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Persistent Pharyngitis/Tonsillitis after Oral Sex

Hi Doctors,

I am a healthy 24 year old male. I gave and received unprotected oral sex from a female CSW on 12/23. I realize this is a low risk encounter. I'm mostly concerned about oral gonorrhea, as I've received the treatment for chlamydia.

On 12/27, I noticed symptoms similar to strep throat- sore throat, feeling tired, enlarged/red tonsils, decreased appetite, but no other symptoms. On 12/28 I examined my throat and saw multiple white spots and streaks on both tonsils. The throat pain was not agonizing, and rather irritating. If strep were an 8-9/10, this was a 4-5/10. I went to an urgent care on 12/23, but didn't disclose the encounter. They did a strep swab, which was negative. The doctor gave me Doxycycline 100mg 2x/day for 10 days.

Taking the Doxy I noticed my symptoms improved, however after a while my throat symptoms were not getting much better and seemed to stagnate.
On 1/2 I saw my primary doctor and told her about the encounter. She ran a NAAT urine test for gonorrhea and chlamydia, and throat culture. All came back negative. My doctor prescribed me 1g of z-pack to take in a single dose if the tests came back positive.

On 1/4 my symptoms got worse. My tonsils began to get the white spots/streaks again, and my throat pain greatly increased. I am also feeling much more run down. I messaged my doctor and she told me to finish the Doxy and wait it out. I finished the Doxy today, and am getting worse.

1) I know that oral gonorrhea is most of the time asymptomatic. When it is symptomatic, what are the symptoms? Do mine fit oral gonorrhea?

2) How likely was the throat culture a false negative, given I was on Doxy?

3) I am very healthy. Prior to this illness I have not been sick in over a year. Timing like this makes me uneasy. If I were to take the 1g of z-pack, would it cure an oral gonorrhea infection? Should I take the whole 1.5g z-pack instead? Would taking a single dose (1g or 1.5g) kill a non-STI related bacterial infection?
3 Responses
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239123 tn?1267647614
MEDICAL PROFESSIONAL
Welcome to the forum.  Thanks for your confidence in our services.  The bottom line:  almost certainly you have a garden variety cold virus, allergy, etc, and not gonorrhea or any other STD.  To your specific questions:

1) This may be more information than you need, but:  As you already know, pharyngeal (throat) gonorrhea generally doesn't cause symptoms at all.  On the rare occasions it does, however, the symptoms are identical to all other causes of pharyngitis:  with a few exceptions, there's really no difference in symptoms between the many viruses, strep, or gonorrhea.  The severity of symptoms is from mild scratchiness to severe pain with fever, pus patches, and lymph node inflammation in the neck --  but all causes can range from trivial to severe.  In other words, there are no particular symptoms that would make gonorrhea more suspicious than anything else -- except of all these causes, gonorrhea is the one most likely to cause no symptoms at all.  That's probably because our throats are normally colonized by bacteria species that are biologically closely related to the gonococcus; our throats probably don't "see" the gonococcus as anything unusual and no immune reaction developes.  (For most infections, the immune response usually is a more prominent cause of symptoms than the virus or bacteria itself.)

In addition to the virtually zero risk of oral gonorrhea by cunnilingus, plus symptoms that favor other infections, the dose of doxycycline you received almost certainly would have promptly cleared your symptoms if gonorrhea if that was the cause.

2) The throat culture was useless while taking doxycycline.  Even if you had gonorrhea, the culture would be negative.  

3) I recommend against further treatment, with azithromycin (Z-pak) or anything else.  Failure of your symptoms to clear on doxycycline is virtually 100% proof against any bacterial cause.  You have a virus.  It will clear in its own good time.  Your past health makes no difference in any of this.

In summary, I'm confident you don't have gonorrhea or any other STD.  If you have any infection from the sexual encounter, it's probably a respiratory virus.  (Being close enough to have oral sex is obviously plenty close to catch a cold!)  Whatever is going on, it isn't going to be harmful.

Best wishes--  HHH, MD
Helpful - 1
239123 tn?1267647614
MEDICAL PROFESSIONAL
1) I personally did much of the research behind the gonorrhea treatment recommendations and every 4 years for a quarter century I have been on the CDC guidelines committee; I wronte much of the gonorrhea treatment recommendations myself.  Effectiveness is not the only criterion for first choice treatment and 10 days of doxycycline will cure nearly all cases.  On top of which, most pharyngeal gonorrhea clears up on its own within several weeks. (I don't know what you mean by "edge cases" of gonorrhea.)

2) I suppose it's true that "most" respiratory viruses would also cause nasal congetion etc.  But certainly viral infections without those symptoms are very common.

3) The urine NAATs for gonorrhea and chlamydia are very forgiving.  Although an initial specimen is preferred in theory, it makes little if any actual difference in test performance.

So I remain confident that your symptoms are not due to any STD and probably not from your commercial sex partner.  Don't take any more antibiotic.  Your symptoms will clear up with time.
Helpful - 0
Avatar universal
Hi Dr. Handsfield,

Thank you very much for your prompt and reassuring response. I appreciate you going into detail about why exactly most oral gonorrhea infections are asymptomatic. Being an engineer, detailed explanations such as yours are welcome and familiar.

A few follow up questions:

1) You mentioned that if I did have pharyngeal gonorrhea, that the Doxycycline would have cleared my symptoms. I have read that the CDC guidelines for pharyngeal gonorrhea treatment are :

"250mg Ceftriaxone IM Injection
PLUS
100mg Doxycycline 2x/day for 7 days
or
1g single dose of Azithromycin"

Given these guidelines, along with some CDC notes indicating possible increased resistance of some gonorrhea strains to Doxycycline, are you of the opinion that 10 days of Doxycycline alone, without Ceftriaxone, would have effectively cured possible pharyngeal gonorrhea? My guess is that the CDC guidelines and notes are written to cover most gonorrhea infections as well as edge cases, and the double antibiotic therapy is more intended for those edge cases. What is your opinion on this?

2) I feel confident in your diagnosis that I have a virus of some sort. The only thing holding me back in that regard is I read that most viral upper respiratory infections include general cold symptoms- nasal congestion, cough, etc. I do not have any of these. My primary symptoms are a sore throat, general malaise, and an on/off headache. Is this still indicative to you of a viral infection?

3) My primary doctor took a NAAT urine sample to test for gonorrhea and chlamydia, but she did not instruct me to use first-stream urine. Instead, I followed the generic instructions in the office bathroom to use mid-stream urine. Later research indicated the test instructions ask for first-stream urine specifically. Is this a big concern in terms of the accuracy of the urine test results?

Thank you very much
Helpful - 0

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