Q:

5/7/2013
I have a 32 year old female patient with the complaint of intense localized burning beginning immediately following sexual intercourse, lasting up to 5 days. No systemic symptoms. Has also been diagnosed with recurring yeast infections, which clear for awhile following Diflucan orally. Burning occurs during time that patient is supposedly cleared from yeast infection symptoms. Symptoms decreased by use of condoms. All of these symptoms occur only recently, with present partner--whom she wants to marry. She has no history of food allergies, and boyfriend is not taking medications.

Questions:
1. Chance of partner-specific seminal causality?

2. Any other basis for partner specificity, or is this just coincidence?

3. Candida relationship? Is there a plausible rationale for testing with Candida, given its ubiquity? If positive, any support for immunotherapy?

4. Any other suggestions for diagnostic or therapeutic attempts?

A:

Thank you for your inquiry.

We have several entries on our website dealing with seminal fluid allergy. You can access all of these by going to Ask the Expert and typing “seminal fluid” into the search box. For your convenience, I have copied two of the most salient responses relative to your inquiry. As you can see from the responses to these previously submitted questions which were formulated by Dr. Jonathan Bernstein, seminal fluid allergy can be partner-specific in some patients.

Most importantly, these two inquiries discuss the use of skin testing to assess the presence of seminal fluid-specific IgE. I believe that the first course of action would be to try and confirm the presence of specific IgE to seminal fluid by testing, using the procedures noted in these inquiries. Dr. Bernstein also notes in one of his responses that an in vitro test for serum-specific IgE has been offered in his office. You could contact Dr. Bernstein to see if this was still available if the skin test was negative and you wanted further confirmation.

However, based upon your history, I think you should also consider another possible diagnosis, and that is vulvodynia. The description of “intense localized burning” is more suggestive of vulvodynia than seminal fluid allergy, at least as it appears in most instances. Pruritus is usually the most prominent symptom of seminal fluid allergy, and is normally not described as a burning sensation. In addition, the fact that the burning is not eliminated by the use of a condom also is more suggestive of vulvodynia (but does not entirely rule out seminal fluid allergy). Finally, the duration of the pain, lasting up to five days, is more consistent with vulvodynia (but again does not rule out seminal fluid allergy).

In summary therefore, I believe that there are two possible diagnostic entities to account for her symptoms:

1. Vulvodynia.
2. Seminal fluid allergy.

The screening test to confirm seminal fluid allergy is the epicutaneous skin test as described in the entries copied for you below. Dr. Jonathan Bernstein may still offer an in vitro test in his office as well, and I believe he may be still consulting on such patients. If your diagnosis does not become clear, you should consider contacting him in this regard.

Finally, I see no need to pursue testing to Candida.

Thank you again for your inquiry and we hope this response is helpful to you.

Seminal fluid allergy
Question posted 8/10/2012
I saw a 22 year old woman with the classic symptoms of seminal fluid allergy with local swelling and burning starting 3-5 minutes after exposure (no such symptoms if her partner wears a condom) followed by 2 days of painful intercourse. This began soon one week after her first encounter with this partner, with whom she began having sex two months ago. She had a previous partner for 3 years without such symptoms. Before that she had a few sexual encounters without symptoms.

I have read all the information on Ask the Expert and on Medline about this topic. The patient did her own "skin test" by applying the ejaculate on her arm and scratching it with a sterilized needle and the result was positive (erythema, swelling and pruritis)!

My questions are:
1. Should I test her? Must I let the specimen liquefy then centrifuge or can I use the specimen without this preparation and must I 'filter sterilize it', which I do not have the capability of doing in my office?

2. Should I test her partner for HIV, syphilis and hepatitis?

3. Does this mean she will have this problem with all subsequent partners?

4. Should I test her partner to control for irritant responses?

5. If it is negative are there other tests I can do (serum etc...) or must I assume that it is a false negative and that the proteins in the sample are not present in sufficient concentration to elicit a positive response?

6. Is there any more data about cross reactivity with dog allergens?
As always, I appreciate your expertise.

Response:
Thank you for your inquiry.

As you know from reading previous responses to “Ask the Expert” questions regarding seminal fluid allergy, Dr. Jonathan Bernstein is an internationally recognized expert in this disorder. He has published extensively in this area, and therefore I am asking Dr. Bernstein to respond to your inquiry. When we receive his response, we will forward it to you.

