STDs Expert Forum
Possible Herpes Pharyngitis
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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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Possible Herpes Pharyngitis

I'm in my mid-20s and have never had and STD.  While traveling just over a week ago I gave oral sex to a random guy I met at a club.  I'll admit the lighting was poor so I am not sure if he had any active lesions or not.  There was no orgasm.  About 4-5 days after that encounter I became extremely fatigued, developed frequent bouts of diarrhea and had temperatures as high as 105.  My friends actually took me to an ED where I received 2 bags of fluids and some blood work which the ED Doc said was normal.  The ED Doc commented on a nasty looking throat which surprised me because I had no pain or only a mild sore throat.  A mono test and strep test were negative and he sent me home saying I had a viral infection.

Over the next 3 days (including today) I've continued to have fevers, though not as high.  I do really have a sore throat now, can barely eat or drink anything.  Looking in my throat I see multiple ulcerations on my soft palate with pus, a couple on my hard palate, both of my tonsils are covered in pus and the back of my throat has a lot of pus and some ulcers on it too.  I don't actually notice any ulcers in my cheeks and there aren't any that I can see on my tongue or lips.  

I went to an Urgent Care and explicitly told the Doc I was worried about this being a herpes infection in light of my recent sexual activity and that I wanted to be tested for it.  He said that it was impossible for herpes to present without lesions on the lips and he wouldn't test me for it, re-tested me for mono and strep (both neg) and sent me home with an antibiotic.

My questions to the Doctors in this forum would be:
-Was the Urgent Care Doc right?  Or is this sort of throat infection a possible presentation of herpes?
-Should I find another center and insist they do tests for herpes?
-Diarrhea usually isn't associated with herpes I thought, am I wrong about that?
-What's the prognosis for herpes pharyngitis?

Thank you in advance for your answers, advice given looks great.
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I'll try to help.  There are some atypical features for herpes, but it still seems like a fair bet.  Most cases of new oral herpes infection would be expected to have more throat and/or mouth pain from the start, either before or at the same time as fever; and diarrhea is somewhat unusual.  On the other hand, the subsequent appearance of apparent ulcerations, including some on the soft and hard palate, certainly suggests herpes.  Given the circumstances, I definitely agree you should be tested for HSV.  But other viruses also might be possible and you need a throat culture for gonorrhea if not yet done done.  Gonorrhea of the throat rarely causes such dramatic illness, but it's possible.

To the specific questions:

1) MedHelp advises forum moderators to avoid criticizing questioners' health care providers whenver possible.  But if you are correctly reporting the urgent care doc's statement, I disagree.  Initial herpes certainly can involve the throat and/or inside of the mouth, without lesions on the lips.

2) You definitely should be tested for HSV, as well as for gonorrhea and other viruses that can cause this sort of picture (coxsackie virus, certain enteroviruses).  Do it soon; as time passes, a culture or PCR test for HSV and other viruses could become negative even if one of them is the cause.  Re-testing for strep would also make sense; the previous test could have missed it.

3) You are correct; diarrhea is not usually part of the herpes picture.  However, it certainly doesn't rule it out.  Diarrhea sometimes is a nonspecific symptom that can be triggered by any severe inflammatory process; or as I said, some other virus might be responsible.

4) Herpes pharyngitis will clear up, with or without treatment, but without treatment it could take a couple of weeks.  Given the circumstances, I believe it would be reasonable for you to be treated immediately with an anti-herpes drug (valacyclovir, acyclovir, or famciclovir), without waiting for the test results.  If HSV is the cause, treatment will markedly speed improvement.  (Unfortunately, there is no treatment that will do much for other possible viral causes.)

If by prognosis you mean the potential for recurrent oral herpes, that is more difficult to predict.  If you acquired herpes from the oral sex event, most likely it is HSV-2; and there aren't very good data to help predict the likelihood of recurrent oral outbreaks in that situation.  As it happens, another question on this forum came up just a few days ago.  See

Bottom line:  See another provider ASAP (or return to the same clinic with a copy of this reply!), insist on testing of your throat for HSV, other viruses, and a repeat strep test; and request a prescription for an anti-herpes drug.

Please return to the forum when you have the answers and let me know how things are going.

Best wishes--  HHH, MD
Thank you very much for the informative reply and detailed reply.  Here is some brief follow up.  I went to a local ED with a copy of this post and discussed my concerns with the ED Doc there.  He was quite sympathetic and ended up repeating a rapid strep, doing herpes cultures, standard viral cultures and GC/CT cultures.  He also gave me a shot of ceftriaxone, wrote me a prescription for valtrex and said hopefully some results would be back in 3 days or so.  It appeared they did not have PCR HSV testing available so I'll have to wait for the slower growing cultures.

Thank you again for the advice.
Excellent!  Please let me know how you're doing in a few days, and report the test results when you learn them.  If HSV is the cause, you can expect your throat pain to start easing within 2-3 days.  (Of course, it might also start to get better on its own, so improvement won't prove herpes as the cause.)

If the HSV culture is negative, request an HSV blood test.  If negative for HSV-2 and becomes positive after a few weeks, it will prove the cause despite a negative culture.
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University of Washington
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