Need guidance on herpes dx

[Jazzman1950]

6/10/10-Had sex with sex worker with condom. Rec'd oral sex and engaged in vag. intercourse.Vag. fluid &/or lubricant on my pubis.
6/13-Developed itchy red patch on pubis where shaft of penis meets pubis. Approx 3 inches across. No vesicles/blisters. Testicles got very red, itchy. Buttocks and anus itchy.
6/17- Dermatologist Dx HPV. No culture taken. Cryosurgery of rash. Healed in 2 wks. but itching cont'd.  Flesh-colored "bump" size of pimple on pubis espec. itchy but dry.
7/10- 2nd Dermatologist said not HPV. Dx "bump" as ingrown hair. Dx itchiness as "jock itch." Rx Desonide 0.05%.
7/26-Urologist did swab test of pubis and "bump."
8/30 Lab Report-
1) HSV viral load by Real Time PCR on Swab #1--  "Results"--"Positive."  "Reference" --5.82 x 10^6 HSV copies /ml transport media.
2)  Herpes Subtype (HSV-1, HSV-2) by Real time PCR on Swab #1--"Results"- "Positive." "Reference"- HSV-2.
3) HPV Type-Detect by Bio-Plex Analysis on Swab #1- "Comment" - "Not indicated."  "Results"-"Not detected."  "Reference"- Subtypes HPV: No subtypes detected
4) HPV -Same test as #3 on Uroswab -2-  "Results"-"Not detected."  "Reference"--Same as #3
9/9- ID Dr. said HSV-2 dormant. No anti-virals nec. Dx itching as fungal. Rx- Diflucan 7 days
9/20- 2nd Dermatologist said shld be on anti-virals.Rx- Continue Desonide
9/20  2nd Urologist  Rx Acyclovir 200 mg. Serum collected for Quest same day.
Lab Results:
HSV 1/2 IGG Herpeselect
HSV 1 IGG Type Specific AB---0.18
HSV 2 IGG Type Specific AB---0.02
10/1- Urolologist said no HSV-2 based on blood serum test.  D/C Acyclovir on 10/1.
Still have itchy red testicles and itchy pubis, buttocks, and anus but to lesser degree.
1) Is DNA Swab test conclusive diagnosis of HSV-2?
2) If so, how can that test result be reconciled with negative antibody test taken 14 weeks after exposure?
3) Should I take another blood serum test? If so, which oine and when given that I stopped anti-virals on 10/1 after tsaking 25 capsules?

[Edward W Hook, MD]

I personally see no need for re-testing.

Currently, antiviral therapy has several potential benefits.  With outbreaks it can promote more rapid healing.  More recently, daily chronic suppressive therapy, which reduces the frequency of recurrences and reduces risk for transmission to inifected sex partners by abouyt 50% is increasingly used by many clinicians for patients whose partners are not infected with HSV-2.  EWH

[Edward W Hook, MD]

Welcome to our Forum. In preparing to address your question I reviewed your other posts and see that you have had two exchanges with Terri related to these events.  Sometimes things are difficult to sort out in retrospect.  The diagnosis of HSV infections can be difficult, even for an experienced clinician.  While the rash you describe does not sound like classical HSV, the majority of herpes outbreaks do not follow the classical pattern.  As a result we urge clients to use swab studies (preferably PCR) to help make the diagnosis.  The sensitivity of PCR tests for HSV is VERY high and it would be quite unusual for the test to falsely positive.  On the other hand it can take months for antibodies to HSV to develop, particularly if you have been taking antiviral therapy.  Reading through the results that you report, it certainly seems that you have HSV-2 infection.  

Let's address your questions:
1.  Yes, the DNA test is currently the best test there is for HSV diagnosis.
2.  As Terri has told you, it can take months to develop a positive antibody test, particularly if you have been taking antiviral therapy.  In addition, a very small proportion of patients, perhaps 3-4% do not develop antibodies that are detected by current tests.
3.  Re-testing is up to you. The swab test, as both Terri and I have told you, is definitive.  If you wish to test again for antibodies, I would be off antiviral therapy for at least a month before re-testing.

Hope these answers are helpful.  They mirror the comments that Terri has already made. EWH