STDs Expert Forum
Sores + Herpes seen in Microscope + many negative blool tests
About This Forum:

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.

Font Size:
A
A
A
Background:
Blank
Blank
Blank
This expert forum is not accepting new questions. Please post your question in one of our medical support communities.
Blank Blank

Sores + Herpes seen in Microscope + many negative blool tests

I've been in what I believe is a monogamous marriage for 15 years.  

In October of 2010 (two years ago), I suffered severe burning pain when urinating and went to an ER.  I also had a sore on my penis.  The ER found no bacteria in my urine and the ER doc was confident that the sore was herpes.  He scraped cells from my penis, prescribed a single Valtrex tablet (ridiculous), and referred me to a Urologist. A few days later, a doc from the hospital called to inform me that I tested positive for Herpes.  I asked if it was Type I or II.  He replied that the test was not that specific.  I don't believe they grew a culture because they used swabs that looked almost like pipe-cleaners -- they just collected cells in the fibers of the swab, and then someone looked at the cells under a microscope to identify herpes markers. To the best of my knowledge, I never suffered any herpes outbreak prior to October, 2010.  

I went to the Urologist who diagnosed me with herpes by visually inspecting my penis.  When I told him I would like to get the diagnosis confirmed (I was referring to blood tests), he replied, "I just confirmed it.  You have herpes.  A blood test is a waste of money because it will just come back positive.

I suffered an outbreak of sores in July (3 + months ago), and went to an internist.  She said, "that's not herpes.  Its a fungal infection."  She prescribed cream, which cleared it up.  She also ordered a blood test (Quest H.Select IGG) that came back at .02 for Type I and < 0.2 for Type II: negative.  I went back and asked for more tests.  She ordered the ELISA and PCR tests.  Elisa result is identical to the first test, PCR states HSV I and HSV II DNA not detected.  Great news.

I keep getting sores on my penis. They appear, then almost heal, then get worse, then better.  They won't respond to prescription anti-fungal cream or pills. Doc just prescribed a steroid.  Sores look like paper-cuts, and sting.  What can it be?  

BTW: 2K characters is not enough!  
239123_tn?1267651214
Welcome to the forum. Thanks for your question.

We'll have to agree to disagree about 2,000 characters.  In the 8 1/2 years since this and the HIV forum have been running, I've never seen a question that could not be asked within that limit -- and if I had my choice, MedHelp would make it 1,000 characters.  The moderators should not be expected to read long essays!

It would seem the test done when herpes was first suspected was the Tzank test.  With it, HSV lesions under the microscope show particular changes, especially (for the pathologically knowledgeable) "multinucleated giant cells".  Until the modern era of virologic diagnosis -- i.e. until 25-30 years ago -- it was the only lab test available for herpes.  But it was always a highly inaccurate test, being both insensitive (missing lots of herpes) and nonspecific (diagnosing herpes that wasn't present).  It hasn't been done by reliable experts and labs for many, many years.

Some of your symptoms sound typical for genital herpes, and of course the opinion of an expert who has examined someone during an outbreak should be respected.  However, your current pattern of symptoms is not typical for herpes, and the HSV blood tests are far more reliable than the Tzanck test.  So I would conclude with virtually 100% certainty that you do not have, and never had, genital herpes.

As to the actual cause(s) of your symptoms, I'm less certain.  If you are uncircumcised, I would speculate about a fungal infection (despite poor respons to antifungal durgs), or nonspecific balanitis -- often a hygiene issue.  If things remain unclear, you would be wise to consult with a dermatologist.  But whatever is going on, I am confident you don't have either HSV-1 or 2.

Finally, I disagree strongly with the doc who denigrated the blood test for HSV.  It isn't perfect, but it's quite good at telling whether or not someone is infected with either virus; and, most important, at distinguishing infection with HSV-1 versus HSV-2.  This is a very important aspect.  In people with genital herpes, the clinical course (frequency of recurrent outbreaks) and potential for asymptomatic viral shedding and sexual transmission to partners are very different (high for HSV-2, low for HSV-1).  I'm very glad you eventually had the blood test; it shows your original diagnosis was wrong.  I hope you can eventually sort out the explanation for your symptoms, but they aren't due to genital herpes.

I hope this helps (despite the 2K characters limitation).  Best wishes-  HHH, MD
5 Comments
Blank
Avatar_m_tn
Thank you for your response.  Bumping up against the 2K character limit prevented me from including additional medical history germane to the situation and questions about what I have.  Nevertheless, I am satisfied with your answer.

After reading your response, I am very surprised that the hospital would elect the Tzank test.  At the time, the sore appeared fresh and ripe (parson my choice of words; I'm sure there is better medical terminology to describe the state of the sore as it was), because they could have tried to grow a culture and carried out blood testing, both of which are substantially more reliable.  This is a big, modern hospital in an upscale urban area.  Their diagnosis and the urologist's somewhat arrogant confirmation of the diagnosis caused my wife and I to have problems in our marriage, and caused me to believe for two years I had something that I do not have.  

