I am a 29 y/Male from Asia. On 21st of June, this year I had a high risk exposure with a Transex csw. I was intoxicated. The exposure involved 1-2 min of oral sex (I received). I used a condom before any contact. This was followed by anal also protected with a condom. (I was the insertive partner) Although we used wb lube the condom tore and I can estimate the time between insertion and discovery of the tear to be about 2-3 minutes. This was followed by changing condom and resuming anal sex. (There was no washing of the penis in between the replacement). There was considerable amount of kissing. For 2-3 minutes, my partner used lube and fingered me. The finger appeared normal w/o visible lesions. She wore a condom and wanted to penetrate placing her penis/genital close to my anus but no insertion. there was negligible or no contact. The condom did not fail and I did not allow insertion.

On the 10th of July, on the 20th day, I felt a slight irritation just inside my anus (perhaps an inch deep or less) while defecating. it was a slight tingling/ticklish feeling. This continued for the next few days, presenting only while defecating or passing wind and occasionally while sitting. The next day I felt a sensitiveness at the tip of my penis just at the urethral opening, it was very slightly inflamed and a little red. No pain while urinating, only slight tenderness and pain when I would touch the tip or it would rub against the cloth. This continued till the 14th of July at which point I noticed dull but light strings of pain in my penis and testicles. But this could be psychological. I also kept squeezing the shaft to observe any discharge and on 4-5 occasions between the 12th and the 16th of July I squeezed out clear white fluid which was transparent and sometimes runny though a little sticky upon rubbing it between fingers. I did not have access to any doctor during this period due to travel in rural areas. It is possible that the discharge resulted from over manipulation and a resultant arousal. I should mention that the inflammation and tenderness at the opening was almost completely gone by the 14th or 15th of July.

In anorectal symptoms I started to feel pain during bowel movement but only during the initial strain and passage. Also as often as seven times a day I would feel a very strong itch inside the anus (to depth 1 inch) and I would have to insert a finger in and feel about for some relief. My finger would often be coated with some white foamish, thread like residue and a bit of blood. This continued till the 22nd of July wen I was advised antibiotics by a doctor by phone. I took Ig Azithromycin and 400g of Cefspan orally in single dose on the 22nd of July. Within a week symptoms all but disappeared. Only an occasional tingle in the anus remains and that too only on 2 or 3 occasions. On the 27th of July, I developed a very painful headache that went in a band around the back of my head and to my temples alongwith intense pain behind the eyes. I also had a stiff neck and pain in the back (upper and lower). Mild nausea continued till the 28th along with this persistent headache. However other than little fever on 27th (99*C), I have not had fever again till today i.e. 3rd of Aug. The persistent headache and neck pain has continued till today everyday throughout 24 hour and exactly in the same location as described above The nausea gone after a couple days, but I had stuffy nose, couple occasions of coughing very tiny amount of blackish mucus, sensation of a possible chest congestion without cough, and a bit of sore throat plus nasal drip and a feeling of upcoming flu for 5 days after the initial attack of headache. I have been taking 400mg Brufen, or one pill exedrine, every day since then to relieve headache. I have also been sleepy, tired, and feeling general fatigued after the 27th and have experiece slight muscle pain too.

On the 1st of Aug, (41 days after the exposure) I took an HIV test with fourth generation ECLIA Cobas 6000 (e601) and also took a RPR test alongwith a complete blood count and LFT. (History: I was diagnosed with Hep E on March 25, 2013 and 'recovered' with near normal LFT on May 15th). The HIV test came back Non Reactive with values of 0.186 (cutoff value 1). The VDRL/ RPR test also came back Non Reactive (Normal). My blood count was also normal except for a low percentage count of eosinophils (at 0.7% with normal being 1-6%). Total WBC was 6.8x10E9/L. My LFT's register a S.Total Bilirubin of 1.2 mg/dl, Direct bilirubin 0.3/mg/dl, and Indirect at 0.9mg/dl (both a little elevated beyond the normal range). My SGPT (ALT) value was a little high also at 51 IU/L.

I had no sexual encounter at all b/w encounter on the 21st of June till today. Before the encounter on the 21st, Only 2 occasions in last seven months where I might have receive protected oral sex from trans csw's. other than that no sex exposure whatsoever.

Questions:

1) Is the HIV test and the RPR test conclusive evidence that I am in the clear for HIV and syphilis? I was advised to wait 6 weeks, but have read on the internet that not only is it inconclusive in terms of window period but that RPR tests are prone to false negative in the secondary stage of syphilis. How confident should I be that I have neither Syphillis and/or HIV? Please advise according to facts.

2) What could be the possible cause of these symptoms. These headaches have neither ceased nor lessened. They are quite intense. Are these symptoms consistent with Genital Herpes? There are no marks, ulcers, lesions, pimples, or any other abnormal spots etc anywhere on visible skin around the groin area or any other place. Even the skin around the anus is clear. This has been the case from the first time I noticed tenderness on penis tip. I have also neither any groin pain or pain in the trunk/thighs/legs etc. Neither I ever had fever other then very slight one on the 27th as explained above.

3) Regardless of whether the symptoms suggest Herpes of any variety or not, I would like to rule it out. I am told that a swab in the affected area is the most reliable method for HSV detection but unfortunately my anorectal 'condition' has vanished and I had no access to a health care provider while the symtoms existed. I understand that the serum testing for HSV-1 and 2 can be complicated. In my city, I have access to an IGM test for Herpes and some test called Herpes Igg without specifying HSV 1 or 2. There is also a HSV-1 and HSV-2 by PCR test but I am told this requires CSF testing. Under these circumstances what test should I go for and what is the appropriate window period. If I went for an HSV IGg test at 45 days, will that be sufficient in ruling out HSV or confirming it?

4) How does Herpes of either variety affect the anal area w/o receptive anal? Is it possible for the virus to enter through the penis but break out in the rectum? Is it possible for the virus to be transferred by fingering to the anus? Does the area of break out necessarily have to be the point of entry of the virus?

5) Is there any point in an anal swab taken at day 45 (6th August) given that the anorectal symtpoms have not occurred from the 30th of July?

6) Could you suggest what are other possible causes of these symptoms? what other STI's that cause symptoms of meatus, proctitis, and the sort of headache/muscle pain/mild flu symptoms in the time frame and order of progression I have described? Can chlamydia cause both proctitis and meatus if it only entered through the penis. Can chlamydia and gonorrhea be transferred by fingering? What about chancroid, HPV or LGV? Are these symptoms consistent with those?

7) Finally what are the chances that these symptoms or some of them are either the result of my earlier hepatitis or a newly acquired Hepatitis that may have occurred in this episode?

Thankyou so much for your time
Zaz85