Professional Opinion HSV2 Sought (HANDSFIELD)

[whattodonext]

Been with lady for 3 yrs.  She has and has had HSV2 for at least 4 years but didn't know (long story) until early May.  It was confirmed by culture and igg specific test.  We had unprotected sex for 1 year and began using condom about 80% of the time last 2 yrs.  She had o/b in early May and we had sex about 10 times during the month.  I'd guess7 of them were with a condom.  She told me of hsv2 status the first of June.  Her ob was close to her vaginal lips but not on.  In the hair area.  Since that time:
1.  IGG combined 1/2 2 tests at 1.4 (ALL BLOOD IS HERPESELECT)
2.  IGM 2 tests at 1.2
3.  IGG specific tests for 2 (4 and all negative), with the last one being at least 8.5 to 9 wks from last sex encounter and around 75 days from first encounter while having o/b.  
4.  Had 1 pimple/bump about 1" left of testicle 6 weeks after last sexual occurrence.  Pushed on, swabbed w/alcohol and had cultured 1 day after noticing.  Had red spots near (appeared on hair follicles maybe where swabbed w/alcohol?).  Culture was neg.  It looked nothing like her o/b...
5.  Feel like lymphs are tender, scrotum feels tingly on a daily basis, and notice white hard bump on testicle (seb cyst?) that has been there for 4 wks. & no change.  Occassionally, scrotum/penis feel hot but don't know if this is a result of excessive self examination or not.
6.  Lots of anxiety.

A. Is skin to skin contact enough or must it come in thru mucous membrane?
B. Your thoughts on HSV2 based on above?
C.  Advice on more testing?

[Edward W Hook, MD]

This is not true however further testing would be a waste of time for you.  Please do not post again regarding these questions.  EWH

[whattodonext]

Dr. Hook, I know you are annoyed with my questions. I am very worried.

I called an std service to schedule a follow up igg and she indicated that only people with compromised immune systems would not have converted at 9 weeks - people with hiv, etc.

Is this true?

Note if I need to pay again, I will.

Thanks

[Edward W Hook, MD]

Yes, that is what I meant.

As I tried to indicate earlier, it is now time for this thread to end.  further questions will be deleted without comment.  EWH

[whattodonext]

4.  Cultures - just so I understand - there is a higher rate of "false negatives" in people w/recurrent lesions that are more than 48 hours in their life (been around a couple of days or more)...

Did you mean to say, "more frequently the case for persons with recurrent healing lesions?"

To clarify, I don't have a lot, if any other instances of lesions, in my genital area.

Please elaborate just a bit and no more questions from me...

Thanks.

[Edward W Hook, MD]

1. I cannot explain why your doctors ordered the tests they ordered. The ID field is rather broad and within it some folks are more familiar with one area than another.  My specialty is STDs and HIV Prevention.  

2.  The combo and the IgM tests simply do not work reliably because they are susceptible to false positive results and lack of specificity in persons who have HSV-1 infection.  Beyond that, the reasons they do not work are nuanced and more complex than can be dealt with here.

3.  You want me to make up a number?  Ok, less than 1%, maybe less the 1/100th of 1%. Your question is asking for precision of a level which can't be done in an online exchange.  I would bet lots of money the you do not have herpes, just as I will be lots of money that you won't be hit by lightening while reading this. That doesn't mean it won't/couldn't happen but it means that it is so unlikely that worrying about it is a bit silly.

4.  You're right many cultures are falsely negative but that it less frequently the case for persons with recurrent, healing lesions. When considered in the context of what you said, as I told you, it does further strengthen that you do not have HSV.

Time for both of us to move onward.  EWH

[whattodonext]

Dr. Hook, thanks again for the feeback.  A couple of parting questions to allow me to put this to bed for now:

1.  I went to an Infectious Disease specialist at my last visit.  Why would they have ordered the IGG 1/2 combo test and the IGM tests if they are no good?  These guys/gals should have been specialists in this.

2.  I read on many of your/Handsfield posts that half or better of the tests in the 1.2-3.5 ranges (on the specific tests) are really negative.  Does this apply to the IGM and 1/2 combo tests as well?  I have also read where Dr. Handsfield says IGM and IGG typically move up in unsion at roughly the same time as opposed to the IGM going up first as some sites will tell you.  Is my understanding here correct?

