Lots of questions about genital HSV-1

[yeahright123]

Thanks for providing this service, Dr H.

I'm a heterosexual male and I've been in a monogamous relationship for about 5 months. A little over 2 weeks ago, my girlfriend and I both came down with genital sores at the same time. We both saw doctors on June 6th, and had cultures taken from the sores for an HSV-1/2 test.

We both got our test results back on the 12th and both tests came back positive for HSV-1. Her symptoms have now gone away, but mine have not. This may be partly due to the fact that the doctor she saw prescribed Valtrex, while my doctor misdiagnosed me as having a bacterial infection and told me to treat it with Neosporin which may have made it worse.

After I got the test results I spoke to my doctor again and got a prescription for generic Acyclovir pills. I have already taken all of them, and while the blisters have healed, there is still a lot of redness and some soreness in the area of the initial infection.

Questions:

1. How long do initial HSV-1 infections in the genitals usually last? Should I be worried that my symptoms have not gone away yet? Should I get another prescription for anti-viral medication?

2. It strikes me as odd that my girlfriend and I would both have initial outbreaks at the same time. Neither of us has ever had a cold-sore or an outbreak before. I guess I can only truly speak for myself that I've been 100% monogamous for the past 5 months, but my girlfriend says she has been too and I believe her. Is it possible that one of us has been carrying the virus for five months or more without having an outbreak until recently, or should I suspect that something shady is going on? The only other thing I thought of is that we both went swimming in a crowded pool about a week before our outbreaks started. I've heard stories of people catching herpes in swimming pools, but I suspect they may be urban legends.

3. We're both concerned about oral sex and transmission of the virus to our mouths. I understand it's extremely difficult to contract the virus in two different sites due to the presence of antibodies once an initial infection has occurred. Should we be concerned or is it true that it's almost impossible to contract the same virus in two different sites? What about other parts of the body? I've read that it's possible to transmit the virus to the eyes or fingers.

4. This is sort of off topic, but I thought you might have some insight into this as well. I have no insurance, so when I went to my $85 dollar doctor visit and he said he wanted to take a herpes culture, I asked, "And how much will that cost?" The doctor told me he wasn't sure, but he guessed it would be somewhere in the neighborhood of $40 dollars. You can imagine my surprise when I opened my mail box to find a bill from Quest Diagnostics for $194 dollars. Is this a reasonable price for this test? And is it legal to bill people for services without telling them how much they cost beforehand?

Thanks, and sorry for the long post.

[H. Hunter Handsfield, M.D.]

YR123:  Most of the time, the initial infection causes the worst symptoms, but there are plenty of exceptions.  But if you're read my initial response, you'll understand I don't think this applies to you.  The most likely scenario (but not necessarily the right one) is that your partner was infected all along but infected you only recently.  Your blood test results will help sort it out.  (I'm not certain it matters, to be honest, but it's up to you.)

ATSTL:  "Quackery" was too strong a term for the lysine-arginine business.  There is a theoretical scientific basis, in that lysine promotes and arginine inhibits growth of HSV in tissue culture.  But several controlled studies did not demonstrate clear benefit of taking lysine supplements, and I am unaware of valid data at all for low-lysine, high-arginine diets in preventing recurrent herpes.  Lysine absolutely has no effect on severity or duration of outbreaks.  A couple of studies appeared to show benefit in reduced frequency, but the research was scientifically flawed; and even those demonstrated trivial benefit compared with studies of antiviral therapy (acyclovir, etc).  The best review of all this business was published in the American Journal of Health Systems Pharmacies (volume 58, p. 298, February 2001).  I don't know what you read in Prevention, but a search of the scientific medical literature shows no more recent work on lysine or arginine in patients with herpes.  (By the way, the whole lysine-arginine business plays into general advice and controversies about healthy diets:  lysine is high in meats, arginine high in veggies, nuts, etc.)

The reason that I come down so strongly against lysine-arginine is that it is unethical and unfair to imply to herpes sufferers that there are simple, non-medical things they can do to control outbreaks, whether from diet, stress reduction, etc.  The vast majority of people cannot identify avoidable triggers or prevent outbreaks, no matter what they do - with a resultant increase in stress and frustration, and it is dishonest for anyone to promote such treatments.  The only things that affect herpes recurrences are the passage of time (gradual reduction in outbreak frequency); and medical treatment with acyclovir or related drugs.  That's all.

HHH, MD

[yeahright123]

Dr. H, You were right about not neading additional treatment, everything seems to be back to normal now. Tbanks.

I just have one more question. How uncommon is it for someone to go 5 months or more after an initial infection without having their first outbreak and to then have a fairly severe one?

I ask because everything I've read suggests that most people get their first outbreak within a few weeks of becoming infected.

Thanks.

[Anxiety to say the least]

Doctor,  I am thread jumping, I know, but I was reading my Prevention magazine last night and they had an article in there about arginine and that it may trigger herpes simplex virus. By may trigget does that mean they do not have substantial evidence to back this info up?  Just curious.  Thanks if you answer.

[H. Hunter Handsfield, M.D.]

