Help with HSV

[Donna03]

Dear Dr.,
sexual history:oral sex w/ 2ppl, give/receive
sex w/1 partner, condom always used
guy1:April-July,oral sex
guy 2:july-oct.sex & oral

S/S:white discharge comes & goes, burning w/urinating. No sores/lesions on mouth/genitals.

July 2007: took z-pack due 2 illness, got yeast infx. tx:monistat, flucanozole.  
had to repeat flucanozole a few times

w/some1 new. had oral sex, had sex in sept.always used a condom, yeast infxn.had never really cleared up.oct 27th had sex,condom broke.went 2 OBGYN on Nov. 20th w/same S/S.she found a piece of the broken condom inside& thought that was y i was experiencing the symptoms i had.
tests:
1. vaginal culture
2. chlaymdia/gonorrhea culture
3. herpes culture
all negative.
things didn't get better went 2 OBGYN again jan.10th w/ same S/S.
tests:
Everything was negative, except was positive HSV-1.  

RPR:negative
HSV-IGM: detected
reference pt: not detected

HSV IGM TITE: <1.10
reference range: <1.10
-------------------------------------------------------------------
HSV 1 AB-IGG: positive, 4.63
reference range: 0.00-0.89
unit index

HSV 2 AB-IGG: negative, 0.01
reference range: 0.00-0.89

1.  Is it possible that my yeast infxn. didn't clear up completely w/ the flucanozole bec. the area was not left alone?
2.  Can HSV-1 develop into HSV-2 on its own?
3.  In Nov. my Dr. did a herpes culture & it was (-), i assume that is bec. i have no lesions.  Now in jan. i am (+) 4 HSV-1, does that mean it is NOT genital HSV-1? or is there no relation?
4.  Could the guys condom breaking inside of me have exposed me to genital HSV-1 or HSV-2?
5.  It has been 3 months w/o any intimate contact. Wouldn it be likely that if i had genital HSV-1 or genital HSV-2 I would have had an outbreak by now?
6.Is it possible that my Dr. thought i had a yeast infxn. when it is really genital herpes? Could i have no lesions, only the yeast infxn. S/S & still have genital herpes?
Thank you

[H. Hunter Handsfield, M.D.]

Your doctor is wrong about IgM testing for HSV.  She was taught what she says, but it is simply wrong for herpes.  Tell her this:  IgM antibody often doesn't appear in initial HSV infections and it often does appear in recurrent infections; therefore, it doesn't accurately do what it intends, to distinguish between primary and nonprimary infection.  Further, the test is very prone to give false positive results.  Herpes experts never use IgM testing except in special circumstances, e.g. in working up babies for possible neonatal herpes.  In adults, only IgG testing is valid for HSV.  Further, IgG antibody almost always appears within 4 months of a new infection, usually 6-8 weeks for the HerpeSelect test.

For further information, use the search function on this forum to look for "IgM" for multiple discussions.  And tell your provider that she can learn more by looking into the medical literature.  If she just searches for author name Rhoda Ashley (my colleage at University of Washington and the world's top expert on HSV blood tests of all kinds), she will easily find reviews and research papers that confirm the points as I just stated them.

You don't have herpes.  Believe it.  If you aren't exposed again in the future, your IgG test will remain negative.  (And a repeat IgM test might be negative as well.  But don't waste your money on it!)

[Donna03]

Hi Doctor,

I saw my doctor today and i just wanted to run past you what she said.

she said that because my HSV IGM is +, it means i have had a new exposure to either HSV1 or HSV2 within the last 6 months.  She said that after 6 months it will convert to IGG, which mine has since i am positive for HSV1 IGG.  But she said that she isn't sure if my new infection is with HSV1 or HSV2 because she said i could have had the HSV 1 infection for awhile and therefore my positive HSV IGM would indicate that an HSV 2 IGG infection is developing. Or she said it could be that the positive IGM indicates the HSV 1 infection, which i tested positive for. she said if that is true then my IGM will be negative when i re-test in 6 months. And i know you said it only takes up to 4 months to test positive for HSV 1 or 2 IGG. she's making it sound like the positive IGM has some value when i know you said that it doesn't. What do you think of what she said?

thank you

[H. Hunter Handsfield, M.D.]

Your questions are just too complex and detailed for proper replies on line.  A couple of additional comments/replies, but you need to find a herpes knowledgeable provider.  Or, going to question no. 6 (what to do next):  check out the Herpes Resource Center of the American Social Health Association (www.ashastd.org).  A 20 min phone call will be much more efficient for all those sorts of questions.

Your HSV-2 result is negative. The test usually becomes positive in 6 weeks or so, but sometimes it takes 3-4 months.  It never takes 6 months.

Most HSV infections, both HSV-1 and -2, are asymptomatic.  However, most infected people have genital sores; the "asymptomatic" ones just have mild sores they didn't notice.  For someone like you, worried about herpes and looking closely, the absence of genital blisters/sores is pretty good evidence you don't have it.

