questions regarding likely genital herpes infection

[bobdoll]

I'm 26/m and recently had a brief protected sexual encounter with a sex worker.  About a week later, I developed what I believe to be a primary outbreak of genital herpes.  It started with an itchy red spot like a mosquito bite located just above my pubic hair area (about 2.5 inches above my penis, basically at my waist).  I scratched it some without realizing it what it might be, and it got a little infected.  After a few days, some small blisters/sores appeared on the spot, and they started to heal after a few more days.  Throughout this time, the spot itched quite a bit but didn't really hurt.  I spent a fair bit of time reading, and I believe my lesion much more closely matches the typical genital herpes lesion than follicitus.  Here are my questions:

1.  Based on my description, is there any realistic hope that this is not genital herpes?  I'm not sure how the virus would've attached so far from my penis, but I haven't really come up with any other possible causes that cause sores similar to the one I described.  

2.  Assuming it is genital herpes, is there much hope that future outbreaks will stay in the same area (above the pubic hair area) or maybe move down to the public hair area, but not affect my genitals?  I have read mixed things about how much the sores move around.

3.  As my lesion was finishing healing, I developed what I believe to be a cold sore on the corner of my mouth.  To my knowledge, I have never had a cold sore before.  This is likely related to the same encounter, and I'm wondering if it might have any bearing on the type of genital herpes I might have?  In other words, would a first cold sore at this time give me any hope that I have hsv-1 rather than hsv-2 genital herpes?  Obviously, whatever it is, it had to be caused by vaginal sex b/c I didn't receive any oral sex on my stomach.

Unfortunately, the thing is mostly healed so I doubt a doctor can diagnose me now.  And now after reading a lot, I'm pretty much convinced I'm screwed.

[bobdoll]

A related discussion, More questions was started.

[bobdoll]

Thanks for all your help, doctor.  I do appreciate it.

I would just like to clarify for people reading in the future that my description of the infection was accurate.  It wasn't a very big or significant infection, just the biggest I remember having because I don't really remember ever having any significant infections.

I will be moving to the support forums to figure out wtf to do now.

Thanks again

[H. Hunter Handsfield, M.D.]

Sorry I forgot the initial location, but I understood the timing.  However, I did not understand the problem was as severe as you imply ("the biggest infection" you ever had) -- which certainly is most consistent with a new infection.  Still, it remains at least a possibility you were infected earlier than you think.  It's up to you whether you want to keep that option open and consider future testing.

Either way, your fiance should be tested for HSV.  That's true for all couples in which one has HSV-2.  If she is HSV-2-positive -- whether because you have a chronic infection or elsewhere -- there is no risk of transmission to her.  If negative, you'll know she is susceptible and can plan on taking precautions to prevent transmission.  (This would also support the conclusion that your infection is new.)

Finally, I hope you don't assume your partner will automatically terminate your relationship.  You know her and I don't, so I'm not in a good position to predict her response to all this.  But not everyone freaks out in this kind of situation.  You might benefit from advice you can find through the herpes community forum about how to discuss genital herpes with partners.

Whatever you decide, I wish you good luck.  That should end this thread.  Take care.

[bobdoll]

My outbreak was above my pubic area, on my stomach, not at my hip.

Reviewing my unfortunate sequence of events:

--4 year monogamous relationship where neither of us have any herpes symptoms

--contact with stripper

--3 days later, basically the biggest infection of any kind I can ever remember having, which happens to look just like a herpes outbreak

--7 days later, positive igm test

--20 days later, positive igg test.  

I don't really feel I need to do any followup.  I don't think there is anything I could tell her that could salvage this, my life is basically flashing before my eyes.  

[H. Hunter Handsfield, M.D.]

Well, your blood test definitely is positive.  However, it remains a good bet that you were infected before your contact with the sex worker, despite your conviction that that isn't likely.  And to some extent sadgirl is correct; only about half of all newly infected people have positive test results by 3 weeks, and often tests at that time are less strongly positive than yours.  So your strongly positive IgG result is most consistent with a longstanding infection. It is also possible you are enitrely asymptomatic and that something other than herpes was the cause of the outbreak on your hip.

Here is what you can do to help sort this out with more certainty, if you want to do so.  First, stay on the alert for a new outbreak in the hip area.  If it happens again in more or less the same spot, it will further suggest that's a recurrent herpes problem and that the previous outbreaks wasn't your first.  If another outbreak occurs elsewhere in the boxer shorts area, it will be consistent with your own analysis -- that your previous episode was your initial infection.  Second, if/when another outbreak happens, see a provider promptly for a test for HSV by culture or PCR, which if positive will prove for sure it is herpes (including virus type).  Third, have another blood test after 3-4 months.  If the numerical result is substantially higher, it will be most consistent with a new infection; if in the same range as now, it will tend to support a chronic infection.

You may or may not be interested on following this up.  On the other hand, wouldn't it be nice if you could in good faith tell your fiance you are chronically infected, without any need to mention the recent CSW encounter?  I truly belive that is not the likely source of your infection.  But all this is up to you.  Good luck with it.

