Does this sound like HSV? (1 or 2)

[worriedworried]

Terri,
Thank you so much for the incredible service you provide here.

39 yo heterosexual female. My timeline:

9/5: Had protected intercourse with new partner. Condom broke twice. Also received and provided unprotected oral sex. He later showed me his STD tests from August. All negative except, of note, if my memory serves me correctly, his HSV2 index score was 1.0. He said “this means I don’t have HSV2” At the time I didn’t know better and believed him (and the result didn’t didn’t seem to be “flagged” in his report).

9/7: Had unprotected vaginal and oral sex with a partner I’ve been seeing (infrequently) for 8 months. We often don’t use protection (stupid, I know!)

9/17: Noticed a tender, olive-size lymph node, and several smaller nodes in groin region.

9/14: Went to an obgyn clinic. Medical assistant administered vaginal swab and blood test (not sure what she tested for) and prescribed prophylactic dose of 1000mg Azythromycin.

9/15: Noticed small, hard, inflamed bump on rear labia. Felt like inflamed pimple, or something I’d nicked shaving (I’d shaved that area more than usual recently). I messed with it slightly using tweezers. It wasn’t painful, more inflamed and raised/hard like a small cystic zit. It felt like inflammation/hardness under the skin, pushing upwards, rather than a blister sitting on top of the skin.

9/16: I went to a private OBGYN hoping she could swab the bump. She couldn’t capture anything. She didn’t think it looked herpetic. I also felt no pain whatsoever during her vigorous swabbing attempts; if anything, scaly surface made it less sensitive than surrounding skin. She said if it were herpes I probably would have been jumping through the roof at that point. The surface of the bump was kind of hard and almost scaly (the way my facial pimples/nodules are when I pick at them). She sent me for blood work to test for herpes (I wasn’t sure if previous doctor had tested for it). I’m not sure what type of test she ordered. She also said I had a yeast infection (not surprising after mega dose of azithromycin, as well as 10 days worth of Augmentin, I’d taken 2 weeks before to fight a bronchial infection) and prescribed Diflucan.

9/18: The bump was still there, but after messing with it a bit more a tiny scab came off the very point of it. Because I’d pulled the top off, the shape was now like a tiny volcano, more ulcer like than before. This worried me, but also I saw it as an opportunity for a successful swab attempt. Still no pain associated with the bump. Perhaps a slight itching or stinging due to exposed top, but nothing noticeable. I went to Planned Parenthood and the practitioner swabbed me more aggressively with a sharper swab. It hurt a bit. I’m not sure if she sent it for a culture or PCR test, but said results would be back in 2 weeks. Her visual assessment was that it didn’t really seem like herpes, but she didn’t really know. I pushed for a percentage and she said 25%. She prescribed Valtrex 1gm/day for 7 days to be safe.

9/19: Bump is flatter now, and tiny divot remains in center, but seems almost healed, with remnants of flakey circle. I’ve been taking daily pictures. The picutres show much more detail than I am able to see and I’m worried by what might possibly look like 2 extremely tiny circles nearby the primary. My mouth/lips suddenly start to feel very dry and tingly. I worry, but attribute it to Valtrex, which I read can cause dry lips.

9/20: Tonight there are actually tiny bumps and one slightly larger bump on my lip! Very scared at this point. Immediately apply Abreva. Also, out of nowhere, geographic tongue and tongue sensitivity appear (I used to get this; haven’t in years; was told it was nothing to worried about).

9/21: Lip bumps pretty much gone by morning. Geographic tongue remains, as does swollen inguinal lymph node. Remnants of labia sore are still there, but barely visible except in magnified camera view.

Background:
-20 years ago, after kissing a guy, I had a very uncomfortable outbreak of tiny, sandpaper textured bumps on my lips. I was a virgin at the time. They resolved after a week, without ever blistering. This happened a few more times over the next 6 years (each time was more mild) but never did it look like a classic cold sore. A doctor at one point told me they were not HVS, but in hindsight I have my doubts.

-The most recent HSV test I could find at home was from 2013 and put me at <0.2 for both HSV1 and HSV2 IgG.

-A month ago, I was very sick from a cold/bronchial illness. As I mentioned I took a 10 day course of high dose Augmentin, and then the 1000mg Azythromycin. This caused yeast symptoms which have lingered through several rounds of Diflucan and many probiotics. I feel that my immunity has been worn down in general (either from being sick, or from yeast overgrowth). I also have a history of Epstein Barr and elevated ANA levels.

Questions:
-Does my genital bump sound/look like HSV to you? Is it possible to have a primary outbreak that is not painful at all (and most likely just one bump). If so, and if you had to guess, would you guess HSV1, 2, or both.
-If I had oral outbreaks many years ago, could my HSV1&2 tests show up as negative in 2013?
-Do the lip/mouth symptoms I had last night suggest that this whole thing was a primary infection during which I autoinnoculated to the mouth? Or could it have been a simultaneous infection? Or just a strange coincidence (either related to Valtrex or not)? Does the sequence suggest anything about whether HSV1, HSV2, or both are at play here? What are the possibilities/likelihoods?
-Any thoughts about the swollen lymph nodes?
-What should my course of action be now?

Many, many thanks for your help!!

