[Question #85] part two Question #64

39 months ago
Hi Terri,

My husband and I have some new information. He thought it would be helpful to provide all of the details here in chronological order before asking my question so that you have everything in one place.
  • My husband and I have been together since early 1999 and we have both been monogamous since our relationship began. We both had multiple partners prior to our meeting.
  • During the week of April 13, my husband first noticed a spot on his lower back/upper buttock that was tender to the touch. He thought it was irritation caused by the messenger bag he carries on his daily commute. Over the following weeks, the discomfort came and went, and it occasionally itched.
  • On May 31 or June 1, my husband noticed the area around the discomfort was moist to the touch. He thinks he may have popped something open while scratching, but isn't certain.
  • On June 2, a doctor at a walk-in clinic looked briefly at the spot, told my husband it was HSV1 ("non-genital," in her words), and prescribed oral and cream antivirals. He started the 5-day regimen that day. (Unfortunately, this doctor didn't order a test or provide any guidance or counseling.)
  • I'm certain that we had unprotected intercourse between April 13 and June 1, and once between June 2 and June 9.
  • On June 9, a doctor at our family doctor's practice looked at what was left on my husband's backside and said it did look like HSV, but it had started healing at this point.
  • In mid-June, my husband met with an infectious diseases specialist at a local hospital who looked at the irritation and said it was either HSV1, HSV2, or shingles. It had healed too much for him to make a diagnosis. His advice was to wait for a future outbreak and have it tested directly. He said if it were shingles there would be only a 5% chance it would return, if it were HSV it could return frequently.
  • On July 9, my husband had a new itchy bump on his buttock in a different location checked by the same infectious diseases doctor. This one never oozed. He said it didn't look like HSV to him. He took a sample on which they did a PCR test. This came back negative for HSV.
  • On July 31, my husband and I both had blood drawn for a type-specific antibody test. I am negative for both HSV 1 and 2. My husband is positive for HSV 1 and negative for HSV 2.
The doctor who consulted with us on July 31 for the blood test said it sounded like my husband had an outbreak of shingles rather than HSV. He based this on his experience with diagnosing shingles in other patience and on my husband's description of the outbreak: to my husband's recollection, the irritation was on one side of his upper buttock, was perhaps the size of a quarter or half-dollar, and was a small number of bumps, perhaps just one bump. Upon giving my husband the test results, this doctor said that he thinks it's likely that my husband contracted HSV1 long ago and that we have nothing to be concerned about.

Now on to my questions: is it possible that my husband's oozing outbreak was HSV1 or given this new information do you think it is more likely shingles? He was under a lot of stress the past 2 years including the death of his father last November. Is it possible that my husband has the HSV1 antibodies due to exposure from kissing a relative as a child or being slobbered on at daycare or sex but has never actually had herpes?

If you believe it was not shingles but HSV1 do you think it is helpful for me to take any precautions at all if I have not contracted anything in 16 years simply because all of a sudden he has one isolated outbreak? does the fact that he had an outbreak make him more contagious? Some doctors have recommended abstaining just before he has an outbreak in the future but I find it frustrating to worry about every itchy bump. He has no recollection of any oozing bumps or cold sores before this outbreak.

Finally, according to your website "Also, and even more importantly, most adults already have oral HSV-1, contracted as a child through kissing relatives or friends." 

So given our situation do you advise we take any precautions for our 3 children as currently we all share toothpaste, ice cream, food and whatever normal families share. 

Thank you.

Emily

Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
39 months ago
Good morning Emily,
That is certainly a rather long and complicated story. 
First, the traditional screening test misses 25% of HSV 1 infections, so it is still possible that you have HSV 1 infection and the test didn't pick it up.  The herpes western blot is far more sensitive for HSV 1 so if it is ever your desire to confirm your negative status, that could be done.
Second, let me ask if your husband has ever had a cold sore in his nose or on his lip - ever in his lifetime . If yes, then that's when the antibody is coming from.  I know you said no, but could he have had this in his nose instead of on the lip?
If no, then the spot on his hip could be HSV 1, but HSV 1 genitally occurs quite infrequently and it might be a long time before it ever show up again, if that's what it ever way.
At this point, there is no way to know if the spot was herpes or shingles.  It would have been best, of course, if the original doctor had swab tested the lesion.  And to say that it is HSV 1, just by looking is incorrect.  Both HSV 1 and HSV 2 look just the same on the skin. 
As for taking precautions:  without knowing if you actually have HSV 1 or not, it is difficult to say.  But let's assume for a moment that you are actually negative.   You've been having sex for 16 years and aren't infected yet, if I was in your place, I would not change a thing.  If he has it, then he's had it all that time, right?  As I mentioned, HSV 1 recurs AND sheds infrequently, so if you do happen to get infected after all this time, it would likely behave the same way in you. 
I do not think there is any need for precautions to protect your children against your husband's HSV 1 infection, wherever it is. No.
Please feel free to ask follow up questions here .

