Differing results for HSV testing

[jds98]

I had an affair,am rebuilding my life with my wife.I used condom but had oral sex from woman,last exposure August 2009. No genital symptoms,but had horrible chancre sores/apthous ulcers all summer,as did my wife.We have had these in past,but never this bad,my wife's looked different than normal.But never had cold sore on lip. My HIV is negative,my wife's hpv is pending.I wanted to get Herpeselect testing,but the lab screwed up and did the following:
HSV Type 1/2 combined Ab, IgM by Elisa   0.74
the negative reference interval is 0.89 or less, so negative
HSV type 1/2 combined Ab, IgG  (does not say elisa)  0.35
the negative reference interval also .089 or less, so negative
I was relieved.  However, I am physician and paranoid by nature, and clearly they did not perform the Herpeselect as we ordered.  I cannot really identify what exactly this specific herpes test they performed sensitivity is.  The lab is very unhelpful as I am the pt, not the ordering doc.  It is labled as glycoprotein G specific, but it is "combined" , and only appears the IgM is ELISA.
So I complained and they said they could add it on with the existing blood in the lab and the herpeselect came back as: Hsv 2 glycoprotein G antibody, IgG  0.84
negative reference is less than 0.89
but to my horror i saw HSV 1 glycoprotein G Ab, IgG  1.24
1.11 or greater equaling positve test..
So now what do I do?  These test results differ?  Should I do immunoblot?  Can they send my existing serum for this?
Or should I just accept that I have to tell my wife I have given her herpes?
Any answer as quickly as possible would be greatly appreciated, as my initial elation at being negative is now replaced by depression

[jds98]

I see I wrote chancre sore in that last paragraph, I meant to say cold sore...

[jds98]

Thanks for your prompt response, you have been helpful and well worth the "donation".

I know you mentioned those were your last answers, I will give more $ if necessary as I have 2 more questions and will cease thereafter.....

1)regarding my 3rd and 4th questions, my concern remains asymptomatic reactivation or asymptomatic shedding, which the literature clearly supports.  I obviously would avoid contact with any cold sore or prodromal symptoms.  I just want to avoid infecting my kids or my wife.  I have also read that when you have chancre sores your chance of shedding hsv may be increased even with lack of cold sores?

2)Given my wife and I as of this date (since exposure in june and august )have not had a single cold sore or genital lesion is reassuring that my positive result may be indeed from a childhood exposure.  But my wife's atypical chancre sore type issues concern me as possibly being consistent with a primary type hsv1 infection.  But since she has had 3 of these episodes my question is do these responses happen once and only once and subsequently lead to cold sore development?

Thanks for your patience, I will ask no further questions.
I just have dreadful anxiety thinking my wife will develop a chancre sore weeks-months from now as a reminder of my horrible mistake.  Having a stronger belief that I've had these positive antibodies all along from my childhood will go along way to helping us move further without dreading a hsv1 outbreak as a visible reminder of my betrayal.

[Edward W Hook, MD]

Ok, you do have HSV-1. You test does not tell you where your infection is or how long you have had the infection.  You are now a member of a "club" comprised of 60% of adults in North America and even higher proportions of persons from other parts of the world.   Of those who have HSV-1, about 90% of those do not know that they have the infection and would not unless they got tested as you did.  You may well have had this infection for years and years.  In answer to your last questions (and my last answers):

1.  In fact it is most likely that your positive test represents infection acquired years ago.
2.  Hard to address this question. Only a HSV tests such as you got will tell you if she already has HSV-1 (or even HSV-2).  That is the risk one takes with testing.
3.  HSV is rarely transmitted through direct contact with persons who have HSV and no lesions. Most transmission occurs as a result of contact with lesions.  HSV-1 is virtually never by sharing drinking glasses.
4.  Very, very low - less than 1% per exposure and perhaps far lower
5.  Both of the regimens you describe are effective for HSV-1 related cold sores.

Take care.  EWH

[jds98]

My wb came back pos for exposure hsv 1,neg for hsv 2.
I know it is far from end of the world this came back pos, but given I had an affair it has bigger ramifications for my marriage. Final questions if you could....
1).I had relations with this woman 4 times, first in june,last early aug. Never did she have any cold sores. I've had apthous ulcers badly this summer, but NO cold sores. I had cold sores corner of my mouth as a child but none as adult. Is it possible my pos wb reflects previous exposure as kid given I've had no symptoms at all this summer?
2). My wife has had no cold sores, but as I've described before,did have weird sensations on lips and abnormal appearing inner, lower lip bumps\ulcers which never ruptured or crusted over.much different than her previous apthous ulcers.Does this sound like atypical hsv or herpes gingivostomatitis? I have been open to her about affair but do not want to put her through stress of testing or assuming she'll have cold sore outbreak (her hpv is pending, that is distressing enough)
3). How do I ensure I don't give hsv to my kids? I obviously kiss them, we share drinks etc. Can it transmit without cold sore being present?
4)What is risk of hsv1 transmit to genitals with oral sex in absence of cold sore?
5)Finally, if we have cold sore outbreak does literature support standard use antivirals 5-10 days or 2000 mg valtrex bid for 1 day?
Thanks

[Edward W Hook, MD]

Yes, the absence of any cold sore or lesion is strong evidence that you did not get HSV.  Atypical lesions are different from no lesions.

This exchange really needs to end.  It appears that each answer just fuels your anxiety.  

If you have questions when your Western blot results are available, please let me know. till then, no further follow-up questions please.  EWH

[jds98]

Finally, I assume it would have to be encouraging that I've never had cold sore this summer since exposure right?

