Cervicitis & Visual HSV Diagnosis; Negative PCR

[brightyoungthing]

On May 19th, after an abnormal pap smear, I was given a colposcopy. Thursday the 21st, I had an extremely strange discharge. I reasoned this was the "discharge" my doctor had warned me about, but it was almost solid, yellow, quarter sized, and completely foreign to me. Friday I came down with extreme lethargy, a high fever, muscle aches, more yellow discharge, and went straight to the emergency room in case I had an infection. The ER doctor concluded that I had infectious cervicitis. I was placed on hydrocodone and antibiotics. Saturday, red bumps appear around my entire genital area. Sunday, the bumps fill and burst in a HSV fashion. They appear dime sized and relatively spread out. Memorial Day Monday, I get ahold of the on call nurse and she prescribes Valtrex for herpes symptoms. My doctor visually diagnosed me on Wednesday the 27th, and took a culture (this is within 72 hours and my first outbreak). He assured me that it was my first outbreak and that my fiance had knowingly given it to me (which I now know is completely presumptuous).

Well, my PCR results are negative and I'm scheduled to have blood tests on Monday. Thing is, I do not trust the accuracy of the blood tests as much as the PCR. Isn't the test supposedly the "gold standard" of hsv cultures? Are false negatives common in PCR testing? Is there a possibility of another type of infection cured through my antibiotic treatment? The symptoms were similiar to a first outbreak, and the flu-like aches, fever, and cervicitis are present in a primary episode, but the PCR is hanging over my head. Also, visually, I've found nothing to confirm my outbreak looked like genital herpes. It feels like I won't get an accurate diagnosis until I have another outbreak (if I do). I have tested negative for all other STDs.

Thank you for your time and I appreciate your response.

[brightyoungthing]

Great, thanks. I've stopped taking my suppressive therapy to see if I have another "outbreak". My doctor did notice two cyst-like formations of scar tissue on my left labia that we are watching closely. Also, I have two easy closing questions and will move on from here.

#1 - Can you give me names of a few other bacterial or fungal infections that may have presented themselves as HSV on the genitals? I would like to do some independent research out of frustrated curiosity. My second opinion doctor offers staph or an exterior yeast infection as potentials. The most accurate visual has been pictures of impetigo and staph infections for the manner in which my blisters presented themselves.

#2 - If my BF has shingles or staph, would either cause a painful bullous rash if trasmitted accidentally? We think he may have had a staph infection on his leg/foot and we share towels, cuddle, etc. I've just never heard of bacteria and fungi on female genitals but I suppose every day you learn something.

You've been great Doctor. Best $15 I ever spent!! Have a wonderful week.

-Lynne

[Edward W Hook, MD]

Some labs call the range between ).91 and 1.10 indeterminate.  Your  BF's result is negative.  Accumulating evidence is that you do not have HSV-2.  Please do not be hard on your doctor over this.  The information as to how difficult it can be to diagnose genital HSV is new and was a bit of a surprise to all of us.  EWH

[brightyoungthing]

The results are in. I saw my ob/gyn today and declined a blood test since I knew the results had a higher chance of being inconclusive, but he and I spoke over the options. Also, he is baffled by my negative PCR as well. He literally said, "I have no idea why that is negative. It looked like a classic case of herpes."

Also, I mistook the time of my BF's last sexual encounter. It was in the first three days of March (we began dating late March). This would be right about 3 months for an IgG test.

Here are my BF's IgG and IgM test results. Yes, he had an IgM before we knew about it disregarding it.

IgM: 1.05 positive
IgG: <0.91 negative

Isn't the standard for IgG 1.10? Wouldn't this mean that another blood test in say, two weeks, may produce a higher result? He has agreed to re-test soon just in case. Thanks again for your time and effort!
-Lynne

[Edward W Hook, MD]

Thanks for the additional information.  If your BF's HSV serology is negative, it makes it far less likely that you had HSV as the cause of your rash.   Furthermore, the information you provide about consistent condom use also makes HSV less likely.  

You are correct that the valacyclovir can make cultures negative and it can accelerate the time to which PCR becomes negative as well.  Hard to say if 2 days would make the lesions of intial herpes PCR negative - I sort of doubt it.  

I'm not sure I would suggest valacyclovir suppression for you at this time for several reasons.  These include:
1. Not sure if this is HSV.  You need a diagnosis.
2.  there are increasing reports of delayed antibody development in persons on valacyclovir suppression.

