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HSV-2 Symptoms

Dr. HHH,
I had unprotected sex on 11/22/07.  On 12/15 I noticed an ulcer and went to urgent care facility.  The doctor saw another ulcer inside vagina.  2 total, not painful, no blisters.  The doctor looked under microscope, but did not mention herpes.  I assumed the culture was being sent to lab for proper testing, it was not.  I was tested for everything else and came back negative.   (The IgG results negative for both hsv-1 and hsv-2 at 3 weeks post exposure).  On 12/16, my primary care physician diagnosed me with hsv-2 based on visual inspection.  She prescribed Valtrex.  The ulcers cleared in about a week.  I had night sweats on 12/16.  Test results from 12/16 visit - HSV- 2 IgG positive at 1.4 and HSV-1 negative 0.3.  I went to a specialist who tested me again at and the results came back as HSV-2 IgG 1.10 at 9 weeks.  Since the initial outbreak I have had constant redness and irritation in vaginal area.  I have noticed that my clitoris always looks chapped.  It could be the depression from the diagnosis, but I am very lethargic all the time now.  Also, since the outbreak, I have had constant anal discomfort, redness on anus, irritation, constipation problems since mid-December.  I did not have anal sex.  I read about Proctitis.  I am concerned that I have this.  These are my questions.  Since my initial outbreak was mild, will my subsequent outbreaks be mild?  Have there been any tests on low IgG? Could this indicate a mild infection?  Should I test again, as results have come back very low?  How do you heal proctitis?  I have not taken Valtrex since initial exposure.  I have not had another outbreak, have not had sex.  What is your recommendation on HSV-2 meds.  Valtrex gave me bad headaches.  Please help me, I am going insane with constant symptoms since this virus took over and my life was forever changed.  Thank you.  
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239123 tn?1267651214
It seems highly likely you indeed had initial genital herpes.  The visual diagnosis by a knowledgeable provider is usually valid and most aspects of your initial symptoms are typical, as is the improvement with Valtrex treatment.  Some asepcts are not typical, especially the apparent delay of symptoms until a little more than 3 weeks after exposure.  It can take that long, but the incubation period usually is 3-10 days.  Also, it is true that your HSV-2 blood test results are on the low side -- technically positive but borderline.

Have you spoken to your November sex partner?  If s/he acknowledges having genital herpes, of course that would support the diagnosis.  If not, s/he can be tested.  If positive for HSV-2, that also would help confirm your diagnosis.

Putting it all together, I think it most likely you have it.  However, I recommend an additional blood test in April, i.e. ~4 months after onset.  Most likely it will be more strongly positive for HSV-2.  In the meantime, if a new outbreak appears before then -- which is likely -- see one of your doctors right away (within a day or two) for a culture, including virus typing.  (It's too bad that wasn't done at the start.  It should have been.)

As all this implies, I am confident your continuing symptoms are not due to HSV.  Herpes outbreaks never last so long; 2-3 weeks is the max, even without treatment.  And herpes outbreaks are manifested only by blisters/sores, not by diffuse redness or irritation of the genital area or rectum.  When someone suggests his or her own symptoms likely have an emotional origin, usually s/he is correct.  However, emotion will not cause acutal irritation you can see -- redness, swelling, etc.  If in doubt, you should return to your provider and get it checked out.  Conceivably you could have a yeast infection or some other genital dermatitis.

To your specific questions:

1) You don't have herpetic procitis, which would have cleared up and typically is much more severe than the symptoms you describe.  It's a really painful condition.

2) There are conflicting profession opinions on whether the severity of the initial outbreak predicts the severity or frequency of recurrences.  The best research, including the most recent study, suggests it makes no difference.  It definitely makes no difference in the frequency of asymptomatic viral shedding, i.e. the potential for transmission when there is no outbreak.

3) The lower EIA ratio on your blood test raises the possibility you don't have HSV-2 at all.  But if you do, it says nothing about the future severity or frequency of either symptomatic outbreaks or viral shedding.

4) I think it is best that you are not still taking Valtrex.  You might want to do so in the future, to help prevent symptomatic outbreaks and reduce the potential for transmission to partners.  But it is best to wait until you have experienced at least one and maybe a couple of recurrent outbreaks, so that you can better judge whether to commit to prolonged therapy. Also, as suggested above, it actually might be in your interest to have another outbreak to confirm the diagnosis.  (Recurrences almost always are much milder than the first infection, and you can start treatment immediately after the culture specimen is collected.)

I am skeptical that Valtrex was the cause of your headaches.  The package insert lists headaches as a possible side effect, but in hundreds of patients, headache was reported by under 5%, and the proportion who complained was identical in those who received either placebo or Valtrex.  Don't be afraid to try it again in the future.

Bottom lines:  I'm about 80% certain you have genital HSV-2.  See your provider about the continuing symptoms.  Follow-up on confirmatory diagnostic tests, and talk to the partner from whom you likely caught it.

I hope this helps.  Best wishes--  HHH, MD
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Your thorough response is much appreciated.  This website has been a lifesaver.  You are doing a great service, Dr. HHH.  Thank you.
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