Chlamydia treatment failure?

[2010Knight]

I got myself into an unfortunate situation and request your valuable advice.

5/3 - had unprotected vaginal sex with person A
5/15 - had vaginal sex with person B.This was with a condom but I'm not sure how well protected I was: when I was washing afterward I noticed some menstrual blood on my penis as I pulled the condom off.
5/18 - noticed some urethral tingling
5/19 - pain while peeing, some wetness under the foreskin
5/21 - suspecting a chlamydia infection, I went to receive a chlamydia/gonorrhea test at a clinic, was told that it could be some kind of UTI or it's possible that I had chlamydia. I requested immediate treatment and was provided the oral drink for chlamydia (believe this was Zithromax) and another pill for gonorrhea. I took those meds in the clinic. I was also provided with tablets to be taken for three days for a UTI. The urine was analysed in the clinic and there was some anomaly with white blood cells but the sample was to be sent away for the actual chlamydia/gonorrhea tests.
5/24 - symptoms have cleared up
5/27 - received unprotected oral from person B
6/2 - had unprotected sex with my regular life partner (person C) - first since 4/24
6/4 - received result of test of 5/21 - was informed that I had tested positive for chlamydia but there was no further action necessary because I had been treated in the office.
6/4 - feel tingling at the end of my penis
6/5 - now have urethral pain while peeing/dull pain at all other times - but no apparent discharge
6/12 - back to clinic, they suspect chlamydia again and provide a weeks supply of doxycycline.
6/15 - the pain I had while peeing is now present always

My questions are:
1. How likely is it that I have chlamydia again?
2. Did the zithromax fail or was I reinfected by the oral from person B? If the former, how?
3. (most importantly) Have I infected person C?
4. Is it likely I initially caught it from person A or person B?

Thank you.

[H. Hunter Handsfield, M.D.]

Personal business has unexpectedly taken Dr. Hook away from the forum for a few days.

That your symptoms are persisting is good evidence they were not due to chlamydia in the first place, or to any other bacterial infection.  A viral infection is possible; a few cases of NGU are due to adenovirus.

See your provider if they don't clear up or you otherwise remain concerned.  There is no more advice that any distant online source can offer, regardless of how expert Dr. Hook or I might be.  Good luck.

HHH, MD

[Edward W Hook, MD]

Related to each of your comments:

Glad to hear the informing persons A & B will not be a problem  They are at risk for infection, for complications of infection if they are infected and for passing infection on to others if they are infected.  

Person C.   Understood.  Given that you have been engaged in a relationship with her for 18 months it's unlikely that she is infected.  As you point out, you would have likely known it before this.

Retests for chlamydia are a problem because the tests can detect dead bacteria for up to three weeks after treatment and cannot differentiate between live and dead bacteria.  I'd wait fr at least three weeks before re-testing for reliable results.

Finally, no risk of infection with masturbation.  It is safe, no risk sex

Hope this helps.  EWH

[Edward W Hook, MD]

Thanks for the detailed description, it helps me to provide relevant information to you.  Your question highlights the fact that in men the syndrome we call NGU and which is caused around 30-40% of the time by chlamydia may be mis-identifed as chlamydia when it is not in some instances.  NGU  is diagnosed by a combination of symptoms and the presence of white blood cells present in urine or a smear of secretions from the urethra.

In your situation, the azithromycin would be expected to cure at least 97% of chlamydial infections.  In addition, it is likely that the antibiotics you took for 3 days for a possible urinary tract infection added to the effectiveness of the therapy.  It would be most unusual if your infection was not cured after this therapy.

Another interesting thing about your situation is that chlamydia is almost never present int he throat and is not transmitted by oral sex.  On the other hand, the non-chlamydial NGU syndrome occurs regularly after receipt of oral sex.  Fortunately, while not caused by chlamydia, it is usually cured by anti-chlamydia therapy.

Now on to your questions but first a question for you.  Did you tell persons A&B that you had symptoms and chlamydia.  The reason that I ask is that although asymptomatic, they both need to be told and treated for chlamydia:

1.  Unlikely. since, as I understand it, you did not have genital sex with A or B since your treatment.
2.  See above.  The most likely scenario is that your chlamydia was cured and that you then got non-chlamydial NGU from receipt of oral sex from B (unless of course you had chlamydia from before your time line started and the infection is present in your regular partner (C).
3.  Hard to say.  She might have already had it (see above).  The safest thing for every-one's health is to be sure that A, B, and C have all been treated (as have any other partners they might have had) before anyone has sex with anyone else again.
4.  No way to tell.  Essentially you had unprotected sex with each.  They both need to be told and treatment.

Hope this helps.  Good luck. EWH

[Edward W Hook, MD]

At this pint your questions are beyond what can be handled on line and should be addressed by your promary care provider.  I will comment briefly howevero on your current issues.  Sorry that you went through the scoping.  

