Prologue:
Have you always heard when your doctor tells you that your tests were all negative but you still have symptoms? They try to convince you that your symptoms are all in your head? Well this a short story about my patient who had something similar. Let’s call her “Lucky”.
The Story:
I encountered a patient named Lucky in April 2018 who has been to so many doctors and had been tested for many investigations. Her multiple doctors told her that her tests were normal despite still having symptoms. One doctor even referred her to a psychiatrist with diagnosis of “anxiety disorder & depression” which is inducing the symptoms..
Lucky came to me on a Sunday and she had a frown on her face like she had something which wore her down. I took a glass of water and we had a little chat just to lighten the mood. So when she had felt much better I started to probe her problem. She is already married but still she developed some discomfort during urination and an ulcer at her vulva. The ulcer is painful and she was tested for Gonorrhea, Chlamydia, Syphilis, HIV, Hepatitis A and Hepatitis B, which blood was taken in another clinic. The test was negative. She was told that she has not gotten any sexually transmitted disease and her ulcer is because she was scratching the vulva until it became ulcerated.
Then she went to another clinic because she still had symptoms and she wanted a second opinion. The clinic took the same test via blood and this time took additional test for Herpes 1 (affecting the mouth) and Herpes 2 (affecting the genital), which was also negative. She was given Augmentin as she was treated skin infection, then told to wait for 1 week for the medication to take effect. A week passed and then there was no improvement.
She then went to a Third clinic who the doctor treated her as syphilis and injected her with Antibiotics once. Even with the Antibiotics given that was little effect to the ulcer. On follow-up she had persistent symptoms and she was dismissed and referred for Anxiety disorder and depression. An itch and white discharge started developing at her privates as a new symptom.
Later on she went for another two more consults at the urologist and gynecologist where her blood was repeated for HIV, Syphilis, Hepatitis A and Hepatitis B. The gynecologist took a high vaginal swab and turned out that it was a bacteria called E. Coli. She was treated again with Augmentin and her leucorrhea was effectively treated but her lesions were still not healing.
Over the period of 2 months she has seen about 4 clinics and 2 specialist clinics. Looking at her results there was definitely something wrong and we are not detecting the problem.
Based on her symptoms she does not seem to have syphilis as the hallmark for syphilis is an ulcer with a central yellowish fluid accumulation and a painless ulcer. Despite she had blood testing for gonorrhea, chlamydia and herpes I was sure that is not informative as the blood test shows only immunity of the person to the bacteria or virus. In cases where the level of the antibody is low still does not rule out disease or if the level is high does not show that there is an ongoing disease in cases where the person has been infected previously with the disease.
Well she is a married woman and she claimed that she has sex with only her husband but she did have sexual intimacy before getting married with her previous boyfriends about 5 years ago. Despite using the condom with her ex-boyfriends she suspects that they may have infected her or worst case scenario is that her husband is cheating on her. When it comes to Sexually Transmitted Diseases in married couples, as a doctor I am always very cautious about these cases because anything the doctor says will make or break the marriage.
Previously I had doctors who will say bluntly to the patient and without a word of caution, end up accusing the partner for cheating. If I do not have any evidence, then it is best to just shut up rather than to antagonize the patient. Some people really delight in these dramas.
Clinically Lucky’s symptoms looks more like Herpes. Classical symptoms of vesicles over the vulva is painful and it burst into ulcers and scabs off. It tends to get worse if there are other evidence of vaginitis or urinary tract infections. In her case she has vaginitis and leucorrhea (whitish discharge from the vagina) 1 month before she had herpetic symptoms. Other infections can lower the skin’s resistance and sometimes other infections like herpes can set in easily.
To salvage the suspicion of the wife that the husband may be cheating on her, I explained to her that Herpes is a common disease in 80% the world’s population. Even a person who has never had sex before can get Herpes. Herpes is easily transmitted via skin to skin contact for example skin brushing against another person, kissing, holding hands or even wrestling. It does not necessary need to be transmitted through sex. There are three types of Herpes Simplex Virus (HSV): HSV 1 (affecting the oral region), HSV 2 (affecting the genital) and Disseminated HSV. HSV 1 can transform and become HSV 2 through skin contact and oral fellatio. Disseminated HSV is eruption of herpetic lesion over the entire body which is very rare.
When the Control of Disease Center put a lot of thought into considering if Herpes is a sexually transmitted disease or a skin disease. It was convenient to classify herpes as a skin disease which leads to sexually transmitted diseases because it can cause lesions over the genitals. In short Herpes is skin disease can be considered as a sexually transmitted disease if the infection if transmitted via sex.
I managed to get a swab sample for Herpes PCR which is 100% sensitive if the swab is taken over the lesion. There is a false negative if the swab is taken at a site which does not have an active lesion because herpes is localized. In short you may be tested negative for herpes if you do not have symptoms but it does not rule out than you do not have herpes. Infectious diseases history, timing, technique to take the sample and to interpret the result leads to diagnosis.
I gave her Acyclovir for Herpes and within 5 days the lesion totally recovered. Her results for swab PCR came back positive for Herpes type 2, which is consistent to her symptoms and history.
Conclusion:
In our world of medicine clinical skills are undermined and most doctors trust laboratory test results rather than to trust their clinical skills and knowledge. In this particular case the patient was tested for herpes antibody (blood) in another clinic but was negative. The doctor dismissed the possibility that the test may be a false negative instead of using their clinical skills and did not treat Lucky as Herpes. Always talk to a doctor before making the right decision together and ask if you have any doubts.