HSV2 oral recurrence

[PDR25]

I was diagnosed with HSV2 about 10 years ago, and the initial occurrence was severe and both oral and genital.  The diagnosis of HSV2 was made with a viral culture.  Since that time, the recurrence of outbreaks has been about 4:1 in favor of the oral outbreak vs. the genital.  Based on reading your responses to other questions about HSV2, it seems odd to me that there would be more oral than genital recurrence, since you have clearly stated that HSV2 rarely recurs orally.  I am confident that the initial diagnosis was accurate as it was done at a very well known and reputable facility.  So here are my questions:

1) Is this scenario even possible?
2) If so, how rare is this?
3) Why would the recurrence be more oral than genital given it is HSV2?
4) How likely is it that I will transmit HSV2 orally?
5) Are there any tests that I should get to clear up any questions?

[Edward W Hook, MD]

Thanks for the clarification and glad to hear that you are benefiting from suppressive therapy.  

If you have not, I would have at least one of your future oral recurrences tested again.  While I doubt that it is happening, I worry that you might have canker sores which are masquerading as herpes.  If that were the case, it would be good news since canker sores are not infectious,

If I were you I would not be concerned about continuing to take the valacyclovir- it is among the safest drugs we have and as long as you don't have severe kidney disease (as in needing dialysis) you do not need to worry.  While the FDA has only approved the drug for a year as suppression, many of us have patients who have taken it without problems for more than a decade.

I wish I could give you more information on the transmission data.  The little data available suggest that persons with oral HSV-2 rarely spread the infection through oral contact but the numbers are small and you see, to be an exception to many of our "rules".  All I can say is use caution.  Sorry I don't have more information for you.  EWH

[Edward W Hook, MD]

The situation you describe is decidedly unusual. While there are numerous reports of persons getting HSV-2 simultaneously at genital and oral sites, studies estimate that the recurrence rates for genital HSV-2 are at least six times more common than oral HSV-2 infections;  some would estimate the rate of HSV-2 shedding from genital infections to be as much as 100 times more common than from oral lesions.  Unfortunately, there is much less information about patterns of HSV-2 at the mouth than at the genitals so information is limitied.  Let's see what we can do with your questions:

1.  Yes, it does happen.  When it does and recurrences occur, they are more common at the genital location.  Simultaneous recurrences do occur but it is rare.
2.  See above.  
3.  I have no idea.  Certain factors do seem to be associated with bringing on oral recurrences.  These include sun exposure, facial abrasion (as done by some plastic surgeons) or other minor facial trauma.
4.  It is almost certain that you ill occasionally shed the virus from the site where your infections recur on your lips.  These recurrences will have less virus present than when you have lesions but it is still potentially infectious to others.  As to just how infectious, I'm afraid it will be difficult to quantify.  Most exposures to persons with asymptomatic viral shedding of HSV do not lead to infection;  at the same time, asymptomatic shedding is so much more common than recurrences that most transmission is a result of expsoure to a partner who is asymtomatically shedding the virus.  
5.  I presume your initial diagnosis involved culture at both sites.  If not, next time you have an oral recurrence, I would get a culture or PCR test from that location.  Otherwise little to suggest from a diagnostic standpoint.  

You did not ask about management but, with recurrences that occur relatively commonly at both your mouth and genitals, I would suggest that you consider chronic suppressive therapy with acyclovir or another anti-herpes medication.  Acyclovir is available generically and is quite affordable and within the year it is likely that generic (and thus lower cost) valacyclovir will be available as well.

Hope this helps. Good luck.  EWH  

[PDR25]

What I get orally is always on the outer skin of my lips and beyond, so I don't think they are canker sores (they're on the inside).  I can get one tested again though in the future just to close that loop.  

It would be easier to not be an exception to the rules, but I'll just deal with it the best that I can as always.  I'll continue on the Valtrex as it does seem to work well for me, especially over the long term.  It took about a year of daily dosage of 1 gram/day to have a dramatic impact on the frequency and duration of outbreaks (for the first year there was no big change, but it went from about 8 outbreaks per year total to 1 per year total given time).

Thanks again for the timely and accurate information.  This was helpful to me.

[PDR25]

Thank you for the prompt reply Doc.  

To answer your question, my initial occurrence was extensively (and painfully from what I recall) cultured at both sites (as was my partners, but that was was only in one site of occurrence) and all three were confirmed to be HSV2.  Were I to name the hospital where this work was done you would recognize it as one of the top three medical facilities in the U.S., if not the world, and that's why my confidence in their result is so very high.  

My recurrences, like most other people, are often related to stress, but they just occur more frequently orally.  I have never had any facial trauma to speak of.

I didn't ask about management as I am a veteran of this experience.  I have been on suppressive (the V medicine) in the past and it is effective to a large extent, but I have some concerns about taking it for so many years as there is little data on long term side effects (thinking liver damage here or who knows what) that I've seen on 5+ years of suppressive therapy.  

I guess I was hoping you might say something like oral-to-oral transmission of HSV2 (from kissing specifically) is less likely than oral-to-oral transmission of HSV1 from the same activity because of the site specific nature of the two strains.