recurrent genital symptoms but neg HSV2 IGG

[GHSV2orNOT]

hi dr,

married male, 38, oral HSV1 (IGG+ long ago).  regrettably, had extramarital sex.  12/07/09 prot oral and vag with CSW, ejaculated in anal area w/ skin contact.  12/14 genital/genital rubbing, unprot oral and prot vag w/ other female, condom broke but she tested neg for HSV, no symptom history.

12/18 5pm cold sore prodrome, took 2g valtrex.  had prot + unprot oral and prot vag/anal with CSW from 12/07.  oral was rough and painful (teeth).  next morn itchy/sore/irritated penis, right side.  tender pimple-like spot, 2 much smaller ones next to it.

squeezed them hard w/ fingernails, broke the skin.  formed lesions (main one was roundish, 4mm diam, 2 others very small slits).  clear fluid only when squeezed.  immediately thought herpes, panicked, took more valtrex (not smart).

mon culture, was neg but it was scabbed.  fatigue, back + leg pain, malaise, inguinal lymphodenopathy on same side only, lesion waxing/waning (scab kept peeling off after shower), eventually healed w/ valtrex.

12/23/09 (unk test, not herpeselect)
HSV1 IGG 59.4
HSV2 IGG 0.1
IGM .75

small cut few days later, same area.  few days later lesion, base of penis (in hair area), very itchy.  doc said prob folliculitis, very fresh culture neg.  these weeks a terrible blur, lost 15 lbs, depressed, nauseous, diarrhea, inspecting myself all the time, etc.  can't recall things clearly.

01/06/09 (herpeselect)
HSV1 4.07
HSV2 0.24
IGM neg (no #s)

01/29 (hs)
HSV1 4.84
HSV2 0.13
IGM neg

feb no symptoms except itching.  03/01 same systemic symptoms but 1st no signs on penis.  then after vag sex w/ wife, tiny sore, cleared in 3 days, no valtrex.  then cut, cleared in 3 days w/ valtrex.

03/01 (hs)
HSV1 3.95
HSV2 0.15
IGM neg

wife has no HSV2 (but results pending) nor extramarital sex.  i was a moron and will not do this anymore, have informed my wife about everything.  concerned about 12/07/09 exposure.  almost sure it is GHSV2 despite 12 wk low neg test. what are your thoughts?

thank you, doctor.

[H. Hunter Handsfield, M.D.]

I can't say the cause of the rash, assuming not herpes.  Many rashes are unexplained, and just about any of the many causes of rash anywhere on the body sometimes can involve the genitals.  You have had oral herpes -- if you have genitals, you can expect it to behave more or less the same.  I can't quote the frequency of regional lymph node inflammation with recurrent oral herpes, but it definitely is uncommon for genital.  Auto-inoculation is not a likely explanation; it is rare except during an initial HSV infection.

As for self-collection of PCR specimens, the Westover Heights Clinic of Portland, OR (www.westoverheights.com) sometimes does that.  WHC is run by Terri Warren, moderator of MedHelp's herpes forum.  But be very clear:  I truly believe you do not have herpes and do not expect the test to be positive.

[H. Hunter Handsfield, M.D.]

Welcome to the STD forum.

The most likely explanation by far is that you don't have genital herpes.  Your initial symptoms really don't fit very well.  In the presence of HSV-1, the initial genital HSV-2 infection rarely causes fatigue, leg pain, fever, or regional lymphadenopathy.  And the penile rash you describe doesn't sound like herpes either, at least not initially. And to catch genital HSV-2 via condom-protected vaginal sex is unusual.  Finally, since a physician thought you had folliculitis (which, by the way, is a more common cause of regional lymph node inflammation than HSV is), that also works against herpes.  Add the negative blood test results at 12 weeks and you can be virtually 100% certain you don't have HSV-2.

The only slight uncertainty is that apparently you have been taking valacyclovir -- although I don't quite follow how consistently you have been doing so.  Usually treatment has no effect on seroconversion to HSV-2, but sometimes it does.

At this point, I recommend you stop taking valacyclovir and stay off it for at least 2-3 months.  If you then have another outbreak, see a provider immediately -- within 1- 2 days -- for viral testing by culture or, preferably, PCR.  If that's positive, of course it will nail down the diagnosis.  If negative, have another HSV-2 blood test in 2-3 months.  I expect that a) you won't have a recurrence and b) the follow-up test will remain negative.

I hope this helps.  Best wishes--  HHH, MD

[GHSV2orNOT]

thanks, doctor.  i don't know, the initial lesion did look like HSV (ulcer with pink base after i broke the pimple/blister which was itchy and tender and kind of like there was some clear fluid in it) and 1st dr thought so, the unexplained recurrent tiny cuts and kind of small chafed looking area scare me.  it is also strange that everything keeps recurring in same general location and symptoms always improved rapidly with valtrex.  

the female who tested neg was supposed to get back to me with updated new test results but now i can't get in touch with her which concerns me as to why.  the 12 week test is somewhat encouraging though as well as your opinion.  i can only wait now and try to get a grip.  i will go with your recommendations and post follow up when i have new test results.  thanks again for helping me and everything you do on this forum.

best.

[GHSV2orNOT]

if i may, just couple more brief questions, doctor and i'll move on.

- i had more than one doctor have a look and although most thought none of the symptoms on the shaft looked much like herpes (bc they say HSV always presents as cluster of vesicles, which is not true) none was able to give me a differential diagnosis (except for folliculitis which only applied to the sore in the hair region) as to what it COULD be that's causing me all this grief if not HSV2.  

unexplained genital lesions/cuts are very suspect, and i never had any in my life despite a lot of sex.  i know it is speculation, but could you perhaps suggest what this might possibly be?  (all STDs are neg, btw.)

- i don't think it will be easy for me to get PCR done at my GP's office.  is there a kit i can get myself somehow?  he uses quest lab nearby.  i could take it there myself directly and pay out of pocket, as long as i can get it done.

- i do get frequent unilateral lymphodenopathy with oral HSV1 recurrences.  is this generally as uncommon as with initial HSV2 in HSV1 seropositive patients?

- lastly, do you think there is any possibility of genital auto- or re-inoculation with HSV1?  have you ever seen it happen with a long-standing oral HSV1 patient?

thanks again, and sorry for the additional questions which i know are not very relevant bc they do not change your assessment.  i don't mean to be a nuisance and try your patience :)

all the best.

[GHSV2orNOT]

thank you, doctor, that does help.  

just to clarify, the 1st doctor thought the 1st lesion (mid-shaft) looked like herpes, a different doctor looked at the lesion near the base and thought that was folliculitis.  there was no lymph node involvement with that lesion, only with the initial episode and the latest "recurrence" feb 28.  i don't trust any of these doctors opinions though, bc during the discussions re igg, igm, symptoms, etc., it was clear to me their knowledge of herpes is lacking.  hence i asked for yours bc of your reputation.

i haven't been taking valacyclovir suppressively, i experience strong side effects which make the fatigue worse.  i only took it for a few days whenever i had symptoms.  i will follow your advice and post a follow up after i have news.  thanks again for your help.