Sincerely,
Phil Lieberman, M.D.

We received a response from Dr. Jonathan Bernstein. Thank you again for your inquiry and we hope this response is helpful to you.

Response from Dr. Jonathan Bernstein:
In response to your questions:
1) I would test her by PST to whole seminal fluid. This requires letting the ejaculate liquefy for 30min and centrifuge for 10 minutes to separate Seminal fluid from spermatozoa. I would also test her sexual partner as a negative control. You do not have to sterilize the seminal fluid for prick testing. Intracutaneous testing to whole seminal fluid should not be performed as it will cause an irritant response.

2) Both the patient and her sexual partner should be screened for STD's.

3) Previously she had no problem with other men. This is variable. Some women have trouble with all men whereas other have symptoms with only one.

4) For localized seminal plasma hypersensitivity, skin testing is not always concordant with serologic testing. I have been offering patients the opportunity to send their serum and their sexual partner's serum and a 5 day pooled ejaculate to our laboratory to test for sIgE to whole seminal plasma.

5) There is no additional recent information about cross reactivity between dog allergens and seminal plasma. In our experience with our patients we have not found there to be cross reactivity with dog allergen and PSA.

6) We are recommending that patients with localized seminal plasma hypersensitivity first undergo intravaginal graded challenge; dilute whole seminal fluid with sterile water to 1:100,000 dilution and instill 10 cc of volume intravaginally every 10-15 minutes up to a `1:1 dilution to see if this alleviates symptoms. There are reported cases that this may be effective. If not then she may be a candidate for subcutaneous desensitization to relevant fractionated seminal plasma proteins.

Jonathan Bernstein, M.D.

Previous inquiry and response:
The reference which you should consult regarding the diagnosis and management of seminal fluid hypersensitivity is: The diagnosis and management of anaphylaxis: an updated Practice Parameter. J Allergy Clin Immunol 2005; 115:S483-S523.

I have copied below, for your convenience, the section on "diagnosis." Diagnosis is confirmed by skin testing as is noted in this section.

The Parameters, as you may know, can be obtained online at the website of the Joint Council of Allergy, Asthma, and Immunology. The Parameters are available without charge. The section on "Seminal Fluid Anaphylaxis" begins on Page S511.

There is an extensive section on treatment which follows the section that I have copied for you below.

Dr. Jonathan Bernstein wrote this section, and has just completed authoring a revision for the new Parameters, which has not yet been accepted for publication. Dr. Bernstein is an internationally recognized expert in the diagnosis and management of patients with seminal fluid anaphylaxis, and could serve as a resource for you regarding any specific questions related to the patient you described.

Thank you again for your inquiry and we hope this response is helpful to you.

Quote from the reference cited above:
"Because sensitive specific IgE assays are not readily available, skin prick testing with whole human seminal plasma from the male partner is recommended for initial screening of suspect cases. Before skin testing, the male donor must be screened for viral hepatitis, syphilis, and HIV infection, and if there is evidence of infection, in vivo procedures should not be performed. Whole seminal plasma is prepared from a fresh specimen of ejaculate. Semen is allowed to liquefy at room temperature and centrifuged at 4C to separate seminal plasma containing supernatant from spermatozoa, which is then filter sterilized. 149-151 The male donor is also tested to control for irritant responses. A positive response is defined as a wheal of 3 mm greater than or equal to that produced with saline with a flare and a concomitant negative response in the male donor. Typically, intracutaneous skin testing to whole seminal plasma has not been performed as a screening test in that it has been previously demonstrated to result in a nonspecific irritant response. Therefore screening for seminal plasma hypersensitivity should be limited to skin prick testing to whole seminal fluid. It should be emphasized that protein allergens contained in whole seminal plasma might not be present in sufficient concentrations to elicit a positive response. Thus a negative skin prick test response to whole seminal plasma does not exclude allergic sensitization. In this case skin test reagents with high diagnostic sensitivity should be obtained by means of gel filtration (Sephadex G-100) of whole seminal plasma to isolate allergen-rich fractions. 149-151 Percutaneous or intracutaneous responses to relevant seminal plasma protein fractions have been detected in all reported cases of anaphylaxis. The presence of positive serologic specific IgE antibodies to these fractions and specific skin tests to the same fractions is highly predictive of a successful treatment outcome with seminal plasma protein desensitization.160.”

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology