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Hsv-1 genitally - Diagnosis confusion!
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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.

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Hsv-1 genitally - Diagnosis confusion!

I'm female, 28 and in a new going on 2 months relationship. Precursor-- the week of symptoms appearing I was diagnosed with strep throat and Chlamydia (great start to the year). I started seeing symptoms of genital herpes (or some other cause) 1 week ago of which are now gone. I immediately got screened for hsv-2 herpeselect igG which came back negative but am still waiting for my hsv-1 igG b/c I opted out of that one initially due to ignorance. I went to my obgyn who took swabs from the active symptoms for what they called igM tests which came back hsv-2 neg, hsv-1 positive. Is the igM a reliable test, bear in mind I should receive my hsv-1 herpeselect igG results tomorrow. My partner received his results this week from type specific igGs both negative and is having no symptoms whatsoever. Is our time frame from potential contraction not long enough to produce antibodies with the igG. How could I have contracted genital hsv-1 if I have not had oral sex from anyone else but him in a very long time?? As far as I’ve understood, the primary outbreak symptoms usually occur 2-21 days after contraction. In addition the nurse at my obgyn told me I wouldn’t have symptoms genitally again but was at risk for oral symptoms to occur now…..what??
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239123_tn?1267651214
Welcome to the STD forum.  I'll try to help.

You don't say anything about what "active symptoms" made you and your ObG concerned about genital herpes.  If you would like to describe them, let me know -- the more detail the better.

However, based on what you say so far, herpes seems unlikely.  It takes a while for the IgG blood tests to become positive, so your negative HSV-2 and HSV-1 results (below) only say you weren't infected as of several weeks ago.  But your partner's negative results are strong evidence against you having a new HSV infection, assuming he is your only sex partner in the past several weeks.  (I assume his "both" negative results means both HSV-1 and HSV-2.)

It is true that if you had an initial episode of genital HSV-1, it is unlikely you would have more than 1 or 2 recurrent outbreaks, maybe none.  With symptomatic genital HSV-2, in contrast, most people have 3-8 outbreaks per year.

Don't have an IgM test.  The IgM HSV tests are very unreliable; here is an earlier thread that explains it.  Although a few years old, the information remains accurate:     http://www.medhelp.org/posts/show/248394

Since it seems unlikely you have herpes, let's discuss your symptoms before any more detailed answers about transmission, recurrent outbreaks, etc.

Regards--  HHH, MD
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Avatar_n_tn
Update, results in: HSV-1 IGG Herpeselect is negative.
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Avatar_n_tn
Thank you so much for getting back to me. Ok symptoms were as of Fri Dec 31: sore throat and swollen glands in neck I assume from the Strep throat. After sexual contact with my partner on Wednesday I was really sore and swollen and noticed some blood after wiping right afterwards. Thurs my vagina started to itch so I took a Monistat 1 Fri. Sat Jan 1st my symptoms turned to burning while urinating with inflamation (inflammation) and redness. My fever never got over 98.8. At this point I did not notice any sores/lesions/blisters on my labia minora.  Monday morning paranoid I went to get screened for stds at Quest via online order and went to the doc to check on the sore throat and burning while urinating (suspected UTI for that), was prescribed a z-pak. By tues Jan 2 I was having pain down there so upon investigation I noticed some sores/ulcers that where white on the interior (some just flesh colored) but didn't notice any blisters. I would say about four and spread out not clustered together. No rash whatsoever anywhere on my body. This prompted me to go to the obgyn to have the sores looked at where she immediately said it was herpes and did a swab and prescribed Valtrex. I confirmed later that day they had done igm tests type specific. That evening I received my results from quest determining everything negative but positive for Chlamydia, which my doc had said the z-pak would take care of it if was present. Mon Jan 10 my gyn said my igm hsv-1 came back positive at which point all my symptoms were gone except what seems to still be some bacteria or yeast around my clitoris.
That's the symptoms.
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239123_tn?1267651214
Thanks for the additional information.  In my opinion, the totality of evidence is against herpes, but it's a close call; you could have it.  Your more detailed description is consistent with herpes, and the opinion of an experienced ObG based on the appearance of your genital lesions has to be respected.  However, even the world's top STD experts and herpes researchers are wrong up to half the time when they suspect herpes.  And since your genital ulcers were "active" when tested, the negative virus test from the lesions also argues against HSV as the cause.  Further, there are other causes of genital ulceration, including some respiratory infections, allergic reactions, and vaginal yeast infections, which can be triggered by antibiotics, including azitrhomycin (Z-pak).

