[Question #6655] Flu-like symptoms and unusually severe oral HSV outbreak after exposures

14 months ago
I recently posted in the herpes forum but would appreciate the viewpoint of an infectious disease specialists regarding some of my concerns.
I am male and have longstanding HSV1 orally and get about 1 outbreak a year on average.
History:
3 weeks ago: Unprotected vaginal sex with new partner 4 times. I considered her very low risk (just got out of divorce, one lifetime sexual partner and 3 kids. Drugs were part of the reason she left, but the drug being abused was adderall). I wasn't very worried about this. This was a one weekend fling. I developed a small cold sore on my lip just before this time and took 4g Valtrex.
1 week ago: Kissing and light petting from a girl I met at a bar.
5 days ago: Kissing and hand stuff from a differnt new girl.
3 days ago: Same girl. Deeper kissing, dry humping, unprotected oral (on me), maybe some very brief skin on skin contact. I was about to perform oral on her, kissing her upper pubic area, but stopped. I don't think my lips contacted her vulva, but if they did it was for a split second. Definitely no penetration at any point.
Right before this encounter 3 days ago, I started coughing. The next morning, I woke up next to her, we resumed some of these same activities from the night before, then I got up, was coughing more and suddenly felt feverish and very, very ill.
Within the next hour I developed chills and severe fatigue. I thought this was the flu and got Tamiflu and took it immediately. I could not get out of bed for 48 hours with a temp of 102.5. The cough wasn't that bad when I was laying down, but if I would get up or take a deep breath I would have a brief fit and cough up a little bit of phlegm. I had a burning sensation in my throat, trachea, and upper chest when breathing, which hurt when coughing.
Today my fever broke and energy started to come back, and I needed to take a long drive. I felt a buzz-buzz-buzz on my lip like a normal herpes prodrome, then 30 minutes later felt a bump in that area. By the time I got home 8 hours later, this had evolved in a very large herpes outbreak. This looked NOTHING like my typical HSV1 recurrences, which is usually a single large fluid filled blister, or maybe two at the most the size of a tic-tac. This area on the side of my mouth was nearly the size of a dime with multiple, probably 10, blisters, much smaller than the typical ones I get, but many more of them and extending more into the skin. I immediately took 2g Valtrex at this point. With the exception of one time in my early 20s when I had two large outbreaks on both sides of my mouth at the same time and my primary outbreak as a child, my outbreaks have all been the very minor "tic-tac" kind.
Given that this was within 2-3 days of my encounter with the the 2nd bar girl, and the severity of the symptoms,I'm worried this could be a new HSV-2 infection on my mouth.
Also, given that my flu-like symptoms started 3 weeks after my unprotected sexual encounter, combined with the unusual HSV outbreak, I'm worried this could be ARS. I have not had a skin rash that I can notice. I have had diarrhea, but I heard that can be due to Tamiflu.
Given all of this, how would you advise me? I'm very worried and don't know what to do.

14 months ago
Also, I'll add this...

About 2 weeks before ANY of these encounters, I was in the South Pacific and believe I may have contracted something like a mild Dengue. I had multiple mosquito bites and developed a raised bumpy red rash over most of upper torso. Didn't really get a fever, maybe a little tired. Went away on its own after about a week.

There's just so much crazy stuff going on with me. I never get the flu or sick in general, and I normally get 1 HSV outbreak a year, if that, and now I've had a severe case of what I think is the flu and 2 herpes outbreaks within 3 weeks, the current one being unusually severe and fast-developing. I just want to make sure this isn't HIV or a new HSV2 infection that I somehow acquired orally because my immune system is all messed up.
Edward W. Hook M.D.
Edward W. Hook M.D.
14 months ago

Welcome to this side of our Forum.  Thanks for your question and the detailed history which accompanied it.  I reviewed your earlier interaction with Terri and agree with all that she said, their is very, very little chance of having acquired HSV-2 from the encounter you describe and once a persons has HSV-1 they do not get other HSV-1 infections from other persons (or at other parts on their body).  I also are confident that other than  I don't have a good explanation for the unusual appearance of your apparent HSV-1 recurrence, while they tend to follow a pattern they do vary.  The only way to find out if the lesion you had was HSV-2 is to have the lesion tested, preferably by PCR.  If the lesion is still there and it is due to HSV-2, the PCR should still be positive.  Blood tests will not be helpful in this situation at this time.

The other flu-like illness you describe certainly sounds like influenza and you did all the correct things.  The possibility of dengue is an interesting one.  In case you are interested, neither the exposures nor the timing are in any way suggestive of HIV.  I'm glad you are feeling better.  I'm not sure there is much to be gained by other testing.

I hope that I've addressed your questions.  If there are other concerns or if I've missed something, please don't hesitate to use your up to two follow-ups for clarification.  EWH

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14 months ago
Thanks Dr. Hook,

While the large herpes lesion didn't progress overnight with the Valtrex, it didn't get any better. And I discovered a second, smaller clustered herpes lesion on the bottom of my mouth (the other one was just above the corner of the mouth). This would be the second time ever I've had 2 separate herpes lesions at the same time.

Let me ask you, is it typical when somebody has a major illness with a high fever, like the flu, that when they get a herpes outbreak during this time, it is far worse than usual? Does the flu beat down your immune system that badly that herpes just goes wild?

I am going to go have these swabbed and will let you know. Hopefully the Valtrex does not interfere with the test.

And just to be clear, you don't recommend HIV testing at all?
Edward W. Hook M.D.
Edward W. Hook M.D.
14 months ago

There are no scientific studies which inform us as to what makes some HSV outbreaks better or worse.  We certainly do know that when persons immunity is weakened by things such as cancer chemotherapy outbreaks can be much worse so there is some logic to the idea that when your body is fighting another illness your outbreaks could be both more likely to occur and more extensive than usual. 

As far as the PCR testing is concerned, the sooner you test, the more likely it is to be positive but we certainly do know that the valacyclovir will shorten the duration that the virus is detectable, if it is HSV-1 as expected. 

And you are correct, nothing you have described suggests a need for HIV testing.  EWH

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