Genital HSV1?

[suesback]

Dear Dr.

about 17 yrs ago, i had an oral encounter. i did not realize it then, but he had a cold sore on his lips at the time (he was also ill with what i later learned was mono). prior to this, i had never had any herpes symptoms in my life and had never been intimate with anyone else. a few years later (i think), i felt a stinging just outside the outer labia when i used soap. when i examined it, it looked like a paper cut.

in 2 months, it appeared again, around the same area. i also experienced a lot of itching on and off in the area. then, a cut would appear, approximately in the same area, every few months. 2 similar lesons appeared on my facial lips as well, on and off, always looking like a minute slit or cut in the skin.

i realized it was probably herpes and i began going to get the area swabbed when i thought i was having symptoms. i did this 5 times and each time, it was negative. a few doctors told me that a false negative is likely with a lesion that small. the blood test was positive for HSV1 and negative for HSV2 exposure.

as the years went by, i continued to get occasional tiny, barely visible slits on my lips, and itching and shoots of nerve pain in the same area on the genitals (i never have itching and nerve pain around the facial lips). a few times, i have also noticed a little burning sensation on my genitals, again in the same area.

it seems as if i can never know 100% if i have genital HSV1 infection...but i am sure i have it. is there any way to really find out? should i tell any future partners that i may have genital herpes? can other conditions cause a similar nerve pain and itching?

also, i am taking 4 g of valtrex a day for another medical condition and have been for over a year (this is an experimental treatment for CFS). why am i still experiencing occasional herpes reactivation (both in the genital and facial areas) even with this huge a dose?

i am very confused and distressed.
thank you for your help.
anonymous

[Edward W Hook, MD]

You are having trouble taking my advice and opinion.  This will be the last answer.  No further quesitons please.

1. You have HSV-1. We do not know where.  Please read my first answer regarding possible ways to address sorting this out if it is important to you.  As I also said, there are many characteristics of the outbreaks you report and the nature history of your recurrent lesions which would be most unusual for genital HSV-1.
2.  Recurrent discomfort and even neuropathy is possible.  There are many possible causes.  You would need to see a neurologist to evaluate this.
3.  Have genital HSV you should tell your partners.  You think you have genital HSV-1. I doubt it.  You need to decide who you believe and act accordingly.  
4.  There is no cure on the immediate horizon. There are many well described management strategies you could look at on the ASHA web site I also mentioned earlier.

End of thread.  EWH

[suesback]

I am very sorry to bother you again but due to the character limit imposed, i do not feel i was clear enough about my situation in my original post. i hope you do not mind my asking a few more questions.

the fact is, the skin cut on the genitals stopped appearing some while ago (it seemed regular for a few years) but i still get intermittent itching and shoots of nerve pain in the same area.

my questions are:

1- given the fact that i had confirmed and prolonged contact with someone with active herpes lesions (and i had even shaved the area just minutes before!), do you still feel that it is not likely that i have genital HSV 1?

2 - is there any other medical condition that can cause intermittent itching and nerve pain in the same area??

3 - if i can never culture virus from the genital area but strongly feel i have herpes there, do i have an ethical obligation to tell future partners (given the fact that almost everyone carries HSV1 and genital-to-genital HSV1 transmission is rare)?

4 - also, how close do you think they are to a cure? i know they are looking at overriding the microRNA that keeps it latent, in an attempt attempted the clear all the awakened virus with acyclovir. do you think this is many years away and could be safe?

thank you very much
anonymous

[Edward W Hook, MD]

This is the observation of many studies involing thousands of observations.  the scientific reason is that the beginning of most infections is a chance event and tht most expsoures to infection do not lead to infection.  EWH

[suesback]

May I ask why a primary infection typically occurs only on one area? I cannot think of a scientific reason why this would be. If more than one area is exposed and there are no antibodies present, why wouldn't it affect more than one area?

Thank you

[Edward W Hook, MD]

No, even an initial infection will typically occur only at a single location.

I do not know about the availability of PCR tests in Canada.  You  might ask on the STD Community her at MedHelp or check out the American Social Health (ASHA) web site for this information.  EWH

[suesback]

Thank you. Another point I did not mention: I also kissed that man (in addition to receiving oral sex). If I had no prior exposure to HSV1, is it not possuble that both oral and genital HSV1 was transmitted at that time since no antibodies were present?

Also, I cannot find the PCR test in Canada. Do you know if it is available here?

Thank you
Anonymous

[Edward W Hook, MD]

To get to the punch line for starters, short of getting a microbiological test which shows HSV to be present at one location or another, there is really no way to tell where your HSV-1 infection is "hiding".  From your description, either of the small recurrent lesions you describe could be HSV but there are several important differences as well.  these include:

1.  It is very uncommon for genital HSV-1 infections to recur at all and the frequency with which you develop recurrences is most atypical, suggesting that this may not be HSV.
2.  It is even more uncommon for chronic suppressive therapy with valacyclovir, taken in the doses you are taking it, no not eliminate or at least markedly reduce the frequency of recurrences
3.  It is also most uncommon for persons with a herpes virus infection (oral or genital) to also have infection in another site, elsewhere on the body.

Taken together, my guess is that the genital lesions you experience are not HSV but of course, I cannot guarantee this.  I would suggest that rather than pursuing the diagnosis with culture, you ask your health care provider to do so with PCR which is far more sensitive than culture for detection of the virus.  I would also suggest you get tested for outbreaks at both the mouth and genitals.  A positive test at either site, pretty much rules out the possibility that there is HSV at the other site.

I hope these comments are helpful to you.  EWH