Testing for Suspected Herpes in an Adult with History of Childhood Genital Warts
For suspected herpes simplex virus (HSV) infection, obtain viral culture or PCR from any active genital, perianal, or oral lesions immediately, as these tests provide definitive diagnosis when lesions are present. 1
Immediate Testing if Lesions Present
- Collect specimens from all vesicular or ulcerative lesions for HSV viral culture or PCR testing, as these are the gold standard diagnostic methods when active lesions exist 1
- PCR has consistently higher HSV detection rates than viral culture and should be considered the preferred test when available 2, 3
- Visual inspection alone is insufficient—HSV can present without typical vesicular lesions in some cases, so specimen collection from any suspicious lesion is essential 1
If No Active Lesions Present
Type-specific HSV-2 serology based on glycoprotein G can detect asymptomatic infection, but has significant limitations including high false-positive rates (50% positive predictive value at 16% population prevalence) and associated psychosocial harms. 2, 4
- The US Preventive Services Task Force recommends against routine serologic screening for genital HSV in asymptomatic persons due to poor positive predictive value and potential for anxiety and distress from false-positive results 5
- If serology is pursued despite these limitations, use only type-specific tests that distinguish HSV-1 from HSV-2, as this affects prognosis and counseling 2
Comprehensive STI Screening Context
Given the history of sexual assault, comprehensive STI testing beyond HSV is warranted:
- Nucleic acid amplification tests (NAATs) for gonorrhea and chlamydia from all sites of penetration or attempted penetration (genital, rectal, pharyngeal as indicated by exposure history) 1, 6
- Serologic testing for syphilis (both nontreponemal and treponemal tests) at baseline and repeat at 6 weeks if initially negative 1, 6
- HIV testing at baseline, with mandatory follow-up at 6,12, and 24 weeks post-assault, as the window period means initial negative results do not exclude infection 1, 6
- Hepatitis B serologic testing if not previously vaccinated 1, 6
Follow-Up Testing Schedule
- Repeat bacterial STI testing at 2 weeks if initial tests were negative and prophylactic treatment was not given, as infectious agents may not produce sufficient concentrations for detection immediately after exposure 1
- Repeat HIV and syphilis serology at 6,12, and 24 weeks after the assault to account for window periods 1
Critical Pitfall to Avoid
Do not rely on a single negative test performed shortly after exposure—the window period for most STIs means early testing serves primarily as baseline documentation, not definitive exclusion of infection 1, 6. Testing too early and stopping there is the most critical error in post-assault STI evaluation 6.
Regarding the Childhood HPV History
The history of childhood genital warts following sexual assault is concerning for past abuse and warrants documentation, but does not affect current HSV testing strategy 1, 7. HPV and HSV are distinct infections requiring separate diagnostic approaches 7.