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Possible non-primary HSV2 infection
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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 non-primary HSV2 infection

Thank you in advance for your help Doctor, it is much appreciated. The story goes like this:

I have been in a sero-discordant, monogamous relationship with a terrific girl for the past 6 months. She has been HSV2+ for the past few years but has never to her knowledge experienced an outbreak - found out during a routine STD screening test. I myself am HSV1+/HSV2- (hence the "non-primary"). She doesn't take daily suppressive antiviral therapy, but our condom use is 100%, literally have never had unprotected sex.

A couple of weeks ago I noticed an oval-shaped red macule measuring approximately 4 mm on the head of my penis, maybe 1 cm lateral to the opening of my urethra. The lesion appeared 15 days after the last time we had intercourse. The spot didn't change much over time. In the first few days it might have got a bit redder, slightly raised, with a bit of shiny flakiness on top. It never blistered, there was never any fluid, no pus, and it never scabbed. It has been 2 weeks now and the spot is nearly gone. I never had any systemic symptoms like fever or fatigue nor any local ones like pain with urination, tingling, or burning. At most there was mild discomfort when the area rubbed on my boxers. I visited my PCP in the middle of all of this, she looked at it under the ophthalmoscope and was convinced that it wasn't herpes. She didn't swab it or suggest other likely alternatives though. She did, however, refer me to a dermatologist who I recently saw. At that point the lesion was not so distinct anymore so looking at the spot wasn't so helpful. We decided on getting a HerpesSelect test done in 7-8 weeks for a definitive answer.

I guess my questions would be, as an expert, how likely would you say that what I had was herpes? How "atypical" would that presentation have been? I know that female --> male transmission rates are low given the precautions we take. Also, is HerpesSelect the way to go or would a Western Blot be more accurate?
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Welcome to our Forum. I'll try to help.  In persons with HSV-1, acquisition of HSV-2 can be somewhat different from the more "classical”  symptoms but not markedly.  You are doing most of what you can do to reduce your risk for acquisition of HSV.   100% condom use should reduce your risk of acquisition from about 6% per year, on average to less than 3% and perhaps more since your partner has never had an outbreak.  Further, the lesion you describe not only sounds very atypical for HSV (it sounds more like fungal infection or some other dermatitis) but occurring more than two weeks since your last intercourse is late for the appearance of a new HSV infection as well.  I very much doubt that this is HSV.  Should it recur, I would work with your health care providers to get a PCR test of the lesion- There does not have to be an open sore or fluid present to do this.

As for the blood tests, in your situation, the Western blot would be the better test since your risk of having a false positive is rather high (in part because of your HSV-1) and your likelihood of having HSV-2 is low.  Personally however, I'm not sure I would seek testing at all, just observe for a recurrence (which I doubt will happen)  EWH
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Thank you for your insight Dr. Hook. If you don't mind, I had a few follow up questions regarding your post.

1) You mentioned that my presentation was more consistent with dermatitis or a fungal infection. Would those be your leading diagnoses based on my description of the lesion and the fact that it resolved on its own in ~2 weeks? I imagine that HPV, lichen planus, and others typically require intervention of some sort before they go away.

2) I will be vigilant for recurrences (hopefully none occur!). Is there a median time interval between the initial outbreak and subsequent ones? Or is it random and more predicated on an individual's associated triggers?

3) With regards to reducing my chances of acquiring HSV2 from my girlfriend: is there any evidence to support that washing the genital area post-coitus reduces risk? I ask because it seems like even condom removal could expose and inoculate skin with potentially virus rich fluids.

As you mentioned, I will discuss doing a Western instead of a HerpesSelect - hopefully the test is offered. I even managed to find to Dr. Handsfield's paper assessing the test characteristics of the ELISA as compared to the WB! Thanks again.
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1.  The lesion and timing you describe in no way suggests HPV.  There are many dermatologic processes that come and go, including fungal infections which is what the rash you had sounds most like.

2.  On average persons have about 3 recurrences of symptomatic HSV-2 per year following the inital outbreak with the first recurrence occurring within 6-8 weeks however this is highly variable.

3.  No there is no evidence that washing after sex changes HSV risk in any way, not that I'm aware that it has ever been studied.  I woul not think it would help however.  

Glad I could help.  EWH
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Avatar_m_tn
Dr. Hook,

So my physician and I went ahead and had the Herpes Select test done and the results came back negative for HSV2. In his words, there was "no evidence of viral infection." I don't have the exact value, but since it registered as negative I am assuming that it was 10.5 weeks after the last possible exposure. Does that timing make you confident I had a true negative? Given that my doctor selected when to test me I would like to think that it was. Any reassurance would be great.

Thanks
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Avatar_m_tn
Sorry, my post got edited funny. It should read:

So my physician and I went ahead and had the Herpes Select test done and the results came back negative for HSV2. In his words, there was "no evidence of viral infection." I don't have the exact value, but since it registered as negative I am assuming that it was < 0.9. I am of course delighted with the results and ready to move on. The only remaining confusion I have is regarding the timing. My blood was drawn 8.5 weeks after the onset of the lesion I described in my first post and 10.5 weeks after the last possible exposure (intercourse with HSV2+ GF). Does that timing make you confident I had a true negative? Given that my doctor selected when to test me I would like to think that it was. Any reassurance would be great.

I'd also like to add that I have not had any similar symptoms or recurrences since.

Thanks
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As I said in my original response, from the outset it was my feeling that the likelyhood of your rash being HSV was low.  The HerpeSelect results add to this feeling and my advice at this time is for you to be confident that your rash was not HSV and that you did not let HSV-2 from your partner.  I would suggest you put this entire matter behind you and move forward.  EWH
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H. Hunter Handsfield, M.D.Blank
University of Washington
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Edward W Hook, MDBlank
University of Alabama at Birmingham
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