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Unusual herpes presentation

Starting at age 9 my daughter had a recurrent, albeit not too frequent sore under her nose that for 3 years was assumed to be impetigo.  Only after her doctor did a swab, was she diagnosed with facial herpes (only under her nostril and inside her nostril), type HSV-2.  The doctor was perplexed by the typing, but assured me this was not a case of genital herpes.  There has never been any indication to consider other wise.

The problem is that she is now almost 13 and her rate of recurrence is 12-15 times this past year, usually triggered by anxiety and/or a notable cold.  The sore has moved more to above her lip, and now onto her upper lip. It presents less frequently under her nose.  She has never had sores anywhere else on her body.  Based on research that I have found, I am surprised that her sores present with such increasing frequency.

We treat it with 1000mg 2x daily as she experiences onset of symptoms.  It is a band aid approach at best it seems...

I have two questions.  First, what are you thoughts about suppressive therapy for a 110 pound 13 year old girl with this presentation and are there concerns regarding long term side effects?

Secondly, and perhaps more confusing to me in regards to future considerations, I would love any information about concerns with transmission in regards to future sexual partners.  Had they not bothered to type it, they simply would have said it was a cold sore/herpes, assumed type 1 in all likelihood, but since they did do a swab we are aware that it is in fact type 2. Should we simply treat this as most people consider oral herpes sores?

Her presentation seems confusing to the doctors that we have sough help from and much of the information seems inconsistent.  I would appreciate any information to help me determine best treatment approach, and to better understand her overall medical condition.
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55646 tn?1263660809
So facial/oral herpes are all the same.  The virus normally enters the body at the mouth because this is where the very skin easily penetrated skin is located.  It then goes to live in the trigeminal nerve.  This nerve group innervates an area from the chin all the way up the to eye.  The virus can travel on any of those nerves to get to the surface of the skin - chin, lip, nose, even eye.  This is all the same; there is no distinction to be made here.  

Someone who is sexually abused only genitally would not display symptoms orally/facially.  However, someone who has been sexually abused by giving oral sex to someone else could certainly present with recurrences in the nose.  I'm not saying that's what happened, I'm saying that could have happened.  

I'm still hoping that the typing was incorrect or entered incorrectly by a lab person or something that easy.  The PCR will do typing and that is now the preferred test for swabbing for herpes.  

You can ask me more questions - this is very important and concerning because it involves a child with HSV 2 orally.  That is definitely cause for concern.

Terri
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Avatar universal
Also, and hopefully lastly, the test that was done was a swab for a HSV viral culture.  That was then followed by a monoclonal flourescent antibody test to determine type.  If we retest, is that a valid and reliable tool, or would you recommend that we ask for a PCR?
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Avatar universal
Thank you Terri, I cannot tell you how difficult this conversation is to have...  I guess what I need to be clear on is that, until 3 months ago she ONLY had the lesions/blister inside and under her nostril.  The doctor referred to it as facial herpes, not oral.  The doctor had even wondered if her skin was open from what she thought was originally impitego and then contracted the herpes virus at that point/opening in her skin.  So, that has been reassuring to me in regards to not being overly concerned about sexual abuse orally.  

Is it not true that herpes blisters show up at the initial point of contact?  Thus, her nasal/facial presentation is far less concerning, albeit confusing if it is in fact HSV2.  I will certainly have it retested for typing prior to pursuing suppressive therapy.  

Could someone be sexually abused vaginally only and then have blister show up under/inside the nostril?
Helpful - 0
55646 tn?1263660809
Well, I think that HSV 1 and 2 are not as clearly defined by location as they used to be, but overwhelmingly, it is the HSV 1 that is more commonly genitally than previously because of the higher incidence of oral sex.  This does not appear to influence the presence of HSV 2 orally.  The vast majority of HSV 2 infection is at least genital.  If she had been sexually abused only by someone asking her to give them oral sex, then she could have it only orally.  

The typing, in this case, is truly essential that it be correct.  If she truly does have HSV 2 orally then I think the risk of sexual abuse orally is far far higher.  Also, HSV 2 orally normally doesn't recur anywhere near this often.  So if the typing is correct, then what the heck is going on.  

As for your last question:  if she truly has HSV 2 orally, then it is very unlikely that would get it genitally at this time.  In fact, she would, in essence, be vaccinated against genital infection.  However, we go back to the original question:  if it truly HSV 2, it is also possible that she could initially have been infected genitally, if the contact was not only oral, she could have originally been infected genitally as well.  

This is such a complicated situation and I feel for you as a mom, this must be so challenging!  

Please - get another swab test done the next time she gets a lesion.  Do it before you treat this outbreak or the result may not be correct.  

Feel free to ask me more questions as you feel the need.

Terri
Helpful - 0
Avatar universal
Terri, I appreciate your question and can only state that I have certainly considered the same and have no reason to have any such concern.  However, the fact that you ask the question is one of the reasons that I am so confused.  

In all of the research that I have conducted, it seems that HSV1 and HSV2 are quite interchangeable... Meaning they are no longer, as a type, singularly connected to a particular location on the body.  Please feel free to correct me if I am wrong.  Her pediatrician and I certainly had this very discussion and she indicated that had this been a sexually transmitted experience, it would not have shown up in her nostril, but rather her genitals, buttocks or perhaps mouth, as the initial point of contact.  Please clarify this issue for me.

Also, what is the real benefit of another swab? It almost seems like typing does not matter, nor dictate treatment in any way.  Correct?

After 4 years how concerned do we need to be, if at all, about her transmitting HSV2, facial/oral type to her genitals?  
Helpful - 0
55646 tn?1263660809
I guess I should also ask the very difficult question of do you think there could possibly be any sexual abuse of your daughter?

terri
Helpful - 0
55646 tn?1263660809
I can see why this is a multiple level confusing and concerning problem.  Recently, I have had two other cases where I believe that typing was incorrect but we can't be certain.  The reason that I believed those cases were mistaken typing is because the antibody test doesn't come close to matching the results of the PCR.  So in your case, if I was your provider, I would reswab and retype when she is NOT taking medication.

Next, I would definitely consider putting her on suppression (daily therapy).  We treat people over the age of 12 as adults in the practice and I think you can do the same with a 110 pound 13 year old girl.  As she moves through her teenage years, she is NOT going to want to be having cold sores constantly - probably already doesn't like them much.  In fact, the studies on the one time treatment of cold sores enrolled subjects as young as 12.  

There is likely nothing wrong with her overall health but her own providers are in a far better position to assess her conditions in general.  

Does that help at all?  Please feel free to ask me other questions about this case.

Terri
Helpful - 0

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