looking for a second opinion

[ntdc]

I believe I have contracted genital HSV from receiving oral sex from a woman in jan of this year. 2 days later I experienced extreme pain in my penis, pain during urination and urinary urgency. I was tested for chlamydia, gonorrhea and bacterial infection, all neg. Also tested for HSV (igg/igm) negative. Igg came back hsv1 = 0.05 hsv2 = 0.13. Dr said he saw no sign of herpes type lesions.

I was not comfortable with the dr so i went to see another one, he prescribed me famvir and told me to come back in 6 weeks for  testing for herpes, though he saw nothing he could culture or anything indicative of herpes. The famvir relieved my symptoms though every time i go off it i get about 5 days of relief before symptoms start to come back. I also have had general (and painful) adenopathy since early feb. but dr dismissed it as no big deal. I took another hsv test last week (7wks after exposure) and it came back hsv1=0.08 hsv2=0.01 (not taken during outbreak). The dr said if I had herpes I would have seen *some* rise in the level  in that time period. He dismissed the fact I still have some symptoms and respond to famvir. My problem with this is at the same time my blood work came back and showed globulin levels low ( my test=2.0 , ref for 26y/o male 2.1-3.7) I asked if this could have screwed up the blood test and he said no , it was not really anything to worry about it was not very low. His opinion was I probably do not have herpes but can come back for testing in 6 mo to be sure.

Should I get a second opinion? Do you think I might have it? What kind of doctor would be the best to see about this, a urologist?

[Edward W Hook, MD]

Last answer.  The chances of a postive test while taking famciclovir are very, very low.  Famciclovir resistant HSV is rare, occurring in less than 1% of persons with HSV but, if you were culturing a resistant HSV lesion, the culture would be expected to be positve.  

For taking a swab test, all one needs to do is firmly rub the lesion with a swab.  The lesion does not need to open or fluid filled.  EWH

[ntdc]

Sorry to bump this old thread but I have a follow up. My doctor gave me a swab kit to take home (he said its preferable for me to do it due to the small window in which you can swab), however my first attempt was not successful the lab reported not enough material to do a culture. I was wondering do you have any tip on swabbing successfully?

Also will antiviral drugs (oral) affect the swab? Should I stop antivirals before attempting this? Do they have any effect on blood tests (slowing time to show positive,etc..) ?

Additionally do you know if its possible for HSV to be resistant to antiviral drugs? I am taking 500mg famvir 2x a day x 7 days for treating outbreaks but I still outbreak even on that dosage, though it is smaller and resolves quicker. At 250mg daily I may as well have been taking nothing at all, no noticeable effect.

Regards and thanks.

[Edward W Hook, MD]

1.  Most people get lesions   You have been examined by 4 doctors and have negative tests.  It almost seems that you want to have herpes.
2.  It is not clear that the test will turn positive.  Your response to antiviral therapy is not typical of herpes infections.  For instance. most people do not get recurrences while on therapy or so soon after stopping therapy.   I think you need to be examined and tested at a time when you have lesions.
3.  See above.  It would be most uncommon for herpes to occur while taking antiviral therapy

EWH

[ntdc]

Thanks for the advice. I have a few follow up questions

1. Does everyone get lesions? I have been examined by 4 different doctors (2 primary care doctors, a doctor at the county STD clinic, and a dermatologist) and all of them said i had nothing that looked like herpes.

2. When the test turns positive will my outbreaks subside a bit? I have gone through 2 months of hell so far, constant pain that subsides to some degree when taking famvir. Once i take the full course it goes away for only 3-5 days then comes back.  The medicine makes me feel really bad  and my doctor has said suppression therapy is generally only needed for people with HIV/Cancer  

3. Is it possible to get outbreaks while on treatment? After the initial outbreak which was treated with single-dose famvir, I had no symptoms for 3 weeks except sore throat/adenopathy. My doctor gave me acyclovir 250mg 3x a day, 7 days to see if it would treat the adenopathy and after a few days on it i had an outbreak. He said that was almost impossible to have an outbreak on a treatment dose. He switched me to famvir (500mg 2x , 7 days) cause its less hassle to take it and ive not gone more than a few days between breakouts.

Thanks for all your help.  

[Edward W Hook, MD]

My opinion is close to your doctor's.  In general, it takes nearly 4 weeks following the beginning of the first outbreak  for 50% of persons with HSV-1 infections to develop a positive antibody test and then can take up to six months for the remainder to develop positive tests.  I would suggest re-testing at 3 months when about 80% of persons have developed positive tests and then again at 6 months if the 3 month test is negative.  Another approach is to re-test your lesions the next time they recur using either culture or, even better yet, the HSV PCR testing that is now available through most large commercial laboratories.

Your immunoglobulins are low normal and this is within the variation of the test.  The low value does not suggest you are immunosuppressed and if you repeat it in the future I predict it will be normal.

I would stick with the doctor you have.  It sounds to me as though he is thinking clearly and correctly about this.  This would be unfamiliar territory for many urologists.  Take care.  EWH