[Question #7373] Concerned HIV/STI

4 months ago
I’ve read most that might be pertinent to my issue but Just in case I missed something. 

Day 1 Protected receptive anal. Also insertive and receptive oral, no ejaculation with CSW. CSW later said he was undetectable. (i am a man)
Day 3 Dry cough. 
Day 4 Sore throat. Masturbated 3 times in 4 hours. Began to feel soreness in urethra and tip of penis later. No discharge. 
Day 5 Fatigue. Dry cough. Urethra and tip of penis sore. Frequent urination. 
Day 6 Tested for chlamydia and gonorrhea (throat swab and urine). Given shot and drink antibiotics. Tests came back negative days later. 
Day 7-10 Sore throat continues. Mild congestion.  Urethra pain continues. Still no discharge. Night sweats for two nights...haven’t had any since.  
Day 10 went to ER for perceived pain on penis. Doctor swabbed penis and took more urine samples for same test above. Came back negative again. HIV blood draw...also came back negative. Strep negative. UTI negative. Doc ruled out herpes. Prescribed Doxycycline.
Day 11-14 Sore throat continues.  No fatigue. Appetite and energy up. Friction and over examination of penis seem to worsen symptoms on penis.  Noticed pain in rectum. 

Questions:
1. Possible HIV infection?test was probably too soon. Could it still be ARS?
2. Can it be flu/COVID and penile issue is a coincidence?
3. Is it possible to have syphilis, herpes or other STI inside rectum with not other symptoms
Outside?
4. likelihood of other STIs such as NGU?
5. Likelihood of urethritis from masturbation?
6. Possible STI in throat with no other signs in oral cavity?
7. Any Reasonable explanation for sore throat after antibiotic treatment? 



H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
4 months ago
Welcome. Thanks for your confidence in our services; for reading other discussions pertinent to your concerns; and for the succinct, objective tone of your question. The issues are very clear.

First some general comments, then to your questions. You don't say whether your insertive exposures ~2 weeks ago were also condom protected. Not highly important for oral insertion, more so for anal. Presumably your partner has known HIV, otherwise he wouldn't describe his viral load as undetectable. For the most part, people are truthful when asked directly about HIV status, so the likelihood is that indeed it was undetectable at his most recent test, in which case there was no measurable HIV risk. It is true, as you can find online and elsewhere (including recent direct-to-consumer drug ads on TV) that "Undetectable = Untransmittable". And your symptoms are less typical for ARS than you might think. Cough and nasal congestion are not typical and neither is urethral pain. Sore throat can be caused by ARS, but rarely with other cold symptoms; and usually with fever, lymph node enlargements, and skin rash. Also, yor sore throat started too soon:  ARS symptoms do not begin sooner than 7-8 days after exposure. Obviously anyone close enough to another person to have sex is also plenty close to catch a garden variety cold virus -- or, as should be obvious as the COVID-19 pandemic rages, coronavirus.

To your questions:

1) Your negative test was too soon to exclude a new HIV infection, but the negative result DOES confirm your symptoms are not due to ARS. Everyone with ARS symptoms more than a few days duration has a positive antibody test.

2) Yes, as implied above. You need COVID testing ASAP; more on this below (no. 5).

3) Yes, internal rectal infections with these STIs are possible. But you don't describe symptoms to suggest any of them; the sex was condom protected; and it's also stoo soon for syphilis symptoms.

4) Urethral pain alone rarely is due to any infection. Almost all men with NGU have abnormal discharge, not just pain. And in the off chance you had undetected NGU, the doxycline would treat it effectively. The lack of improvement of penile pain suggests your genital discomfort is not due to any bacterial infection, STD or otherwise.

5) Masturbation doesn't cause urethritis. Vigorous manual stimulation could do it, but I'll bet you've masturbated previously without this happening. However, a urethral viral infection is possible. Conceivably herpes, but unusual without external penile blisters, sores, etc. Is there any redness, swelling, or other evidence of visible irritation of the meatus (urethral opening)? If so, one possibility is adenovirus. Some types of adenovirus, which typically causes common colds, can readily infect the urethra during oral sex. I also wonder if the pandemic coronavirus can infect the urethra. I see no reason why it cannot, but it has not been reported in the medical literature. If you were to come to my STD clinic, I would be inclined to obtain a urethral swab for COVID-19, in addition to a routine nasopharyngeal swab. And by the way, although adenoviral urethritis is painful, it clears entirely over a couple of weeks, with no long term consequences.

6,7) No STI causes sore throat with any regularity. The most common throat STI is gonorrhea, but >90% are entirely asymptomatic. Just as for your urethral pain, persistence on doxycycline is good evidence against any bacterial infection. This much more likely a viral infection, either garden variety viral pharyngitis or perhaps COVID-19.

Please follow through ASAP with your PCP or other doctor or clinic for COVID-19 testing, to perhaps include your urethra. I look forward to hearing the outcome. In the meantime, if you're in touch with your CSW partner, you should tell hinm what's going on and suggest he also get checked for COVID.

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

HHH, MD

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4 months ago
Thanks for the response. I've been on antibiotics for over 12 days now (adding Doxycycline 6 days ago) and the symptoms in my penis have persisted. Thought it might've been a virus. Insertive oral was not protected. Questions and answers from your response...

1) Thanks that's helpful. I'll be sure to retest in a few weeks.
2) COVID is possible. Will get tested tomorrow and post results when they come up.  
3) Thanks. I've been very conscious about small changes in my body. Probably nothing more than that. Why did you rule out herpes in rectum? Assuming because of everything else that's going on...
4) Could the injection and drink (can't recall the meds) have treated the NGU as well...or is Doxycycline the only effective rx? (Didn't start Doxycycline until Day 10).
5) There is redness in the meatus and slightly sensitive. This was more prominent from days 4-7. Has subsided since but still noticeable. It's probably better today than it was yesterday. So if I there are no external sores, blisters, it sounds like you're ruling out herpes. Reading past posts, it's rare for herpes to show up after two weeks. Is that accurate? 
6/7) I read up a little on adenovirus and what I feel is consistent with that. Should've also mentioned that the physician at the ER on day ten looked at my throat and determined that the redness was consistent with virus. Like you said...because this has persisted, it might be a virus. 

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
4 months ago
1) Thanks for the thanks. You can definitely expect future HIV testing to remain negative.

2) Please also request both urethral swab and urine specimen be tested by COVID-19 PCR. Show them my comments above. I have discussed this situation with a top-line COVID expert who agrees with this. At least the specimens could be collected. If your nasal swab is negative, then nothing more need be done. If positive, then the urethral and urine specimens should be tested. In the event these are positive, you could make a small mark on medical history; in that event, your doctor(s) should report the case to a medical journal.

3) There is nothing in your symptoms to suggest rectal herpes, and your anal exposure was condom protected.

4) The injection was ceftriaxone, for gonorrhea. If the "drink" was a bitter white powder in water, it was azithromycin, effective against chlamydia and most cases of NGU. The doxycycline is evven more reliaable against both of these. So you've been double treated for NGU.

5) It's conceivable your urethral problem is herpes, but very unlikely for the reasons you state. But you could ask your doctor about a urethral PCR for HSV. I see this as a low priority, but perhaps a negative result would further reasure you about it.

6) Yes, all this is consistent with adenovirus. And also with COVID-19, hence my advice above.

In general terms, I would say your apparent priorities seem to be reversed. By far the most importnt possibilities here concern COVID-19, not STD. If you have adenovirus, it doesn't matter-- it will clear up soon with no long term consequences. And no other STD is likely. Focus on coronavirus until it has been tested and ruled out.
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