STDs Expert Forum
Confusing Herpes Case
About This Forum:

The STD Forum is intended only for questions and support pertaining to sexually transmitted diseases other than HIV/AIDS, including chlamydia, gonorrhea, syphilis, human papillomavirus, genital warts, trichomonas, other vaginal infections, nongonoccal urethritis (NGU), cervicitis, molluscum contagiosum, chancroid, and pelvic inflammatory disease (PID). All questions will be answered by H. Hunter Handsfield, M.D. or Edward W Hook, MD.

Font Size:
A
A
A
Background:
Blank
Blank
Blank
This expert forum is not accepting new questions. Please post your question in one of our medical support communities.
Blank Blank

Confusing Herpes Case

I had sores 2 doctors visually stated looked like herpes (02/21/11). I was never swabbed for culture. Several IgM/IgG tests have been negative since, including the most recent (blood draw 04/18), though the second to last tests were (perhaps false) positive (1.44 where >1.09 is pos). No repeat outbreaks or certain symptoms. One partner has no symptoms or lesions but was swabbed and tested viral culture positive, but negative IgM and IgG. Another partner has no symptoms or lesions and these results, quote "IgM pos. IgG 1/2 pos/neg". All of us will be retested for IgG. I'm getting conflicting information from 3 different doctors, and from what I read online about how long it takes to seroconvert and what results really mean and I'm very frustrated and confused.

It is now about 3 months since my apparent outbreak. Questions: What is the longest period of time it is possible for an infected person to take to seroconvert IgG? (I've been told by doctors or read estimates from 2 months to 1 year - or forever!). I'm now ruefully aware the antibody tests have significant false positives/negatives. Can the viral culture be false positive? If I or my partners continue to test IgG negative, and have no further symptoms, how long should we continue to retest before we conclude we do not have herpes? I'm beginning to fear we may never have real certainty and I very much appreciate your help.
Related Discussions
239123_tn?1267651214
Welcome to the forum.  I'll try to help.

First, let's consider your doctors' visual diagnosis.  Two docs' opinions have to be respected, if they are quite experienced with herpes.  However, even the world's top herpes experts commonly misdiagnose it -- they sometimes believe herpes is likely when it isn't, and they mistakenly believe herpes is something else.

Second, I'm puzzled by a partner having no lesions and yet having a viral culture test.  Even if it was a PCR test (which picks up more infections than culture), it is extremely rare to have a positive result without an obvious blister or ulcer.  Are you certain about this?  Were you there at the time?  Are you getting a straight story from him?  His negative blood test results reinforce my doubt that he is infected.

Third, as you already know, your blood test results do not support a diagnosis of genital herpes.  You were tested a bit early, but most people with new HSV-2 infections have positive IgG tests within 6 weeks.  However, you don't say whether your suspected herpes was treated with an anti-herpes drug like acyclovir or valacyclovir, or if you are still taking it.  Early treatment can delay positive test results.

Some additional details of your own symptoms also would be helpful.  In addition to the questions I've already asked, how many genital lesions/sores were there?  Exactly where were they?  (Vaginal opening?  Labia minor or major?  Both sides of your genital area or only one side?  Swelling or tenderness in the groin?  Fever or headache?)

So based on what I know so far, I am on the fence; but if I had to guess, I would say that most likely your genital lesions were caused by something other than herpes.  But if you can fill in some of the unknowns, I'll try to help with a more certain answer one way or the other, and with thoughts about additional tests.  

Regards--  HHH, MD
18 Comments
Blank
Avatar_m_tn
I'm a 46 year old male. My sores were numerous, maybe a dozen or more total, mostly around the base of my penis and scrotum, with one small one on the lower shaft of my penis. They were raised blisters with dimples. I've seen at least one herpes pic online they resembled. They stung/tingled painfully and the skin around my whole genital area was very sensitive. After showers they sometimes exuded whitish material. Important note: I shaved my whole pubic area 3 days before the outbreak - I believe that this could have spread the infection around from where it was originally, including to my scrotum. The lesions opened creating reddish "cut out" looking areas for a couple of days. They healed in a bit under 2 weeks. I was treated with valacyclovir through most of this time. The night before I first noticed the sores I was very lightheaded and ran a fever.

Both my partners are women. I also thought it odd that the first would test culture positive with no lesions, so asked her to specifically ask ger doctor "Did you see any kind of lesion at all when you swabbed me?". Her doctor insisted he did not, he simply swabbed her vaginal area after she told him of my outbreak, and sent it in for culture.

