Questionable Herpes Diagnosis

[harpsicor]

Doctor,

Last week my girlfriend performed unprotected oral sex on me. The next day she developed a cold sore on her lip. Two days later I had a red rash on fold in between leg and groin. (A red area about a 1cm in length and a 1mm in width.) It was located about where my pubic hair ends and where my leg begins. (In that crease of skin.) It did not hurt when touching it, there was some mild itching and what I perceived as tenderness directly underneath the red area. I went to my doctor on the 3rd day.

I told him my girlfriend has genital herpes. We have not had sex in 8 weeks. I had a blood test at to test for herpes at 5 weeks, it was negative. (~3 weeks ago.) He told me most people will test positive for herpes after 3 weeks. I told him that we engaged in oral sex, but failed to mention that the day after she developed a cold sore. (It was not visible that night.)

He looked at the lesion and told me "it did not look at all like herpes" and told me it was a small yeast infection or heat rash. (I had been dirt-biking all weekend.) The inspection was visual, and did not include a swab. He prescribed ciclopirox. At 7 days it looks like a small bit of light red skin. The tenderness from my groin is gone. I am concerned with the accuracy of my doctor diagnosing me with a visual inspection.

I am wondering if:

1) I can be sure based on his examination that I don't have genital herpes. Are visual diagnosis’s pretty reliable with experienced doctors?
2) Is it even possible to swab a red looking area of skin when there is no blister, liquid, etc?
3) Would you recommend I have a herpes blood test again, and if so, when?
4) If I did have HSV-1 on my genitals but it did not recur, then would the blood test be limited in helping me determine whether or not I have it on my face or on my genitals?
5 )Would an HSV-1 outbreak look any different than an HSV-2 outbreak on the genitals? If so, could this perhaps be a factor in my doctor possibly misdiagnosing my condition?

[Edward W Hook, MD]

So, as I undertand it, your GF has genital and oral herpes.  You had a negative blood test for HSV-2 about 5 weeks following exposure, followed by an exposure to her (oral) the day before she developed a cold sore. (BTW, it is not particularly likely that she was shedding HSV-1 the day before she developed her cold sore, thus I do not think your risk from receipt of oral sex the day before her lesion appeared need concern you). Now about a week later, still no lesions other than the heat rash (and that is what it sounds like to me as well).  With that background, straight to your questions:

1.  Visual examination is good but not perfect.  Where it breaks down is with atypical, recurrent presentations. I suspect your doctor's exam is pretty good.
2.  Yes, swabs can be taken from atypical lesions, even if they are just red areas and positive cultures are regularly obtained from them.  Many physicians are not aware of this however.
3.  Based on what I understand, as summarized above, I do not think there is much to be gained by you having a repeat blood test.   Over half of blood tests are positive within 21 days of exposure.  If you develop recurrent lesions or new lesions you have questions about, you may want testing but with lesions, culture or PCR tests are better than the blood test.
4.  The blood test can tell you whether or not you have HSV-1 but not where it occurred.  If it occurred on your genitals it would not be expected to recur and would not be likely to be transmitted to future sex partners.
5.  No, the initial genital outbreak would look similar, whether it was caused by HSV-1 or HSV-2.

I doubt that your doctor has misdiagnosed you and doubt that what you describe is genital herpes.  With that in mind, I would encourage you to continue to practice condom protected sex with your GF.  

[Edward W Hook, MD]

Sorry, we do not look at pictures on this site.  If you wish a professional opinion you would be far better served by seeking an opinion from a person who has the opportunity to examine you.  EWH

[harpsicor]

Hello Doctor,

Forgive me if this is inappropriate. I just noticed (9/15) a pimple looking lesion on my left thigh/buttock area. It is a single lesion, and is moderately tender. (As I would imagine a pimple would be back there.) It is red, with a slightly white center. I have a picture of it, but I am not entirely sure how to post it. I fully understand if this requires another donation, I am just wondering if I should be concerned or not. Thanks again so much.

[Edward W Hook, MD]

Not if lesions are not present.  I would not worry.  EWH

[harpsicor]

Thanks again for the help. One last thing: Would a herpes outbreak cause the left buttock to be sore? It feels sort of like I worked out or did something aerobic in the last few days but I haven't. There is a tight/sore feeling on the left side of my buttock, sort of closer to the hip. Should this worry me at all? Thanks again.

[Edward W Hook, MD]

A heat rash should resolve rather quickly and be visibly improved in two or three days.   total resolution can take longer.  Cmplete resolution cna take longer.  I'd just keep going with the cream as it sounds as though things are improving.  

If this is not happening then other possibilities need to be considered- a fungal infection perhaps.  As other possibilities are considered however, what does not need to be considered is herpes.  EWH

[harpsicor]

Last question,

If it is just a heat rash, how long would you anticipate that it would take to resolve itself? I've been using the cream now for about 4 days, and there is still a circular(ish) type red patch that's about 3 mm or so in diameter.  (The area seems to be completely painless). Overall, it's been 7 days since the day I noticed it. Is the fact that it's not gone yet any reason to be concerned?

Thanks again for all your help. Best wishes.

[Edward W Hook, MD]

You are correct.  that, as well as your descrption are the reasons that I doubt that what you decscribed was herpes. EWH

[harpsicor]

So you are saying that if she was in fact shedding the virus from her mouth at the time, her mouth would have had to physically come into contact with the area of skin where the redness appeared? (The crease between my leg and groin, near the pubic hair.) I ask because I don't believe she did in fact come into contact with that part of my body.

Thanks so much again, I really appreciate your time.

[Edward W Hook, MD]

You would expect to see herpes lesions on areas exposed, or potentially exposed to lesions. Far and away, in men the penis is the most likely site.  Lesions can appear anywhere, based on peoples' activities but other locations are unusual.  EWH

[harpsicor]

Doctor,

I appreciate your quick response. One follow up. I asked my doctor where I would expect to see herpes lesions if I were to acquire the virus, he said on my penis or buttocks. Does that mean I can rule out the possibility of herpes if it is not actually on those two areas?

Thanks so much.