Testing for antibodies

[nycer56]

I am really trying to put herpes out of my mind, but I just don't know what to think.  I had an encounter in early Jan. when I could have contracted it.  Since then, I have had multiple "outbreaks."  The first, which took place about 10 days after the encounter, was the most severe: two open 'weeping' sores (which healed in 2-3 days-- one at the base of the shaft, the other about an inch away on the scrotum), very intense itching (which for whatever reason was MUCH more pronounced when walking/running).  The itching flared up a few days before the sores, and lasted a few days longer.  It was most noticeable on my scrotum and, to a lesser extent, in my pubic hair.    That whole bout lasted about 10 days, and after it....nothing.  Everything completely went  away.  But since then, the same basic cycle has repeated several times.  I haven't had sores like the first time, but I have had the exact same itching, plus some small, paper cut-like tears generally on the bottom part of the scrotum (this has happened in a few of the episodes).  The area beneath the scrotum (perineum?) is sometimes involved too-- very dry and itchy, as is the beginning part of the anal area.  

A dermatologist has prescribed powerul creams which have done nothing for the itching when I have it (it isn't a constant itching-- but it is more intense when I move, sort of feels like its on the skin, not deep within it) and he also put me on a course of antibiotics, in case there was a bacterial infection.  Nothing.  

Obviously, what seems weird is the timing of the first symtpoms, the fact I had the two sores, and the episodic nature of the outbreaks; for weeks in between them, I'll be symptom free. (And I know you've said itching/scrotum involvement doesn't really suggest herpes...but what else could this be?)

Anyway...the reason I'm confused is that I've taken the HerpeSelect test 4 times...and it's beennegative for both types all 4 times.  The most recent test was 129 days after the possible exposure....18 1/2 weeks.  I felt VERY confident in that result....then I had another outbreak in the last week, and now I don't know what to think.  My question is about people who don't develop antibodies.  How many people is this the case for?  How many people take longer than 18 weeks to seroconvert?  And if I have herpes, but don't develop antibdoes....does that indicate I'll have more frequent outbreaks, since my body won't have as much defense against herpes? (i.e., could that explain why I have had frequent outbreaks with negative results?)  I'm sorry for the length on this.  I really thought I had peace of mind until last week...

[H. Hunter Handsfield, M.D.]

It is almost certain you don't have genital herpes, for 3 overlapping reasons.  1) Your symptoms are compatible with herpes, because it is such a variable disease, but they are very atypical.  2) A dermatologist didn't think you have herpes. (You don't say that directly, but s/he would not have prescribed "powerful creams" for herpes.)  3) It is rare for people with HSV-2 to not seroconvert by 4+ months.  For you to have herpes, all 3 of these improbabilities would have to turn up the wrong way; the odds of that are extremely low.

I suggest you arrange with your dermatologist to be seen on short notice (within a day) if you develop the recurrent symptoms again, so s/he can collect a specimen for culture (even better, PCR) for HSV.  But in the meantime, you should assume you do not have genital herpes.

And, in the exceedingly unlikely chance you in fact have herpes, the lack of a measurable antibody response does not predict the frequency of recurrent outbreaks.

Good luck--  HHH, MD

[nycer56]

Thanks for the reply.  The reassurance is comforting.  The dermatologist thing is not so comforting, mainly because I realized the second time I went to him that he was unaware that there are now type-specific blood tests.  He thought the igm was the only one available, and toldme that testing was therefore useless, since most people have HSV-1 from childhood.  (I went to an STD clinic to take the HerpeSelect on my own.)  So I haven't been comforted by what the dermatologist has said.  

Just one follow-up, though: Is there any actual data on how many people don't ever develop antibodies?  How rare is rare?  Thanks again....

[H. Hunter Handsfield, M.D.]

Find another dermatologist.

Probably 1-2% of people with genital herpes don't develop antibodies.  But it doesn't apply to you.  You definitely don't have herpes.  (Even if there were no available blood tests, the rest of your story would convince me you don't have it.)

HHH, MD