resistant herpes infection

Dear Doctor

I was diagnosed with HSV-2 approximately one year ago. After the initial episode I continued to have monthly outbreaks. I started suppressive therapy with valtrex 1000mg po qd in November 2008. Since then, I still have monthly outbreaks (during which I increase my dosage to twice daily), and I don't believe that valtrex shortens their duration. At this point, I am very concerned about resistance.  I realize that resistance is usually a concern amongst those who are immunocompromised (I am HIV negative and have no other reason to be immunocompromised). But I did read a case report of someone who was not immunocompromised who was transmitted resistant virus by someone who was HIV positive. In my case, I had sex with a condom with someone who I was dating for several months. Unfortunately, though we discussed STDs, I do not trust that any of his answers were honest. Approximately 6 months after we stopped dating, I developed genital lesions. I did not have sex during the 6 month interval. In addition, I had not had sex for two years prior to dating this person.
Regarding the lesions - they are not ulcerated. Usually I will have a small closed bump on my labia or my buttocks. Because the lesions are closed they cannot be cultured and sent for resistance testing. Would it be reasonable to have my doctor culture my cervical fluid? Or, do you think that my course as described is not unusual and that eventually valtrex will begin to work?  Thanks for your thoughts on this.

[Edward W Hook, MD]

There are several unusual elements to your history.  Have you had a positive culture for HSV?  Do you know what type of HSV is causing your lesions. Sometimes other genital processes including a number of skin conditions can mimic HSV.

HSV can be cultured or detected with a PCR test (even more sensitive) even if the lesions are not blisters or ulcers.  You need to have you lesions tested.  

Acyclovir resistance does occasionally occur in non-immunocompromised persons but it is, as you point out, uncommon.  If you have a positive culture for HSV, it can be tested for acyclovir resistance.  Another possibility however is that the reason for your non-response is that what is being treated is not herpes.  One way to find this out is by stopping all antiviral therapy and see what happens.  Since the therapy is doing so little, I doubt there is much to lose.  If the nature of your recurrent symptoms does not change, then it is either not HSV or something else.

This is where I would start on dealing with your problem.   Hope these suggestions  are helpful to you.  EWH