3.  I see where you say my chances of having acquired HSV 2 are "very, very low."  If you were to be forced to quanitify this (in perecentages) what would be your educated guess?

4.  And lastly, the cultured bump I had (written in the original post), you state the test "further strengthens the evidence that you do not have HSV-2 at this time."  Given that I DID have a bump and that so many cultures yield false negatives, why do you say this strongly suggests I don't have HSV2?  

These are my last questions and thank you again.  Your replies really mean a bunch to me.  When I went to the ID clinic in a fairly large city, it appeared I knew more, from having read this board, than they did... :(

[Edward W Hook, MD]

1.  This is correct
2.  That is not necessarily true but the rash you describe as her OB would be "typical"
3.  No herpes outbreak would last a month without change.  the cyst you not is likely just that.
4.  Yes, in most OBs the lesions are clusters and they are located on the penis.

EWH

[whattodonext]

Mr. Hook, thank you for your very detailed answer and quick I might add.

1.  I know that anxiety can cause a lot of problems.  I have examined myself at least on the hour for the last 12 weeks.  I have read where Dr. Handsfield has said that one would not have tender and/or swollen lymph nodes (at least I think I've read this) unless one had lesions at the time.  Is this correct?

2.  It is also my understanding from reading one of HHH's posts that in most cases the one getting infected (me in this case) usually has an o/b that looks similar to that of the one that has infected you.  Her's looked like poison ivy rash.  If I were to have gotten it from  her, would my bump have looked more like hers?

3.  The fact the apparent sebaceous cyst not having changed in a month is a good sign this isn't herpes (hard/white on scrotum), right?

4.  Are most initial ob's, if any, more likely to be in clusters and on the penis in men?

Thanks again!!!!!!!!!!

[Edward W Hook, MD]

Welcome to the Forum.  Dr. Handsfield and I share the forum.  You got me.  FYI, the reason we share the forum is because we have worked together for nearly 30 years and while our verbiage styles vary, we have never disagreed on management strategies or advice to clients.

Your partner has HSV and it appears that you have not acquired infection at this time.  I will comment a bit on the tests that you have had and them both answer your specific questions and add a comment or two.  

Your tests so far.  The combined HSV-1/-2 tests and the IgM testing is a waste of time for you.  We urge clients not to get these tests as they are so often misleading and confusing.  They offer you no useful information.   Your negative IgG specific HSV-2 tests on the other hand does provide useful information.  The relevant time period is the time since your last encounter and at 9 weeks somewhere between 80 and 90% of persons who have acquired HSV-2 will have positive tests at that time. Thus while not yet definitive (got to wait to 6 months for that) your results, particularly when you have not experienced an outbreak, are strong evidence that you have not gotten HSV.

Testing your suspicious lesions was an appropriate thing to do as well- good job.  That the results were negative further strengthens the evidence that you do not have HSV-2 at this time.  Tingling, itching and notation of cysts and other findings are a common result of careful self-examination and scrutiny but are not suggestive of HSV.  

Bottom line, it is unlikely that you have acquired HSV-2 from your partner. This does not surprise me and should not surprise you.  Most exposures to partners with HSV, even when those partners are having an OB, do not lead to transmission of infection.  I have patients who have been is relationships with infected partners for decades who have not acquired the infection.  That said, it is reasonable and appropriate to take precautions to make sure you do not become infected.  

In answer to your specific questions:
A.  HSV does not need to be transmitted through a mucous membrane. It can occur with skin-to-skin contact.
B.  See above.
C.  The chance that you have HSV at this time is very ,very low.  Repeat testing is a matter of your comfort level.  Personally I see no need for testing.

Finally a few comments on prevention.  you are doing many of the things which help to minimize HSV transmission- your partner has disclosed her infection, you use condoms (mostly), and you avoid sex when she is having an OB.  the only other thing proven to reduce risk for getting HSV is if your partner were to take daily suppressive therapy with an antiviral agent such as valacyclovir.  This will reduce your risk of infection still further.

I hope these comments are helpful to you.  Take care. EWH