Because I also know herpes especially initially can present atypically.

[jds98]

Thanks for the prompt reply, you have been very helpful.

I got home from work tonite and looked very closely, all the areas are inside the lower lip, nothing on the outer lip. What remains concerning is they are not at all like classic apthous ulcers. But also not any yellowish drainage like I believe you see with herpes prior to drying out and becoming cold sore correct?. I just am quite paranoid and got concerned after I learned of herpes gingivostomatitis. Does my better description of these areas help in any way?
I know the western blot will be confirmatory, but know I will be waiting over a week and very anxious about how to handle this with my wife. Will be honest with her but don't want her worried over a false positive.
I considered the zovirex to help prevent the outbreak early but will hold off.

[Edward W Hook, MD]

I cannot say if this is a HSV outbreak or not.  You don't know that you have HSV either. With this many questions and ahving htings be so far up in the air, I would not prescribe antiviral therapy att this time.  You'd like to find out what is going on
  EWH

[jds98]

Or And again please keep in mind I've had apthous ulcers but no cold sore of any type this summer or any symptoms similar to hers currently.

Thanks.

[jds98]

The lab that did the herpeselect is sending my serum off to u of washington for western blot.

Unfortunately, today few hours ago my wife keeps itching her lower lip, denies burning or real pain, "just feels weird and like a pimple". Similar area more on inner surface of lower lip on other side, but not outside lip like the first one. No blister, just small bump she keeps itching. Again, my wife has always gotten severe aptous ulcers and due to the stress of my affair very poor eating, sleep and lack of usual exercise.

So I do I prescribe her zovirex to help limit this potential outbreak?  If you cannot rec pharm tx over internet I understand. I will rephrase, does this sound like herpes, a bump like that in 2 places?  

Thank you. Hopefully that was last question until blot results.
Should I advise her to avoid kissing our kids?  

I wish so much I had the western blot result in hand to help this.

[Edward W Hook, MD]

The best information and most studies regarding false positves is for HSV-1 and for those studies the cut-off at which false positves become a non-issue os above 3.0.

Yes the other test, in that it was a type-specifi test does help.  I do not have data on its false negativity rates but understand it is comparable to HerpeSelect.

Finally, the answer is possibly but not likely for recently acquired infection.  

EWH

[jds98]

Dr Hook,

Thanks for your prompt reply.  I wonder, if you feel is 1.24 along with my other testing is the lower level consistent with a false positive, what usually is the level you see where you would be more leaning towards it being a true positive?

I have read these forums on this site and see a lot of postings with levels around 3-5.

Also, is the test they performed by error prior to the herpeselect valid such that it helps you tell me you feel it is more likely to be false positive?  

I found the exact label of the first test they performed,  it is as follows:
Herpes simplex virus type 1 and/or antibodies, IgG & IgM with Reflex to Type 1 & 2 glycoprotein G-specific Ab, IgG.
Are you familiar with this and have any idea of the frequency of false negatives on it?

Finally, do you feel it is possible I would have HSV-1 Ab 3 months post exposure without ever having any cold sore?

I will likely obtain the western blot assay you suggested for confirmation, but responding to my above questions to help provide some more info would be appreciated, as I know that test takes awhile.

Thank you very much.

[Edward W Hook, MD]

Welcome to the Forum.  Your test results, when looked at in toto are really not consistent with HSV.  The performance of most type specific IgG assays for HSV is very similar to one another.  HerpesSelect was the first available but since then others have become available and perform similarly.  Furthermore, nearly all of them use and ELISA format to generate their test results.  Your HerpeSelect HSV-1 result is in the range in which a substantial number of the tests are false positive.  That would be my guess as to what is going on.  If you want a definitive answer, you should request a Western blot assay from the University of Washington. The test takes a while to come back but that is the "gold standard" test which was used to define the performance of the HerpeSelect and virtually all of the other newer type specific HSV antibody assays.  To get this test done, I would suggest sending another specimen (and I doubt that your earlier specimen is still in the lab or, if it is, that you really want to have them send that one off).  

There are no data to suggest that aphous ulcers are contagious.  Furthermore, as to why they have been more severe for both you and your wife of late, that is difficult to say.  They tend to wax and wane for reasons that are unclear although some have said that anxiety can make them worse.

Hope these comments are helpful to you.  EWH

[jds98]

And I apologize for the running dialogue, but I meant Western blot specifically when I asked if I should do immunoblot.

I have done some more research and see my result is a very low positive, and that can be reflective of a remote exposure.  But I have not been with anyone other than my wife for 20 years, but could my 1.24 result still be from a past infection in my youth if I've never had a chancre sore, only apthous ulcers?

Also, I had EBV in college, does that do anything to increase false positives?

I just really need piece of mind and plan on being honest with my wife once I have all the data before me.  I don't want to worry her needlessly if you think this is not a new exposure or possibly a false positive.

I am sorry, but as they say, physicians make the worst patients!  And I am so humiliated to use my primary care doc or any doc I know in the community with these questions, which is why I have turned to you.

Thanks.

[jds98]

I am sorry, also wanted to ask about my 9 year old son who gets bad apthous ulcers.  Any chance he is exposed from us with goodnight kisses, sharing beverages, utensils etc?

And I guess without cold sores I was concerned as our mouth ulcers were quite severe, and my wife's were different than her previous ones, and I have read of herpes gingivostomatitis.  We didn't have any ulcers in our throat, but my tongue looked like one photo I saw online.

Thank you sir