Oral Outbreak Induced?

[SadTimmy]

Dear Dr. Warren,

I wrote a few months back that I had been tested positive for HSV-2, first by IgG, then confirmed by WB. I tested negative for HSV-1 by IgG. The woman I am dating was subsequently tested for HSV-2 since we were having unprotected sex and was confirmed negative by IgG. She did not test for HSV-1 as she did have cold sores as a child, so we assume she is HSV-1 positive. Since receiving my test results we have been using latex condoms to help prevent transmission. Last weekend we had sex and, again, used latex condoms. Today she had a cold sore develop on her upper right lip. We are concerned for a couple of reasons. Firstly, she has not had a cold sore in many years, and, secondly, the cold sores she has had have typically developed on her lower right lip and have developed gradually, starting with a tingling sensation. Thus, the development of her current cold sore concerns us as it neither developed gradually nor in the same place. She did perform oral sex on me this last weekend, but over the latex condom. It is likely that she touched me around my waist area during intercourse and then touched her lip in the spot where the cold sore has now developed.

Our question is obviously about the development of this cold sore. We would like to know your thoughts on the likelihood of just a random HSV-1 oral flare-up versus the possibility we might have been too latent in our protective practice which resulted in her possibly contracting oral HSV-2. Or the possibility that our intercourse could have somehow induced an HSV-1 oral outbreak after such a long dormant period?

I should say, as I said in my previous message to you, that we did have unprotected sex, both oral and vaginal, for a few months prior to me being diagnosed with genital HSV-2 and she did not have any cold sore outbreaks during that time. Although we both realize after having researched the virus that shedding can occur any time and that transference could also occur at any time.

  

[Terri Warren, RN, Adult Nurse Practitioner]

I have to say I think, with a fair degree of certainty, that the cold sore is probably just her old kind, HSV 1.  She could test again, but I wouldn't recommend that she lose sleep over it.  Four months would be the timing.  Yes, I would contact your diagnosing provider about the suppressio prescription.  Can't imagine why you would have to go in to get that.  

Terri

[SadTimmy]

Hi Terri,

Thanks for the quick response. My girlfriend was unable to get her cold sore swabbed due to the tight timing; I didn't see your response until later in the afternoon yesterday and she would have had a tough time getting in to see her physician that late. Her cold sore is healing now, so I am not sure if a swab is even possible at this point. Suggestions? She thought she might request another HSV-2 blood screen on her next regular visit, but I know in earlier correspondence you recommended at least four weeks from the time of an outbreak? So the antibodies have time to multiply I believe?

Regarding the suppressive therapy, we had not gone that far in our protection measures but will now make sure that is included in our efforts. I am hoping I can just phone my physician to request a prescription since he is the one whom helped me get the WB test and is aware of my condition. Unless there is an easier way you can suggest?

We are still a little concerned about the recent outbreak because of the inconsistent severity and location (I said lower right lip is where she has had them in the past, but it is actually the lower left). Plus the fact that she touched me with the same hand she put to her mouth in the upper-right location where the cold sore developed. Seems like an odd coincidence, but your comments helped. Still, we do think a follow-up of some sort is warranted to be sure, if you think that is appropriate.

Thanks again for your timely response and insight.

[Terri Warren, RN, Adult Nurse Practitioner]

My best guess is that she simply has a recurrence of the cold sores she has had in the past, and that the timing is coincidental, not significant.  Since you are writing to me the day after the cold sore developed, I would suggest that today she go in and get the cold sore swabbed and see what type it is.  I would put my money on HSV 1, but given everything you've said, I think swabbing it would reassure you both.  You've done all the appropriate things to protect her (though you didn't say anything about suppressive therapy?).  When she has this swabbing done, she needs to ask that the test used be PCR, not herpes culture.  It is far more sensitive than culture, but gathered in the same way.  If you have trouble with that, let me know.    And I would be interested in how this turns out.

Terri