A 23-year-old man presents to your clinic with a chief complaint of “rash on private area.” He is healthy at baseline and takes no prescribed medications. He has never been diagnosed with an STI in the past, and states that the rash appeared 2 days ago and is spreading. It is somewhat painful and mildly pruritic. He reports that there were initially fluid-filled “blisters,” but these have all opened and “sores” are remaining. He denies dysuria, fever, or rash elsewhere, but admits to mild, diffuse achiness and fatigue. Over the last year, he has had 4 female sexual partners and engages in both oral and insertive vaginal sexual activity. He admits that he does not always use condoms, and never wears one when receiving oral sex.
On exam, his vital signs are normal and he is in no distress. A chaperoned genital exam reveals approximately 12 to 15 round, erythematous ulcers on the base and shaft of his circumcised penis. There are no remaining vesicles and no urethral discharge; the testicular exam is normal. Both he and you are concerned about primary HSV infection. Which of the following choices represents the best testing and treatment plan for this patient?
a. No testing for HSV should be performed since there are currently no vesicles that can be unroofed in clinic. Treat presumptively for primary HSV with valacyclovir and offer testing for gonorrhea, chlamydia, HIV, and hepatitis B and C.
b. No testing of the lesions is advised since there are currently no vesicles that can be unroofed. Send serum testing for HSV-1 and HSV-2 IgM and IgG. Await test results before beginning therapy.
c. Attempt viral culture by rolling a swab over a few of the open lesions. Treat presumptively with valacyclovir regardless of test results. Offer more thorough STI testing.
d. Send NAAT testing for HSV-1 and HSV-2 by rolling a swab over a couple of the open lesions. Treat presumptively with valacyclovir and notify the patient when his test results return. Offer more thorough STI testing.
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Answer: D. NAAT testing is more sensitive and generally yields quicker results than viral culture. NAAT testing can be performed on open ulcers and does not require fresh fluid from unroofed vesicles. There is a high likelihood of primary HSV infection in this case, beginning antiviral therapy empirically can reduce the duration and intensity of symptoms, and antiviral medications are generally well-tolerated.