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Chances of HIV/HERPES transmission with RASH, TYPE-I DIABETES.

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ME: mid 40 yrs old female, type 1 diabetic diagnosed in 2008, last tested for STDs in Dec 2013 (including herpes and HIV) results negative, status of male partner unknown

PROBLEM: Had unprotected sex with a man 48 days ago (engaged in oral and vaginal without ejaculation); 4 days later felt tingling in genital area; have had a couple of minor headaches between then and now; 12 days after tingling in vaginal area, one tiny sole blister appeared near groin on my upper right thigh (it was the size of the top of a pin and had a white head; I did not touch it), next day it was gone; experiencing mild intermittent pain in my right armpit, but feel no swelling; left side of my groin has mild pain, but feel no swelling; as days pass, mild tingling still persists but no sign of outbreaks until day 44 where in the same area I got the aforementioned blister, a group of what I would called bumps/pimples sprouted. The skin beneath had some redness. It wasn't really itchy though. Within 8-12 hours, the bumps/pimples were gone. Today (9/5/14) this same area was mildly itchy and a red rash appeared where those bumps/pimples were a few days ago. The rash is mildly sore.

QUESTIONS: -What are the chances that this is genital herpes?
-If a man has genital herpes and a woman gives him oral, can she get oral herpes?
-What are the chances of HIV transmission unprotected male to female without
ejaculation?
-Since I am a type 1 diabetic, would I display symptoms sooner or later than the
average healthy person? Would it take longer for the antibodies to show up in my
system for both herpes and HIV?
-Can symptoms for genital herpes present themselves individually (for instance if I
only experience mild tingling, itching, and short lived breakouts, but not open,
weeping sores or ulcerations, and no flu-like symptoms)?

Category: Sexually Transmitted Diseases(STD)Specialist

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Category: HIV- AIDS Specialist
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Hello.
Thank you for your query at DoctorSpring.com.

I have gone through your history in detail and understand your concern.
Your symptoms of tingling in the vagina, headaches and pain in the armpit all do not indicate any STD. Rather, tingling in the genitalia is usually observed post-sexual exposure in persons anxious about STDs. So please do not worry about it. The headaches and pain in the armpit are not specific to any STD either and are nothing to worry about.

As for the rash in the groin which started as a pimple, it seems likely to be folliculitis (bacterial infection of the hair follicle).

Now let me answer your questions individually.

-What are the chances that this is genital herpes?
This is unlikely to be Herpes. Your presentation is, like you know, not classical. The only point in favour of Herpes is that the lesions have occurred at the same site but this can happen with Folliculitis too.

-If a man has genital herpes and a woman gives him oral, can she get oral herpes?
Yes, she can.

-What are the chances of HIV transmission unprotected male to female without
ejaculation?
Whether ejaculation happened or not is not significant for calculating HIV risk. The exact percentage cannot be given but most studies have shown a HIV transmission risk of around 0.1 % through unprotected receptive (male to female) vaginal intercourse.

-Since I am a type 1 diabetic, would I display symptoms sooner or later than the average healthy person? Would it take longer for the antibodies to show up in my
system for both herpes and HIV?
You would be symptomatic at around the same time as an average healthy person. Antibody production against infectious diseases is not affected in Diabetes. So it would not take longer. In Diabetes, the immune system is not deficient but certain local and other factors are responsible for increased tendency for infections.

-Can symptoms for genital herpes present themselves individually (for instance if I only experience mild tingling, itching, and short lived breakouts, but not open,
weeping sores or ulcerations, and no flu-like symptoms)?
Symptom severity and presentation of Herpes may vary between individuals but a presentation like yours in uncommon.

The only way to conclusively rule out Genital Herpes is to get tested. You can get serologic testing for HSV or a HSV PCR Assay (Herpes Simplex Virus- Polymerase Chain Reaction Assay) done. Meanwhile, you can apply an OTC antibiotic like Neosporin ointment on the affected area, 2-3 times daily until resolution.

I hope this was helpful. Feel free to ask queries.

Thank you.


Patient replied :

Thank you Dr. Sebastian for your time and your answers to my questions. I plan to get tested after 90 days in order for me to get conclusive results.
As a follow up to my questions could you please take a look at my photos and see if they resemble genital herpes? I can't attach them to this email for some reason, but I have sent them to the email [email protected] with the Order ID/consult "223386"
There are 4 photos to review. I would really appreciate you insight on what you think these photos may show.
Thank you very much.


