Herpes symptoms, neg or equiv test results

[teeheehee]

Hi. I am female, 23, a med student.

0-1 mo: possible exposure from a person who had never had symptoms but had never been tested. We had unprotected sex 10 times. I had had no other sex partners at that point.

12 mo: First outbreak- Culture negative. Description of outbreaks is below.

14 mo: this same ex-partner tests negative on a PCR Blood test

18 mo: I test negative on a Type-specific ELISA antibody test, negative for both types. I don’t know the exact titre results.

36 mo: Second Outbreak- Culture negative.

60 mo (now): HSV 1 and 2 test for both IGg AND IGm. The IgG was a titre of 1.00 (normal range 0.0-0.8) and IgM titre was 1.98 (range 0.0- 0.9).  The test was not split by type.

I have had five other partners, all protected. Most recent= 6 mo. ago. Never had cold sores. had chicken pox.  Have a highly reactive immune system (ex: I had the hepatitis B vaccine 10 years ago, and my titre now is 63.) Been tested for STDs including syphilis

Outbreaks:  
Start as red itchy bumps on the inner side of the inner labia.  Very itchy, mildly painful, but definitely not “tingly”.  Within 24 hours I have a high fever (104 degrees).  Fever lasts a couple days, bumps turn into ulcerative very herpes-looking things after about 24 hours, and they last around a week and a half.  They are VERY painful. Both times I had outbreaks I was stressed, little sleep, and physically challenged.  I went on valtrex both times, and I don’t know if it made a difference in symptoms.

Questions:
1. Which is most likely: False negatives, False “positive”, or infection occurred between the two outbreaks causing the incongruent results
2. What do you recommend?  Is it worth getting the western blot?
3. If this final test is negative, what else could it be?  It is hard to believe that it is NOT herpes, because the symptoms fit so well. I thought that it might be shingles on an S dermatome. Is shingles a possibility, and is there a diagnostic way to confirm shingles?

[H. Hunter Handsfield, M.D.]

Good luck to you.

[teeheehee]

Thanks for the clarification.
In case you are curious: Yes, Jewish.  Yes, commonwealth. : )  No family history, IBS, or arthritis.  Yes, hives and canker sores.  I need to see an immunologist anyways for the hives, i will ask about behcet's or other possibilities. And a derm. next time an outbreak occurs.

Lesions are bilateral, but much greater on one side than the other.  The lesions were also almost identical both times.

Thanks for your advice, and for clarifying my test results. (for some reason my doctors think that the best location for the results is in my file rather than in my hand).  Good to know also that the tests are not titres (or titers).

[H. Hunter Handsfield, M.D.]

In addition to FMF, I should mention Behcet's syndrome, also characterized by fever and genital (and often oral) ulceration, and also especially common in people of Mediterranean ancestry.

[H. Hunter Handsfield, M.D.]

The evidence is very strong that you don't have genital herpes.  First, your blood tests both were negative.  The second result might be in the equivocal range, depending on the specific test that was done, but for practical purposes is meaningless.  The IgM result is to be ignored entirely.  You undoubtedly have been taught that, for many infections, IgM antibody appears earlier than IgG, so positive IgM and negative IgG means a recent infection.  Unfortunately, it doesn't work that way with HSV:  many people with early infections do not develop measurable IgM antibody; IgM antibody sometimes is present in chronic infection; and most important, false positive results are extremely common--undoubtedly explaining your test result.

Second, your symptoms don't sound much like genital herpes.  Although fever is common with the initial outbreak, recurrent episodes rarely cause fever.  Any genital sore looks the same as herpes, once it becomes ulcerative.  You don't say whether the lesions are unilateral or bilateral, but recurrent herpes is usually localized to one side or the other, not both--and pretty much always on the same side each time.  Finally, primary resistance of HSV to valacyclovir and related drugs is very rare.  Therefore, lack of response to treatment is strong evidence against HSV as the cause.

So you can put HSV to rest as a cause of your problem.  Same for shingles; not a chance.  I am prompted to ask your ethnic background.  If you are of Mediterranean origins--Armenian, Italian, Turkish, Ashkenazic (sp?) Jew, then you provide a pretty classical story for familial mediterranean fever, which is characterized by very painful genital ulcerations with fever.  I would also wonder about Stevens Johnson syndrome, but only if during outbreaks you also have a skin rash elsewhere on your body.  Other systemic inflammatory conditions also could be responsible.  For example, if diarrhea is a problem, be aware that some people with inflammatory bowel disease can get syndromes like you describe.

Bottom line:   If you haven't seen a health care provider for this problem, that's obviously your next step.  If you have and no clear answer, get a second opinion.  Specifically, talk to a dermatologist (undoubtedly you can find a good one at your med school) and arrange to be seen promptly if/when the next outbreak occurs.  Or if you fit the ethnic pattern, a rheumatologist, who might have the best experience with FMF.

And a final education point, since you're a med student and I'm a professor:  The HSV test result numbers are not titers (or titres--are you in the UK or a Commonwealth country?).  It's an optical density ratio.  The term titre is limited to tests measured by serial dilution.

I hope this helps.  Best wishes--  HHH, MD