Risk of HSV and advice

[concernedRN12]

Dr,
Thank you for your realistic and practical answers to many of the post I have read. I am in disbelief that I am even here but have been relatively consumed with worry in the past 2 week and wanted another opinion.

I am an RN so I know all about clinical symptoms of HSV. I recently started dating a man and we had sex 3 times over 2 weeks, unprotected. He has no history of STD's or any symptoms (which I know does not rule out HSV)

About 6 days after our last encounter I had 2 small areas that looked initially like ingrown hairs but did blister slightly and open to shallow ulcers. I felt no other major symptoms, was not flu like and remained afebrile. I did notice tingle/prickly feeling however and mild irritation at the sites. Upon exam by my gynecologist, her guess was that it was not HSV, as she said it did not look typical. She did not think a script for Valtrex was indicated. We did cultures for bacteria and HSV and blood tested as well, to be safe.

She called yesterday to say the culture was negative. The blood work will be back in a few days. She told me to try and relax a little either way but I am struggling to do so, as these symptoms I am experiencing seem classic HSV and the areas have not yet gone away (11 days today.) She did start me on antibiotics in case it was MRSA or folicultits.

My question or need for guidance is- If all comes back negative what is the best way for me to proceed? Should I assume based on my symptoms that I got false negative results and retest later or allow diagnostics to be my indicator and wait and watch for any recurrent outbreaks (which hopefully don't occur)? The man and I are no longer dating and I am very nervous about all of this and how it will impact my future dating, even though clinically I know it is usually a minor thing. Statistically it seems unlikely I would have gotten it from him but the symptoms have my head swirling. Just needing some advice and support.... Thank you, Hopefully negative

[H. Hunter Handsfield, M.D.]

Welcome to the forum.  Thanks for your question.

Most likely you don't have genital herpes.  As you already know, the apparent association of your lesions with hairs is typical for folliculitis and atypical for herpes.  Folliculitis lesions could have a blister-like component, and many will ulcerate as they progress.  The negative HSV culture is also evidence against herpes -- not proof, since the culture can miss many infections -- but still pretty good evidence.  The same can be said about your doctor's opinion based on examination:  evidence but not proof against herpes.

You don't say the exact location of your lesions, but initial herpes doesn't usually predominate in hair-bearing areas like the pubic area or labia majora.  For infection to take, usually the virus has to be massaged into the tissues, so that initial genital herpes lesions in women usually are at the sites of maximum friction during sex, like the vaginal opening or labia minora.  And initial genital herpes usually causes several lesions, not just one or two.  Finally, the risk of catching herpes after only a couple of sexual exposures with a partner without known genital herpes is low.

None of these arguments is definitive, and it remains possible that you acquired herpes.  But for that to be the case, several unlikely events would have to break the wrong way:  apparent low risk exposure, in a hair-bearing area, hair association of lesions, only two of them, and negative culture.  I can buy any one of them going the wrong way, but the statistical probability of all going that way is very, very low.

Another possibility is that you do indeed have herpes, but not an initial infection -- i.e. you are experiencing the first recognized recurrent outbreak of a longstanding infection, unrelated to your new sexual relationship.  About 40% of apparent initial genital herpes falls in this category, and this would be consistent with having only 2 lesions and in a hair-bearing area.

Since you are concerned, blood testing is in order.  If you are still in contact with your partner, you could ask him to be tested, which would help determine whether he could have been a source of infection.  And you could be tested now and perhaps, depending on the result, again in 3-4 months.

Feel free to return with follow-up comments to let me know the results if you and/or your partner are tested.  In the meantime, I think you can be quite confident you don't have genital herpes.

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

[H. Hunter Handsfield, M.D.]

