Trying to confirm a HSV diagnosis and how to work it out within my marriage

[ToughSpot]

About 2 mos. ago, my wife suffered what seemed to be a severe allergic reaction to chlorine in an indoor pool.  She had redness on both sides of her labia minora around her vaginal opening (in that deep fold), with severe discomfort (stinging on urination).  She went to see her G.P., who tentatively diagnosed a urinary tract infection and went through a string of antibiotics (prescribed 3 different drugs in response to various test results).  The meds seemed to provide some relief, but the symptoms didn't go away completely.  I was concerned by the way they had her jump from antibiotic to antibiotic over a course of several days as urine results came in.  

This was followed by varying levels of discomfort and different attempts to sooth the redness with desitin, steroid creams, etc.  She saw a gynecologist, who advanced the idea that it might be herpes.  We have been together for 17 years in a monogamous marriage, but I had recurring fever sores since I was a child.  They come back about every 2-3 years.  I have been very careful about any contact when I have an outbreak or feel a telltale tingle, but I never knew there was such a thing as asymptomatic shedding.

My wife tested negative for IGG and a tissue culture (but the culture was taken just recently -- are they only good at the very beginning?), but positive for IGM at a 1:20 dilution(?), according to her doc.  I did have an outbreak several weeks after the initial "swimming pool incident" on my lip.  The theory is that my wife got an irritation in the pool, that we subsequently had oral sex and I was "shedding" pre-outbreak (about 2 weeks prior), and perhaps that set up ideal conditions for a infection.  So she started Valtrex and Zovirax a few days ago, but it's too soon for her to say she's feeling relief.

Please advise on the following:
1.  Seems I should get tested to see if I have HSV-1 or HSV-2?  If I can confirm it's HSV-1, she may feel better with the assumption that HSV-1 is a bit less problematic than HSV-2 when on the genitals (?)  
2.  Is it common for the initial outbreak to be so severe/long duration?  We're talking more than 2 mos+, unless we started out with an irritation from the pool that perhaps led to an infection and then subsequent HSV.  How long before the Valtrex and Zovirax should provide relief?
3.  There were never any blisters.  Just red, sometimes broken skin...but not so dissimilar in appearance to a severe allergic skin reaction, either, where the skin can get red, puffy and broken in spots.  Pap smear was normal.
4.  I'm not too concerned (I can wear a condom, no big deal) but my wife is concerned that she might be able to transmit the infection to my genitals, where I've never had a problem (just my lip).  Am I unlikely to be able to contract this back in a different place if it came from me originally?
5.  How long should my wife wait before another IGG test?  Does a negative IGG prove that this is a recent infection?

[H. Hunter Handsfield, M.D.]

I'll bet your wife doesn't have herpes at all.  The time course is atypical; continuing symptoms for 2 months (even with variable severity) is highly atypical.  And diffuse redness doesn't suggest herpes, despite her provider's suspicion.  His suspicion might come from just being careful about an irritating genital problem not responding to ttreatment for other conditions.

The IgM result isn't helpful; see many other discussions on the uselessness of HSV IgM testing (search for "IgM" and "herpes diagnosis").  Presuming the IgG testing was a type specific test for both HSV-1 and -2, all you can say is that your wife had no evidence of antibodies against either virus at the time she was tested.  It can take up to 3 months (sometimes even longer) to develop a positive antibody test, but the commercial type-specific tests (e.g., HerpeSelect) usually are positive within 6-8 weeks.  On top of all this, "a few days" usually is plenty of time to see significant benefit for antiherpetic therapy.  (Giving 2 drugs is atypical, but my guess is she is taking valacyclovir orally and acyclovir cream or ointment. The latter isn't helpful and adds nothing to the potential effect of the pills.)

So my main advice is to await further diagnostic information and to see how she does on antiherpetic treatment over another few days, and especially for another HSV blood test 3 months after symptom onset.  Until and unless the diagnosis of herpes is concerned, I suggest you not be tested.  If it turns out she indeed has HSV-1, it won't be necessary; you can be certain you have HSV-1.  If there is a surprise and your wife has HSV-2, then you should be tested.

I think those comments answer all your specific questions. Let me know if I can help further, though.