I'm not wishing a recurrence on your but I do want you do know if this is HSV or not.   I'd stop the valacyclovir and see what happens.  Should a recurrence occur, I would not re-start the valacyclovir until you've had a repeat PCR to give you the highest possible chance of getting an accurate test result..  

Hope this helps.  Let us know what your and your BF's serologies show.  EWH

[brightyoungthing]

Also, we've been together for 3 months so far. Thanks!

-Lynne

[brightyoungthing]

Thanks again for the quick response! Let me try and answer these questions as best I can. And yes, it is comforting to see you just as confused as me! I'm a medical student and have been incredibly humbled by my own body and the complexity of this situation. I have a new respect for every doctor dealing with STDs.

First, the PCR was a culture swab from an open lesion. This would theoretically be a primary episode lesion and I would have ingested 4 Valtrex prior to the culture.

I spoke with my BF immediately following the diagnosis. He had never experienced an outbreak or symptoms and denied any outside sexual relations. I've no reason to suspect unfaithfulness and I do believe him. His last sexual partner was in January of this year. He agreed to an STD test including an HSV blood test Tuesday June 2nd. His results were not ready at the end of the week, and I'm unsure of the test he took (at the time I didn't know about the uselessness of IgM). I will definetly look into that.

We last had sex May 11th and stopped all sexual contact due to my abnormal pap smear (possibility of HPV). The culposcopy would have been 8 days after, and the outbreak would've been 13 days later. I know there is still a chance of transmission, but if it helps, we always have protected sex since I am not on birth control (which is funny because this all started with me trying to get on it).

If he has an IgG test come back negative, especially after that length of time since his last partner, I would assume I did not get it from him. I was mainly concerned about the negative culture because of the sensitivity and accuracy. This would be a new infection and so I also worry about a false negative IgG. I'm also following "suppressive" therapy including once a day Valtrex. If Valtrex can hinder a culture, will it act similiarly in a type sensitive blood test?

Thanks for your detailed list of questions; I hope we've progressed.

[Edward W Hook, MD]

I'm afraid that sorting this out may take a little while.  You have taken the right steps and are doing the right thing but getting to the bottom will require waiting for accurate antibody (blood) test results which can take up to 3-4 months or, as you suggest, waiting for another outbreak at which time you can have a repeat PCR or culture.  There is much about what you state that makes me wonder if you do have HSV.  I have my doubts.  Let’s revisit your situation in step-by-step fashion.

I don't do culposcopy but it sounds as though the vaginal discharge you experienced starting May 21 was likely to be the result of the culposcopy and an expected one at that.  Following culposcopy (and possibly biopsy) it is possible that the post-procedure findings could be mistaken for infectious cervicitis.  On the other hand, flu-like symptoms (fever, muscle aches and a genital rash) are not an expected occurrence following uncomplicated culposcopy and suggest that something else might have been going on.  The doctor you saw raised the possibility of HSV which may have been reasonable but was not a sure thing (about 20% of clinical diagnoses of herpes made by experts turn out to be wrong. This is the reason we urge people to do PCR or culture to verify clinical impressions).  That your PCR (was it a PCR test of culture?  At one point you say culture, elsewhere you say PCR) was negative makes it less likely you had HSV although the valacyclovir does make these tests negative soon after it is started.

By the way, your rash and flu-like illness could have been something else such as a reaction to something you were exposed to during culposcopy or other dermatological reaction.

Bottom line.  It is not clear to me that you have HSV.  When you have a blood test on Monday it might help (PLEASE be sure this is a type specific test such as the HerpeSelect and please do not waste your time of money getting an IgM test, they are worthless and frequently misleading).  At that time a bit over half of type-specific blood tests for HSV (be sure you have a type specific test) will be positive but the reminder may take as long as 4 months to become positive.  In addition, if your test is positive, unless you have been tested in the past, it may or may not be related to your illness two weeks ago.  Remember that 1 in five American adults has HSV-2 and 90% of those do not know it until they are tested.

One more set of questions and 1 more suggestion:

The questions are about your BF.  IS your relationship monogamous?  For how long?  Have you asked him if he has HSV?  Has he had a HSV blood test?  When did you last have sex before your culposcopy?  (typically people who get HSV have their first outbreak  4-10 days following exposure.  If it had been longer since you last had sex, it makes HSV from him less likely).

My suggestion is that your BF should also get tested with a good type-specific blood test for HSV.   If he does not have HSV, you could not get it from him.

Sorry for the complex answer.  The situation however is complex.  I hope these comments and suggestions are helpful.  Please feel free to reply with answers to the questions I've asked above.  EWH