What is the treatment for infectious mononucleosis?

Treatment of Infectious Mononucleosis

Infectious mononucleosis is primarily managed with supportive care as there is no specific antiviral therapy proven to alter the course of the disease in immunocompetent individuals. 1, 2

Diagnosis Confirmation

Before initiating treatment, confirm diagnosis with:

• Clinical presentation: Triad of fever, tonsillar pharyngitis, and lymphadenopathy 2
• Laboratory findings:
  • Atypical lymphocytosis (>10% of total lymphocyte count)
  • Heterophile antibodies (Monospot test)
  • If Monospot negative but clinical suspicion high: EBV-specific serology (IgM antibodies to viral capsid antigen) 1, 2

Standard Treatment Approach

First-line Management

• Supportive care:
  • Adequate hydration
  • Analgesics/antipyretics (acetaminophen, NSAIDs)
  • Rest as tolerated (guided by patient's energy level, not enforced bed rest) 2, 3
  • NSAIDs may be particularly effective in patients with atopic predispositions 4

Activity Restrictions

• Avoid contact sports or strenuous exercise for at least 8 weeks or while splenomegaly is present to prevent splenic rupture (occurs in 0.1-0.5% of cases) 2

Monitoring

• Monitor for complications including:
  • Airway obstruction from tonsillar hypertrophy
  • Splenic rupture
  • Neurological complications
  • Hematologic abnormalities 2, 5

Special Circumstances

Severe Symptoms or Complications

• Corticosteroids may be beneficial in cases of:
  • Respiratory compromise
  • Severe pharyngeal edema with potential airway obstruction
  • Massive splenomegaly
  • Hemolytic anemia
  • Thrombocytopenia 1, 3

Immunocompromised Patients

• In immunocompromised patients with severe EBV infection:
  • Consider reducing or discontinuing immunosuppressive therapy if possible 1
  • In severe cases, antiviral therapy with ganciclovir or foscarnet may be considered despite limited evidence 1

What NOT to Do

• Acyclovir is not recommended for routine treatment of infectious mononucleosis in immunocompetent individuals as meta-analyses of clinical trials have shown no benefit 1, 3
• Avoid routine antibiotic use unless there is evidence of bacterial superinfection
• Do not enforce strict bed rest 3

Duration and Follow-up

• Most symptoms resolve within 2-4 weeks
• Fatigue may persist for several months after the acute infection 2, 3
• Follow-up to ensure resolution of splenomegaly before clearing patient for contact sports

Common Pitfalls

1. Misdiagnosing streptococcal pharyngitis as infectious mononucleosis (or vice versa)
2. Prescribing amoxicillin/ampicillin, which can cause a maculopapular rash in EBV-infected patients
3. Failing to counsel patients about the risk of splenic rupture and the need to avoid contact sports
4. Overuse of corticosteroids in uncomplicated cases
5. False-negative heterophile antibody tests early in the course of infection 3