recurrent chlamydia vs HSV2

[jjjj986]

Hi all, new to the forum, but appreciate this community, the wisdom and the guidance.

Here is the scenario: I am 40, married hetero essentially monogamous male who recently had an indiscretion involving oral and (briefly unprotected) vaginal sex several times with a promiscuous woman (not my wife). I have no diseases but the usual oral cold sores couple times a year like 80% of the world.

The woman tested positive for only chlamydia (so she says) and she called to disclose that. I was asymptomatic, but I was treated anyway with azithromycin. Since exposure I have developed 3 new flare ups of oral herpes ulcers on first my lower lip then upper lip in more dramatic than usual fashion. Now over 6 weeks after exposure I have developed urethritis (tenderness) and dysuria. No genital lesions, but still trying to heal the lingering oral ulcer. No fevers or other symptoms. HIV negative 6 months ago (work related testing) but never been tested for other STD's.

So, breaking it down: one exposure to known chlamydia, now with urethritis despite azithromycin, and a flare of oral ulcers.

Here are the questions:
1) Could there be resistant chlamydia despite azithromycin?
2) Could she have maybe oral Gonorrheia which she transmitted orally without testing positive herself? ie. what is causing my urethritis?
3) What is the likelihood I contracted new oral HSV2 from her (on top of my usual oral HSV1)?
4) What are the chances HSV2 causes urethritis with no visible external genital lesions?
5) Is it likely or even possible to contract HSV2 infection in two sites at the same time, or does an oral flare-up make genital infection unlikely?


It's puzzling and vexing, and I really appreciate any thoughts you can offer.

[Edward W Hook, MD]

My suggestion would be to make sure you are tested for objective evidence of urethritis.  This might include signs of inflammation (white blood cells) on a stained smear of genital secretions obtained with a swab taken from the penis or in a sample of urine collected just as you begin to urinate. If there is no objective evidence, my advice would be to not worry further.  EWH

[jjjj986]

Thank you for your prompt, knowledgeable and non-judgmental response. I am getting tested today, but I'm not sure my PCP is super well-versed in this topic.

BTW I should have mentioned, I have told my wife, she got azithromycin too at the same time, and we abstained for a week after treatment.

My urethritis does not seem like a baseline occurrence.  To answer your question, I was starting to notice symptoms when I heard my liason was chlamydia positive, and then we took Azithromycin. I waited weeks to figure out whether it really was more than transient irritation. Now, I have dysuria regularly, in addition to itching, and a broken glass sharp feeling in the urethra from shaft to tip now. No drainage though.

Thanks for allaying my fears about HSV2. Sounds unlikely, and stress was decidedly a factor.

Seems like I could still have NGU, or less likely resistant chlamydia. I will post my testing results when I get them back, but from a tactical standpoint I'm wondering about treatment for my partners (past and present). I.e. do my wife and (my liason) need to be treated with that same backup regimen flagyl/doxy if they have no symptoms after azithromycin? And I know G can have oral carriers, but can those other two (C/NGU) have oral carriers and be asymptomatic, but need treatment?

My liason DID notify me; should I notify her that it's not resolved or is she done treatment if she is doing fine?

Thanks for reading this and I'm so grateful for this resource. My PCP, I know, is just not equipped to handle these specifics.

[Edward W Hook, MD]

Welcome to the Forum.  I'll try to help.  You are fortunate that your partner did the right thing and notified you that you had been exposed - not everyone would do this and, as you can imagine, letting you know about this probably was not easy for her.  Treating you for your exposure with azithromycin was precisely the right thing to do.  At the time you were treated did you have symptoms of urethritis?  The reason I ask is that, following your exposure, you may or may not have acquired infection but it would be unusual for a person with asymptomatic infection to develop symptoms AFTER treatment.  On the other hand, all too often after an exposure that, in retrospect, one wishes they had not had, persons tend to examine themselves and be far more attuned to genital sensations than in periods when they are not concerned.  This in turn leads to noticing what turn out to be normal sensations that might have been not noticed or ignored at other times.  I wonder if this was a contributor to your situation.  

Secondly, did you have sex with your wife in the time period between your exposures and your taking azithromycin.  If so, perhaps your wife was infected and you have since been re-infected through another exposure.    

With this as background,  let's work through your questions.

1) Could there be resistant chlamydia despite azithromycin?
Treatment failures with azithromycin are rare but have been described.  It is not clear to me that you have been tested-were you?  If not, your urethritis could be due to something other than chlamydia. the recommended approach for documented recurring urethritis following azithromycin treatment is to take doxycycline 100 mg orally twice daily for 7 days, plus a single, one time dose of 2.0 grams of metronidazole.  

2) Could she have maybe oral Gonorrheia which she transmitted orally without testing positive herself? ie. what is causing my urethritis?
Unlikely.  Gonorrhea is usually successfully treated with azithro and when it occurs is typically symptomatic with visible discharge.   The best way to address your continuing symptoms is to seek testing.

3) What is the likelihood I contracted new oral HSV2 from her (on top of my usual oral HSV1)?
Oral HSV-2 is very rare and if you had gotten HSV-2 orally or genitally, you would be expected to have more lesions.  I wonder if your increased frequency of recurrence could be a manifestation of stress?

4) What are the chances HSV2 causes urethritis with no visible external genital lesions?
Very, very low.

5) Is it likely or even possible to contract HSV2 infection in two sites at the same time, or does an oral flare-up make genital infection unlikely?
Perhaps surprisingly, even when persons are exposed at multiple sites, they typically develop infection at only one site.  these infections are just not that easy to transmit and chances of getting it simultaneously at two sites is almost immeasurably low.

I hope my comments are helpful. Sounds like you would benefit from seeing a knowledgeable clinician who could perform some testing. EWH