I had an oral lesion and did not suspect Herpes...my partner then got it genital

On 7/29/05 I first noticed a sore lesion inside of my mouth, lower lip by the gingiva. I am an MD also and looked at it and but did not suspect Herpes. To my knowledge I had never had "cold sores" before. Several days later the pain grew more intense and I consulted a doctor. By this point I had had intercourse (oral and vaginal) with my current partner. I was placed on acyclovir. My parner soon developed pain on intercourse and a tender inguinal lymph node. About a week later she developed a classic herpetic rash in the genital area.

My blood work was sent on 8/11/05 (14 days after I first had oral symptoms). I had no IgMs but I was positive IgG for HSV-1 (titer 5.9).

Her herpes genital  CULTURE came back positive for HSV-1 only (no HSV-2 for either one of us).

Needless to say it was a very dark day for both of us. We have been miserable trying to make sense of our new predicament.

My questions are: 1. Does it seem likely that this was not my very first exposure/infection to HSV-1 ince my IgGs were positive  but not my IgMs?

I have never had any such symptoms before but may have carried the virus. I am asking this because I understand that it is posible to spread the virus from the oral to the genital area (auto-inocculation)  IF it happens during the original infection, but not later after one develops immunity. I have not had any genital symptoms but I am concerned that I may develop them in the future since my partner has them and I was exposed genitally (no condom) during her breakout. Since I have had no symptoms genitally what can I do to confirm or rule out my having HSV-1 genitally? If I end up dating someone new in the future (no plans right now) what should I tell them about my genital "herpes status"? I know I have it orally now.

My partner is extremely depressed and wishes to know what her course will be. I have read with her the previous postings on this site and it does seem a little bit comforting to know that she could not spread genital-to-genital HSV-1 to a person who already has been exposed to HSV-1 (more than 1/2 of the population at her age of 30). Is this an absolute medical certainty that existing IgG's are 100% protective?

Last question: Is there any truth to the fact that Nonoxynol-9 (spermicide) is also microbicidal and kills HSV1 and 2? Could this be used effectively by someone (in gel/lubricant form) with  genital HSV-1 between outbreaks and without condoms during intercourse to prevent transmission to an un-infected partner, ie. killing the small amount of possible virsal shedding that might occur when there are no symptoms?

Thank you in advance for your time and effort answering these questions!

[H. Hunter Handsfield, M.D.]

I hope you will understand if I don't try to answer all the overt and implied questions in detail; it would take a couple of volumes.  It sounds like you have some misconceptions about HSV infections--ie knowledge level probably typical for most MDs (not knowing your specialty).  Much of what you need to know is covered in the herpes article in the link at the top of the STD forum ("STD Quick Facts and Articles"), and in information provided by CDC (www.cdc.gov/std) and the American Social Health Association (www.ashastd.org).  Or go to any infectious diseases texbook.  Some brief responses:

It is clear you have oral herpes due to HSV-1 and transmitted it to your partner by cunnilingus.  Your infection most likely is chronic, perhaps acquired in childhood.  The atypical part is having an intraoral lesion; most recurrent oral herpes lesions are external, and I have often told questioners in this forum that apparent canker sores rarely are herpetic.  On the other hand, initial herpes often is mucosal, and 14 days is (barely) enough time to develop detectable HSV antibody (IgG).  But chronic/recurrent infection seems most likely.  You'll probably never know for sure.

IgM antibody is meaningless in herpes.  Contrary to other infections, for reasons not well understood, IgM antibody often is absent in initial infection and often reappears in recurrent outbreaks.  Despite availability in many labs, it is a useless test that I have never ordered on a patient.  Make sure the IgG test you had was truly type-specific, such as Focus Technology's HerpeSelect test; the numerical result is consistent with HerpeSelect, but that test doesn't even come in an IgM version--so make sure the IgG test was the right one.

You are wrong in believing that HSV-1 is no longer transmissible after the initial infection and development of antibody.  Recurrent outbreaks, including subclinical viral shedding, are the source of most spread to other persons.  Same applies to genital HSV-2 infection.

Genital herpes due to HSV-1 usually has a benign course in terms of recurrences.  Unlike HSV-2, most people have only 1-2 recurrent outbreaks over the next couple of years, than no further ones (40% have no recurrences at all).  Also, asymptomatic viral shedding of HSV-1 is rare in genital infection.

Antibody to HSV-1 (or HSV-2) is protective, in that seropositive persons are immune to acquiring new infections with the same virus type.  Neither you nor your partner will ever acquire another HSV-1 infection.

N-9 will not protect against herpes or prevent viral shedding.  You can be sure you do not have genital HSV-1 infection.

Good luck--  HHH, MD