Curious if I should be 100% sure it's HSV.

Dear doctor,

Approximately 2 weeks after protected sex with a woman who I'm fairly sure I contracted the symptoms from, I had a single painless sore similar to a pimple appear on the head of my penis. A few days later 2 more similar looking painless sores appeared on the shaft. I immediately went to a doctor at an STD clinic who visually diagnosed it as herpes. She also gave me a week's supply  of acyclovir. The same day I went to get an igg and igm test, the doctor who drew blood for those tests said he could not be sure if it visually looked like herpes. Later in the day, and for the next 3-4 days it was painful to urinate and my meatus appeared inflamed or swollen immediately after urinating. When the painful urination had subsided I had felt the lymph node to the right of my groin was swollen.

There was also another woman I had unprotected sex with approximately 1 week after the first woman. She was diagnosed with BV about a week after I had slept with her. No idea if this has any connection or affect on me. Her HSV results were negative and has had no symptoms yet.  

2 weeks after visiting these doctors my igg and igm results came back negative. Now I know the igm test is virtually useless so I'd like to know if, based on these symptoms, I should be 100% certain that the cause is herpes? The painless sores, painful urination, and lymph node seem to all be pointing in one direction.

[H. Hunter Handsfield, M.D.]

Welcome to the forum and thanks for your question.  I'm sorry you're having to deal with this over the holidays.

There's a lot of to respond to here. My first reaction is the mixed messages between condom protected sex and the symptoms afterward.  Was there any unprotected contact, e.g. oral sex, before the condom-protected vaginal sex?  If not, I doubt the problem -- whether herpes or other STD -- was acquired during that event.

You'll also need to tell me more about the second sexual exposure.  If I correctly understand the timing, your symptoms began 2 weeks after the first and 1 week after the second exposure.  Why do you attribute the symptoms to the first and not the second?  Was the second exposure also unprotected?  The second partner's BV could suggest a higher risk of having herpes or other STD -- although apparently you already know that her HSV blood test is negative.  (That's pretty quick.  Are you certain about that result?)

As for the penile lesions, herpes is the most common cause of new genital pimple-like lesions, and one doctor thought that's the best bet.  The second, however, apparently found them atypical for herpes.  Most herpes lesions are painful, but not all are.  The apparent urethritis could be herpes, although herpetic urethritis usually is more painful than you seem to imply.  Whatever the cause of the penile lesions, it seems possible the apparent urethritis is unrelated, i.e. NGU or gonorrhea.

As you seem to know, your negative IgG antibody test (presumably you mean negative for both HSV-1 and 2) is good evidence that if you have herpes, it's the first infection, not a recurrence of a longstanding infection.  And you also are correct in your understanding that the negative IgM isn't definitive one way or the other.  However, given all the other uncertainties, my best guess is you don't have herpes.

You don't mention a viral test (PCR or culture) from the penile lesion(s).  That's too bad -- either a negative or positive result would have been very helpful.

You also don't say whether your apparent urethritis has been treated?  Or what your doctors thought about those symptoms, or the results of tests for gonorrhea and chlamydia?  It's hard for me to imagine that one or both doctors didn't order these tests.  Also, I would have though you would have been treated for the urethritis, but you don't say anything about it.

Please return with the answers to the several quesions I have asked or implied and we'll see if I have any additional advice.  In the meantime, I would suggest you continue to follow-up closely with either or both doctors or clinics.

Regards--  HHH, MD

[manhattanlife]

I also tested negative for syphilis, gonorrhea, chlamydia, and HIV, as well as a UTI.

[H. Hunter Handsfield, M.D.]

OK, that takes care of the gonorrhea/chlamydia question.  But I still wonder about examination and testing for nongonococcal urethritis (NGU), e.g. by microscopy for urethral white blood cells; and the other uncertainties implied above.

[manhattanlife]

Dear Dr. Handsfield,

Thank you for your prompt and thorough response. I suppose it isn't the most ideal Christmas gift but such is life. I was mentally bracing myself for a positive result from the HSV igm tests but now I am just anxious and confused since I have to wait till mid-January to redo the igg test. The woman from the second encounter also has no symptoms so I was just more cautiously optimistic, which prompted me to ask for your advice.

First, yes I received unprotected oral sex during the first encounter, circa November 23rd. Knowing this now, would you presume it is HSV-1 (if it is herpes)? There were no visible sores though, but I have heard the virus can be transmitted via saliva, or reside in the esophagus.

You are correct about the timing of the symptoms regarding the two exposures. I attribute the symptoms to the first encounter because the second encounter was with someone I know and used to date, while I knew nothing of the sexual history from the first woman. I have had unprotected sex with the woman from the "second exposure" in the past so I'm more worried that I unknowingly infected her than the other way around. She has been tested for all STD's, including a swab of her vagina, and she also mentioned that a piece of tissue was removed for testing. All her tests were negative but as I understand, swabbing the vaginal wall is worthless if there are no sores. I informed her to get retested as soon as possible. Or maybe she should wait till an accurate igg test can be administered (sometime around mid-January). Could it also be possible that I did not infect her if I had herpes for only one week?

The second doctor who examined my genital lesions was unable to see them in their natural state because the first doctor had poked at them thus causing them to burst a bit. Even though the lesions had only appeared for less than 8 hours he stated that it was too late to take a swab test

I did mean that the igm tests were negative for HSV-1 and 2, yes. But yes, it would have been my first exposure, and likely would have occurred from the exposure with the first woman based on my knowledge of the second's history.

My urethritis seemed to disappear 3-4 days after the first signs of the penile lesions. Although the the lesions take longer than that to heal.
When first seeing the doctor the painful urination or swollen lymph node were not present. When seeing a doctor for the igg and igm results, I was informed that only a igg test would be conclusive but that those are all herpes symptoms. Would the doctors not treat me for urethritis if they assumed it was directly associated with herpes? I noticed that if I spread the meatus when urinating, it was less/not at all painful to urinate. Could there be a correlation between the BV infection the second woman had and the urethritis?

