Does the rash or the serology win?

[MsFrog]

Drs, would please review (i) a rash description (from 2000) and (ii) a set of test results (from 2009)?

Rash: Sept 2000, received oral sex. Rash occurred about 7 to 10 days after.
Started with red bump on the inner aspect of labia majora, next to the hair. Bump had a 'whitehead' (was pimple-like) which, when burst, gave out watery pus then formed a shallow 'crater'/ ulcer(?).
Started acyclovir 400mg 5x day within 24 hours.
Next few days, several other bumps came up in the pubic hair (bilaterally) which progressed to be small sores.
One 'lesion' occurred on side of the clitoral hood, but none on inner or outer surfaces of labia minora that I recall.
Some new lesions occurred while I was taking the antivirals.
Had tender lymph nodes in my groin.
Rash took 3 weeks to heal.
My ‘partner’ was promiscuous man with poor oral hygiene (brown dirty teeth around the gums). It was NOT my wish to receive oral that night and I was too shy to go to a GP for help.

Tests 2009:
Was symptom free for 9 years (and no other sex in that time), then started to get some tingling, prickling and stinging in my genital region.
Went to Dr, she ordered;
HSV1&2 IgG tests; both -ve.
Western Blot for HSV1 (-ve) and another IgG test for HSV2, also -ve (5 weeks after first tests).
HSV PCR from swabs of stinging labia minor (3 times over several months), all -ve.
The stinging labia episodes (only ever right sided) last for a few days (3 to 10) every 3 to 4 weeks. I haven’t seen any obvious lesions on labia minor. Dr Hook previously said not due to HSV, but… I’ve seen several Drs since then and none have been able to give me a plausible alternative diagnosis.
So, rash in 2000 seemed like HSV, but 2009 serology suggests otherwise.
1. Does the rash or the serology win?
2. Could mouth bacteria or any other oral pathogens have caused the rash I described?
I'd really like to know whether I did or did not get HSV that night in 2000. Can I ever really know?

[Edward W Hook, MD]

I understand your frustration but fear that we may have reached an impass.  You asked for my opinion and I gave it to you, based on my nearly 30 years in the field, as a researcher on the topic and based on my regular interactions with other experts.  Doing tests does no good if you do not plan to believe them, even following multiple tests.

Scrutinizing your genitals is unlikey to provide you with other information and the sort of recurring pain and discomfort you describe in the absence of lesions or a positve test is not consistent with the intermittent nature of HSV recurrences and associated pain.  

Of course Bartholin's glands can become infected but when they do there are lesions.  

I worry that your continuuing focus on HSV will impair your ability to seek other answers.  Sorry to not be of more help.  EWH

[MsFrog]

Thanks, Dr Hook.

You have given me the best advice a distant expert can (which is much appreciated), but I just can't shake the idea that I picked up HSV all those years ago. I must say it didn't really strike me as folliculitis cos it did not look/feel like facial acne does and also cos of the lesion occurring on the clitoral hood where no hairs are. I was so surprised to get negative blood test results, that is why I asked my Dr for further confirmation (hence WB test).

If I stopped getting these debilitating stinging sensations on the inner labia then I wouldn't be so fixated with HSV. When I examine the inner labia surface I cannot see any typical OBVIOUS lesions. I have examined with a mirror and magnifying glass, even shining a light obliquely across the stretched-out skin surface to discover if I may have missed any small ulcerations not visible when light shines directly on the skin. In your experience, should one have to look this hard for a lesion or should they be obvious if they are causing such pain?

The area that the pain keeps occurring in is around where the right Bartholin's gland exits the body, but often the pain seems to get referred forward to the antero-lateral right labia surface (causing stinging) and backwards across the perineum to the right side of the rectum (causing a burning sensation), as if you slung a rope under your right groin and rubbed it back and forth. Do HSV infections of the B gland/duct occur? Could unseen lesions within the vagina cause these diffuse stinging symptoms?

I apologise for asking questions that directly contradict your earlier advice to stop worrying about HSV, but my mind needs a lot of contrary evidence to drop HSV (I know the blood tests are ‘good’, but unfortunately they are fallible). A plausible non-HSV explanation for the original rash and the more recent stinging sensations would certainly help!

Thanks your patience with a woman who has lost a lot of self-esteem since this all began last year.  

[Edward W Hook, MD]

Welcome to the Forum. The serology wins.  There are many other processes which can mimic genital herpes.  The rash you describe has several aspects which are not suggestive of HSV such as the fact that the initial lesion was pimple-like and that lesions continued to occur after starting acyclovir.  Furthermore, you have not had recurrences.  The rash you describe sounds more like folliculitis or perhaps a minor skin infection than anything else.  Its appearance may not have been caused by your exposure but rather could have been an unfortunate coincidence.  

Your multiple serological test results indicate that you have not had a HSV infection and while your PCR tests do not conclusively rule of HSV by themselves, considered with all of the other test results you mention, there is very little to support a diagnosis of genital herpes.  

There is little reason to think that you have HSV,  Time for you to stop worrying.  EWH