Your "Is it true?" questions: Yes, all those things are true. Did you think I might have changed my mind since yesterday?  

It is also true that immune deficient people can have problems with chronic yeast. But more than 99% of people with persistent or recurrent yeast are immunologically normal.

Please do your own research on herpes before you ask more questions.  In addition to ASHA, you can read excellent information on line at places like www.metrokc.gov/health/apu/std (where I wrote much of the information myself), www.cdc.gov/std, or www.westoverheights.com.

In the meantime, trust me:  Almost certainly you do not have it.

[Donna03]

Dear Doctor,

Thank you so much for your thorough responses and for putting my mind at ease.  I was hoping i could ask you a few more questions.  

1.  When i spoke to the nurse over the phone she said that my doctor wanted to have me re-tested in 6 months to see if i had HSV-2.  Being that my number for HSV 2 AB-IGG is 0.01 does that mean something may be developing?  Or if i had HSV-2 would i test positive for it now like i have for HSV-1?

2.  Does it take longer for the antibodies for HSV-2 to appear in the blood? Is it possible i already had HSV-1 and we never knew about it bec. i was never tested and maybe HSV-2 hasn't appeared yet?

3. When i spoke to the nurse she was scaring me saying that HSV-1 can lead to HSV-2, which you said isn't true.  Therefore, when i am retested in 3 or 6 months is it safe to say i will test negative again for HSV-2 if i do not have any exposure between now and then?

4.  Is there a difference between herpes and asymptomatic herpes? Since i am positive for HSV-1 does that mean i have it and am contagious even if i don't have symptoms?

5.  So is it true that if i already had oral HSV-1 and received oral sex from someone who had HSV-1, I would not get genital HSV-1 because i would be immune to new infections? Likewise is it true that if i did not have oral HSV-1 and received oral sex from someone who had HSV-1, I would get genital HSV-1? But we are assuming that i have asymptomatic oral HSV-1 due to the fact that i have not had symptoms of either kind?  

6.  What do you recommend my next move be, if any? I would like to get to the bottom of the yeast infxn. like symptoms, but if it is not herpes and turns out to not be a yeast infx. what do you think it could be?

S/S again: white discharge, but isn't always there, may appear later in the day and is easily washed away in the shower. burning when urinating, but also not every time i urinate.  the area may also be red and raw one day and then be gone the next. there is sometimes an overral burning sensation that i can feel when just walking or sitting.  and occassionally i have experienced some shooting pain inside.

My doctor thinks i have a chronic yeast infxn. and has put me on a 2 month course of fluconazole.  I'd also like to mention that i had some problems with my thryoid.  i was hyperthyroid for 5-6 months and my doctor thought i had grave's dz. but now my numbers are dropping and i feel much better, so he thinks it is sub acute thyroiditis.  my OBGYN said that chronic yeast infxns. persist in people who are immune compromised, which i might have been for that period in time. I'm not sure if this is related at all but just wanted to mention it.

Thank you for your time.

[H. Hunter Handsfield, M.D.]

I'll try to help. To jump to the main point:  Almost certainly you do not have genital herpes due to either type of HSV.

You describe nothing that suggests genital herpes.  It is true that herpes can cause quite varied symptoms, and it isn't unreasonable to think about a possible role for herpes in someone with otherwise unexplained genital symptoms.  But if I had seen you as a patient, even if I recommended an HSV blood test, I would have told you to expect negative results.  And that is what you have.  The tests show positive for HSV-1, just like half the adult population (mostly reflecting childhood infection, with or without recognized cold sores).

To the questions themselves:

1) I cannot comment about the possibility of persistent yeast infection.  Fluconazole is highly effective but not perfect.  Also, yeast infections often return, even after succesful treatment.  This is a question for the provider who is treating you for yeast.

2) No.  The numbers refer to the virus, not the disease.  In other words, HSV-1 does not mean oral herpes and HSV-2 does not mean genital herpes.  Either virus can infect either area of the body.  As I said above, most likely your positive HSV-1 result is due to an asymptomatic oral infection, not genital.

3) Even in people with herpes, tests for the virus usually are negative, except when the specimen is collected directly from a herpes sore.  Even then, the test can be negative.   Your negative culture test doesn't help one way or the other to know what you have.  There is no way to know whether your HSV-1 infection is oral or genital, but as I said above, oral is far more likely.  Anyway, most people with genital HSV-1 don't have recurrent outbreaks and infrequently pass the infection by sex -- so if your infection happens to be genital, it probably doesn't much matter.

4) Of course unprotected sex could expose you to either virus.  But you aren't at risk for a new HSV-1 infection; people are immune to catching the same virus a second time.  And your test results are negative for HSV-2, so that's not an issue.

5) Yes.  Along with all the other evidence, the absence of symptoms tends to confirm you don't have genital infection with either HSV type.

6) Yeast infections can cause similar symptoms, but they look quite different.  Your doc's diagnosis of yeast infection is highly reliable, if not perfect.

Bottom line:  Almost certainly you do not have genital herpes.  For sure you don't have genital HSV-2.

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