Odd oral herpes outbreak or HIV ulceration?

[Johnken55]

I am a 30yom with HSV-1 diagnosed cold sores. They have always occurred on my left lower lip with the same prodrome of itchy/tingling. I recently went to Asia where I performed unprotected oral sex on a man. No ejaculation. Two days later, I met another man who I had protected insertive intercourse.

I returned two days later after a 15 hour flight and started with a runny nose and malaise. I slept poorly that night and felt off the entire next day. The next two days I had an odd constant headache like my entire brain was inflamed. I felt warm and uncomfortable, but not sure if it was a true fever. The next am, (6 days since oral sex) the left side of my neck and top of my mouth was sore. I was hungry, but even if I ate or drank anything, I would feel nauseated and my stomach was upset. Thinking I had a GI bug, I went to bed and unexpectedly slept for 18 hours. The headache and congestion lingered when I woke so I took 2 tabs of Motrin which stopped the headache but I looked into my mouth and saw ulcers on my left hard palate. I have never had introral herpes. The next day I got a rapid HIV test which was negative. Today is day 9 after oral sex and only the painful lesions remain with a small cough. My PCP prescribed me valtrex and thought this was herpes from flying stress and said I could just get HIV tested at 3 months for peace-of-mind.

With my cold-sore history, I would think that I shouldn't be getting a "new" infection of palatal herpes with such a severe prodrome of symptoms. The timing and headache/oral ulcer/GI upset symptoms make me concerned for HIV seroconversion after some reading online which has me SO worried. Is it typical to get this sudden flare of new herpetic symptoms when stressed? Does this seem more like seroconversion? Would the mucocutaneous ulcerations associated with seroconversion look like a herpes outbreak?

[Edward W Hook, MD]

Your neck soreness is most likely related to swelling of the lymph nodes of your neck and is a non-specific finding.  

The term "mucocutaneous lesions" is likelywise a gereral. non-specific term.  Trying to generate more specificity for the term is nothing more than an excercise in frustration and a waste of time.  EWH

[Johnken55]

Oh I probably should have been more clear. i didn't have a sore throat which I usually have with my URI infections. This was more of a particular soreness along my anterior left neck in the soft tissue. Maybe a swollen gland? I don't know if that changes anything.

[Johnken55]

Thank you for a prompt and reassuring response! The dermatomal distribution and vesicular lesions look identical to most of the images I've seen for palatal herpes. If we were to just assume herpetic lesions, is that what they mean when they describe "mucocutaneous" ulcerations of ARS or is that referring to a different presentation?

[Edward W Hook, MD]

Welcome to our Forum.  I'll be glad to comment.  My guess is that what is going on here is neither a new manifestation of your oral herpes nor ARS related to recent HIV acquisition.  While I, like your doctor would have probably initiated valacyclovir because of concern that your sore throat and palate lesions might be HSV, my suspicion is that this is not a recurrence of your HSV-1.  As you point out, typically HSV/cold sore recurrences follow a somewhat predictable pattern and with the exception of initial episodes to have lesions inside the mouth is quite unusual. Another uncommon but well described possibility is that you may have acquired oral HSV-2 from performance of oral sex.  If so the valacyclovir should help.

This is not a manifestation of the ARS.  The onset is too soon to be ARS, acquisition of HIV from fellatio, while reported, is extraordinarily rare, and the other symptoms you mention would be atypical.

What is most likely is that this is a non-HIV, non-HSV viral infection acquired in your travels, perhaps through direct contact (i.e. kissing if it occurred) or through your activities of daily living during the travels. There are many community acquired viral infections that can cause oral vesicles and sore throat.  

At this time, in addition to continuing your valacyclovir, there is little to do other than take symptomatic treatment and wait this out.  On valacyclovir there is little benefit to viral culture or PCR.  Should the symptoms get worse, you may wish to seek the advice of your doctor to make sure this is not a bacterial infection.

I hope my comments are helpful.  EWH