[Question #8632] Doubting my results
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41 months ago
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37y old. Developing country. Had some
encounters with CSWs in late 2021. Protected vag and anal, received unprotected
oral every time. Latest on Nov/6th, 21st and 27th. On Dec/3rd I had sex with a
non-CSW. Protected vag, briefly unprotected oral (no ejac.) and unprotected cunnilingus.
4 days later, I had lip blister, diarrhoea. After 3 more days, latest partner sook
care for “allergic reaction”. Social media shows she faced a time of worryness
and convalescence.
I also felt very sick (~ 37,5C) Several systemic
symptoms along weeks (can state all, if relevant). Before It all, ultrasound of
the neck (oct/1srt) revealed 2 reactive nodes left side of neck (1,82cm and
0,9cm). I did not follow-up with ENT doc.
Saw an ID doc on Dec/15th. Tested HIV
RNA Quant (dec/15th), DNA Quali (dec/27th), Elisa 4th gen. (jan/6th), RNA Quant
(jan/7th), RNA/DNA Quali HIV-2 (jan/24th) and 4th gen. Elisa (feb/11th). All neg.
Other: near cut-off chlamydia IgM, high EBV IgG (29 – > 0,99) and Zoster IgG
(4.238 – >110); serum ferritin (379 – 22~280), IgA (371 – 40~350), IgE (174 –
0~140) and ANA 1:160 thin speckled. CD4 counts: 696,3 (37,6%) in jan/7th and
897 (39,3%) in feb/15th, with CD8 545. ID doctor referred me to rheumat. who
told me to move on.
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H. Hunter Handsfield, MD
41 months ago
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Welcome to the forum. Thank you for your confidence in our services.
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You really needn't be at all worried about HIV. Your comments indicate you are aware your partners' health issues have likely explanations other than HIV, and so do yours. And you describe entirely safe sexual exposures: although some people with HIV have believed they acquired their infections by oral sex, there has never been a scientifically validated case of HIV acquired from mouth to penis, or by cunnlingus in either partner. And condom-protected vaginal sex also is exceedingly low risk.
Most important, your HIV test results are conclusive. Indeed, had I been in charge of your care, I wouldn't have done all those HIV tests! I'm not actually arguing against them or your ID doctor's expertise: given your symptoms and concerns, a case can be made for the extensive evaluation you had. In any case, it is absolutely impossible to have HIV in the face of negative genetic testing (RNA, DNA) at the times you had them, or with negative antigen-antibody (AgAb, "4th generation") tests, especially the one on Feb 11, i.e. 6+ weeks after your last sexual exposure. HIV test results always overrule symptoms and exposure history, no matter how typical for HIV they may seem. In any case, there are many far more common causes of reactive lymph nodes in the neck (two of which I'll mention below). So for sure you can disregard HIV. Your ID doctor likely gave similar reassurance.
Having a "lip blister" plus evidence of reactive lymph nodes in the neck suggests possible newly acquired herpes; and conceivably your latest partner's "allergic" symptoms were herpetic (although impossible to know without more detail about them). It's too late to attempt diagnosis of HSV1 and 2 by PCR (which would have been wise when you had the lip blister), and at this point even a positive blood test would say nothing about when you were infected. (In some developing countries, up to 90% of people your age test positive for HSV1, usually reflecting undiagnosed childhood infection.) And herpes can't explain ongoing symptoms at this time. But still it might be discussing HSV with your ID consultant.
There's nothing in your story that suggests herpes zoster. Where did that idea come from? Most adults test positive for EBV IgG antibody, so that doesn't mean anything. I can't imagine why CD4/CD8 testing was done: normally it is recommended only in people with documented HIV infection. I have no comment about your ANA results.
Final thought: you say nothing about syphilis, which is rampant in some developing countries and in some sex workers. And syphilis conceivably could explain both reactive lymph nodes and other nonspecific symptoms. If you've not been tested for it, definitely do so.
I hope these comments are helpful. Let me know if anything isn't clear.
HHH, MD
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41 months ago
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Thank you so much for the prompt and clear answer, Dr. HHH.
I should clarify that my ID doctor didn´t ask for all these test. I sook some by my own account. She was reluctant even to test for HIV-2.
First CD4 count was also taken by my own account. Second count was I guess part of a T and B cell panel ordered by the rheumatologist.
As for herpes, when I had the first consultation the sore was already dry, because I had self-medicated myself with Valacyclovir for 5 days (didn´t take anything else). Recently I though that this medication could have interfered with HIV testing, my doctor didn´t say anything about it, but I was relieved after reading yours and Dr. Hook´s opinions about this subject here. My IgM was positive for herpes (not distinguished), but doctor said that IgM, specialy with low titles, is not a good marker for recent herpes infection.
I was tested twice for syphillis, negative. Haven´t had any genital sore. I guess the doctor had a little suspicion because of neurological symptoms and some desquamation of hands and soles.
About Zoster, I had this concern because of high titles revealed by test and neurological symptoms I experienced.
What made me really worried was the thought of transmitting HIV to the last partner. Also, I was called again by the lab after a few days to recollect blood due to some technical issues with the DNA PCR. At the time I was convinced It was because of a positive result that needed confirmation and they were not telling me, which made me desperate for weeks.
If what I said here changes anything in your first evaluation, please share.
Thanks again.
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H. Hunter Handsfield, MD
41 months ago
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I'm glad to hear of the negative syphilis tests, and thanks for the additional information. It doesn't change my assessment or advice. My only additional comment is that my experience is that most physicians, including many or most ID experts, do not understand the nuances of HSV serology. That yours understands the unreliability of HSV IgM antibody testing suggests she is very knowledgeable about herpes, and probably HIV and other STDs as well. That increases my confidence you can rely on her evaluation and recommendations.
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Perhaps the only remaining issue, from an STD and infectious diseases standpoint, is whether a follow-up HSV blood test (IgG only) would be a consideration. It takes up to 12 weeks to develop measurable HSV antibodies. If your prior negative result becomes positive, it would indicate recent HSV infection. Of course you would want to know if you are at risk for recurrent outbreaks and/or HSV transmission to sex partners. Something to perhaps discuss with your ID consultant.
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