If you read the thread whose link I provided, you will understand why your positive HSV IgM result doesn't mean very much.  On the other hand, it could indeed mean you have a new HSV infection and your IgG result will become positive for HSV-1 or HSV-2.  But if so, we still have to explain the source -- and your partner's negative blood test makes him an unlikely source.  It is possible your partner has HSV-1 or HSV-2 with negative blood test result; about 15% of people with HSV-1 and 5% with HSV-2 have persistently negative blood tests.

If you have herpes, I don't understand why your ObG suspects HSV-1.  Of all new genital herpes, about half are due to each virus -- so on that basis it's a 50:50 toss-up.  And the IgM test is not type-specific; it makes no distinction at all between the two viruses.  However, if this does turn out to be herpes, I agree HSV-1 probably is indeed more likely, because it's more likely your partner has HSV-1 with negative blood test than HSV-2.

The next step should be another type-specific IgG blood test, for both HSV-1 and HSV-2, in a few weeks.  Until then, if you are still taking Valtrex, you should stop it.  Early treatment sometimes delays development of positive blood tests, making accurate diagnosis more difficult.  It's safe to stop.  In the event you develop recurrent genital sores, you can restart the drug; and that also would allow another opportunity for a culture or PCR test for HSV on genital lesion(s).
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Avatar_n_tn
I definitely feel more hopeful of having not contracted hsv-1 genitally, but I will get retested by IgG in a few weeks. I was thinking 6 weeks from now?? And yes, I am on Valtrex so I will stop that as well.

In the meantime I suppose I should refrain from all sexual activity until my next round of results come back. I'm not sure about the risks of hsv-1 genital tranmission, genital to gential (genital) or genital to oral.

Thanks again for all your help and advice and suggested threads, I will post my re-test igG results then.

Best.
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Avatar_n_tn
Revision: the nurse informed me wrong on the test taken. The test taken at my obgyn on my results sheet was by Real Time PCR with a negative result for hsv-2 and positive for hsv-1. Both of my IgGs were negative along with both IgGs negative for my partner.
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239123_tn?1267651214
Aha!  So you definitely have a newly acquired genital HSV-1 infection.   You don't need another blood test to prove it.  However, you might still want to be tested in a few weeks to confirm it turns positive, which might avoid confusion in the event you have additional HSV blood tests in the future.

Most people with genital HSV-1 do not have frequent recurrent outbreaks; 40% have none at all and most of the rest have only 1 or 2 more outbreaks in the next couple of years, then none.  In addition, asymptomatic viral shedding is not very common, and genital to genital HSV-1 transmission appears to be uncommon.  For those reasons, ongoing suppressive treatment with Valtrex or similar drugs usually isn't necessary for genital HSV-1, unlike HSV-2.  Here is another thread that has still more information about genital HSV-1:  http://www.medhelp.org/posts/STDs/Recently-diagnosed-with-Genital-Herpes-HSV1/show/969931

