Unusual presentation

[OverinformedHCP]

Hi Terri and thanks for all you do. I am myself a healthcare provider in Canada.
Approximately a year ago I was diagnosed with Crohns. This came with hemorrhoid and fissures. I’ve since gone into remission thanks to entyvio).
In January I had what was diagnosed as yeast. I got on Valtrex right away before Dx/exam. I was seen at the STI clinic and told “there was nothing to swab”. I had some mild redness and irritation at the time.
Fast forward to June of this year I had a protected sexual encounter and 4 days later got flu and aching symptoms. Nothing genitally until yeast symptoms a week later; once again seen by the STI clinic. Told there was nothing to swab. I once again got myself on antivirals early on only to be told it was not herpes/not swab appropriate.
July 24-26 I had frequent, vigorous protected sex. I once again got those telltale yeasty symptoms and decided to trust it was yeast. Fluconazole and boric acid suppositories helped a lot. There was rough anal play (no anal sex, just digital) involved. About a week later I noticed a hemorrhoid and two days after that some anal rawness and pain. I discontinued the anusol thinking it was a reaction. The pain worsened over two days and I once again put myself on Valtrex 1000mg PO BID just in case. Two days later I had bilateral inguinal lymph swelling. The pain subsided to just itching and I have noticed occasional bleeding with bowel movements. Frequent self examinations (yay for way too much barely applicable textbook knowledge) have yielded one instance of tiny white pinpricks (tender, clustered) which cleared hours later. They didnt appear to ulcerate but the area was raw/tender. This was all on my anus. Afebrile, some referred pain in buttocks esp w BM
Pretty sure it’s HSV. If I got it last January as I suspect, will this product tell me? https://www.stdrapidtestkits.com/herpes-2-rapid-test-kit
I’m staying on Valtrex 500mg daily just in case. Will this affect whether futures swab/serology is accurate?

[OverinformedHCP]

Update: I did the test listed above yesterday and it was negative.

Possibilities:
1) too early to test (and I was actually exposed end of July, but I don’t think so, based on these weird yeast-like outbreaks)
2) inaccurate test
3) it’s HSV-1 (not 2)
4) my daily antiviral is suppressing the antibodies enough to cause a false negative.

Interested in your thoughts.
Wondering if you are able to arrange the Western Blot for Canadians as well?

[Terri Warren]

1) too early to test (and I was actually exposed end of July, but I don’t think so, based on these weird yeast-like outbreaks)
Yes, too early for reliable test
2) inaccurate test
only because of the timing
3) it’s HSV-1 (not 2)
True, if you received oral sex

4) my daily antiviral is suppressing the antibodies enough to cause a false negative.
that is also possible. You taking Valtrex intermittently whenever you get worried is not a great idea if you want a reliable test. I kind of wish you wouldn’t do that.

The symptoms that you describe do not sound herpetic to me.

Yes, we can arrange western blots for Canadians. But I would recommend staying off antivirals for three months before doing so. And if you have symptoms during that three-month period that concern you, get a swab test but don’t take antivirals.

terri

[OverinformedHCP]

I’ve managed to arrange a Western Blot for myself (if I can get the sample centrifuged somewhere in my province). I spoke with a lab supervisor at UW and she mentioned that the Valtrex should not affect results? Can you point me to some evidence/research on the subject? I imagine it’s limited but I’d like to investigate; researching this virus has become an obsession. I can see why you work in the field. It’s fascinating when it’s not happening to you.
As I mentioned, I am immunocompromised. I would be absolutely devastated to get (another?) outbreak on my anus, as you can imagine having Crohns makes that whole area a war zone. For the record I did receive analingus. Lucky me!
I just don’t know what else the white tender spots could be. My nerve pain/lymphedema/discharge felt classic. They were gone when I woke up and removed the ice pack hours later; replaced by significantly tender raw spots that REALLY HURT for 3 days, took about 10 days to heal visibly and 18 days to stop itching internally They were not on a red base (though there was erythema and scant swelling once the spots disappeared). I know shingles is usually unilateral. My gonorrhoea/chlamydia & syphilis are negative.
I’ve been reading about aborted lesions when antivirals are introduced quick enough. I did have some itching both internally and externally until today as well. I saw the STI clinic yesterday and the RN agreed a IGG test is unlikely to be very helpful. She did do a spec and swabs and noted healthy tissue and vaginal flora.
At this point I’ve made a small care plan for myself. Bear with me:
1) repeat the HSV2 test I listed above in mid to late November
2) I’m so scared to go off these antivirals, especially given the reduction in transmission rates in discordant partners. How deeply could they affect results?
3) if the test is negative proceed with the Western Blot, as HSV1 remains part of the differential diagnosis
4) obviously if I have a fresh crop of lesions I’ll swab promptly.

