What is the recommended treatment for mononucleosis?

Treatment of Infectious Mononucleosis

Infectious mononucleosis requires primarily supportive care, as antiviral therapy with acyclovir does not improve outcomes in otherwise healthy individuals. 1

Diagnosis Confirmation

Before initiating treatment, confirm the diagnosis with:

• Complete blood count with differential (looking for >40% lymphocytes and >10% atypical lymphocytes) 2
• Heterophile antibody test (Monospot) - sensitivity 87%, specificity 91% 2
• Consider EBV viral capsid antigen (VCA) IgM antibody testing if Monospot is negative but clinical suspicion remains high 3

First-Line Treatment Approach

Supportive Care

• Adequate hydration
• Analgesics and antipyretics for fever and pain control
• Rest as tolerated (activity guided by patient's energy level) 4
• Avoid contact sports or strenuous exercise for at least 3-8 weeks or while splenomegaly is present 5, 2

What NOT to Use Routinely

• Acyclovir and other antivirals (no proven benefit) 1, 6
• Corticosteroids (not recommended for routine treatment) 4
• Antihistamines (not recommended) 4

Special Circumstances

Severe Airway Obstruction

• Corticosteroid therapy may be indicated for severe pharyngeal edema or airway obstruction 1, 4
• This is one of the few scenarios where the benefits of steroids may outweigh potential risks 6

Immunocompromised Patients

• Require closer monitoring as they are at higher risk for severe disease 2
• In severe primary EBV infection in immunocompromised patients, consider:
  • Reduction or discontinuation of immunomodulator therapy if possible 1
  • Ganciclovir or foscarnet may be considered (more potent than acyclovir for EBV) despite limited supporting evidence 1

Monitoring and Complications

Monitor for Complications

• Splenic rupture (0.1-0.5% of cases) - most feared complication 5, 3
• Neurological complications
• Hematologic abnormalities
• Hepatic involvement (elevated liver enzymes common) 2

Expected Recovery Timeline

• Most symptoms resolve within 2-4 weeks
• Fatigue may persist for several months 4
• Most patients have complete recovery without long-term sequelae 5

Patient Education

• Inform patients that infectious mononucleosis is self-limited but may take weeks to fully resolve
• Advise about avoiding contact sports due to risk of splenic rupture
• Explain that fatigue may persist for months after other symptoms resolve
• Reassure that most patients recover completely without specific antiviral treatment

Pitfalls to Avoid

1. Unnecessary prescription of antibiotics (ineffective against viral illness)
2. Routine use of corticosteroids outside of specific indications like airway obstruction
3. Premature return to contact sports (risk of splenic rupture)
4. Failure to recognize EBV infection in immunocompromised patients, where it can lead to more severe outcomes including lymphoproliferative disorders 1