Good luck--  HHH, MD

[ralston]

I'll let Dr. H. comment on the probability that your wife has herpes.  Two months would be a long time for an outbreak.  
Hypothetically speaking, assume it is HSV-1.  I have some things to add if it is, as I was in a situation opposite of yours.  Imagine how shocked I was after 10 years of monogamous marriage find I aquired herpes.  It looks like I got HSV-1 from oral sex from my wife (despite no evidence of outbreak).  
I was pretty devastated for a while, but upon doing a ton of research, it looks like things aren't so bad.  So assuming your wife does have HSV-1, here is what I found out:
1.  You almost assuredly cannot get the virus transmitted to your genital region; your body already has antibodies against it.  It's rare to transmit via genital to genital contact in anybody, let alone someone with antibodies against HSV-1.
2.  You can use a condom, but odds are low you will contract the disease.  There is no definate evidence that I know othat condoms prevent genital HSV-1 transmission anyway.  A recent big study showed that condoms protected against HSV-2 but there was no statistically significant protection for HSV-1.  This doesn't mean that condoms do not protect against HSV-1, but as of now there is no evidence that I know of that they do.
3.  Your wife could take suppressive Valtrex, which would in theory further reduce the risk of tranmission (though once again the studies have been done with HSV-2, not 1).  
4.  Outbreaks of HSV-1 are rare, and the virus sheds asymptomatically less than HSV-2.  
5.  Bottom line -- you can use condoms and/or Valtrex, but odds are very good that you can use nothing and you'd be fine.  You have to decide with what risk level you are comfortable.  Also, be thankful you have a supportive partner, because way too many who aquire this disease don't.    
I'll let Dr. H. correct any inaccuracies, and good luck.

[Englishman]

Dispite no concrete evidene that condoms prevent against HSV-1, theoretically it must do. Since latext does not allow any STD pathogen to pass through, I would assume that if the lesion(s) are covered and no infectious material (skin cells? fluids? blood? saliva?) is present other than that covered by the condom then transmission must be impossible. However in the real world I guess infective material may be present beyond the visible lesion and may move under the friction and forces of sex. I was thinking the other night that a condom could be moudled to a sheet of ultra thin latext about A4 size with the condom in the middle. When you where it, it would protect the pubic region too. It may be amsuing at first, but then I'm sure some people used to laugh at the thought of wearing a condom. Just an idea.

[ToughSpot]

Thanks for responding about your own experience.  The duration does seem long, and probably only another IGG test in a month or two will answer the question with certainty.  My greatest concern in the meantime is getting my wife some relief from her discomfort.  Considering that she's not sure that the diagnosis is correct, she's not too keen on the drowsiness she's experiencing from the Valtrex.

The gynecologist my wife saw stated she had expertise in Herpes.  She looked at some tissue scrapings under a microscope in her office before sending out the blood and tissue samples to the lab, and her response was "I see a ton of white blood cells -- there's a lot going on here, perhaps a severe allergic reaction."  She didn't make a diagnosis of HSV with certainty based on the look under the microscope.  But she felt there was some visual evidence based on the appearance of the "rash" that it could be HSV...she noted the "lacerations" of the skin.  However, once the IGM test came back in, her office defaulted to a HSV diagnosis.  When my wife called the doc to ask her about the apparent lack of accuracy in the IGM (based on our readings here), her doc responded about the 1:20 dilution, whatever that means.

In the meantime, I feel like a walking timebomb/Typhoid Mary, whether I have a sore on my lip or not.  I've been living with oral herpes for over 30 years without being too concerned -- just careful when I had the occasional outbreak, and I never knew it could be in your saliva 5% of the time or about asymptomatic shedding.

[H. Hunter Handsfield, M.D.]

The additional discussion doesn't change my initial opinion and advice.  Try to put herpes out of your mind as a likely explanation, unless confirmed with future testing.

I am not persuaded your wife's gyneologist really is much of a herpes expert.  Apparently she is unaware of the problems with IgM testing, which is no more reliable at a titer of 1:20 or any other number; and it seems she performed a Tzanck test (looking for evidence of herpes infection under a microscope)--an ancient, discredited test that is difficult to interpret, even by real experts.  And I already mentioned the atypical nature of the treatment she apparently prescribed.

Find out whether your wife been tested by culture for atypical yeast infection, such as Candida glabrata (vs the more common C. albicans), which is resistant to the usual yeast treatments.

HHH, MD

[Savian316]

A related discussion, What should I think was started.