I used condoms with both women for genital sex, but had unprotected oral sex with both.

What about HSV-1? Because of the second partners (admittedly not yet reliable) positive type 1 result, I have been considering whether my infection was from unprotected oral sex with one or the other, which I then gave to one or the other.

My latest IgG test for which I have a result was drawn in April, a full 2 months after the apparent outbreak and was negative. I had blood drawn this week for a retest and expect a result on Monday 05/22. I would be most grateful for anything you can suggest that will give me (us) certainty if we continue to test negative for IgG.


Blank
Avatar_m_tn
CORRECTION - the majority of the sores were not ON my penis, but around the pelvic area surrounding my penis, just to be clear. Just one on the shaft on my penis.
Blank
Avatar_m_tn
HERE'S THE WHOLE STORY IN DETAIL, POSTED IN INSTALLMENTS

I am a sexually active 46 caucasian male. I have had 12 sexual partners over about the last 3.5 years. On 02/18/11 I shaved my entire pubic area with an electric clippers, including my scrotum and the shaft of my penis, as I was in the habit of doing. I noticed some extra irritation but wrote it off to razor burn. Several days prior to this, I had a bad headache with no apparent cause, and some back pain (which could have been from new exercises I was performing at the gym 3x a week). On 02/19 I had a strange light-headness and fever. On the morning on 02/20 I awoke to find numerous raised blisters with dimples, mostly around the base of my penis but also a few on my scrotum and one on the lower shaft of my penis. I had had a case of molluscum in the summer of 2008 that took cryo treatment and a couple of months to completely clear, and thought it might be the same thing again, though it did NOT look like my earlier molluscum had.  On 02/21/11 I went to my family doctor (GP) who said the sores looked like herpes ("80% sure"). That day he ordered a standard IgG (HerpesSelect type I assume). I had previously had a negative blood antibody test of this type in November 2010. He did NOT swab me for a viral culture (I didn't know any better at the time and am quite upset that he did not know better). The antibody test from the 02/21 draw was negative. That week I also visited a Dermatologist who examined my sores and concurred that they looked like herpes. He, also, did NOT perform a swab for a viral culture.

The sores that appeared on 02/20 behaved as follows. They eventually opened, leaving reddish "cut out" like lesions. They were painful in a tingling and twinging way, and my skin the whole area was very tender. As they healed, some of them exuded whitish material that looked like pus, especially after the heat of a shower. It took a little less than 2 weeks for them to completely heal (no scars or marks of any kind - completely cleared from skin). The GP prescribed generic valacyclovir which I took starting 02/21. I got a refill after about 2 weeks, a stronger dose, and finished the prescription. The sores seemed to respond (become a little less painful at least) in response to the drug, but I can't be sure that the progression of the sores would have been different without it. Note also, I believe the pattern of sores at the beginning of the outbreak somewhat followed my shaving track from three days before the outbreak, especially on my scrotum. I have not had any additional outbreaks as of today (05/20) since the initial outbreak, although I have had some slight lightheadedness with no explanation the last 2 days or so, but no fever.

Before I describe my own subsequent tests and results, here are details about my partners. On 02/21 I informed a total of 4 women who I thought might possibly be infected.
N had no symptoms when I contacted her on 02/21. She had a negative herpes antibody test in early 2010. We last had sex, unprotected on 12/22/10 (about 2 months prior to my outbreak). She had sex with no other men since beginning to date me in February of 2010. In late February 2011 she was retested (antibody) and the result was negative. To my knowledge she has not been retested. M had no symptoms when I contacted her on 02/21. She had a negative herpes test in September 2010. We last had sex in August(?) of 2010. She has yet to be retested. K had no symptoms when I contacted her on 02/21. She had never been tested for herpes before. I was the only man that she had had sex with since the end of her marriage of 15 years (separated for ? 1 year) and she had no other partners but her husband during her marriage (her ex-husband denies any affairs during their marriage). We had last had sex on 02/16 - only 3 days before my apparent outbreak, protected genital and unprotected oral. Our last occasion of sex before that was 01/18. In early March 2011, though she had no symptoms, her doctor took a swab for a viral culture and it tested positive, but not typed for HSV1 or HSV2. She was antibody tested later in March, IgM positive, IgG negative, not typed for HSV1 or HSV2. She continues to have no symptoms. She has yet to be retested. D had no symptoms when I contacted her on 02/21. She had been tested for herpes and other STDs in a standard panel not 2 weeks prior to my apparent outbreak on 02/21 and all results were negative. We had sex the night before I noticed the outbreak, on 02/19, the same night I noticed the fever, protected genital and unprotected oral. We had both oral and genital sex that night, but neither of us were aware of my lesions until the next day, 02/20. She was tested on the evening of 02/21. I have not seen a copy of the results but she has described them for me as follows: "IgM pos" (HSV type 1 or 2 were not indicated). "IgG 1 / 2 pos/neg".  No numerical values were reported. She has not since been retested She has an appointment with an Infectious Disease Specialist on 05/23 at which she will request advice and a retest. She continues to have no symptoms.
Blank
Avatar_m_tn
To return to my own testing:

After the initial negative IgG result, I requested that my doctor perform an IgM using blood from the original 02/21 draw (because I believed that would provide information as IgM peaks much sooner - I now understand that the IgM test is not very reliable). The IgM test reported on 03/03 from the 02/21 draw was negative. My GP said "this test is 95% accurate" (false!) and said it was good evidence I did not have the disease.

In this interval I saw an Infectious Disease Specialist, Dr. L I gave him all the above information, including about my outbreak and the test results of my partners. He refused to consider any of this information as evidence in my diagnosis, stating that only an outbreak that he personally examined and swabbed and/or a positive IgG antibody test result would allow him to diagnose me. He advised me to wait another several weeks before being retested.

I chose not to wait that long and on 03/14/11 asked my original GP to order a repeat IgM/IgG, but due to an error at my GP's office, the lab did not type for HSV1 or HSV2. The results said both IgM and IgG were positive ("1.44H" where ">1.09" was considered positive). Because this result was not typed, I requested the lab repeat the test using the original 03/14 draw, but the results came back on 03/22 negative for both IgM and IgG HSV1 and HSV2  (under "<.091").

At this point the Specialist insisted I wait until at least the 3rd week of April 2011 for a retest. My blood was drawn for a retest on 04/18/11, IgM and IgG typed HSV1 and HSV2 and all results were again negative. I reminded him of my outbreak and the positive test results of my partners which he again refused to consider as evidence. He stated he had never seen a herpes patient take as long as myself to seroconvert IgG. He wrote my original GP an order for retest to use at my discretion, but advised me that he believes I am negative for herpes and that a retest is not necessary.

I strongly suspected Dr. L had reached a misinformed and inaccurate conclusion, as I had read that some patients can take several months to seroconvert. I made an appointment with a second Infectious Disease Specialist, Dr. T, and gave him all the above information and results. He agreed that it was prudent to consider my apparent outbreak and partner test results as evidence that I may very well be infected and agreed to continue investigating. I was retested on his order, IgM/IgG typed, and I expect to receive results on 05/22.
Blank
Avatar_m_tn
I need your analysis of my case to date, but also reliable answers to the following questions:

Is it possible for the viral swab test to be false positive? Both Specialists and my reading indicate they are rarely inaccurate. My partner K had this positive result (not typed) but like me has yet to receive a positive IgG result.

Can you interpret the test result that my partner D got, as described (she read it to me verbatim). Note she will be retested soon.

I now understand from reading that the antibody tests are far from perfect and that there is a tremendous amount of room for doubt and interpretation with both the IgM and IgG, depending on the method used and many other factors. I've read different estimates and am very confused about all this. What is the longest period of time that it is possible for an infected patient to take to seroconvert IgG? I've read 16 weeks, but rare cases taking many months or even over a year.

Some of the reading I've done, especially in online forums, fills me with additional uncertainly surrounding apparent positive results. How many times should I get an IgG retest to be absolutely certain it is not a false positive?

I am very frustrated, not to mention angry with my first two doctors, both highly educated and compensated professionals, for what I see as their inexcusable ignorance about an incurable STD. I desperately need answers to the above questions, and the most important question: if the IgG result I get on 05/22 is still negative, at what point can I safely say I do not have herpes if I continue to test negative? Like so man other people, I just want to be certain whether or not I and these people I care about have this disease so we can all get on with our lives.  
Blank
239123_tn?1267651214
Whoa!  Far too much information!  The 2,000 character limit (about 400 words) is there so the moderators don't have to read 3 page essays.  Condense your follow-up comments to a couple hundred words, limited strictly to the information I requested -- then we'll take it from there.