Your infection almost certainly was acquired no more than 3 weks before onset of symptoms, most likely 3-5 days.  (Your apparent strep throat might have in fact been an initial oral herpes infection, with a delay in onset of genital lesions.)   In any case, if your information is correct that your current partner is your only sex partner recently, then he is the only possible source of your infection, despite his negative blood test.  As discussed above, he may just be one of that 15% minority with HSV-1 with negative antibody tests.  Another possibility, which I didn't think to mention above, is that he recently acquired his infection, either orally or genitally, from another partner, then transmitted it to you before his blood test became positive.  This is statistically a little unlikely.  On the other hand, the chlamydia had to come from somewhere -- so perhaps he has indeed had other partners and infected you with both STDs simultaneously.  Which of these scenarios makes most sense to you?  Have you spoken with him about possible exposure to other partners?
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Avatar_n_tn
Ah yes, after doing some research last night after my last post I did have to concede I have a newly acquired genital HSV-1 infection. I will do another blood test in 6weeks to avoid any confusion in the future.

My current partner is my only partner, now almost a two month long relationship. We suspected he gave me Chlamydia from someone he had sex with just before we started seeing each other. As for the HSV-1, he had mentioned once his mother has cold sores from time to time but insisted he had never had one.

So, please allow me to confirm some things. Correct me if I am wrong on anything. Since my igGs came back negative this is certainly newly acquired and most likely within 3 weeks of first symptoms. Prob 3-5 days before which I did receive oral sex 3-5 days before my symptoms. Since my boyfriend is my only current partner it is certainly he who transmitted it to me genitally via oral or genital to genital despite the fact his hsv-1 igG blood test came back negative? This puts him in the minority 15% that test negative but still carry the virus or he will test positive later because he acquired it from someone recently?

From what I've gathered via research and your suggested threads:
1. HSV-1 genitally it rare to pass to someone who already has it in either location.
2. After my 10 day dose of Valtrex I should opt out of suppressive, one because it sheds less and cause few if not no recurrent outbreaks; and two because I should see what my natural (no medicated) recurrence is going to be?
3. Genital hsv-1 to genital in a non infected person is uncommon.
4. Although there is a social stigma against the genital location for hsv-1 it has less recurrent outbreaks than someone with oral herpes because it is out of its site of preference?

I did order a book to read about all I should be aware of and prepared for health wise and relationship wise.

One question I did have was you mentioned "(Your apparent strep throat might have in fact been an initial oral herpes infection, with a delay in onset of genital lesions.)" Can oral herpes cause a genital outbreak without having it genitally? That is prob a silly question. In addition, the nurse at my obgyn said I would have no recurrent outbreaks genitally but would could have oral herpes sores from now on....is this true? Doesn't really add up to me.

Thank you so much for your help, you've given me much more information than my provider.

Best.
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239123_tn?1267651214
Thanks for the additional information.  Most likely your partner has a longstanding oral infection, not a newly acquired one.  But there is no way to know for sure.

1) People are immune, or at least highly resistant, to second infections with the same virus type, anywhere on the body.  Couples do not ping-pong their HSV infections back and forth.  And if and when you have future partners, if they have been infected with HSV-1, it is unlikely you would ever infect them again with your own HSV-1 infection.

2,3) You correctly understood my comments above.  This doesn't mean genital to genital transmission cannot occur, but it probably is uncommon.

4) Yes, the lower rate of recurrence and asymptomatic viral shedding probably has something to do with anatomic sites of preference for HSV-1 vs. HSV-2.

5) HSV doesn't travel through the body; if the sore throat etc was herpes, it didn't travel to your genital area.  The genital infection came directly from your partner, likely by cunnilingus.

I think that should wind down this thread.  Glad to have helped.  You might consider perusing the herpes community forum, which is moderated by excellent counselors.

Which book did you order?  I can strongly recommend Understanding Herpes, by Terri Warren (moderator of MedHelp's herpes forum) and Managing Herpes by Charles Ebel and Anna Wald.
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Avatar_n_tn
Thanks again, and I will keep up with the herpes community forum. The book I ordered: "The Good News About Bad News:...." by Terri Warren so I guess I made a good purchase!

Best.
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