I should clarify one point.  The Urologist did not denigrate the blood test.  He was overly confident in his diagnosis from the exam that he believed it was a waste of time and money to do a blood test.  His point was that he was certain that blood testing would produce a positive result.  He responded to my request as if I were proposing an effective test to determine the sky's color.  What's the point?  It will just come back "blue."  That was his attitude.  He did not comment one way or the other about the reliability of herpes' blood testing.  

Thanks again.
Blank
239123_tn?1267651214
I'm sorry to hear your apparently false herpes diagnosis caused the problems it did.  I can't judge why your hospital chose such a poor test for HSV.  Indeed, I'm not positive that's what happened -- it just seems a logical possibility based on your story.  No other HSV test relies primarily on microscopy, but  you might double check with the hospital lab.  If they did do that test, it might be it wasn't the hospital's or the lab's fault.  The specific test done is generally based on what the doctor orders. Even if a much better test is available, if the doc requests a Tzanck test, that's usually what is done.

Perhaps "denigrate" was the wrong word to describe your urologist's view of the HSV blood test.  But based on this clarification, he was still dead wrong.  A positive Tzanck test, or a clinical diagnosis of "obvious" herpes, still leaves virus type unknown -- and it is very important to know whether genital herpes is caused by HSV-1 or 2.

And by the way, research shows that highly experienced (even renowed) herpes researchers often are wrong in their visual diagnosis of genital herpes lesions.  They frequently miss herpes when lesions are atypical, and they often believe herpes is present when it is not.  That's why every suspected case should be confirmed by a reliable lab test ("reliable" doesn't include Tzanck) for HSV, as well as a test to determine virus type.

Finally, while all the evidence supports the conclusion you do not have genital herpes, I can't say there is zero chance of it.  If and when you have any further recurrent symptoms that suggest herpes (penile blisters/sores, a recurrence of severely painful urination), it would be wise to have another direct HSV test -- for sure a PCR this time.  But I don't think this is going to happen.
Blank
Avatar_m_tn
I will request my records from the hospital and post-back exactly which test they did, to be sure, and will post back.  

You suggested a PCR the next time I had sores.   My only concern would be that my new doc might start to think that I am crazy if I show-up in her office again asking for more herpes tests.  Up to now, she has ordered three different blood tests at two different times, all of which are negative.  As I indicated in my original post, one of the blood tests my doctor ordered was called the "PCR," (specifically: HSV,TYPE 1/2 DNA,REAL-TIME,PCR), which did not detect HSV 1 or HSV 2 DNA.  I assume the PCR test you are suggesting is similar insofar as it is testing for herpes DNA, but the material tested is from a sore or lesion, not blood.  Am I right?  So long as I am not infected in the future, I'm guessing that the probability of a positive PCR test is close to zero, given my prior three negative blood test results.

Still, I am puzzled about the sores I have now.  They are not getting worse, but really they are not getting better either.  The fact that they are not crusting over and going away suggests something other than herpes. I am circumcised and shower and wash with soap 5 to 7 days a week. There are two, each with what appears to be a paper cut going down the middle.  From time to time, one or the other stings.  For now, I am gong to try the topical steroid I was just prescribed and hope that it somehow helps them to heel.  

Thanks.  
Blank
239123_tn?1267651214
Something is mixed up in terminology:  PCR is not a blood test.  It would seem you had a PCR test for the virus from your genital area.

"The fact that they are not crusting over and going away suggests something other than herpes."  Exactly right.  Given this description, I retract my advice about another PCR from the lesion(s).

I would not generally assume that a urologist is especially expert in skin lesions, even if they affect the genital area.  If you have not seen a dermatologist, that would be a logical next step.  And I would strongly advise you not to use the steroid before doing so; that could seriously impair the ability to make an accurate diagnosis.

So now I'm modifying my advice about further follow-up comments:  if you find exactly what test was done (Tzanck, culture, or PCR) on your genital lesion(s), let me know what it was.  Also feel free to report the outcome if and when you see a dermatologist.  But let's not have any further follow-up comments except those.
Blank
Continue discussion Blank
MedHelp Health Answers
Blank
Weight Tracker
Weight Tracker
Start Tracking Now
RSS Expert Activity
469720_tn?1388149949
Blank
Abdominal Aortic Aneurysm-treatable... Blank
Oct 04 by Lee Kirksey, MDBlank
242532_tn?1269553979
Blank
The 3 Essentials to Ending Emotiona...
Sep 18 by Roger Gould, M.D.Blank
242532_tn?1269553979
Blank
Control Emotional Eating with this ...
Sep 04 by Roger Gould, M.D.Blank