[bobdoll]

I would say there is basically 0 chance I was positive before this incident.  About half of people seroconvert within 3 weeks, perhaps even more than than if you haven't already been exposed to hsv-1 (I wasn't).  

As for the "initial outbreak is usually close to the penis" thing, I don't really know.  All I know is I found some other cases like mine (ie., http://www.herpes-coldsores.com/messageforum/showthread.php?t=17847) and in pretty much every case where the thing really did look like herpes (red bump followed by blisters followed by sores), it was indeed herpes.  

[sadgirl789]

Sorry about the test results.

I was reading your post and thought about something.  Your encounter with the sex worker was near the end of March (judging by your posting dates) and the final blood test was likely taken a week ago (April 8th or 9th, perhaps).   That's only approx three weeks between encounter and positive blood test. Doesn't it take much longer, a min of six weeks to seroconvert to HSV2. Isn't possible you were already HSV2 positive (perhaps years ago) and the lesions on your groin were a recurring infection and not the initial one (which would be in keeping with the idea that the initial outbreak is usually on the penis or close to it).  

I'm not a doctor but like you have been reading about this stuff myself, going through something similar.....

[bobdoll]

igg hsv-2 3.7

game over.  I knew this was coming.  Now I get to explain to my soon-to-be-ex fiance how I got drunk, had 5 minutes of bad sex with a stripper (with mr. trojan on!), and contracted an incurable std.  life's a *****.  

[H. Hunter Handsfield, M.D.]

This is a blood test result.  As I said, it is positive but probably false.  You provide no reports for any direct test for the virus from a swab.  You'll have to clarify with your doctor's office whether they did one.  If they did, ask whether the specimen was sent for culture or PCR (polymerase chain reaction test).  While you're at it, ask whether an IgG blood test was done in addition to IgM.

If they tell you the IgM blood test was positive, tactfully ignore it -- for the reasons just discussed above.

[bobdoll]

I'm confused.  I was under the impression they were doing a swab test, not a blood test.  They did eventually come back and take a blood sample, but never told me what it was for.  So it appears that I still don't have my swab results?  And that my blood test is positive?  

[H. Hunter Handsfield, M.D.]

Your IgM HSV blood test is positive, suggesting a recently acquired HSV infection.  However, the IgM HSV tests are highly unreliable and it remains unlikely you have herpes.  In addition, the IgM test cannot distinguish between HSV-1 and 2; it means only positive for one or the other.  Only IgG HSV-2 testing should ever be used.  Unfortunately, a lot of health professionals not highly experienced in herpes don't know this, and labs continue to offer a lousy test because docs keep ordering it --also becasue it's cheap with a large profit margin.  Wait for the IgG results and I will comment one more time.

Here is a thread that explains the IgM problem in detail.  Even though over 3 years old, the information remains accurate:  http://www.medhelp.org/posts/show/248394

[bobdoll]

Well, I'm having trouble posting the results for some reason, but for both Herpes 1 and Herpes 2, it says >1:80  Titer  <1:10.  I have no idea what this means.  

[bobdoll]

Sorry, the results were:

                           RESULT      UNITS       RANGES
herpes 1 Ab, IgM  >1:80           Titer          1:80           Titer          <1:10

[bobdoll]

I got my swab test results:

                           RESULT      UNITS       RANGES
herpes 1 Ab, IgM  >1:80          Titer          1:80          Titer          <1:10

I'm not sure what this means.  It says Titer <1:10 is negative.  So is this a negative or a positive or what?  Can you tell what kind of test this was from the results?

I didn't think the antibiotics were very effective.  The original sore is basically healed up now, but the antibiotics caused a fair amount of stinging/burning.  

Also, the other day I masturbated several times and then I felt some tingling in my penis, and I was sure I was experiencing prodrome.  I was waiting for a big outbreak but it never came.  

Still not very hopeful

[bobdoll]

I actually respect your opinion a lot, which is why I posted here after reading your diagnosises for hours.  I apologize if I am being irrationally paranoid, although I'm sure you're plenty used to that trait in patients.  

Also, you have a fair point regarding which users make final comments.  Admittedly, the few cases like mine which turned out to be herpes were all reported on forums for people with herpes.  It may be the case that there are lots of other similar cases that ended up not being herpes which were unreported.  Those forums also seem to express a general sentiment that doctors are too quick to reject herpes in non-standard cases, but that again may be because they were the exception to the rule (and the only ones to report).

As for my case, time will tell, but I'm certainly rooting for your side!

[H. Hunter Handsfield, M.D.]

Obviously my opinion doesn't mean much, if you continue "90% sure it's herpes".   I remain equally confident it is not -- now even more so, given your doctor's opinion.  

As for frustration about not seeing final comments from forum users, you can be very sure that anyone who turns out to actually have herpes, after Dr. Hook or I predict they do not, would have posted that fact.  You can assume that all those people did not have herpes.  That will be the case here too.  

