Atypical HSV-1 w/back leg pain

[jakex]

My wife had a 6 month affair with a high risk individual.

She had unprotected oral/vaginal sex in January. Sex was mostly protected otherwise during the 6 months.

July 26  she had a 2 minute vaginal exposure when condom fell off.

July 29  leg pain started, that felt like a pulled muscle.

July 30 she had  vaginal discomfort, that felt like an abrasion, but no blisters.

August 1 there was a positive HSV-1 culture.

August 5 She began taking Valtrex at higher dose initially, then went to normal dose.

September 9: Valtrex increased from normal dose to triple dose.
The vaginal outbreak/lesion continued.

September 19 HSV-1 serum FOCUS test was 1.2, barely positive, HSV-2 negative.

September 22 she was switched to Acyclovir at high dose and then settled to 2/day @ 400 mg.
Buttock pain, lower back pain and pain down both legs continue.

October 8 vaginal lesion healed.
Buttock pain, lower back pain and pain down both legs continue to date.

Questions:
1) Is the vaginal sex in July the most likely cause of the HSV-1?
2) Can HSV-1 genital infections be caused by mouth to mouth kissing?
3) Should she continue with the anti-viral medicine and for how long?
4) Buttocks and leg pain does not seem to be a common Herpes symptom. Is something else going on?
5) What other STD tests should the husband, have? Husband is negative for HSV-1 and HSV-2.
6) What future sexual precautions should I take with my HSV-1 positive wife?
7) Can I get HSV-1 oral or genital infection from kissing or having oral sex with my wife?

[Edward W Hook, MD]

We receive many questions relating to efforts to try to sort out the timing of HSV infections.  In most cases it is an exercise in futility.  The nature of mutliple contacts and the ability of herpes infections to recur at highly variable intervals make this very diffiuclt to do.  What you know for sure is that there was a genital culture which was positive for HSV-1.  Who gave it to her and when is difficult to say.  

Statistically we know that most genital HSV-1 infections come from receipt of oral sex from a partner who has oral herpes, that when HSV-1 occurs in the genital region it recurs less than genital HSV-2, has less associated asymptomatic shedding of the virus and thus is less likely to lead to traqnsmission to other partners, either through oral sex by an uninfected partner or genital sex.  For all of these reasons, as well as a lack of studies on the matter, most specialists feel less strongly about the role of antiviral therapy (valacyclovir or acyclovir) in management of gential HSV-1 infections.  

As for your questions:
1.  See above, no real way to say.  He might have had genital HSV-1 which he gave to her or might have transmitted through oral sex.  Taking the long view, it is irrelevant- she has it.
2.  The lesions of initial HSV, whether caused by HSV-1 or HSV-2 typically clear completely in 2-3 weeks.  Recurrences clear in a week or less.  If she has had lesions for more than 10 continuous weeks, the lesions are almost certianly not HSV and warrant re-evaluation.  EWH  

[jakex]

Dr. Hook,
Thank you for your reply.

Here is the information you requested:

The HSV-1 culture was from the vaginal area. This was the first outbreak of herpes in her life and her husband is HSV-1 negative. So it's safe to presume the affair caused the outbreak.

In answer 1, you say genital HSV-1 is usually acquired through oral sex. I assume this is means he most probably gave her genital HSV-1 by oral sex. The only oral sex on her, however, was 6 months prior to the outbreak. My understanding is that first symptoms show much faster than that. This means that her genital HSV-1 was transmitted via vaginal sex or could it be through kissing? What do you think?

In answer 7, you state, if she has genital HSV-1, which she does, it would be unusual for me, the husband, to get HSV-1, through oral sex on her, unless there was a lesion contact.

From this can I conclude that genital HSV-1 usually is gotten from an infected mouth, but does not transmit easily to an uninfected mouth?

Finally follow up: is 10 weeks a really unusually long time for the lesions to clear?

Thank you!

[Edward W Hook, MD]

You do not say where the site of her HSV-1 culture was. Knowing this will help me to elaborate on the comments I'm about to make.  

The topic of herpes is a complex one.  The disease is common with HSV-1 being present in over 60% of adults and HSV-2 (the virus which causes most genital herpes) being present in about 1 in 5 Americans.  For both infections, the majority of people who have the infections are not aware that they are infected, either because they either acquired it without knowing in the past or because they misidentified their herpes as something else.  I will do my best to answer your questions but in general, many of these questions and information about herpes can be obtained by accessing excellent informational web sites such as the one run by the American Social Health Association (disclosure, Dr. Handsfield and I are both on the Board of Directors of ASHA).  Now, for your questions:

1.  HSV-1 can cause genital herpes but when it does, it is usually acquired through oral sex.
2.  HSV-1 is most commonly transmitted to mouth to mouth through kissing
3.  Most people would don’t treat HSV-1 infections causing genital herpes. It rarely recurs and is rarely transmitted.
4.  It is unlikely that her buttock and back pain are related to herpes.  While many people worry about it , it is unlikely.  If it were herpetic in origin, I would expect valacyclovir or acyclovir to help.
5. General STD screening, primarily for chlamydia and gonorrhea.  He is unlikely to have an STD however.
6.  If she has genital HSV-1, the risk  of infection is very low and can be brought to close to zero with consistent condoms use.
7.  If she has genital HSV-1 it would be possible but unusual to get HSV-1 through oral sex on her unless there was a lesion you had contact with.  

Hope this helps. Check out the ASHA web site. EWH