen a blister that turned into an ulcer on the penis, I would know what it was, but given I never felt any bump there I'm trying to hold out even a tiny bit of hope this may be something else. It's not an easy area to see.

Sorry for the long posts, I just want to give you as much information as possible since you can't see it.

Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
19 months ago
I honestly don't think this fits well with new herpes.  I would expect, if you used a condom and contracted herpes, the ulceration would be at the base of the penis, not the anus.  I understand that you are having muscle discomfort and odd sensations but that could be many things.  I doubt that unless the yeast infection was really bad that it would cause an ulceration at the anus.  Also, the ulcer came up significantly after the normal time that we would see lesions.  I'll be eager to hear your test results but honestly, this just doesn't sound like herpes to me and given your own stated OCD about getting herpes, I don't think we can necessarily trust your opinion about this.  What test results are you waiting on?  I assume you've tested negative for HSV 2 in the past?

Terri
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19 months ago
Thanks, I got the test results back.

The swab test was negative for HSV1 and HSV2. It was a PCR swab.
I first noticed some itching in the area on Wednesday. I had pain in the area on Friday. I took a picture on Saturday and it was an open wet ulcer.
I went in Sunday morning and had it swabbed. The guy took 3 swabs, one aerobic bacteria, one anaerobic, and one viral. I don't know the order he took them in. It was very painful when he swabbed it, so as far as I could tell it was still a moist open ulcer that was sampled.
On Monday, I took a picture, I could see that the middle of the ulcer was gray / yellow.
On Tuesday, the pain was mostly gone and you could barely see any open area at all.
On Wednesday, the pain was totally gone and everything looked totally normal on the photograph, couldn't tell where the ulcer was.
Thursday, still totally normal, like nothing happened.

If you go to the Wikipedia page for "genital herpes" that nightmarish picture of the vulva in the top right with all those ulcers? Mine looked JUST LIKE one of those ulcers. Right on the area in front of the anus where the perineum begins. Except it was just a single ulcer, not multiple, and the whole anal area and right perineum was red and looked irritated. This has since died down. This is why I was so concerned, along with the CDC's website that says essentially all anal/genital ulcers in sexually active young people are either herpes or syphilis!!!

Going back, on that Wednesday, I had eaten extremely spicy Thai food, had diarrhea immediately afterwards, and the next morning as well. Could this have caused it?

The bacterial culture actually grew a little bit of Group B strep, and they wanted to give me antibiotics. Can group B strep cause a single ulcer like this?

Unfortunately they did not send the order for the HSV1 and HSV2 blood antibody, they only sent the HIV order (which was negative), so I did not get the antibody results. The last time I was tested for HSV antibodies was 11 years ago when I had my very first sexual partner. I have had 5 others total.

It sounds like you thought this was probably a recurrence and not an initial outbreak? I did have unprotected sex twice with another girl in May, but never had any symptoms at the time, but again was taking Valtrex briefly.  But again, wouldn't it show up on the penis as a recurrence and not the perianal?

My question is, based on what I have described, can I trust the PCR swab test and put this issue to rest right now? I am not eager to go back in and have the antibody test done again. This past week has been total hell for me. I thought I had this 100%, my life was over, and was having suicidal thoughts. I am going to see a therapist next week to work on some of these things. I am scared this was a false negative and nothing else could explain that ulcer.

Appreciate your thoughts.
19 months ago
Also, could you comment on whether the Valtrex I was taking could have affected the result of the swab test?

I was taking Valtrex at the time of the encounter and took it for 5 days post encounter then stopped completely. I had taken it on and off for maybe a week beforehand.

The lesion in question developed about 17 days post encounter, so I had been off of Valtrex for about 12 days when I first noticed pain in the area. I did NOT take anymore Valtrex when I noticed symptoms. So it was swabbed on day 20, 15 days after Valtrex was stopped.

Since this thing appeared and developed after I had been off Valtrex for about 12 days, that means if it were hsv, there would have been active virus to detect? Or would Valtrex still have had some sort of impact? I thought the half life was around 12 hours.

If you could clarify, that would be very helpful. This is really upsetting. I'm looking for any reason to question this test result. Maybe they didn't store it correctly, maybe they swabbed everything off with the bacterial cultures, maybe the Valtrex from 2 weeks prior somehow screwed it all up, etc...