I was instructed to retest for herpes in mid January, roughly 1.5 months after the first symptoms appeared, unless lesions reappeared, then it is surely herpes and I should return.

But, based on the symptoms of the 3 lesions, painful urination, and swollen lymph node, would you assume these three point to herpes? The swollen lymph node implies that there is a infection or virus to fight, no?

I apologize for the convoluted message doctor, but appreciate your help.

Best,

[manhattanlife]

Dear Dr. Handsfield,

I wasn't sure if you were alerted to my reply because I may have not posted it properly, but please see above for my reply to your questions and comments. I greatly appreciate your time and advice.

[H. Hunter Handsfield, M.D.]

There's a lot to digest here.  I'll have a response before long.

[H. Hunter Handsfield, M.D.]

Sorry for the delayed follow-up response.

I'm afraid that even after carefully reading all the information, I can't say with any confidence just what is going on here.  My best judgment is you didn't catch HSV of either type, but that's a soft call. If I were a betting man and had to lay odds on the chance you caught herpes, I would say something like 25-40% chance -- i.e. nothing you should rely on.  If you did catch herpes, I would be inclined to suspect HSV-1 rather than HSV-2.

I do think the second sexual partnership is a potential source for this problem, if you have an STD at all.  In my opinion, both of your partners should be comprehensively examined and tested for all common STDs.  You have a responsibility to discuss the situation with both of them and advise them accordingly.

As for your apparent urethritis, that's also a mystery.  The transient nature, i.e. resolution without treatment, favors herpes.  However, HSV urethritis usually is more severe than you describe.  Nonchlamydial NGU can clear up on its own, without treatment -- so that's also a possibility.  BV in women has never been associated with any clinical symptoms or other abnormality in their male partners, so I doubt this is related to your symptoms.

At this point, I would sit tight and wait for the 6 week mark for a repeat HSV antibody test (IgG only).  If that test is negative, have a final test at  3-4 months.  As you were advised by one of your doctors, of course be seen immediately if new genital lesions appear for direct HSV testing.

[manhattanlife]

Thank you for your advice, and consultation Dr. Handsfield. It's been very helpful to get detailed answers from a professional.
I'm sorry to bother you with one last series of questions, and I know you have many responses to get to so I understand if you can't answer this, but one question still persists.

1) Are you saying it is essentially possible to have lesions, painful urination, and a swollen lymph node appear, and the cause not be HSV-1 or HSV-2?

2) If it were not herpes, there must be an infection of some sort that has caused that lymph node to swell?

Thanks again for all you help.

[H. Hunter Handsfield, M.D.]

Is it possible you don't have herpes?  Yes.  You correctly list features that argue in favor of it, but there are other features that are atypical, hence my uncertainty.  I would advise doing your best not to speculate, but to follow the advice you have had about follow-up testing.

[manhattanlife]

Dear Dr. Handsfield,

I'm not sure if this question falls within the parameters of my original thread, or if I would have to start a new one, but I have a follow-up question.

My IGG test 7 weeks post presumed exposure came back negative for HSV I and II.

To reiterate, I saw 3 separate pimple like lesions on my penis 5 weeks ago. One appeared 4 days before the other 2, none were painful. A burning sensation at my meatus at the same time as these lesions were present. Meatus exhibited redness. Over the past 5 weeks there have been sparse instances of tingling when urintating, clearly not painful though like the first 5 days of the lesions. And last, a swollen right lymph node in my groin 4 days after lesions were seen. The lymph node is still noticeably swollen to the touch. There have been no more outbreaks similar to what I experienced 5 weeks ago since.

My question is: If the lymph node is swollen, the body must be replying to something. So is there a correlation between detectable antibodies in the blood and the presence of lymph node swelling? Should my certainty that it is not herpes increase if the IGG is negative, but the lymph node is swollen?

Also, do you know the percentage of people that should be positive at 6 weeks? The answers seem to vary greatly.

Regardless I plan on re-testing at 16 weeks. Thank you again for your time and thoroughness.

[H. Hunter Handsfield, M.D.]

Thanks for the follow-up.  Your negative blood test confirms my suspicion:  it is very unlikely you have herpes.  When people acquire HSV-2 asymptomatically, it takes longer for measurable antibody to develop than in those with overt outbreaks.  If your symptoms had been due to HSV, there is at least an 80-90% chance your blood test would have been positive.

"If the lymph node is swollen, the body must be replying to something." True enough.  But there are many different potential possibilities, many of which are more common than herpes.

You can expect your 4 months follow-up test to remain negative.  In the meantime, you should go forward with a high degree of confidence you don't have genital herpes.

And by the way, all these responses assume you have not been taking any antiherpetic drugs like acyclovir, valcyclovir, etc.  They can delay positive blood test results.  If you have been taking any such drug, it is important that you stop it until you have the 4 month blood test.

[manhattanlife]

I greatly appreciate the prompt response and am hopeful by your optimistic reassurance.

Would you recommend seeing a urologist regarding the NGU or other potential issues?

Regarding the drugs question. I took acyclovir(one pill 3 times a day) for one week after being visually diagnosed for herpes. That ended 4 weeks before taking the recent IGG test. I assume there would not be an impact on the test results?

Regardless of the outcome, this has been quite a life changing experience for a 26 yer old, for the better.

[H. Hunter Handsfield, M.D.]

That dose would not likely have any effect on the blood test.  But don't take any more.

If you are no longer having urethral symptoms (discharge, pain with urination), I don't think you need any further STD evaluation for NGU or anything else.