Terri
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39 months ago
This is the test we got based on your recommendation from my question #64 from some weeks ago. 

http://www.questdiagnostics.com/testcenter/testguide.action?dc=TH_HerpeSelect

It says at the bottom it is more than 90% accurate :

"Interpretive Information

These assays are highly sensitive (91%–100%) and specific (93%–100%) for HSV-1 and HSV-2 infection, even in the absence of symptoms. Thus, a negative result suggests absence of infection. Because antibodies may take several weeks to reach detectable levels after primary infection, negative results should be confirmed by repeat testing 4 to 6 weeks later in cases of suspected early infection.

A positive result strongly suggests infection with HSV."


Thus I am not sure why you are saying there is still a 25% chance my negative is false. If I had known the test you recommended was only 75% accurate I might not have paid for it. Do you believe it is accurate for my husband's positive?

Based on what we have told you and the results quest diagnostic test, can we safely rule out HSV 2? That is the one that is more troublesome so that would be a relief.

Neither my husband nor I have any recollection of any type of cold sore or oozing sore anywhere on our bodies including our noses. My husband is not sure whether or not he would have remembered something from childhood. As I mentioned in the previous thread, question #64 which I think I submitted under sexually transmitted diseases not under herpes, he does recall a pimple on his penis once in adulthood. He said it looked just like a pimple like a white head but he does not remember whether or not it oozed.

Finally, to be clear, you are saying if you were in my shoes, you would not suddenly start using condoms or abstaining at ANY TIME (for example if my husband felt a suspicious itch or even if he had another outbreak on his buttocks which this time we would have tested straight away) since I likely am  A) immune or B)already have it but am asymptomatic or C) will get it from him whether or not I take any precaution since condoms and abstinence during breakouts are not that helpful and my symptoms if i were to suddenly contract it would be infrequent. 

Also you are saying that even though HSV1 can be transferred by kissing and my husband has it, we don't need to do anything special with regards to our children?

Thank you.

Emily


Terri Warren, RN, Nurse Practitioner
Terri Warren, RN, Nurse Practitioner
39 months ago
Let me restate that - if your husband has a cold sore on his lip, then he should avoid kissing the children.  But if he has cold sore at the time, he can safely kiss the children in the way that a parent kisses a child - closed mouth peck.  Kissing may be a risk for transmission of HSV 1 oral infection if the kissing is an open mouthed or french kiss, but not the kind of way an adult kisses their children.  There needs to be enough virus present and transferred to infect another person and that is not the case with a kiss with no cold sore. 

As for the test:  The problem with the HSV 1 test is not false positives (normally) it is false negatives.  So your husband's HSV 1 positive result should not be a worry.  And yes, new data that we have suggests that it does miss about 25% of infections.  But that would not cause me not to do the test for my patients because the positives are quite reliable, and one would not want to start out screening with the more expensive and complicated test. 

And yes, I believe that you can safely rule out HSV 2.  The test misses about 2-3% of cases of HSV 2, but really, if you both test negative at this point, if I were in your shoes, I would feel reassured and move along.  As for sex - I wouldn't take any routine precautions like starting to use condoms at this point.  But everyone is different, and you might be more cautious than I am, so you should adjust your behavior accordingly.  First, you don't know if his HSV 1 is oral or genital .  And if it is genital, it is shed infrequently.  And then there is the issue of you guys having sex for years and you not getting infected already.  Again, if you want to be incredibly cautious (and that's OK if you want to be), he should take daily antiviral therapy and you could also use condoms with intercourse. 

If at some point you really want to know if you are HSV 1 positive you could get a western blot. 

Terri
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