Symptoms of Herpes with no Antibodies

[Sally51955]

Hi Doctor,

I received oral sex from a guy about 7 months ago, and developed a paper cut-like lesion below my clitoris within 2 weeks.  The same lesion (in the same location) has reappeared a total of 4 times over the last 7 months.  Each time, the lesion lasts for about 3 days and then is followed by intense itching on my inner labia for a few weeks.  (The itching is not coming from the same spot as my lesion, and only begins after the lesion has healed.)  I got tested with the HerpesSelect IgG tests for both HSV 1 and 2 at 3 months and 7 months post-exposure, and everything came out negative both times.  I’ve also been tested for all other STDs, yeast, and bacteria, all of which were also negative.  I have not had the opportunity to do an HSV culture, but hope to do so if the lesion comes back again.  So my questions for you are:

1. Does this sound like it could be herpes?

2. What are the chances that I am one of those rare people who has herpes but doesn’t develop HSV antibodies?  What percent of people with HSV 1 or HSV 2 in the genital area don’t develop antibodies?

3. I plan on getting pregnant in the near future.  If I am indeed someone who has herpes but does not develop antibodies, am I going to risk passing this on to my baby, since I won’t be able to pass the antibodies to the baby?

Thanks for your help,
Sally

[H. Hunter Handsfield, M.D.]

Thanks for the follow-up.  For the reasons in my original reply, I continue to believe herpes probably is not the cause of your recurrent genital lesions.  It is more likely that, like half the population, your positive HSV-1 test is the result of an unrecognized oral infection, probably in childhood.

However, I could be wrong.  There are two ways that might sort it out.  First, do what I already suggested -- see a health care provider immediately (within a day) of the next time the lesion recurs, so it can be tested directly for HSV.  I predict that even you do this several times, there will be no positive results.  Second, ask your doctor for a prescription for an antiherpes drug like valacyclovir (Valtrex).  If you take such treatement daily and your lesions stop recurring, it will suggest I am wrong and you really have genital herpes.  If it makes no difference, it will confirm my belief against herpes.  (However, I suggest you not try the second strategy right away.  Try the first strategy until recurrent lesions have been tested at least 2-3 times.)

You have a misunderstanding of the HSV blood tests.  Western blot detects IgG antibody.  Your negative HerpeSelect test does not mean you don't make IgG antibody to HSV-1; it means only that HerpeSelect didn't pick it up.  That is the case in 10-15% of HSV-1 infections (and about 5% of those with HSV-2).  To your specific questions:

1) If you indeed having herpes episodes, it is not possible to predict the frequenty of future outbreaks.  There are no data on the natural course in patients with unusually frequent outbreaks of genital HSV-1.

2) There are no known differences in outbreak frequency in people with or without false negative blood test results.  Probably it makes no difference.

3) Similarly, your negative HerpeSelect test results probably have no bearing on the risk of transmission to a baby during delivery.  However, I do agree that if and when you become pregnant in the future, you should definitely inform your obstetrician of this problem (whether or not genital HSV-1 is confirmed); s/he will know how to go about preventing transmission.

I'll be interested to hear more if and when your lesion(s) have been tested for HSV and/or you have tried suppressive antiherpes theraoy.

[Sally51955]

Hello Dr. Hansfield,

I know that this discussion was closed some time ago, but I wanted to let you know that I got the western blot done and it came back positive for HSV 1 and negative for HSV 2.  I did this just 2 weeks after a HerpesSelect test that came back negative for both types.  I called the people at the University of Washington and they informed me that I should trust the results, as the western blot is more reliable than HerpesSelect and that the HerpesSelect test has a significant false negative rate for HSV 1.  Even though I don't have the IgG antibodies that the HerpesSelect test looks for, I had some type of HSV 1 antibody that the western blot was able to detect.  I also am confident that the infection is genital because I have never had a cold sore or any oral symptoms ever in my life.

Given this information, I was wondering if you could please answer a couple of questions for me.  