In looking against at your original question, I'm not at all sure you need additional treatment.  It's only indicated if new lesions are still appearing.  No additional treatment will speed up slow healing of existing sores.  Don't make your own treatment decision; see your doc (or a different one if not convinced of his herpes expertise) to confirm whether you need additional treatment. (I don't advise specific doses; it gets too close to practicing medicine from a distance.)

The lysine/arginine stuff is quackery.  You can eat whatever you want.

Good luck--   HHH, MD

[Anxiety to say the least]

Doctor,
You say that the lysine/argentine is quackery?  I have never heard such good news in my life.  I have been avoiding my favorite nuts and dark chocolate for nothing?  I have still not figured out what is gong on with me, but I was told to stay away from the foods high in argentine.

[yeahright123]

Thanks for the quick reply, I really appreciate it.

I'm going to call my doctor tomorrow and see about getting a prescription for Valtrex. My physician is clearly not an expert in STDs so I wonder if you could tell me what dosage you would recommend?  

Also one more question as long as I'm here. I've read on other sites about the effects of Lysine/Arginine ratios in ones diet, but I also read in your reply to another post that you don't believe Lysine has any positive effect on herpes outbreaks. Does that mean Arginine also has no negative effect? In other words, can I still eat peanuts and chocolate?

Thanks.

[H. Hunter Handsfield, M.D.]

Aside from antiviral therapy, there is nothing that has been shown (with scientific validity) that influences the frequency or severity of genital herpes recurrences, asymptomatic shedding, and so on.  No diet, no meds, no stress/anxiety reduction, nothing.  Oral HSV-1 recurrences are influenced by local trauma (e.g., sunburn, local surgery) and other illnesses, hence the names fever blisters and cold sores.  No triggers have ever been proved for genital herpes due to HSV-2.  To my knowledge there are no good data either way for genital HSV-1, however.

HHH, MD

[H. Hunter Handsfield, M.D.]

Aside from antiviral therapy, there is nothing that has been shown (with scientific validity) that influences the frequency or severity of genital herpes recurrences, asymptomatic shedding, and so on.  No diet, no meds, no stress/anxiety reduction, nothing.  Oral HSV-1 recurrences are influenced by local trauma (e.g., sunburn, local surgery) and other illnesses, hence the names fever blisters and cold sores.  No triggers have ever been proved for genital herpes due to HSV-2.  To my knowledge there are no good data either way for genital HSV-1, however.

HHH, MD

[HHH,MD]

I didn't fully answer question 2.  One of you acquired the infection from your partner, sexually (assuming you both are being truthful about not having sex with others).  YOu did not catch it from a swimming pool or any other nonsexual source.  That simply does not happen, regardless of the fact that you have "heard stories".

HHH, MD

[H. Hunter Handsfield, M.D.]

Perhaps most important, initial symptoms do not necessarily mean initial infection.  It is possible one of you has been infected for some time, but only recently had the first recognized symptoms and also transmitted to the other person.  From the duration of your outbreak and the brevity of your partner's, the best bet is that she has been infected for some time and transmitted the infection to you.  Genital-to-genital HSV-1 transmission is not common, but it can occur and seems to explain your situation.  This assumes the virus type was not mis-identified.  If you want to sort this out clearly, you might be able to do so with blood testing.  If you move quickly and both of you have HSV blood tests (for both HSV-1 and -2) right away, then if negative for either virus, repeat testing in a few weeks, you might be able to nail down who was infected first.  But as I implied, I'm not sure this is crucial at this point.

1) Initial genital herpes due to either type can last up to 3-4 weeks, or (rarely) can have a stuttering course for 6 weeks.  Acyclovir is a pretty good drug, but has poor bioavailability; only about 20% is absorbed from the GI tract, and in some people it can be as low as 10%.  That's the main advantage of valacyclovir (Valtrex) or famciclovir (Famvir). Also, HSV-1 is less responsive to antiviral therapy than HSV-2.  You might have needed a bigger dose.  In any case, discuss this with your provider. If you still have new lesions appearing, you probably need another course of therapy.

2) Yes, the situation is atypical.  See my opening comments.

3) Reinfection (either from outside or by transfer from one's own infection, called autoinoculation) of a new body part usually occurs only in initial HSV infections; it is rare once an HSV infection is established in one anatomic area.  If one of you is experiencing an initial infection (you, most likely), that person is, for now, susceptible to autoinoculation and to "superinfection" from your partner's genital infection.  However, after a few months, that won't really be a risk. Use common-sense hygiene after using the toilet or otherwise touching your genital area, but that's about all.

4) I never cease to be amazed at the giant profit margin showing up these days in lab tests.  That cost seems high to me, too.  But I doubt it is illegal.  I'm no medicolegal expert, but my guess is that your doc is not legally the provider of service for the lab test; and unless s/he deliberately gave misinformation, I doubt s/he is responsible for a higher cost than you expected.

Assuming there is no error in the virus typing, i.e. you both have HSV-1, this probably will all fade into nothingness after a few more weeks.  Statistically, the likelihood is neither of you will have frequent recurrences and that each of you will be immune from re-infecting each other at any anatomic site.

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