[Terri Warren]

I would disagree with whomever you spoke with at UW. A lab supervisor? Do you recall who is was? I’ve had two patients who have taken valtrex since a brand new infection who did not seroconvert by the blot until after the stopped suppression – one did this for 9 months and another for two years.

You could certainly have anal herpes, from your description, and possible HSV 1, yes.

1) repeat the HSV2 test I listed above in mid to late November
I think you could do a normal IgG for HSV 1 and 2 in NOvember.

2) I’m so scared to go off these antivirals, especially given the reduction in transmission rates in discordant partners. How deeply could they affect results?

So are you saying that you have a partner that is negative for HSV 1 and 2? And the sexual contact that you had was with someone different? I’m a bit confused about this part. Could you clarify? If you do go off daily antivirals, the risk of infecting someone who is not already infected does go up, correct. You’ll need to weigh that risk against getting an accurate diagnosis. If you do go off antivirals, yes, any symptoms should be promptly swab tested using PCR or NAAT testing.

3) if the test is negative proceed with the Western Blot, as HSV1 remains part of the differential diagnosis.
‘
Correct

4) obviously if I have a fresh crop of lesions I’ll swab promptly.
Definitely.

Terri

[OverinformedHCP]

Hi Terri

Little update for you. I did a home HSV 1/2 rapid test last Tuesday and it remains negative. I never heard back from the lab. My infectious disease doctor stated that if my IGG is neg at 6 months I should consider myself negative despite suppressive therapy? I’m hoping you can share some peer reviewed evidence on delayed seroconversion that I might bring to the table, as I would like his management plan to be an informed one.

I had a single bump on my inner thigh, but with ice, tea tree oil and an increase to 2g for a few days in the Valtrex it popped on its own overnight and showed no signs of ulceration. It was non tender. This was just prior to the onset of my period AND I has just switched to the 500mg daily (I’ve since started back at 500mg BID in anticipation of an upcoming entyvio infusion). Prodromal symptoms too.

I spoke with the partner who I suspect passed it. He said he’s never had any symptoms but his ex used to get cold sores.

I have been feeling near constant sciatic-like pain running down my right thigh. Ugh!! Suggestions?

Reminder I am immuncompromised; I’ve been in remission for Crohns since June and on entyvio infusions since December. My gastroenterologist was clear that the Medication should be held if there is an active (diagnosed) lesion. I have not yet been able to get a swab done as I panicked the first time and it disappeared so quickly with the second.
Questions.

1) is there evidence that the course of herpes could be worse in terms of outbreak frequency and severity since I immediately went on a suppressive dose following my first perceived outbreak? Am
I disallowing my body’s ability to build an immune response?
2) are there predictors for the severity of the disease? Do antivirals affect this?
3) if I go off the antivirals in order to get a proper serology result, and start getting outbreaks again; can this be a catalyst to resistant strains? Again I know this is more common (4-7%) with immunocompromised individu

[Terri Warren]

To be clear: I spoke with the lab director at UW about your comment. He stated that that person gave you incorrect information. He agreed that antiviral medicine can indeed impact the western blot. I don’t believe that there is literature on this, but I have seen it at least three times in my patients and I know the lab director has as well.

1) is there evidence that the course of herpes could be worse in terms of outbreak frequency and severity since I immediately went on a suppressive dose following my first perceived outbreak? Am
I disallowing my body’s ability to build an immune response?
No

2) are there predictors for the severity of the disease? Do antivirals affect this?are
There are none, but if you on suppression, clearly the disease will not be as severe. Is that what you are asking?

3) if I go off the antivirals in order to get a proper serology result, and start getting outbreaks again; can this be a catalyst to resistant strains? Again I know this is more common (4-7%) with immunocompromised individuals.
No! It would simply allow you to have an outbreak that would be typed, if it happened, and then you could go back on suppression.

Terri

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