1.  I had 5 recurrences of genital HSV-1 during the past year (the first year after my exposure.)  Is it likely that I will continue to have such frequent recurrences for the next couple of years?  I know that the rate of genital HSV-1 in future years usually drops off, but the recurrence rate during the first year is also generally very low, which mine was not.

2.  Do you think that the fact that I do not have IgG antibodies, but instead have some other type of antibody is the reason for my increased rate of recurrence?

3.  I know you said the risk of neonatal herpes is low, but does the fact that I do not have IgG antibodies change that at all, and should I be concerned during pregnancy?

Thank you for your continued help during this time.  I know this is a long post but I just found out about my HSV positive status today and wanted some answers to help with my concerns.

Sally

[H. Hunter Handsfield, M.D.]

The few people with HSV-2 with negative blood tests usually have negative results both by IgG and Western blot.  But this is irrelevant to your situation.  The totality of evidence proves you don't have it.  Re-read my replies above and concentrate on them.  Then try to stop obsessing about herpes.

That will be all for this thread.  I won't have any further comments or advice.

[Sally51955]

Hi Dr. Hansfield,

Would the 5-15% of antibodies that may be undetectable by herpeselect be detected by the western blot?  In other words, does the western blot test for additional antibodies besides the IgG antibodies tested for by herpeselect?

Thanks

[Sally51955]

Thank You!

[H. Hunter Handsfield, M.D.]

Oral HSV-2 can happen but it is quite rare; and when present, viral shedding is rare so transmission is uncommon.  In 30+ years in the STD business, I have never seen nor heard of a patient who acquired genital HSV-2 through oral sex.

[Sally51955]

Thank you so much for your response Dr. Hansfield, I really appreciate your help.  I just have one additional question.  You stated that HSV 2 is out of the picture because my exposure was through oral sex. But would it have been possible for my partner to have had HSV 2 orally if he contracted it from someone while performing oral sex on them?  Thanks again,

Sally

[H. Hunter Handsfield, M.D.]

Welcome back to the forum.  I reviewed the discussion you had with Dr. Hook 5 months ago and agree with his opinions and advice.

It is possible to have atypical symptoms, and it is possible to have HSV with persistently negative blood tests, and it is possible to have such frequently recurrent herpes due to HSV-1.  (HSV-2 is out of the picture since your exposure was by oral sex.)  But for all these factors to all have such an atypical outcomes is statistically impossible for all practical purposes.

When it is said recurrent HSV outbreaks are usually in the same location each time, it generally means within an inch or so.  Herpes rarely recurs repeatedly at exactly the same spot; that fact suggests something other than herpes.  Also, herpes doesn't cause itching except at the site(s) of herpes lesions.  And herpes rarely recurs as frequently as you describe; even HSV-2 doesn't often occur as often as once a month, and for HSV-1 it is extremely rare.  To your specific questions:

1) For the reasons just described, your symptoms are highly atypical for herpes.

2) Around 5-15% of people don't develop measurable antibodies -- 5-10% for HSV-2 and 10-15% for HSV-1.  But you must not focus on just these percentages.  The judgment you don't have genital herpes is based on a combination of all the factors you describe -- the nature of the exposure, you symptoms, and your test results.  Taken together, these factors provide virtually 100% assurance you don't have it.

3) There should be no herpes-related worries about pregnancy.  Even if against all odds you actually have it, the risk of transmission to a baby is very low in recurrent herpes.  The high risk of neonatal herpes comes when a woman acquires HSV toward the end of pregnancy.

If you want still further reassurance, you could follow through with your plan for an HSV test from your clitoral lesion if and when it appears again.  I'm not recommending this, but if you do it, try to have a PCR test rather than culture, if available from your doctor or clinic, and needs to be done within 24 hours of onset of the lesion.  You can expect a negative result.  In the meantime, continue to work with your provider(s) about other causes of your symptoms.

Regards--  HHH, MD