[bobdoll]

I went to the doctor yesterday.  He inspected the region with a flashlight and told me that there was no way it was herpes and that it was folliculitis.  He based this on the location (upper pubic region) and the fact that I never felt much pain.  I asked for a blood test, he told me there was no point because 80% show up positive (this obviously gave me some concerns about his competence).  He said they could test the sore itself for best results.  So the nurse went ahead and prodded the area until it started bleeding and then swabbed that.  

Now with 2 doctors doubting herpes, I'm feeling a little better, but still like 90% sure it's herpes.  I'm skeptical of the relevance of pain, since I would expect that people feeling pain are more likely to go to the doctor, and also that I would feel less pain because the skin in the pubic region is less sensitive.  And I have found at least 2 examples online of guys with similar sores in the pubic region / stomach which were repeatedly diagnosed as folliculitis and ended up being herpes.

In any event, my plan of action now is to wait 48 hours and get the test results from the swab.  I understand that a false negative is quite likely (although my doctor seemed fairly confident the test would be accurate for me).  So if I test negative, I will try to find another doctor who can do the typed blood test for me.

The also gave me a prescription for antibiotic cream.  So, I'm going to apply that and try to evaluate how effective it is.  Not sure how much that will help with the diagnosis though since it's already mostly healed.  

I'll make sure to follow through with whatever happens.  I find it really frustrating how many times I read about somebody whose case sounded just like mine, but who never followed up to tell us the results.

Fingers still crossed...

[H. Hunter Handsfield, M.D.]

This doesn't change my opinion or advice.  The body has only a limited number of ways it can react to infections.  Many skin infections have similar manifestations, including herpes and staph/strep. Even with "Not much left to inspect", the HSV blood test can be done -- and should be done the earlier the better, as a baseline against which to compare a repeat test in the future.  In the meantime, I continue to doubt herpes.

[bobdoll]

Thank you very much for the detailed response, Doctor.  

I did leave out some potentially relevant information.  I originally hoped it was folliculitis because before the infection, I had made an ill-advised attempt to trim my pubic hair with a nail clipper.  Also, the first thing I scratched was more like a pimple and it bled after I broke it.  I think there may have been a few separate ones also.  So all that points to folliculitis, but what scared me was the progression that followed.  Large red itchy bump followed by sores/blisters on the bump, which seems to describe a herpes infection exactly.  Could a staph or strep infection take on the same development pattern?

I tried to check for hairs growing out of individual sores but I couldn't really tell.  The problem is that I put bandages on the thing a few times early on and those ripped basically all the hair out.  I doubt that helped the infection.  I make all kinds of good decisions.  

Not much left to inspect, but I'll go to a doctor tomorrow anyways.  Keeping my fingers crossed...

[H. Hunter Handsfield, M.D.]

Welcome to the STD forum. I'll try to help.  Although it is conceivable this is herpes, I disagree -- based on your description -- that herpes is more likely than folliculitis or some other bacterial skin infection.  To your specific questions:

1) You hit the nail on the head with "I'm not sure how the virus would've attached so far from my penis".  That is valid reasoning.  In general, HSV infection requires the virus to be massaged into the affected area.  For that reason, the large majority of initial herpes outbreaks appear at the sites of maximum friction during sex:  the penis, vaginal opening and labia minor in women, the anus following anal sex.  Further, initial herpes generally doesn't occur predominantly in hair-bearing areas, but that's exactly where folliculitis and other superficial bacterial infections are most prominent.  My guess is that your skin is colonized with bacteria like staph or strep; that you spread it around by manipulating the initial lesion; and that this in turn resulted in secondary infection of other hair follicles.  One clue:  examine the lesions closely.  If a hair is emanating from some lesions, it's folliculitis. Herpes lesions are not generally associated with individual hairs.

What to do now?  You need diagnostic testing.  It's too bad you didn't see a health professional immediately, i.e. within a couple days of onset of the cluster (if not the initial lesion).  If there still are active pustules (pimple-like lesions), see a doctor or clinic ASAP for possible testing both for HSV and perhaps for staph, strep, etc.  If it has pretty much healed up, have a blood test for HSV; and if that test is negative, have another in a few weeks to see if it becomes positive.  My bet is that it will not.

2) At this point, I recommend not speculating about herpes outbreak.  We can address that if the diagnostic evaluation proves me wrong, i.e. if it's really herpes.  (But the quick answer is that recurrences could be anywhere in the "boxer shorts" area; you cannot assume they would be in the same spot as the initial HSV infection.)

3) It would be pretty unusual to acquire herpes simultaneously at both genital and oral sites, but it can happen.  However, the initial oral HSV infection usually is more widespread than you describe, i.e. multiple sores in and around the mouth.  Even without past known oral herpes, this still could be a herpetic cold sore -- perhaps triggered by the skin infection of the abdomen.  (The very names "cold sore" and "fever blister" reflect the fact that outbreaks are often triggered by other infections.)  Or the oral lesion might be only a coincidence.

I'll be happy to advise your further if and when you return with a comment to report the outcome of further clinical evaluation and lab testing.  In the meantime, most likely this isn't herpes.

Regards--  HHH, MD