Thursday, May 18, 2006

Herpes, To Test or Not To Test

Recently some new tests for herpes have become available which are both helpful and confusing. I would like to review the indications for testing after a brief review of herpes.

Type 1 Herpes Simples virus (HSV-1) is responsible for most oral herpes commonly known as cold sores, but it can also cause genital ulcers.
Type 2 Herpes (HSV-2) is responsible for 85% of genital herpes. HSV-2 is the most prevalent sexually transmitted disease (STD) in the United States. 45-60 million people, 1 out of 5 Americans, live with this infection. There are 1 million new cases each year. About 25% of the US population aged 25-45 years old has been exposed to HSV-2 compared to 90% of the population exposed to HSV-1.

Signs and symptoms vary. The classic finding is a cluster of tender blisters which turn into shallow ulcers. The first episode is usually the most severe and may be associated with symptoms such as fever. A culture of these lesions is the gold standard to establish the diagnosis.

A variety of triggers such as stress, fatigue, mechanical irritation, and menstruation can cause the symptoms to recur. Recurrent symptoms are usually milder than the first episode, but the psychological impact of the disease can be severe. Depression and anxiety from fear of recurrent attacks or transmission to current or potential partners are not uncommon. The infection may be transmitted even when there are no symptoms. This is called asymptomatic shedding which occurs in nearly all infected individuals. Condoms help protect against herpes but they are not 100% effective.

So what about testing ? HSV type specific serological (blood) tests are now available, however, the test is NOT recommended for routine screening in the general population. Who may be considered for the test? According to the 2003 California STD Controllers Guidelines, HSV-2 serology may be used in this group but mostly if it will impact behavior.

--Asymptomatic partners of HSV-2 positive patients.
--Diagnosis of atypical genital lesions.
--Screening of high risk behavior patients.
--Selected pregnant patients.
--Asymptomatic HIV positive patients.

As an aside for the docs, IgM testing is not recommended.

Treatment is available which can reduce the severity of the disease, the number of recurrences and the transmission risk to partners. However, there is no cure. Vaccine trials are underway. Herpevac is one of the many under investigation.

Resources for patients with HSV: National Herpes Hotline (916-361-8488), American Herpes Foundation (201-342-4441), American Social Health Association ( 919-361-8400), and social web sites .

References:2003 California STD Controllers Association Guidelines. Shedding in the absence of lesions. Wald A et al. N England Journal of Medicine. 2000;342:845-850. Managing patients with genital herpes and their sexual partners. Patel, Rompalo. Infect Dis Clin Norht Am 2005;19(2):427-38, x. Tracking the Hidden Epidemics, Herpes. Dr. Huyen Cao, Director of International Cellular Immunology, California Department of Health Services.
Photo courtesy of: Worried.

19 comments:

Anonymous said...

I'm choosing to post here because I can do it anonymously. Do you know any good (by which I mean statistically robust) studies that explain the risk of transmission of herpetic whitlow, HSV II type? What is the risk from kissing, from sexual contact? Protected with a barrier? With suppressive *acyclovir? My searches are yielding nothing because it's a rarer disease, and I'd like to have real information.

Dr. Taraneh Razavi said...

Interesting question. To clarify, are you asking about transmitting the virus from a whitlow to other body parts or the other way around.

In the following study, there was documentation of a dental hygienist with a herpetic whitlow who was not wearing gloves and who had transmitted herpetic lesions to almost half of her patients. She had HSV1 type and not type 2.
http://www.cda-adc.ca/jcda/vol-66/issue-10/554.html with reference to
Epstein JB, Rea G, Sibau L, Sherlock CH, Le ND. Assessing viral retention and elimination in rotary dental instruments. J Am Dent Assoc 1995;126:87-92.

In another study they found 8 nurses who contracted the whitlow by being exposed to oral secretions of patiens.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=144709&dopt=Abstract

The above studies are small. I will see if I can come up with more research.

Anonymous said...

can you give herpes whitlow to your children by holding their hands?

Anonymous said...

if anybody knows symptoms of herpes well i could use your help. after a night with a girl i woke up with several red bumps, not clustered at all, above my genitals. my pelvis was somewhat sore, but the bumps went away quickly. about three weeks later i now have several canker sores under my toungue. does this sound like herpes to anyone?

Anonymous said...

