Driving myself crazy with worry

[shouldIbeworried1968]

I am in a long-term relationship with my girlfriend of 9 years, although both of us occasionally have encounters with others (we are completely open with each other, I trust her completely). Although we do not use protection with each other, we always use condoms with other partners and get STD tested occasionally. We have never had any problems before.

I have not had any outside partners in five months, but my girlfriend had an outside encounter (using protection) in late October. I had unprotected sex with her two days later. About 10 days later, I developed a red area on a small part of my scrotum. I thought it was just jock itch, so I applied antifungal cream. However, the itch continued to get worse. On close examination, there were three reddish bumps. There was no liquid seepage but it looked strange. There was no pain, just itch. I did not run a fever. I did have a swollen lymph node in my neck one day but I was sneezing and had post nasal drip and thought I had picked up my child's head cold.

I never saw a blister, but one morning the bumps had changed and looked like tiny ulcers. My doctor (who knows my sexual history) examined them under a special lamp. He said there was some ulceration, but it did not look like herpes lesions or other STDs to him and looked like a bacterial skin infection .I asked if he was sure, and he said that while herpes can present itself in unusual ways, there was no blister or liquid present for him to run a viral culture, and that a blood test would not reveal useful information if exposure was recent. He prescribed azithromycin to kill any bacteria, a steroid cream to reduce the rash, and told me not to worry.

A week later, the rash is much better and looks about 95% healed. The itch left after day two of the antibiotic, but I still worry that it was herpes.My girlfriend has been symptom free the entire time and thinks I am worrying about nothing. Am I?

[Terri Warren, RN, Adult Nurse Practitioner]

If you were our patient, with this description, we would definitely be doing antibody test for herpes on both you and your partner.  Bumps that turn into ulcers are concerning, certainly.  It may not be herpes, but you need to have herpes ruled out, in my opinion.  He is correct that the antibody test at this point may be too soon.  By six weeks from infection, 70% of people who are going to make antibody will have done so.  It may be worth testing now and then testing again when 4 months have passed.  Can you look back at your old STD screens and see if herpes antibody testing was done previously?  It is often not included in STD screens so it would be good to know.

Let me know.

Terri

[shouldIbeworried1968]

A related discussion, Update was started.

[Terri Warren, RN, Adult Nurse Practitioner]

Yes, that is a good strategy.  Let's see what her test shows.

Terri

[shouldIbeworried1968]

The doctor gave me a Famvir script so I have been taking that the last week. The genital problem has cleared up completely and you can't tell there was anything wrong at all down there. The finger issue is still present but greatly improved.

I'm confused too. I guess all I really know *for certain* is that I have HSV-1 in my finger from the swab test. I can't remember ever having a finger problem like that before although maybe I did in childhood and don't remember.

I guess at this point the thing to do is take another blood test in a couple of months and see if the HSV-2 is still low positive? My girlfriend will also get tested next week.

We are trying to decide what to tell our other partners.

[Terri Warren, RN, Adult Nurse Practitioner]

Honestly, your situation is confusing to me.  It is a rare situation where someone has HSV 1 at one location and then gets it at another.  If you did have an HSV 1 positive test in 2006 (and I can't imagine why the insurance company would have tested you for herpes) then this is not new infection and we know it is really HSV 1 from the swab test, right?  That's why we never say never.  You may have recurrences on your finger (likely will) so you might want to have herpes medicine on hand in case you get that tingling prodromal feeling in your hand

Terri

[shouldIbeworried1968]

I remember one very clearly in high school that was very painful, although I hadn't been kissing or anything like that so I don't know how I got it. According to my memory this was on the lip, so I always thought this was a cold sore as opposed to a canker sore, although I suppose I could be wrong. It was more than 20 years ago after all and perhaps the memory is unreliable.

By the way, thank you very much for answering my questions and helping me work through the possibilities. My GP is a good doctor but he is a family physician, not an HSV specialist, and it is useful to have another viewpoint on what is going on.

[Terri Warren, RN, Adult Nurse Practitioner]

When you describe having cold sores as a child, you mean blistery things on the outside of your lip vs. sores in your mouth, right?
Terri

[shouldIbeworried1968]

OK, now this gets even stranger.

