indeterminate diagnosis for HSV 1

[quandary]

Hello,

I tested positive HSV 1 on an IgG AB Herpeselect test in December, and negative for the other STDs that are tested in a standard screening. In the beginning-middle of April, I noticed a couple of sizable genital lesions that I clearly had never had before. About a week or two after I noticed these symptoms, I had a viral culture (via swab) taken by an ER doctor at a walk-in clinic, as well as the standard panel of STD screening tests (blood/urine based). I was given acyclovir to take for a week based on her clinical impression, which did not visibly reduce the size of the lesions. The panel of STD screening tests again confirmed I had HSV 1 but nothing else, and the culture came back negative for HSV 1 (non isolated).

About 10 days after the culture results, I went to a infectious disease doctor and a dermatologist (in the same practice), who both agreed that the lesions did not look like herpes, and they gave me a topical antibiotic. They ordered a biopsy to rule out a fixed drug eruption, and the biopsy report said:

“Given a lack of interface changes, an infectious etiology or trauma is favored over a drug eruption. Although there are focal features which are suspicious for herpes virus infection, no specific viral cytopathic changes are present.”

Based on these results, the dermatologist thought there that there was perhaps a recent HSV shedding occurrence, but that perhaps both the swab and the biopsy were done too late after the onset of legions to detect the actual virus. Ultimately, he said he could not give me a firm diagnosis, but said he thought trauma or HSV were the most likely causes, and I can’t remember any trauma.

To try to pin this down, I recently had a doctor at a walk-in clinic do a swab and send to Quest for a NAAT-PCR test, and I’m awaiting the results. I still have one lesion left that is sizable and has not begun to scab over. However, despite the fact that this lesion has not healed, from what I understand there is a decent chance that this test will also not detect the virus, given that the lesion at this point is about 4-5 weeks old.

Given these facts:
1. Do you think it’s likely I had a herpes outbreak?

2. I don’t understand what ‘suspicious specific focal features’ (from the biopsy report) would entail precisely. Would you be able to elaborate?

3. Do you think I have an obligation to disclose to any future partners if the NAAT-PCR test also fails to detect the virus? Again, under this scenario, I would have an ‘unexplained’ case of a lesion whereby HSV was not ruled out but not ‘ruled in’.

Thanks!

[Terri Warren]

I have not seen a herpes outbreak last 4-5 week long, the same lesion? No.
I’m not sure what that is talking about, honestly. Maybe multinucleated giant cells which are present with some of the herpes virus family in lesions? No clue, actually.
Have you ever had a cold sore in your lifetime on your lip or in your nose? When was the last time you had a sexual contact? Has this person ever been tested for HSV 1 and 2?

Terri

[quandary]

Thanks Terry. So just to be clear on my first question-given the facts I presented, you do not think it’s herpes because the duration of the lesion is too long (4-5 weeks), correct?

To answer your questions-
1. I don’t specifically remember a distinct episode of having a cold sore on my lip or nose, but I would guess I have had something resembling a cold sore on my lip in my life.

2. I have been in a monogamous relationship for the past 10 months. I last had sex with her before the onset of my lesion (i.e., the beginning of April). My girlfriend was tested for the usual STDs in October and was negative, but was NOT tested for HSV 1 or 2 (apparently that’s standard for women who do not meet certain risk parameters). She routinely gets tested for the other STDs by her gynecologist, but she believes the last time she was specifically tested for HSV 1 and 2 was when she was in her early-mid twenties, which was about 10 years ago.

Do you have any thoughts on my third question regarding disclosure obligation given my indeterminate status? I have told my current girlfriend, but want to understand what this means for me if I were to have future partners. Does my second response above affect your answer to my question?

Thanks!

[Terri Warren]

I would say that I’ve never seen a herpes outbreak last that long, no. So to me it seems unlikely to be herpes. Have bacterial cultures been taken from the lesion? If not, they should be. What was the index value on the HSV 1 antibody test, can you find out?

1. If you have ever had a cold sore, then your HSV 1 antibody is due to that. If you can’t recall, then it could be either oral or genital.
2. I think it is important that your partner gets tested for IgG antibody to HSV 1 and 2. I’m not positive what you mean by indeterminate? You mean antibody positive and swab test negative? You could certainly be infected orally and not realize it. I’ll be eager to hear how the PCR comes out. I’m guessing negative.

I think you can discuss your HSV 1 status with partners in the future if your IgG antibody is a firm positive. That’s why I want to know your index values.

Terri

[quandary]

Thanks Terry

Regarding your questions/comments:

1. I was tested with an IGg test twice this past year. In mid-December of last year, my HSV1 IGg index was above 5. In mid-April, my HSV1 IGg index was 4.74.