19 months ago
I went back and looked at a picture I had taken on July 31st (9 days post encounter and 4 days post stopping Valtrex), and there was a tiny flesh-colored bump in the exact location the eventual painful open ulcer developed 8-9 days later. No surrounding erythema, and I don't remember any itchiness or pain or tingling at the time, but there's no denying there's  a tiny oval shaped bump at the exact same spot where the ulcer eventually developed.

This has me entirely freaked out. I am wondering if I didn't notice the lesion until it was in the ulcer stage  and just totally missed it while it was a papule/vesicle. What are the odds this tiny flesh colored bump brewed for 6-7 days asymptomatically until I noticed an itch then pain and took the picture and discovered the ulcer? The reason I had taken that picture on July 31st was because I was trying to look at a bump on my thigh, but it also gave me a clear view of the perianal region, so I went back to see if something had been in the area where the ulcer developed and sure enough, there was a tiny little thing there (flesh colored though, not red).

All of this together is making it really hard to trust the PCR swab result.
19 months ago
Well, nevermind. The urgent care clinic and/or lab screwed the test up.

They took two swabs (viral and bacterial) and two vials of blood. I did not get the results from the hsv antibody test because I was told the order was never sent.

There were two pages of lab result. One page with one "specimen" and another page with another "specimen" The source of both specimens on the report was listed as "AU Anus"

The first specimen results were:
HIV non-reactive
Bacterial culture #1: 1-2 colonies group B strep
Bacterial culture #2: Mixed site flora

The second specimen results were:
PCR DNA
HSV1 negative
HSV2 negative

Obviously you can run an HIV test on a swab from an ulcer. That's a blood test. And it appears they ran bacterial cultures on my blood, not on the swab.
The second specimen, I can only assume was the second vial of blood, and they ran HSV DNA PCR on the blood.

I tried to get answers, and the lab wouldn't talk to me, and there was a different provider at the urgent care who said he would look into it. I don't know what happened to the swabs. I am hoping there is some way for the lab to confirm if the PCR test was run on blood or the swab. It was LabCorp.

The provider didn't know what PCR was. I asked him to make sure they did a PCR test instead of viral culture. It appears the secretary phoned in authorization or something for it.

Anyway, I'm nearly certain this is herpes. I don't know what else would cause a raw open perianal ulcer that healed on its own in 5 days and was preceded by some itching and uncomfortable sensation in the area. I remember the girl briefly touching me in that area once (because it was odd) and she must have scratched the perianal skin with her nails. I didn't notice symptoms until 15 days later (including the leg aches and headache), I think because the Valtrex I took for 4-5 days post encounter stunted the growth of the virus initially. I'm sure that flesh colored little spot I noticed on the photograph 9 days post encounter eventually grew into a blister and ulcerated, I just never saw the blister because where it was.

I had them draw blood yesterday for the IgG and IgM antibodies (now 4 weeks out). I will post when I get those results. 

I know this is an odd first presentation. Maybe it's a recurrence? Hopefully the blood test will shine some light.
I'm really struggling with accepting this. I was always so paranoid, avoiding sexual encounters, obsessing about possible symptoms, worried about getting herpes my whole life, and now it's finally happened. I was hoping I could get back with my former partner of 7 years and get married. So much for that. Threw it all away over someone I wasn't even in a relationship with.

Appreciate your thoughts.
19 months ago
Ignore the last post. The office confirmed with the lab that the PCR and bacterial culture results were in fact from the swab.
Still curious if taking Valtrex for 4-5 days post encounter could have affected the PCR swab of a lesion that developed 10 days after the Valtrex was stopped. Valtrex would only affect the PCR swab result if it was taken after the lesion developed and before the swab was done, correct? In other words, if the lesion developed and grew while I was not taking Valtrex, the virus will be untainted and can be amplified normally. Or would Valtrex effect from 2 weeks prior somehow still have an effect?
Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
19 months ago
I thought you said that you were taking Valtrex 15 days before the visit.  If that is correct, then it would have no influence on the swab test.
As to the lab specimens:  The PCR was negative and the timing off medication was appropriate.  If you want to follow up with an IgG test at the appropriate interval (12 weeks from the concerning encounter) that's fine. 
Reviewing all that you have written, I can see that you are very very focused on your genital area and on the issue of herpes in particular.  I think this could be clouding your judgement about what is going on here.  If the IgG result is not adequate to reassure you about this lesion (if negative) you could get the herpes western blot for greater reassurance.

Terri
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