Sorry I miscontrued your gender, by the way.
Blank
Avatar_m_tn
If you read only the post above that begins "I'm a 46 year old male. My sores were numerous..." it answers your questions pretty concisely. Sorry, just trying to provide you with as much data as possible for a complicated and confusing case.
Blank
239123_tn?1267651214
OK.  The description of your early symptoms doesn't sound typical for herpes.  Initial genital herpes usually involves the penis or other areas that get maximum friction during sex.  That's because the virus typically has to be massaged into the tissues for the infection to take.  Therefore, the location -- in particular the pubic area -- is atypical.  Many (most?) cases of suspected initial herpes in hair-bearing areas are actually folliculits, which is often triggered by shaving.

So I would have thought you didn't have herpes, and that's still my conclusion, since it is also supported by the negative blood test results.  However, with your doctors' belief you had herpes plus the apparent positive culture in a partner, herpes still has to be a significant possibility.  And having taken valacyclovir, it is possible that a positive blood test result is delayed.

I'm not sure I completely follow your blood test results.  You said the initial test was apparently only for HSV-1?  But later you had both (HSV-1 and 2), yes?  And apparently negative, I believe.

I suggest two main steps at this point.  First, await the outcome of your partner's infectious diseases consultation and that doctor's advice for her, which may have implications for you.  Second, plan on additional blood tests, given the possible delay caused by valacyclovir.  Probably another test at 4 months would make sense, and maybe yet another at 6 months if the 4 mo. results are negative.  In the meantime, don't take valacyclovir or any other antiherpes drugs.  Should you develop a possible recurrent outbreaks -- new genital area blisters/sores -- see a doctor or clinic immediately (within 1-2 days) for a direct test for the virus by culture or, preferably, PCR.

Blank
Avatar_m_tn
Is that also true of HSV-1 infection oral to genital, the amount of friction needed to massage the virus into the skin? And not to be graphic, but I can see how the area on the upper scrotum and around the base of the penis could experience quite a bit of friction during sex.

I don't know much about what folliculitis looks like, but again, I really doubt that's what this was. The blisters were raised, puffy looking, a quarter to a half inch in diameter, and they were tingly and painful and burst open in exactly the same pattern I've read and been told that herpes blisters do. The continued to sting and tingle as they healed. Two different doctors, one a Dermatologist, who had diagnosed herpes before, said that's what they looked like (I do realize however that doctors can be wrong on visual examination). Question: if it wasn't herpes or folliculitis, what else acts like what I just described? I don't think anything but herpes does...

Thank you for the information that valacyclovir treatment can delay an antibody response. That may explain why I'm testing negative at over 3 post apparent outbreak. I expect to get a retest result today, will post and update here.

Again, my initial test was IgG only and negative. I asked for an IgM test immediately after that which was also negative (from same original blood sample). I was retested again for IgM and IgG (a little less than a month latter) and that was positive ("1.44H" where ">1.09" was considered positive). Because that test was not "typed" for some reason, I asked for a retest on the same blood sample at the lab and the IgM and IgG that time were both negative (under "<.091"). I was tested one more time for IgM and IgG from blood drawn on 04/18, negative. And I await a new result today.

I will follow up with my partners and ask them to get consultations and retests. Thank you for the information that it can take several months to turn positive. I will certainly request a viral culture PCR is I have another outbreak (none yet). Question: Why am I getting so much different information about the length of time it takes for infected people to seroconvert, including from doctors? My first IDS specialist basically insisted I was negative and washed his hands of me as a patient because he personally had NEVER seen a patient take more than 2 months to go IgG positive, whereas you are telling me I should be retested a 4 months!



Blank
239123_tn?1267651214
You're expecting too much for an online forum.  Please look at other threads to see the level of detail expected and accepted for follow-up comments.  On some professionally moderated forums, the moderstors set their browsers so see the initial question only, no follow-up comments.

IgM HSV testing is useless; see http://www.medhelp.org/posts/STDs/Confusiion-over-other-IgM-Herpes-posts/show/248394

Your ID specialist probably is right, and probably is truthful in saying he has never had a patient in whom it took longer than 8 weeks for positive blood testing; I'm not sure I have seen such a patient either.  But he might not know about treatment delaying seroconversion, which is relatively new inforamtion.

Feel free to post your subsequent test results -- but just the results, not all the extraneous information.
Blank
Avatar_m_tn
UPDATE

Sorry, not trying to abuse the forum! Thank you for the info re IgM.

