Oral HSV-2

[kager]

At the end of November, I came down with a severe sore throat, that eventually manifested into a 103 deg fever, swollen lymph nodes, weight loss (from not eating), and ended with laryngitis which I am still recovering from. My throat, from the tonsils back, was coated with white pustules as I've never seen before. I was tested for strep (negative), mono (neg) and put on antibiotics (2 separate ones) which didn't seem to help. The sore throat lasted around 2+ weeks. Towards the end, I saw an ENT who put me on antibiotics and oral steroids and has been seeing me for the lingering laryngitis.

Concerned about my immune system, a battery of blood tests were performed. HIV was negative as well as thyroid, etc, but today he received the results from the HSV test and informed me that it came back positive. Specifically, he said I was positive for HSV-2. There were two parts to the test, one indicates that the exposure was somewhat recent, the other part simply said that I had been exposed. As I am not terribly sexually active, I can probably determine where the infection came from.

I have never experienced an outbreak of genital Herpes (and from what I've read, I would have definitely known if it did happen, as I'm pretty compulsive about making sure that area is healthy), and I have never had cold sores on my lips, and from what I read, the typical period from contact to initial outbreak is around a week or so, so I am way passed that (nearly 3 months since last contact with anyone). The last sexual encounter involved some kissing and male/male oral sex only - nothing else.

1. Is this feesible to have Oral HSV2? Everything I've read about Oral HSV-2 says that it is very rare.
2. Is it possible to have genital HSV2 without ever having an initial outbreak?
3. Is it common for Oral HSV2 to move to the genital area?
4. My throat is now clear of any white; am I contageous. I've read otherwise, but not sure.

[H. Hunter Handsfield, M.D.]

Yes, HSV-2 can cause oral infection with symptoms like you describe.  There usually would also be sores in the mouth and/or around the lips, but not necessarily.  Still, that’s probably not what you had.  The severity of your symptoms means that if HSV-2 was the cause, it was an initial and not recurrent infection.  That means you caught it 3-10 days before onset of symptoms.  Since your only oral exposure to someone’s genitals was 3 months early, herpes is very unlikely.

Several other possibilities exist, including undiagnosed viruses or even things you were tested for (like strep), since the tests are not perfect.  Or maybe infectious mononucleosis; your symptoms are very typical for mono.  Most docs would recognize mono as a possibility, so maybe you were tested for it – but maybe not, since you don’t say so.

So your positive blood test for HSV-2 probably has nothing to do with the illness you describe.  Half to 70% of men who have sex with men (in the US) have positive HSV-2 tests, so no surprise there.  The test for “early” infection undoubtedly was an IgM antibody test.  Those tests are notoriously unreliable and despite what you were told, does not accurately indicate recent infection.  (For many forum discussions about this, use the search link and enter “herpes diagnosis”, “HerpeSelect”, and/or “IgM”.)

To your specific questions:

1) Yes it occurs and yes it is uncommon.  Probably HSV-2 doesn’t explain your symptoms.

2) Yes. Most people with positive HSV-2 tests do not recall ever having symptoms that suggest genital herpes.  Assuming receptive anal sex (bottoming) is part of your sexual repertoire, your asymtomatic HSV-2 infection is equally likely to be anal or genital.

3) HSV does not migrate through the body.  Self-infection of a new body part by touching an infected area and transferring the infection elsewhere (called autoinoculation) sometimes occurs but is rare.

4) Since HSV-2 probably wasn’t the cause of your illness, you’re not infectious to anyone by oral contact.  However, your positive blood test result indicates you can potentially transmit infection to someone by anal or genital contact.  The absence of genital or anal symptoms makes no difference; all infected people have periods when the virus is present without symptoms. You should inform future partners of your infection before having sex with them and stick with safe sex practices.  You also could be treated with anti-herpetic drugs (e.g., valacylovir) to reduce the chance of transmission to partners.

Two final take-home messages:  First, people with HSV-2 are at significantly greater risk of catching HIV if exposed, even if they have no symptoms.  You need to be especially conscious of safer sex practices and take particular care to avoid sex with HIV positive partners.

Second, many people who are asymptomatic but found to have positive blood tests come to recognize symptoms of recurrent herpes that they didn’t notice earlier.  Be aware of mild genital or anal blisters, sores, itching, etc – and if you notice anything, see a health care provider within 1-2 days to confirm the diagnosis.

Excellent information on herpes and HSV-2 is available at several websites.  Some of the best are www.ashastd.org, www.cdc.gov/std, and www.metrokc.gov/health/apu/std (where I wrote much of the information myself).

Best wishes--  HHH, MD

[kager]

Thanks for your reply, but I think I may have led you astray on one point, specifically regarding the last sexual encounter.

The last encounter I described was around mid November, and the initial symptoms that I described (sore throat, etc) started showing up on November 24, which would be about one week later. I was simply saying that since that encounter, I have not participated in any sexual activity. The illness started around November 24. Forget about the three month window that I mentioned, as that was simply an error on my part.

I'll heed your recommendations.

[kager]

Also, in my initial note, I did mention that I was tested for Mono (they suspected that) and it was negative (I was tested twice for that) and strep (tested once - negative).

Thanks for your prompt reply!

[kager]

I'm for yet a third reply, but I'm a little scatterbrained after today's visit. The other thing I wanted to mention was, that the test results provided to me today indicated that the exposure was recent. The doctor said that there are two parts to the blood test result, one that tells if the antibodies exist, and the other that tells whether the exposure was somewhat recent. He indicated that the exposure was recent, which would then have to date back to that November encounter. So, assuming that the first exposure to HSV-2 was in November, the only thing that has happened to my body was what was going on in my throat - nothing around the genitals.

Sorry for 3 replies, but today was a little shocking and I'm just a little off today.

[H. Hunter Handsfield, M.D.]

Sorry I missed the information about mono.

I understood perfectly about the test for recent exposure and responded above.  As I said, undoubtedly that was an IgM test and was meaningless.  It does not prove your infection was recent.  It could be recent or old; there simply is no way to tell accurately by any blood test.  Many providers don't understand the poor performance of IgM testing for HSV, like yours (apparently).

However, with the clearer description of the timing, indeed it is possible that HSV-2 was the cause of your pharyngitis etc.  It's by no means definite, however, and there still are atypical features, including the apparent absence of open sores in your mouth and the fact that the first episode of new HSV infection usually doesn't last as long as your apparently did.

Oral HSV-2 infection often doesn't result in recurrent outbreaks, but if you do, most likely recurrences would occur on or near the lips, just like cold sores due to HSV-1.  In that event, return to your doc within 1-2 days of onset to be tested for the virus, including virus type.  But if that doesn't happen, and if you never notice genital or anal symptoms for similar testing, most likely you will never know for sure the anatomic site of your HSV-2 infection, whether it was recent or new, or whether it was the cause of the pharyngitis.

There is one additional clue that you might pursue.  Assuming you know or can identify your oral partner from November, you could speak with him and perhaps learn that he has genital herpes; or perhaps persuade him to be tested for HSV-2.  If he is HSV-2 negative, it would prove that wasn't the source.

[kager]

Thank you for responding. This information helps to understand a bit about what's going on and how to go forward. I'll read a bit more on the other sites just to educate myself. It's disappointing that the IgM test is not particularly useful (or accurate).

[kager]

A related discussion, HSV-2 Asymptomatic viral shedding was started.