1.  80-90% of perople with herpes are unaware of their infection.  the fact that you have never had, or at least recognized a cold sore does not mean that you don't have HSV.  With test results that you do it is close to certain that you do.  there is no way to tell how long you have have had your infection -probably a long time.  Odds are that you did not get this last May.

2.  No,

3.  This is unlikely but that is really something that you and your health care provdier need to sort out  

4.  Possible.,  A single treatment with metronidazole, 2.0 g would tell you.  If you  have trich however, odds are that you did not get it through receipt of oral sex.  .

Hop this helps.  EWH

[2010Knight]

I forgot to mention that I have never had any oral HSV1 symptoms that I remember. Also as a fifth question - why would the doc state a negative result over the phone when the HSV1 result seems to be positive?

Thanks again.

[2010Knight]

I'm not sure whether I should post another in another thread - please let me know if the following is inappropriate.

To follow up on this, to date my symptoms have not gone away and to some extent have gotten worse:

6/24 - in the absence of a primary care physician, I visited an urgent care clinic and was provided with another round of azithromycin and a shot (that I didn't get the name of). Cultures and urine sample were taken.
7/2 - The symptoms still being present a week later I registered with a PCP and was diagnosed with prostatitis (slight enlarged prostate) and referred to a urologist. Tests (chlyam/gon) of 6/24 are negative.
7/18 - Urologist dismissed the possibility of prostatitis and suggests balanitis due to hypospadius, or possibly a mild UTI. Suggests applying triple anitbiotic cream to the urethra opening.
7/25 - noticed two  small lesions on the shaft of my penis, under the foreskin area. Both are small, and don't appear to be fluid filled.
7/28 - visited PCP - he observes the lesions and dimisses the possibility of herpes but tests anyway (HSV1/2, HIV, syphilis). Suggests discontinuing antibiotic cream
7/29 - four lesions appear on the head of my penis, the previous lesions are nearly gone. The lesions appear just as a red colouring which subsides after a few days. One in particular appears to have a head on it for a few hours, but it doesn't burst or scab over before slowly disappearing over a few days
7/29 - have noticed a rash on both inner thighs
8/5 - results of 7/28 test are in, told "all negative" over the phone.
8/8 - visited urologist for a scope - no internal problems noted but he observes the rash and suspects a yeast infection. Prescribes nycostatin powder. Heavy urethral pain due to scope.
8/12 - inner thigh rash is disappearing and no further lesions appear on head of penis. Urethral pain appears to be subsiding.
8/12 - results are sent to me:

HSV 1 IGG antibody  3.46
HSV 2 IGG antibody  0.07
HERPES I/II (IGM) 0.69

So, to my questions:
1. Do the results suggest HSV 1 infection acquired in May, or previous to that?
2. Are the lesions likely to be genital HSV1?
2. Would a yeast infection cause the urethral pain?
3. Is trich an alternate possibility for the urethral pain?

Thank you for your valuable help.

[2010Knight]

At what point should I assume that the doxy did not work?

I was prescribed a week of 200mg a day on 6/12 and had my last dose on the morning of 6/19 - yet I still have symptoms today (6/24) - that is, redness around urethra opening, dull tingling pain at all times, a slight watery discharge (only enough to collect under my foreskin) and pain while peeing.

Any ideas? I was concerned that I might have heat damaged the meds by leaving them in a warm car for a few hours on 6/13 but I still got some of the side effects afterward (slight stomach upset).

Thanks again for your help.

[2010Knight]

Your advice does help a lot, thank you.

I'm taking from this that I'm unlikely to be infected with Chlamydia any more and therefore that person C was not affected by my stupidity. I will abstain and hold off on informing her at least until I can get a reliable test in a few weeks.

Persons A+B - already informed.

Thanks again and best regards.
K

[2010Knight]

Thank you for your detailed and timely response.

I did not tell person A or person B at the time of the genital sex as at the time I didn't know that I was infected. However this won't be a problem as they were casual partners and there will be no further encounters with either again.

I realise that the safest course of action is to also inform person C. Unfortunately that's not going to be easy due to my poor choices with regard to persons A and B - so I would rather only do this if there is a very good chance that I have infected her.

How likely is it that person C may have had it already? Bearing in mind that we have been having unprotected, manogamous intercourse for 18 months with no apparent symptoms. Would I not have shown symptoms prior to this (given that I appear to be in the 50% that do show symptoms)?

How soon from now would a retest (on myself) be reliable? I am abstaining with person C at this time until I can be sure that I am clear.

Also as a final question - during the encounter on 5/27 I masturbated person B - is it possible some of her bodily fluid could have passed via my hand to my penis causing infection?

Thank you so much for your valuable advice.
K