2. A viral culture was taken to test for HSV 1 (Herpes Simplex Virus Culture with Reflex Typing) in mid-April, and the result was not isolated (ie, negative). I don’t believe a bacterial culture was ever taken-HOWEVER, a biopsy was taken in late April per my first post above to rule out a drug reaction, and based on the cellular structure (I suppose) the dermatologist who ordered the biopsy did not think the lesions were bacterial in nature.

3. My girlfriend is getting tested shortly.If my girlfriend’s HSV 1 IGg tests come back positive, I assume you would be ok if I resume having unprotected sex with her once my lesions are healed? If her test comes back negative however, what would you recommend as far as precautions (condom, Valtrex, etc.)?

4. By ‘indeterminate’, I meant that I have tested positive twice on an antibody but negative on everything else. I actually had another swab done and got the results after my last post a couple days ago. As I mentioned, I also had a PCR test done since my last post, which also came back negative. So by ‘indeterminate’, I am essentially saying my two antibody tests are positive, but two cultures, a biopsy, and a PCR test are all negative.
HOWEVER, my two cultures, my biopsy, and my PCR were all done between 1.5 weeks and 4.5 weeks after the lesions appeared, so I am worried that the virus retreated before the cultures, biopsy, and PCR test were performed, and that the remaining lesions were still around because they simply still needed to heal after the actual virus retreated. So I understand I very likely have the HSV 1 virus, but I think it’s very unclear whether I had an actual genital outbreak or whether the virus can still be considered aysmptomatic- but please let me know if you would characterize the probability another way (eg, I probably don’t, I probably do, etc.)

5. Regarding disclosure to future partners (if we break up), I’m asking more about whether I ‘should’, not whether I ‘can’. I realize you are not an ethicist, but I have noticed that you have indicated that there are potential legal issues with not disclosing genital HSV status, and in general you are willing to offer your personal opinion on these kinds of ethical questions, which I highly appreciate. Given the facts I have described to you, I was hoping you could offer your thoughts on whether I needed to bring it up with future potential partners. I really wouldn’t want to for obvious reasons, but ultimately I want to ‘do the right thing’, whatever you think that may be.

Thanks

[Terri Warren]

3. My girlfriend is getting tested shortly.If my girlfriend’s HSV 1 IGg tests come back positive, I assume you would be ok if I resume having unprotected sex with her once my lesions are healed? If her test comes back negative however, what would you recommend as far as precautions (condom, Valtrex, etc.)?

Yes if she also tests positive, then you can have sex as you wish.

4. By ‘indeterminate’, I meant that I have tested positive twice on an antibody but negative on everything else. I actually had another swab done and got the results after my last post a couple days ago. As I mentioned, I also had a PCR test done since my last post, which also came back negative. So by ‘indeterminate’, I am essentially saying my two antibody tests are positive, but two cultures, a biopsy, and a PCR test are all negative.
HOWEVER, my two cultures, my biopsy, and my PCR were all done between 1.5 weeks and 4.5 weeks after the lesions appeared, so I am worried that the virus retreated before the cultures, biopsy, and PCR test were performed, and that the remaining lesions were still around because they simply still needed to heal after the actual virus retreated. So I understand I very likely have the HSV 1 virus, but I think it’s very unclear whether I had an actual genital outbreak or whether the virus can still be considered aysmptomatic- but please let me know if you would characterize the probability another way (eg, I probably don’t, I probably do, etc.)

I believe you are infected with HSV 1 but the timing of the swab tests has not been optimal. Or perhaps these lesions are not herpes.

5. Regarding disclosure to future partners (if we break up), I’m asking more about whether I ‘should’, not whether I ‘can’. I realize you are not an ethicist, but I have noticed that you have indicated that there are potential legal issues with not disclosing genital HSV status, and in general you are willing to offer your personal opinion on these kinds of ethical questions, which I highly appreciate. Given the facts I have described to you, I was hoping you could offer your thoughts on whether I needed to bring it up with future potential partners. I really wouldn’t want to for obvious reasons, but ultimately I want to ‘do the right thing’, whatever you think that may be.

I would disclose because if it comes up later and becomes an issue, trust may be more difficult to deal with than anything else, honestly. Also, there are legal issues, yes. Though with HSV 1, I think the legal question is far more iffy than with HSV 2 disclosure.

Do you know the index value of your HSV 1 antibody test result? If below 3.5, you may wish to get confirmation

This is your final post on this subscription. If you have more questions, you can certainly renew.

Terri

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