I just got the culture for my finger infection result back. The swab test came out negative for HSV-2, but positive for HSV-1. I asked the nurse if it was a PCR test or a culture and she said the lab work she was looking at just said "viral culture" and didn't know if it was PCR or not. But either way, she said the thumb infection was positive for HSV-1, NOT -2.

You are right, the HSV-1 blood result said "less than .90". I asked the nurse to clarify.  The IgM result isn't back yet but ignoring it is fine with me.

I am trying to figure all of this out.

So, what do we know?
A) I had cold sores as a child but nothing in the last 20 years and no genital problems until recently.
B) I know I was negative for HSV-2 in 2009.
C) I was positive for HSV-1 when I took a test for an insurance company in 2006, but I don't know what the exact number was or what the test was. Perhaps I should just discard this data point given that I don't know the details.
D) Recently I had a suspicious area on my scrotum which wasn't checked in time to culture but certainly looked weird enough to make me think herpes.
E) This was followed shortly by a confirmed HSV-1 infection in finger.
F) Most reliable blood test shows negative for HSV-1 but slight positive for HSV-2.

Trying to find a scenario to fit these facts, I am assuming that the HSV-1 in my finger just hasn't shown up in the bloodwork yet.

Perhaps I have had HSV-2 for awhile and never had symptoms, but recently picked up a genital case of HSV-1 which got transferred to my finger due to the hangnail injury?

Is it possible to have BOTH HSV-1 and HSV-2 in the genitals?

I have to admit I am very confused about what is going on here. My doctor won't be back until after Christmas.

I guess the thing to do is re-test in a couple of months, continue taking Famvir as prescribed, and avoid anything but monogamous contact with my girlfriend. And we need to get her tested too.

[Terri Warren, RN, Adult Nurse Practitioner]

It's still difficult to know what to make of these test scores.  Actually, I am guessing the HSV 1 result is not .90 but there is likely a "less than" in front of the .90 value  The HSV 2 score is a very low positive.  If the PCR or culture is positive, then we will know that you have HSV 2 or HSV 1.  Until then, let's hold off on guessing about this.  If the swab test is positive, we need talk no more.  If it is negative, then I would recommend a confirmatory test for this very low positive HSV 2 IgG.  The IgM, again, should be ignored.

Terri

[shouldIbeworried1968]

I have some partial test results back now. The culture (I am still not sure if this is was a PCR or not) and the ImG test are not back yet, but I do have the IgG test results:

IgG result
HSV-1     .90
HSV-2    1.18

I thought HSV-1 would be somewhat higher since I have tested higher than that in the past, although the nurse said that .90 is considered negative. But the 1.18 HSV-2 is definitely positive she said.

So, I have HSV-2. We'll see what the tests on the blister fluid show.

Looking back on this, my possible exposure would have been the first week of November. If this is a new infection, would my body have had time to get the HSV-2 antibodies up to 1.18?  Or is it possible that I have actually had HSV-2 since before November and just didn't know it?

[shouldIbeworried1968]

I don't know if it was a PCR or not but I will ask him when I get the results. I know him well and we have a good relationship. Yes, he gave me antibiotics for the erythrasma at the first visit and the redness area cleared up in two days. However, you can still tell where the lesions on my scrotum were. They aren't completely healed yet. And the blistered area on my finger screams herpes. I assume I infected myself through a hangnail that I had there.

He was confident enough in the herpes diagnosis to start me on Famvir.

Yes, my girlfriend was with another person about 12 days before my problem appeared. We have an open relationship but we always "approve" extra partners before hand.They used protection, but that isn't foolproof of course. This was her second time with this particular outside partner.

My girlfriend and I had sex two days after she was with the other guy. We did not use protection. So the timeline was A) GF has encounter with another guy, uses protection B) two days later my GF and I have sex without protection  C) 10 days after that I start having problems.

I am actually OK psychologically. All I care about is her. Having an open relationship has been fun but while we always used protection outside the relationship, we knew we were still running a risk. We were monogamous for a long time before we experimented and we can easily to back to being monogamous.

Once I have the final test results tomorrow we will inform our other partners. .

