Following up on Oral HSV2 questions yesterday

[laurabrowne]

Dr Handsfield:

I paid for another question because I didn't want to take advantage of yesterday's thread.  Since oral HSV2 followup is such a timely matter, I wanted to give you my status today and see if you felt I needed to followup with a doctor.  Please know this is not paranoia.  I just wish to be certain that I am not overlooking anything important.

I did not end up with a cold sore afterall.  There's nothing on my lips. The bump under my lip went away.  Yesterday, I noticed a small bump in my mouth that looks like it's filled with blood, like when you bite your cheek.  It is dark red/almost black, looks like blood under the skin.  There are a couple tiny surface skin white marks in the area...like light abrasions.  One was there before the bump appeared.  My throat became fairly sore again yesterday.  It looked like there was some white on it when I checked.  Today, my throat is significantly better and my swollen gland has gone down considerably.  My questions:

1) I wasn't sure what sores in the mouth would look like. None of this hurts at all.  It isn't blistery either.  Is this anything I should be concerned about?  
2) Can the sore throat alone be an indicator?  
3) Does any of this sound like something I should follow up on for an oral or throat swab?

Once again.  I thank you.  I just want to assure that I am not overlooking anything.

[Edward W Hook, MD]

1.  I'm not sure I agree with him. Both the PCR and the culture are tests for the presence of the virus- either it is there or it’s not.  False positive tests of these sort are rather rare. In contrast, false positive blood test looking for antibodies to the virus are rather common.  

2.  Asymptomatic shedding is more common than most people think.  The best information we have is about genital shedding and the data show that persons with genital HSV-2 have asymptomatic shedding about 10% of the time.  I suspect that, because of location, oral asymptomatic HSV-2 shedding would be less frequent but it is hard to say just how low it might be.  Most exposures to asymptomatic shedding however do not result in transmission of infection.  This issue, of course is in no way germane to your situation.  

3.  Trauma and friction do lead to slightly more :"efficient" transmission since they lead to small, microscopic abrasions which can enhance transmission. EWH

[laurabrowne]

Thanks so much Dr. Hook for all the clarification on your site and my questions.  I did ask my dentist this morning if they would look at it and they referred me to the oral surgeron. He, as you predicted, did not feel that it looked like herpes at all but rather a viral infection of some sort.  So, I do have just a few more questions based on what the oral surgeon said:

1) He said that he wouldn't do a swab without a true lesion that he thought was herpes because there is a good chance that I could get a false positive reading. Did I misunderstand that; although it's not necessary, that this was an option?  Why would he recommend against it?

2) He said if I did have HSV2 and I don't have a herpres lesion at the time that I don't need to worry about being contagious.  Would he say that because the frequency of asymptomatic shedding is so small?  He was very reassuring that I need not worry about it regardless.  Of course, I know you cannot answer for him.  I just thought you may be able to shed some light.

3) Lastly, it's almost embarassing to ask this, but how much does the vigor with which oral sex occurs influence the probability of contracting the virus? Is the likelihood increased somehow by a more vigorous act?  Just wanted to know for future reference.

Thank you so much for your kindness and guidance.

Lynn

[Edward W Hook, MD]

Welcome back to the Forum.  You're kind to not want to take advantage of your ongoing thread with Dr. Handsfield but your questions are not excessive and answering questions is what we are here for.  I'll weigh in and give you my thoughts but, for future reference, it is fine to continue a thread. Further, in that we ask our clients to not more than twice in any 6 month period in order to allow others to have the chance to ask their questions, we would not want to you "burn" your opportunity for further questions should they come up.  I have reviewed your interaction with Dr. Handsfield and agree with all that he has said.  Now, with the opportunity to follow things for a bit, it appears that the area of soreness and sore throat you have experienced is not HSV but some other process, most likely unrelated to your rather low risk encounter with a partner who has HSV-2.  In general, as suggested by Dr. Handsfield, HSV-2 does not "like" to infect the mouth and rarely does.    

Let's work through your questions:

1) I wasn't sure what sores in the mouth would look like. None of this hurts at all.  It isn't blistery either.  Is this anything I should be concerned about?  
Clinically, HSV-1 and HSV-2, once the infections are established, have very similar appearances.  Thus, had you gotten HSV-2 orally, it would appear like an initial outbreak of oral HSV-1.  What you describe does not sound like this.  It sounds to me as though you may have some other viral sore throat, of the sort most people get from time to time.  

2) Can the sore throat alone be an indicator?  
Not typically.  It is far, far more likely that the presence of your sore throat is not due to HSV-2.

3) Does any of this sound like something I should follow up on for an oral or throat swab?
If you were my patient I probably would not feel it important to do a PCR or HSV culture but if your level of concern is high, all you would have to do is put up with the inconvenience and cost of getting  the test and in the long run, that may not be too much to ask.  Put another way, what will give you peace of mind:).

finally, BV is not an indicator of HSV.  BV is a disruption of the normal bacteria in the vagina in which some organisms grow, out of balance, to high concentrations.  Unfortunately, it does have a tendency to recur and sometimes requires repeated therapy, even with the same antibiotics – typically metronidazole-  to finally get things settled down.

I hope my comments are helpful. EWH

[laurabrowne]

As a side note question, is bacterial vaginosis ever an indicator of a new Herpes infection?  I've had 2 minor bouts with it over the past few months. My dr thinks the original infection was from antibiotics.  He treated me twice thinking I never got rid of the 1st infection.  It's been gone for at least a month or more now but seems like it may be starting again.  As I mentioned prior, I never had intercourse with this man.  Prior to my first oral experience which I performed on him last week, I did have a few instances in which he performed oral on me in the past.  He's never had an indication that he has oral HSV2.  This may be a stretch, but since I am asking everything here, I figured I'd make sure there is no correlation to be concerned about.  Thank you.