Positive culture then negative blood tests for 8 years

[SQNYC]

Dear Dr.,

8 years ago I had a positive HSV1 culture, but a negative blood test.  I assumed I had it, but had not yet developed antibodies.  

Last year I repeated the blood test (HerpesSelect) and it was still negative.  My doctor told me that there must have been a mistake with the original positive culture as there is no way to have it and not develop antibodies.  So then I thought I didn't have it.  (I had never had any subsequent lesions.)

But then this month I had suspicious lesions that again cultured positive for HSV1.  And for the third time my blood work is negative for HSV1 (and HSV2) (HerpesSelect).  My current doctor is telling me that the culture doesn't lie and that no matter what my antibody status is that I do in fact have HSV1.  

I am currently taking a daily suppressive dose to reduce the likelihood of transmission to my partner, but obviously don't want to take a daily drug unnecessarily. If I have had a positive culture, do I definitely have HSV1?  Is it possible to have had lesions but not "have"/"carry" HSV1?  Does the possession of antibodies have anything to do with being able to transmit the infection?  

Thank you for your help.  The lack of clear medical advice on this matter is frustrating!
Best,
SQ

[Edward W Hook, MD]

The Western Blot performed at the University of Washington is the standard to which all other blood tests are compared.  that is what I would recommend as the "best" test for your partner.

As far as what it would mean if your WB at UW was negative, that would be difficult to say since the event is so rare and there are no studies of this situation.  let's cross that bridge if we get to it.  If you choose to get a WB, please post the result. EWH

[SQNYC]

Thank you for your responses!  I have only had the initial outbreak 8 years ago and the one this month.  And I have not been on a suppression dose.  

Is there a test you would recommend for my partner as most likely to catch whether or not he is hsv1+?  

And if I were to have a WB test conducted by UofW and it too came back negative, would that have any implications for whether or not I am likely to be able to transmit the infection?  Do people who are sero-negative still shed with the same frequency as people who are sero-positive?

Thanks again.
SQ

[Edward W Hook, MD]

Welcome to our Forum.  Many questions in a most unusual set of circumstances.  I will do my best to help you but before I do, I must remind you that genital HSV-1 is far, far less well studied than HSV-2 and therefore there are fewer data.  I will try to distinguish between statements based on data from well conducted studies and information based on clinical observations.

1.  Negative blood tests.  For a person to have recurring genital HSV-1 is unusual and it is even more unusual to have negative blood tests in such a situation.  Believe your cultures- repeated positive cultures for HSV-1 are clear proof that you have HSV-1.  As for the antibodies, the HerpeSelect, while a good test, is a better test for HSV-2 infections than HSV-1.   I would suggest you request that a specimen be sent to the University of Washington for Western blot.  The chances are pretty good that it will be positive for antibodies to HSV-1.  There are a small proportion of patients with HSV infections (1 or 2) who do not develop antibodies but there are a larger (but still small) proportion who are positive on Western Blot but not HerpeSelect.

BTW, how frequent are your genital recurrences?

2.  Your partner.  If your partner has HSV-1 and a positive antibody test, my advice would be to not worry about the need for suppression and likely transmission.  Your partner's antibodies are protective and the clinical observation of many specialist in the field is that if you each have HSV-1 (or -2 for that matter) even if you acquired it from different sources, you are not at all likely to spread the infection to your partner.  

3.  Valacyclovir.  There are no studies to indicate how quickly persons become non-infectious when taking antiviral therapy.  In studies of viral shedding the therapy "shuts off" shedding within a day or two and thus persons are probably non-infectious at that time.  As far as VCV dose, the studies of oral HSV-1 show clearly that the higher 1.0 gram dose works better and faster than the lower dose.  The same is true for genital HSV-2 infections but the dose most often quoted, because it was the dose studied is the 500 mg dose.   As I said, all data however suggest the 1.0 gram dose of preferable to the 500 mg dose, both for suppression of HSV-2 and therapy of oral HSV-1.

4.  Toilet seats.  There is no evidence that HSV is spread on inanimate objects.

Hope this helps.  I realize it does not give complete answers to all of your questions but I hope they are some help.  EWH

[SQNYC]

Sorry to keep hitting you with questions, but I've just read a response you wrote elsewhere about Valtrex and HSV1.  You wrote that the dose should be 1000mg twice a day.  My doctor gave me a prescription for 500mg twice a day, which I've been taking for 8 days.  The lesions are "healed" in that they are not oozing, painful, tingling, or crusty.  The skin is soft, but some redness remains.  Should I up the dose for the last few days?  

And what is your recommended suppressive dose?  (Assuming my partner does not have HSV1 antibodies.)  My doctor told me to take 500mg once a day.  

I have also read on other threads here that you do not consider transmission likely/possible through things like toilet seats.  However, as my lesions could actually touch a toilet seat I do worry about this with respect to passing it on to my children.  Additionally, my initial outbreak 8 years ago (accompanied by severe pain) occurred the week after giving birth vaginally to twins.  I had been on strict bedrest for months with *no sex of any kind* (not even with myself), and I can assure you that there was no sexual contact post delivery and episiotomy.  So I am concerned about how easily this might be passed on.  I would appreciate your thoughts.

Ok, I promise to stop now!  

SQ

[SQNYC]

I did not make clear that my lesions presented genitally (if that makes a difference in your answers).  My partner believes he is + for HSV1 due to childhood cold sores.  He plans to be tested (so that I could avoid taking the suppressive dose), but I don't know whether we should believe the results either way.  Assuming I have it, Is there a test you would trust for him in this situation?

And while we're at it (!) how many days after having a lesion (and taking Valtrex twice a day) does the increased risk of transmission return to its norm?   I've been taking it twice a day for 8 days now, but can still see a red dots at the lesion sites.  Does that mean there is still an increased risk of transmission?

And how long does one have to be on the suppressive dose to benefit from the reduced risk of shedding?

Again, many thanks for your help.