You can expect your partner's result to be negative.  As for "it seems so improbable to me that I would suddenly get two separate sports of bacterial infection 6 days post sex", that's what logicians call post-hoc reasoning, i.e. after the fact.  You need to look at it this way:  a few million episodes of sex with new partners occur in any given week, and in the same week a few million people probably get new bacterial infections of the groin or other pere-genital areas.  Of course some people will experience both events.  That doesn't mean they are linked.  In other words, it is by far the most likely explanation that your skin infection and your new partnership are simply a coincidence.  (The post-hoc fallacy almost certainly is the reason some people attribute brain tumors to cell phone use, to pick a common example.)

[concernedRN12]

Hi Dr. H,

A little update.... my blood work came back today negative (as I assumed it would, as I have never been in a high risk situation or had symptoms until this last one)

Fortunately my partner is testing on Monday so if he is negative then I can finally breath easy. I am just still so upset and nervous because it seems so improbable to me that I would suddenly get two separate sports of bacterial infection 6 days post sex, and also experience tingling and some pain. Seems like classic HSV symptoms. But I am trying to take a bit of hope from your first response about the location and probability of all those factors that would have to break in a particular direction for the virus to have been transmitted.

I don't remember ever being able to get a hair out of either spot but the one larger spot did have a notch type feeling in it at the beginning (like a deeply impeded hair) but I never actually found one. Another unlikely option my gyno brought up was shingles.... I am just racking my brain to find any alternatives. So far bactrim has not done much (as you said) Gyno said bacterial culture showed strep but no MRSA. How long would you expect a bacterial infection to take to clear up versus an initial HSV infection??

I don't know, trying to have some hope and wait till my partners blood results come back next week. Thanks for your insights in the meantime-

[H. Hunter Handsfield, M.D.]

Thanks for the additional information, which makes it even less likely you have herpes.  You are correct that the fold between the thigh and the perineum (or groin) is an uncommon location for new herpes, but a common one for bacterial infections.  If the lesions started as nodules in the skin, rather than superficially, that also would argue in favor of a bacterial infection over HSV.  However, antibiotics are often not very effective against such kinds of infection, and your Bactrim may not make much difference.

The frequency or severity of recurrent herpes outbreaks are not obviously related to severity of the initial episode.  The main factor there is virus type:  genital HSV-1 causes many fewer recurrences than HSV-2.

[concernedRN12]

Dr.H,

Thank you so much for your in depth answer and helping put my mind at ease. I will have the results of my blood work back by Thurs so I will know if I have actually had HSV for years and been asymptomatic. Or will have a baseline from now on if it is negative.

The man I was with, although I am no longer dating him, has been supportive and kind and has agreed, although he has never seem symptoms that he wants and will go test. That way if all my tests come back negative as well as his I will know these little spots are a coincidental nightmare!

And to answer your question the two spots are right in the crease where upper thigh meets perineal area. In the area where my underwear would hit, certainly in a hair bearing area. Upon exam by my Gynecologist she saw no evidence of lesions inside or near my labia. She said, as you did, that sores in an initial outbreak typically occur closer in but I also know every presentation is different.

I have not gotten word back on my bacterial cultures but have started a 7 day course of Bactrim imperically. Would it be possible this staph infection could cause the minor burning/tingling sensation that has me convinced this is HSV? I have never had an infection like this before so am not sure of how painful or irritating it would likely be. How soon should I expect the lesions to clear after beginning Bactrim? And if my cultures for staph also come back negative, what does this mean?

In reading other posts you have done about risk of transmission and the fact that mixed couples have only produced a 5% transmission rate after a year of unprotected sex gives me some hope as well. Having only 3 encounters with this man would make my transmission rate low, so I am hopeful. But I suppose we will have all the answers after my blood work and his come back.

My gynecologist also said many women have a severe initial outbreak (which if this is mine is certainly NOT severe) and then never have another outbreak. Is there any link between severity of first outbreak and chance of follow up outbreaks?  (ie mine being mild may result in even milder or absent recurrences?)

Thank you so much for your educated advice and support. As I have never felt at risk for STD's before and never experienced symptoms like these I have myself pretty freaked out and reading much of the garbage on the internet does nothing to ease my mind. I will remain hopeful but aware that even with positive results life goes on, and goes on well....