Hello.
Thank you for your response.

I forgot to add that I have gone through your pictures. Based only on your symptoms, I had a differential diagnoses of Folliculitis, Candidiasis (fungal infection) or genital Herpes. After having a look at the images of the skin lesion, folliculitis seems more likely and I gave my opinion as the same.
You need not wait for 90 days, if you are getting a HSV PCR Assay.
Even Rapid serologic testing can be done now. The rapid test has a sensitivity and specificity of 97 and 98 percent, respectively, and positive and negative predictive values of 92 and 99 percent, respectively; meaning it is highly accurate. In the presence of an active infection, HSV IgM will be postive. IgG antibodies take longer to develop and may not be positive but IgM should be positive for you, if you have Herpes.

Let me know if I can assist you any further.
Thank you.


Patient replied :

Dr. Sebastian, if I may ask these final questions please:
Please forgive me and I apologize if I am misunderstanding your words, but I have heard IgM tests are a waste of time and money because they don't tell if it is HSV1 or 2 among other things. I'd read that the IgG tests are way more reliable. Are you suggesting I get the IgM too?
Also to ask about your answer about the HIV male to female transmission.....you gave a percentage rate of 0.1%. Is that with or without ejaculation? I have read all different percentage rates from 0.05-0.19%....and it being one or the riskiest ways to transmit HIV, I was understandably concerned. Could you also give your opinion on an unprotected one time exposure risk? I'd read that an infected male could infect a female 1 in 1000 encounters whereas that risk in cut in half for a female to male transmission.
And lastly, I know you are not an endocrinologist, but have you heard that Type 1 diabetics can suffer from something called Vaginal Paresthesia (tingling in the vagina), and do you think I could be suffering from that?
Thank you


Hello.

No, I am not suggesting that you get an IgM test done. I apologize that I was not clear enough.
I had suggested the HSV2 - PCR Assay or a Rapid serological test, either of the two.
The currently available rapid tests are either specific for HSV2 alone or a combination kit with individual tests for both HSV1 and HSV2. So these tests are type specific.
One such test is the POCkit HSV-2 Rapid Test. You can get it done even now as it is quite sensitive and can pick up an infection as early as two weeks post exposure and at 4 weeks, it is even more sensitive.
Its overall sensitivity and specificity is more than 90 %. This detects not only the IgG antibody which appears late but also the HSV2 IgM antibody, produced early in the infection, against the virus's surface glycoprotein. This is what I meant when I said IgM can be positive in a scenario like yours.
When you say IgM test being useless, you are probably referring to the older enzyme immuno-assay tests which are no longer recommended. However, none of the currently available and clinician recommended tests for Herpes are useless.

There are currently no clear cut and 100% reliable studies on HIV transmission risk. Various studies quote a range of percentages. I had given you an average which also means to say that the chance of an infected male infecting a female is about 1 in a 1000 encounters. This risk can be of concern but statistically it is quite low. I had mentioned previously that the occurrence of ejaculation or its absence was not considered. This was not a variable in the studies. So I cannot comment whether it is with or without ejaculation.
Regarding infected female to male transmission being carrying half the risk compared to the other way around, a few studies have reported such an occurrence.
If you are worried about HIV as well, you can get a 4th generation antigen - antibody combined HIV test. This can be done as early as 3 weeks post exposure. A negative after 6 weeks is practically conclusive as well.

Vaginal Paresthesia is unlikely in your case since you seem to have developed this symptom only after the sexual act. So rom my experience and in my opinion, it is more likely to be a psychosomatic symptom rather than a clear neurological one.

Thank you.


Dr. Jaydeep Tripathy
Category: HIV- AIDS Specialist
Experience: 
MBBS from Sri Ramachandra University in December 2011
M.Med (Family Medicine) - TNMGR University, Chennai
MBA-MPH in Public Health in March 2016, SRM University
Finished AFIH in March 2016, SRM University
MRCP ( UK ), Internal Medicine, Royal College of Physicians, June 2016
Fellowship in Diabetology from Martin Luther University in January 2017

Currently Resident Physician, in MD Radiodiagnosis - Kamakshi Memorial Hospital, Chennai
Dr. Jaydeep Tripathy and 4 other Medical Specialists are ready to help you

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