You may remember me from last week. I am the guy who had a new partner (female) and was prophylactically taking Valtrex. I stopped taking Valtrex 5 days after the encounter (condom-protected), had some weird leg tingling, then 17 days after the encounter developed brief itching then pain around the anus. @ 19 days photographed and realized I had an open ulcer on the perianal-perineal transition, had it swabbed @ day 20 (still open and painful at this point), the ulcer then totally healed by day 23.

The swab PCR test came back negative for HSV-1 and HSV-2. I'm worried it was a false negative because it started to heal the next day after they swabbed it and was totally healed 2 days later. I don't know what else would cause an perianal ulcer like that other than herpes.

I have HSV-1 since childhood, but have not had a cold sore on my mouth in over a year.

I went in 4 weeks post exposure (day 28) and had blood drawn. Here are my results:

HSV 1 IgG: 55.50 (High)

HSV 2 IgG: <0.91 (negative)

HSV, IgM I/II Combination 0.91 (High)

My concern is the IgM. It lists negative as <0.91, equivocal as 0.91 - 1.09, and positive as > 1.09

I know IgM is often falsely negative, but I let them do it in hopes it would be negative. But it just BARELY registered. This has me entirely freaked out.

I haven't had a cold sore in over a year. I know IgM can be elevated during HSV recurrences. So if it wasn't the cold sore that elevated it, that means it was probably a new HSV-2 infection that elevated it and the IgM is just tapering off because it was drawn 28 post exposure (5 days after lesion had totally healed).

Can you provide some insight on what this "equivocal" result means and if it's more likely due to my old HSV-1 or a possible HSV-2 infection acquired 28 days prior?

How likely are my negative swab and negative IgG to be true at this point?

Should I ask the partner to get tested?

Just to be clear, I haven't had a clinical reactivation of my oral HSV-1 in over a year (no cold sores). So why is the HSV IgM not negative?

How fast does IgM fall off after a non-primary first episode infection of HSV-2?

Would you expect someone with prior HSV-1 infection who acquired HSV-2 28 days prior to still have a definitively "high" IgM response? Or would it be negative? The equivocal scares me because it makes me think it WAS high, but is in the process of falling now that the ulcer has healed and so much time has passed.

Put another way, if someone with prior HSV-1 came in with a recent exposure and tested high on IgM but hadn't had an oral outbreak in years, would that make you more concerned the IgM represents a new HSV-2 infection? I know negative IgM doesn't mean much, but what about when it's positive or equivocal like that in the setting of known HSV-1 infection but no recent outbreaks?

I think you are placing WAAAAAY too much confidence in the reliability of the IgM test.  It is NOT type specific and any reliable lab will tell you so. People with HSV 1 will regenerate HSV IgM periodically, probably often with no symptoms at all.   In addition, 0.91 is NOT positive, it is just barely into the equivocal range - just barely.  I would ignore it completely.  I would follow the CDC guidelines and never use this terrible test. In my experience with people who have had this done elsewhere, it is falsely positive for HSV 2 80-90% of the time, compared to the IgG result obtained at the proper timing after a concerning encounter. 

Terri

Some specific questions:

Is the duration of my symptoms consistent with first episode non-primary HSV2? Painful raw spot for about 4 days, then totally healed over the next 2-3 days? No crusting or anything, but it was on the perianal skin.

How often do you see a single ulcer in first episode non-primary HSV2? Are there usually multiple lesions?

If this were a new HSV2 infection, what would you have expected my IgM and IgG to be at 28 days post-encounter in the setting of initial Valtrex use? I have read multiple things about IgM. Some sources say it becomes detectable after 10 days then declines after 14 days (so you have a tiny window to detect it)? Other sources say it stays elevated for 2-3 months after initial infection. What's the truth? I'm wondering if I can take any solace in the fact that my IgM wasn't overtly positive.

For the IgG, would you expect me to be testing in the equivocal or low positive range right now?

Do you see primary outbreaks around the anus in heterosexual men who exclusively wore condoms? She touched the area briefly a single time with her finger and had fake nails so am wondering if she scratched the skin.

Finally, is it appropriate to go to this partner and ask her to be tested? She says she gets a "yeast infection" once or twice a year. That's what set this whole thing off. 2 days after the encounter she told me she had a "little bit of a yeast infection and it hurts" then told me she gets these and they usually clear up in a few days with OTC treatment. She was under a lot of stress at the time, and this set my mind off with the gears turning.

Because of the timing and duration of the symptoms, I was wondering if this was not a primary outbreak but a delayed recurrence from my partner back in May I had unprotected sex with, but the fact the IgG was negative I guess excludes that. The only possibility is that it came from this girl.

Thank you for putting up with my neuroticism. I was 100% convinced I had this but now I'm not so sure, but I'm afraid to even get my hopes up a little.

How much can I trust the negative PCR swab? The ulcer hurt when he swabbed it, so it was still open (I had noticed the pain about 2-3 days prior with the itching a few days prior to that). But the next day, the center of the ulcer turned yellow/gray, the day after that it was almost totally closed up except for a tiny crack, and the day after that you couldn't feel anything or see that there was ever anything there.

Does this sound like there still would have been viral DNA for him to catch?

If you were taking antiviral medicine at the time of the swab test, that could definitely influence the swab test to move in the direction of a possible false negative.

I think I've said that the IgM should be ignored so I'm not going to answer questions about this dreadful test

If you are newly infected and not taking medicine, you MIGHT start to show it up on the IgG test, yes

We don't normally see primary (or non-primary) infection around the anus in straight men, no, but often as recurrences.

I think it's fine for you to ask her to test - and she can feel free to say yes or no. 

I would advise holding off on more antivirals as they are confusing your picture, yes?

Terri

I have asked her to test, and she is going to.

Regarding your comment about antivirals affecting the swab test, I just want to clarify the timing as previously you said it wouldn't have affected it, now you're saying it might have.

I was taking Valtrex for about a week prior to the encounter, then I took it for 4-5 days after the encounter (july 22) then stopped completely.  No more Valtrex since July 27th. Photograph on July 31st showed a tiny raised flesh colored bump in the area the ulcer would develop.

Noticed sudden single episode of itching (~5 minutes) and tender feeling but no bump around August 7th. Noticed pain August 9th. Photographed August 10th and saw it was an ulcer/raw spot. Swabbed on August 11th when it was still raw and tender. Still painful and raw Aug. 12 but starting to heal. Fully healed Aug 14th.

Blood test was on Aug 19th.

Based on your personal experience and the timing above, how much can I trust the swab test PCR result? Symptoms developed about 12 days after stopping Valtrex, and the ulcer was swabbed 15 days after stopping Valtrex. It was raw and open when swabbed but must have been starting to heal because it was totally healed 3 days later. How much does this sound like first episode non-primary herpes to you?

And last question, how much would my Valtrex use around the encounter affect IgG testing at 28 days and going forward? if I test at 12 weeks with no further Valtrex, is that trustworthy?

Thank you for all of your help through this incredibly difficult time.

You are pressing me for an exact answer and I just don't have that for you!  I think it is unlikely that the Valtrex impacted the swab test but I suppose it's possible that it could have.  If the swabbing was done 15 days after stopping Valtrex, I think it is unlikely that have influenced the swab test.

I can't really keep track of exactly how much Valtrex you have taken but if less than 2 weeks, 12 weeks should be fine.  For each week over 2 weeks, I think I would add a week in time as a precautionary measure.

Terri