I thought I was OK, but now I'm scared

Hi Dr. Hook and/or Dr. HHH,

So I posted two concerning exposures (yes, high risk) in the past on the community forum and I have been experiencing some worrisome symptoms. I'm male and I'm 24 in NYC and am a medical student.

Oct 21, 2009 - I met another man online (age 35-40, successful) and we had oral sex and before I knew it we decided to have anal (which I never do). He asked me to be the insertive partner, but I had trouble achieving an erection, so he suggested I do it without a condom (dumb, I know). Before I did, I asked his status and he said he was negative as of 9/09. I am circumcised. I was the insertive partner for about 20-30 seconds before I switched to the condom. I was then the receptive partner, after I insisted on having him put on a condom (whew...only 30 seconds cause it hurt). In the coming weeks I got scared and over the phone he agreed over the phone to get tested again (who knows if he did, but 1 wk later he said negative). Then, I also felt 1 preauricular lymph node and one cervical lymph node, plus had some dysphagia which I thought could be esophageal spasm (runs in the family I think)...but which I thought could also have been esophageal candidiasis. I got tested myself at 1 wk, 4 wks, and 76 days (all NEGATIVE on Oraquick with fingerstick).

3/8/2010 - I decide to mess around with another man (age 35, also a successful businessman) off the net, for what I had planned to be low risk fun. We had oral sex and masturbated. When he came his semen got on the head of my penis and I immediately freaked out that my urethral meatus was exposed. He said he was tested negative 12/09 and that there wasn't anything to worry about. He says he always practiced safe sex, even with a previous boyfriend 10 years ago who was HIV+. I presumed that he was telling the truth.

Continued...

[H. Hunter Handsfield, M.D.]

The reason for the 2,000 character (about 400 word) limit is to require that the entire question fit into the original quesiton field; it is not appropriate to spill over into a comment field.  Reduce your question to the required length and then re-post it below, in a new comment window.  Then I will respond.  In the meantime, if this concerns the same question you asked in the HIV community forum last month, the replies will be the same: You were not at risk for HIV, do not need testing, and any symptoms you might have cannot be due to HIV from that event.

HHH, MD

[nycbuddy2]

April 2-3, 2010 (Day 26 since last exp) - I develop a painful aphthous ulcer in my mouth (buccal surface) about 0.5 cm in diameter. I have gotten little sleep on my rotations. It started as a tingly feeling in my mouth, and to my recollection there was no trauma involved. Next, I had a hard time sleeping as I became acutely nauseous (no vomiting though) during the night. I woke up in a sweat with fever (didn't measure, but very obviously a fever) and epigastric pain. I do recall eating sushi the previous night, but I doubt it was food poisoning/acute gastroenteritis as I had 1 bowel movement but no diarrhea. The nausea resolved, but the rest of the day, I was super fatigued with muscle aches and pains and this fever. I took Tylenol twice during the day, which helped. I had 1 bowel movement - no diarrhea. No lymphadenopathy that I can appreciate, though I am a skinny person and can feel some small cervical ones at baseline.
I did my usual reading on uptodate.com and looked up some articles, but it's really scaring me. I have not felt this way in >1.5 years, so this is concerning to me. I have had influenza a few years ago, so I know the extent to which the flu can be debilitating. This episode lasted for 24 hours which makes it questionable.

April 4 (Today): Wake up after 9 hours of sleep feeling fine. No more fever (subjectively, though I don't feel like there's one anymore), but the aphthous ulcer is still there.

OK, here's the breakdown:
1. I felt comfortable about the 1st exposure after being tested negative at Day 76.
2. I asked about the 2nd exposure in the community forum, but am still afraid of exposure to the urethral meatus.
3. Considering the time frame (Day 26) of the onset of my fever/myalgia/abdominal pain (without diarrhea/vomiting)/aphthous ulcer and the reading I did on uptodate.com, I'm super scared about this being ARS or some manifestation of seroconversion. In my favor though - no diarrhea, no sore throat, and resolution of symptoms in 24 hours.
4. Could this be acute food poisoning? A late manifestation of ARS from my 1st?

