[Question #7475] Concerns on testing - Dr. HH

4 months ago
Hi Dr. Hunter Handsfield, 

I am a male and on 14th November, I received and gave unprotected oral to a male escort. There were no visible lesions  or ulcers, both around their genitals and their mouth. 

On 6th December (22 days later) I noticed an ulcer developing on just below my penis head and a slighty tender lymph node in my left groin. I went in for a testing on 8th December (24 days later) and results were as follows:

Chlamydia / Gonorrhoea urine test - negative 
Chlamydia / Gonorrhoea throat swab - negative
Syphilis blood test - negative 
HIV 4th Gen test - negative 

While awaiting results, my ulcer began oozing pus and I was overcome by panic and fear. Believing it's syphilis I began taking doxycycline  pills (100mg, twice a day.  After 3 days (Tuesday 8th, Wednesday 9th and Thursday 10th) I got to my senses that this is wrong and stopped taking them, so I took 6 in total.

Today, 12th December (28 days since possible exposure) I went in for another Syphilis and HIV test. Since Wednesday, my ulcer has also began shrinking in size and healing. It's now about a 3rd of what it was. 

My questions are: 

1. How reliable are my first results 24 days after possible exposure? 
2. Would the 6 doxycycline pills taken already have had such a positive effect on the ulcer? 
2. How reliable will my second results 28 days after possible exposure be? 
3. If they are not reliable, how long should I wait before retesting? 

Thanks in advance


4 months ago
One additional question; I know taking the doxycyline was a mistake but should I continue them at this stage and finish the remaining 11 days? 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
4 months ago
Welcome to the forum. Thanks for your confidence in our services. FYI, it's only by chance I'm answering your question rather than Dr. Hook: as explained in the forum's introduction and FAQs, users do not have the option of selecting the moderator who responds. Dr. Hook and I have identical experience and expertise.

Probably your self-diagnosis is correct:  you have syphilis. As you now realize, it was a mistake to start doxycycline. Although it is usually effective and it has started to cure you, it would have been better to wait for a confirmed diagnosis. And exactly as you appaently are worrying, partial treatment of early syphilis can interfere with diagnosis. However, having stopped doxy, please do not restart it; far better to see a doctor or clinic ASAP to confirm the diagnosis and for proper treatment with an injection of long-acting (benzathine) penicillin. Doxycycline is a back-up for penicillin allergic persons or if benzathine penicillin isn't available, but is inherently less reliable and, as you apparently know, requires treatment for a full two weeks. Your latest blood test probably will be positive, but not necessarily:  it takes up to 6 weeks for a posiive blood test; and partial treatment with doxy could delay a positive result. In other words, if positive it will confirm the diagnosis; if negative, it won't either confirm or refute the diagnosis. Regardless of the current result, you'll need another blood test at the time you recieve penicillin:  it is desirable to know the peak RPR or VDRL Assuming a positive result either now or when you get penicillin, you'll need follow-up testing over at least the next year to follow the result and assure that treatment is effective.

In the meantime, you should inform your partner from a few weeks ago, if you are in touch or can locate him. Also, of course, anyone with whom you've had sex since that event.  If you're in the US, once the diagnosis is confirmed, you can expect the public health department to be in touch about assuiing that all partners are informed and treated.

I hope this information is helpful. I look forward to hearing more once you've been examined and properly treated. It's best to find a doctor or clinic known to be experienced with syphilis, such as a local health department; in the UK, a GUM clinic; an Australian federal sexual health centre; or their equivalent, depending on where you are.

Please keep me posted --   HHH, MD
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4 months ago
Hi Dr. Hunter Handsfield, 

Thanks for your reply and expert opinion. 

I am in the Netherlands and visited the SOA GGD clinic here - equivalent of UK's GUD. 

My testing history is now as such: 

24 days post exposure 
Chlamydia / Gonorrhoea urine test - negative 
Chlamydia / Gonorrhoea throat swab - negative
Syphilis blood test - negative (0.4)
HIV 4th Gen test - negative  

28 days post exposure 
Syphilis blood test - negative (0.4)
HIV 4th Gen test - negative 

32 days post exposure 
Syphilis blood test - negative (0.4)
HIV 4th Gen test - negative 

The clinician I have seen has now recommended to test every 3 weeks until we reach the 3 month mark for syphilis, in which case I'll be in the clear. With regards to HIV, he says the risk of transmission from receiving oral is already virtually non-existent and that result after 32 days is 99.8% reliable and there is no need for any worry. 

What are your thoughts on the above? 

Thanks! 


H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
4 months ago
Amsterdam's GGD is one of the most expert STI/HIV clinics in the world. Its medical director, Dr. Henry de Vries, is world renowned in the STI/HIV field -- and a personal friend and colleague of mine. (I would rank GGD above most UK GUM clinics.) You can rely absolutely on the scientific rigor and quality of care you are receiving.

I suspect you may have linked with a somewhat conservative clinician, although I suppose it is possible the clinic policy is to retest persons for syphilis as long as 3 months after exposure. I've never heard of it taking that long and consider 6 weeks conclusive in all cases. I agree HIV testing is >99% conclusive at 32 days.
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4 months ago
That's very encouraging to hear re: the Amsterdam GGD. 

You said "I've never heard of it taking that long and consider 6 weeks conclusive in all cases." However, I did initially say that I took doxycycline on days 24, 25 and 26 post possible exposure. Would that delay a positive result even at 6 weeks or do you expect that to be conclusive? If you expect a delay, by when can I consider a negative test conclusive? 

Secondly, as my sore has healed, shall I still refrain from sexual contact until I conclusively test negative? 

Thanks 


4 months ago
And thirdly, I've read that a syphilis chancre/ulcer does not usually ooze pus. Is that correct?  I'm beginning to wonder if what I had was even syphilis or not. 

Thanks! 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
4 months ago
In my last reply, I was forgetting the entire context of your question. Disregard it entirely -- apologies!

Since you likely had syphilis based on your symptoms etc, your blood test might eventually become positive, and in this situation the advice to keep testing out to 3 months makes sense. (As I said, you can rely on the expertise and advice of GGD!) I would have thought they might have treated you with benzathine penicillin, however -- so perhaps they were more skeptical that you had syphilis than I was. Alternatively, maybe they believe doxycycline cured it. Doxy for only 3 days is not advised (shoud be 14 days), but we really don't know the minimum amount that might be curative, and 3 days might have eradicated syphilis if you had it. In that case, your blood test might never become positive. If it does not, it would conclusively prove that you don't have syphilis now, but you would never know whether you never had it, or had it and were cured. 

Finally, it is true that chancres don't usually ooze pus. That fact argues against syphilis as the cause of the problem. However, it's not conclusive evidence in and of itself.
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