[worriedworried]

PS – I have pictures detailing day-to-day progression of bump. How can I send these to you? Again many thanks for this service!!!!!

[worriedworried]

Update: I just spoke to the partner with whom I had intercourse on 9/5 (the one with whom the condom broke). It turns out I had misunderstood his HSV1&2 IgG test results. They were 3.5 and 2.5, respectively (NOT 1.0, as I’d thought — I think I was reading the reference range).

[worriedworried]

An update that I really I wish I wasn’t making. My Dr. just called with my HSV IgG results. Negative for HSV1. Positive for HSV2 with score of 3.7.

I’m feeling quite devastated right now.

In light of the new info, I guess my questions have changed a bit:

1. Does this score give any indication of when I might have contracted this?
2. Given that my current OB is the first I’ve ever noticed and is accompanied by a still quite enlarged inguinal lymph node, should I assume this is my primary outbreak?
3. What do you think of the brief appearance of bumps/tingling on my lips? Does it sound like I cross infected myself with HSV2 during this primary outbreak?
4. I’m still curious about those lip episodes I used to have in the past (and the fact that my HSV1&2 always both tested negative until now). This most recent minor lip outbreak certainly resembled those.
5. Should I take this as a definite diagnosis? Or is there any room for ambiguity?
6. What is my best course of action from here? Do you recommend further testing? Should I go on suppressive Valtrex therapy for awhile? (Beyond the 7 days I’m currently taking it).

[Terri Warren]

oh my gosh, I’m really sorry. I know you must feel sad. So you had sex with the person with herpes on the 5th and testing on the 16th? And your result is 3.7? I would say it is extremely unlikely that this is new infection, no. That’s only 10 days and that’s the earliest I have seen anyone in my practice go from negative to positive and their index value was 1.2. I would strongly suspect that this is NOT a new infection for you but rather an established infection. In fact, the bump to which you refer may or may not be herpes – you will likely find out soon, particularly if a PCR swab was taken.

The little bumps on the lip sounds like you got a mild case of HSV 1 as a young person. The person who has HSV 1 already and contracts HSV 2 may or may not have any apparent symptoms.

We recommend that any person with an index value of 1.1 to .3.5 get a confirmatory test and I have had patients with scores as high as >5 not confirm with a western blot. Crazy, huh? I know. If you want to be absolutely sure, I would recommend the western blot. If the western blot is positive then yes, go on suppression and even if you don’t and accept this as positive, you may benefit from suppression if you are having sex with an uninfected person.

Terri

[worriedworried]

Thanks so very much for your response.

So, the stress I was experiencing must have gone to my head a bit, and the numbers I gave you for the 9/5 encounter were incorrect. I meant to type that they were 0.35 and 0.25 (for HSV1 and HSV2, respectively), so I am assuming that this person was negative.

Given my HSV2 score of 3.7, do you have any sense at this point how long I may have had the infection? I know it’s impossible to pinpoint exactly when, but is there any kind of range of dates (weeks? months? years?) I might be thinking in terms of?

Also, it does appear that I have a negative score for HSV1 (this has been the case in the past as well). If I am indeed negative for HSV1, would this lead you to question my positive HSV2 score a bit less? Or could 3.7 HSV2 still be falsely positive? Basically, would you still recommend a Western Blot for HSV1 negative, and HSV2 3.7?

On the other hand, given my lip rashes 15-20 years ago, should I assume my HSV1 result is a false negative (note, it also showed up negative in a test I took a few years ago….I’m still in the process of digging up additional past tests, to put together a better timeline; I only know that this is the first positive of anything I’ve ever received).

Do you think the slight inflammation of my lip 2 days ago was some kind of autoinnoculation with HSV2? Is it possible to autoinnoculate yourself with HSV2 from genital to mouth? If so, would this only happen during a primary OB? Or could it happen during any outbreak? Or, if I do in fact have both HSV1&2, do OBs of the two viruses tend to appear simultaneously? (or would that be unusual).

I understand that my current minor bump (which appears to be pretty much gone at this point) may or may not have been HSV-related. Still, how long should I wait before having sexual contact again with a non-infected partner? I plan to switch to ongoing suppressive therapy until I know more, and to fully disclose my situation to any future partner, but I’m just wondering what the normal waiting time is/should be — for either a primary outbreak or a recurrent outbreak. This would apply to kissing too, not just intercourse.

If what I’ve just experienced now (suspect bump on labia, and then brief appearance of lip symptoms) is in fact an outbreak, if you had to guess, given my index scores and symptoms, would you say that if this is a primary outbreak or a recurrent outbreak?

Finally, any thoughts about the swollen lymph node?

I hope I haven’t asked too many questions. Many thanks for all of your wonderful guidance.

[Terri Warren]

If you do have HSV 1 and the test missed it, it would not likely influence your HSV 2 index value, no. And there is no way to know at this point how long you have been infected, not at all. There is about a 90% chance (based on combining studies) that your western blot would confirm as positive. If the lesion was herpes, I would expect you might have a little lymph node enlargement (or whatever it is might cause lymph node enlargment). Your lip symptoms would not be autoinoculation as it appears you have been infected for quite a while and autoinoculation doesn’t happen normally outside of the first infection time period. If the lesion is herpes, it is a recurrence.

Terri

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