Hi dr. razavi,

i need an e-consult pls. i underwent a routine STD blood test (including genital swabbing) plus urine test.

unfortunately, i tested mildly positive (1.39) for herpes simplex type 2. the consulting doctor (who wasn't very good) at the lab ordered a retest because it was mildly positive and i have never had any blisters or symptoms that are related to genital herpes.

also, the last time i had sexual contact was 6 months ago (i received unprotected oral sex, and had sex with a condom - also, the partner did not touch her vagina before giving me oral sex).
* i did kiss someone at a party 3 months ago, but only that.

also, my sister had an oral herpes outbreak 2 weeks before my test (we share drinks etc)

and i also received my second out of 3 injections of Guardasil (vaccination for HPV) around a week before the test.

the results for the retest come out in half a week... but im going out of my mind with worry.

what are my chances of the herpes 2 antibodies being a false positive?

thanks dr. razavi.

Anonymous said...

Dating and have acquire an full of zip popular life is certain for those who are polluted with herpes because consumers are so scared in this day and period that they back below average-tempered in fear of contagious something. This is why everyone who lives with herpes should be forthright and honest with their mate because it’s not daylight-haired to them if you’re intimately involved with them and they have no design you’re fouled with a contagious bug.

Anonymous said...

One out of five of the total adolescent and adult population is infected with genital herpes. This is very common now.

Anonymous said...

One out of five of the total adolescent and adult population is infected with genital herpes.

Steve said...

What do you think of the std testing service SxCheck? I had a great experience using them, and they make it easy to share test results, and they use IGM (as well as IGG) testing. As I understand it, IGM is for detecting acute (?current?) infection, so it can be useful as part of the screening process (relying upon IGG as the primary result).

Anonymous said...

Dr. Razavi,

Do you know what year it was that these "type-specific" tests for HSV-1 and HSV-2 came into use?

Anonymous said...

if you have herpes whitlow and touch yourself or another's genitals can you get genital herpes?

Dr. Taraneh Razavi said...

Yes, you can.

gasp said...

Dr., i have two questions, both concerning Human Papillomavirus. I received an abnormal pap smear with asquous cells back in 2001 or 2002. I ended up getting a leep cone procedure on my cervix and then all my paps were clear. i get regular screenings now every year. I have never before shown any other signs, but now I've noticed abnormality on my tongue and the surface is sensitive when i brush my teeth, even if i don't actually brush my tongue. I thought at first I'd burned the taste buds, but that usually heals fine and this hasn't gone away. is it possible that the type of hpv i have results in this as well.
also, since my diagnosis i have had a son who will be a year old next month. i was researching and came across an article concerning breastfeeding and am now terrified that i have infected my son. How contagious is hpv if i nurse, or if he drinks after me???
when i got the surgury they told me there was an actual HPV test, but it was too expensive. I was never really satisfied with that answer, and now i wonder if i should swallow the expense and test both of us, and my husband. what would you recommend?

JB Harrison said...

Great info on an often over looked subject, thanks

Anonymous said...

Is it true that the presence of genetal herpes can be "95% ruled out" if a person's urine sample tests negative for red blood cells and negative for white blood cells one week after the sexual encounter- and then a second urine sample also tests negative for red blood cells and negative for white blood cells a week after that (two weeks after the sexual encounter.) My doctor said that said he was "95 % sure" that I do not have genetal herpes based on that. Is that a medically correct analysis on his part?

Dr. Taraneh Razavi said...

Sorry, I do not agree with this analysis for ruling out genital herpes.

Anonymous said...

I had an HSV test done and HSV 2 came out negative, but HSV 1 count is 1.01, marked as equivocal and is said it may indicate early infection.

I have always been careful with sexual contacts and never had cold sores. I was on a few dates with someone and we shared a drink and a kiss 4 days before the test, could it be that I contracted the virus? Does it even make sense to retest?

Dr. Taraneh Razavi said...

If the HSV test was the usual blood test which checks for IgG anitbody (a later stage developing antibody) then it would be unusual for it to turn positive after only 4 days. It is possible to have been exposed in the past but to not develop the cold sores, or it is possible that it was a lab error.

Since about 90% of the population have been exposed to HSV1 and since the finding would not indicate any treatment or behavior change then it would probably just be an unnecessary expense to retest it.

Donald said...

There are different stages that someone may be in where having herpes is concerned. The most immediate is if you have your first active outbreak. The second is you have recurring outbreaks. Thirdly, your outbreaks are currently under control but you know you need more help. Lastly, your blood test is positive but you have never had an outbreak to date.