[Terri Warren, RN, Adult Nurse Practitioner]

I think he's doing fine, but the IgM test should never be used to diagnose herpes.  It has many many issues and problems.  My advice would be to ignore the IgM test  and pay attention only to the IgG test.  Remember, if this is a new infection, and it could only be new if your girlfriend just acquired it, your IgG will not be positive.  Also, I would check with your doctor and be certain that the test that was ordered from the swab from your finger was a PCR not a culture.  It may be too late to make a change if he happened to order a culture, but you can try to be certain as PCR is far more sensitive than culture.  However, with blisters, even a culture might be sensitive enough.  

Did he treat you with antibiotics for erythrasma?  It is a bacterial infection caused by a specific bacteria.  I'm wondering if a bacterial culture was done to confirm that diagnosis.

So you've not been with anyone else for five months, how about your girlfriend?  

Terri

[shouldIbeworried1968]

This morning I woke up and found three unusual-looking painful blisters on my left forefinger (which makes this difficult to type!). The blisters were near what I thought was a simple infected hangnail. The whole area this morning is much more painful than the genital problem ever was. Considering everything else that has happened, I returned to the doctor.

He immediately said "this looks like textbook herpetic withrow" and took a sample of clear liquid from each blister for culturing. He also ordered IgG and IgM blood tests.

He re-checked my scrotum with the Wood's light and said that the reddish area he had diagnosed last week as erythrasma has cleared but he could still see where the small ulcerations had been. He said they were almost healed and like last week, there was no fluid there to culture directly from those spots.

I said "is it possible that I had both erythrasma and herpes in those spots,and that at some point (despite my obsessive handwashing) I transferred the virus to my finger?"  He said "that's probably exactly what happened."

He is "90% certain" that this is herpes, but given the relative mildness of my symptoms and the fact that my girlfriend remains symptom-free, he isn't sure that this outbreak was my initial exposure and that I may have been carrying this around without knowing it for awhile.

He says that with the direct fluid culture from my finger and the results from the IgG and IgM tests, we can make an educated guess about if the exposure was recent or not. I hope to have the results by Monday. My girlfriend will get herself tested as soon as possible as well.

Anyway, that's what's going on. Any comments would be helpful. Does my doctor sounds like he knows what he's doing?

[shouldIbeworried1968]

Sorry to keep typing here but I guess I am trying to work out the possibilities in my mind. I suppose we could have caught it in 2012 but didn't have anything that was an obvious breakout until now. Perhaps I have had it before but wrote any symptoms off as jock itch, which I have had a few times.

If we turn out to be positive for HSV-2, how far back should we go in informing partners?

[shouldIbeworried1968]

Checking again, I see that I did have an HSV test in 2009 and it was negative. So we know for sure that we were both negative for HSV-2 through the end of 2011. Neither of us had any herpes-like symptoms in '12 but we weren't tested for it. Other STD screens were negative. Our other partners are people we know well and they haven't reported any problems. If they caught something FROM us I'm sure they would have said something, and we trust them to have been honest with us rather than put us at deliberate risk.

I have not had any encounters with anyone but my girlfriend for five months. So if this is herpes it seems likely to be a new infection from one of our partners who did not know they had it, but who gave it to my GF, with her then giving it to me, but with everyone else being asymptomatic but me.

In any event, we need to get tested.

[shouldIbeworried1968]

Well we tested positive for HSV-1 and negative for HSV-2 in 2006. Both of us had cold sores when we were teenagers but none since and we never had genital issues that were suspicious before, so we assumed the HSV-1 were oral infections from childhood. My girlfriend had HSV testing done again in '11 and was negative, although I was not tested.

As I said, my doctor knows about our lifestyle choice but didn't seem to be thinking of herpes at all until I mentioned my worry. He seemed certain of the erythrasma diagnosis because of what he saw under the Wood's lamp. Would herpes look like erythrasma under the lamp? I went to the doctor a few hours after I noticed that the bumps had changed for the very reason that I thought I needed to have a culture done, but he said there was nothing there he could culture. I suppose it is possible that I had erythrasma AND herpes?

Or perhaps one or both of us acquired this in the last year and this was the first noticeable breakout?

I think the bottom line is that we should get tested and avoid contact with other partners in the meantime.

[shouldIbeworried1968]

For what it is worth, the doctor said I had erythrasma after looking at the affected area under the Wood's lamp. My girlfriend says I need to trust the diagnosis and stop worrying, but of course I tend to hypochondria and wonder if he was wrong.