I will definitely get tested at the 6 wk and 3 month mark again, but I would really appreciate your advice.
Many thanks.

[nycbuddy3]

To finally respond,
FYI, in 10/09, I met another guy online he asked me to be the insertive partner, but I had trouble achieving an erection, so he suggested I do it without a condom (dumb, I know). Before I did, I asked his status and he said he was negative as of 9/09. I am circumcised. I was the insertive partner for about 20-30 seconds before I switched to the condom.In the coming weeks I got scared and over the phone he agreed over the phone to get tested again (who knows if he did, but 1 wk later he said negative). I got tested myself at 1 wk, 4 wks, and 76 days (all NEGATIVE on Oraquick with fingerstick).

So, on 4/2-3, 2010 (Day 26 since latest expo) - I developed a painful aphthous ulcer Friday in my mouth (buccal surface) now about 0.6-0.7 cm in diameter. I have gotten little sleep on my rotations. Next, I couldn't sleep as I became acutely nauseous (no vomiting though) during the night. I woke up Saturday in a sweat with fever (didn't measure, but very obviously a fever) and epigastric pain. I do recall eating sushi the previous night, but I doubt it was food poisoning/acute gastroenteritis as I had 1 bowel movement but no diarrhea. The nausea resolved, but the rest of the day, I was super fatigued with muscle aches and pains and this fever. I took Tylenol twice during the day, which helped. No lymphadenopathy I could appreciate, though I am a skinny person and can feel some small cervical ones at baseline. Woke up the next day feeling perfectly fine, normal temp.
I did my usual literature search and saw how mucocutaneous ulcers are hallmarks of ARS. I have not felt this way in >1.5 years, so this is concerning to me. I have had influenza a few years ago, so I know the extent to which the flu can be debilitating. This episode lasted for 24 hours which makes it questionable.

Could this be ARS if only 24 hrs with this major aphthous ulcer? Or a brief GI thing?
Thank you for your advice. Really appreciate it.

[H. Hunter Handsfield, M.D.]

First, it is not possible to catch HIV and have negative blood tsts 76 days later; and it seems clear your partner didn't have HIV anyway.  So the October exposure is irrelevant.  And your current symptoms don't suggest HIV anyway.  I don't know where you learned that "mucocutaneous ulcers are hallmarks of ARS".  A hallmark is a nearly universal, classical finding.  In fact, such lesions are uncommon manifestations of ARS.

Anyway, your test results prove that something other than HIV has to be the cause of your symptoms, assuming you haven't been exposed since last October.  I would say the same thing if you described typical ARS symptoms, which you do not.  And of course that you "have not felt this way in 1.5 years" is irrelevant.  Any symptom or group of symptoms has to have a cause and a start time.  That you happen to be fixated on a particular sexual exposure of course ignores the hundreds of times you have had other environmental exposures or nonsexual contact with other human beings over the past 6 months.

So, as I predicted at the start, I really have nothing to say that you didn't hear on the community forum.  Continue to work with your health care provider(s) about the cause of your aphthous ulcer.  But forget HIV.  

That wll be all for this thread.  It is unlikely there is any information you could provide that would change my opinion or advice.

HHH, MD

[nycbuddy3]

Thank you for your response. Two FINAL remaining points that I think haven't been raised yet.

1. In general, is the size of the ulcer correlated to HIV? (Minor vs. major)
2. Are HIV-associated aphthous ulcers usually multiple (vs. solitary)?

Thanks once again this was very helpful. And that's all from me.

[H. Hunter Handsfield, M.D.]

Irrelevant since a) you don't have HIV and b) ARS doesn't cause aphthous ulcers at all; when such problems are "associated" with ARS, it is because there are simultaneous other causes of the ulcers.

That's definitely the end of this thread.