Actually, today my IDS told me I am finally IgG positive (it's been over 3 months post-outbreak)  though he was not in the office and did not have the values or the HSV-1 or HSV-2 type. I expect those Wednesday and will post.
Blank
Avatar_m_tn
IgG test result today from blood drawn on 05/16 was positive, 2.5
Neg <.09
Pos <1.0
They were supposed to type it HSV-1 or HSV-2 but for some reason did not. I had my blood drawn again today for a retest to get the type.

So I am positive after all.
Blank
239123_tn?1267651214
It seems likely that this result confirms your herpes diagnosis.  However, I am unaware of HSV tests that give such a numerical value but do not include testing for virus type.  Anyway, let me know that result when available.
Blank
Avatar_m_tn
Update. This is frustrating as hell. Here's the result:
Herpeselect Type specific AB HSV 1 IgG and Type specific AB HSV 2 IgG
Both were "out of range". Result = <.90
neg = 1.10

This is the SECOND time I've had a "combo" assay for 1/2 IgG (did not differentiate type) come up positive followed by a type specific assay that came up negative!

I would be most grateful for any advice you have about what this means and what I should do next.
Blank
Avatar_m_tn
CORRECTION
The reference range is 1.10 = positive.

Actually the test I posted about on the 25th had the same reference range, I think I mistyped on that post too, sorry
Blank
Avatar_m_tn
CORRECTION - PROBLEM WITH TYPEFACE
This message board is not taking the special characters I type (greater and less than symbols) so I'm going to type it out.

Reference range for the test I wrote about today and the one on 05/25
Negative is under .90, Borderline is .90 to 1.10 and positive is anything over 1.10
Blank
239123_tn?1267651214
OK, now the tests are clearer.  Some labs initially test with a non-type specific antibody test that does not distinguish HSV-1 from HSV-2 antibody.  If that result is negative, no further tests are done; a negative result is considered definitive.  If positive, the lab then goes on to undertake type-specific testing, which is inherently more accurate.  It is the type-specific results that count.  Yours are definitely negative.

So at this point we can summarize your situation as having had initial symptoms that seem consistent with herpes but not typical, primarily by virtue of their locattion -- which suggested folliculitis, for which you were at increased risk due to recent pubic area shaving.

Also, you have definitely negative blood test results.  The puzzle is the positive nonspecific antibody test.  One possibility is that you have HSV-1 (not necessarily related to your genital symptoms, since half of all adults have HSV-1).  The type-specific antibody tests miss around 5-10% of HSV-1 infections.  They are less likely to miss HSV-2.  Further, if you had new genital herpes caused by HSV-2 in February, probably you would have had one or more recurrent outbreaks by now.

An additonal uncertainty is that a couple of doctors thought your initial outbreak was herpes; but I already discussed the problems with accurate visual diagnosis.  Another is the reportedly positive HSV-2 test in a partner. But of course it is possible a partner indeed had HSV-2, but that you weren't infected.

My synthesis is that you probably did not have genital herpes, and I am especially confident you didn't have HSV-2.  I cannot rule out the possibility you had an inital genital HSV-1 infection.  However, genital herpes due to HSV-1 usually causes few or no recurrent outbreaks and probably is not frequently transmitted sexually to partners.

My final advice is that you go forward with good confidence you don't have genital herpes; and knowing that in the slight chance you have genital HSV-1, it probably won't matter very much.  If you should have symptoms that suggest a recurrent herpes outbreak -- which typically would be a small patch of genital area sores/blisters -- you seek care immediately (within a day) for a culture or PCR test for HSV from the lesions.

That should end this thread.  Take care.
Blank
Continue discussion Blank
This Forum's Experts
239123_tn?1267651214
H. Hunter Handsfield, M.D.Blank
University of Washington
Seattle, WA
300980_tn?1194933000
Edward W Hook, MDBlank
University of Alabama at Birmingham
,
MedHelp Health Answers
Blank
Weight Tracker
Weight Tracker
Start Tracking Now
RSS Expert Activity
242532_tn?1269553979
Blank
The 3 Essentials to Ending Emotiona...
Sep 18 by Roger Gould, M.D.Blank
242532_tn?1269553979
Blank
Control Emotional Eating with this ...
Sep 04 by Roger Gould, M.D.Blank
242532_tn?1269553979
Blank
Emotional Eating Control: How to St...
Aug 28 by Roger Gould, M.D.Blank