What is the inpatient management of acute mononucleosis?

Inpatient Management of Acute Mononucleosis

Supportive care is the cornerstone of inpatient management for acute mononucleosis, with corticosteroids reserved only for specific severe complications such as airway obstruction. 1, 2

Admission Criteria and Initial Assessment

Hospitalization for infectious mononucleosis is typically warranted for:

• Impending or actual airway obstruction
• Severe dehydration
• Significant organ complications (splenic rupture, severe hepatitis, etc.)
• Neurological complications
• Hematological complications (severe thrombocytopenia, hemolytic anemia)
• Inability to maintain oral intake

Initial Evaluation

• Assess airway patency and respiratory status immediately
• Evaluate for signs of dehydration and hemodynamic stability
• Examine for complications: hepatosplenomegaly, neurological deficits, severe pharyngeal edema
• Laboratory assessment: complete blood count with differential (looking for >10% atypical lymphocytes), liver function tests, heterophile antibody test 1

Treatment Algorithm

1. Supportive Care (Primary Management)

• Adequate hydration (IV fluids if unable to maintain oral intake)
• Analgesics and antipyretics for pain and fever control
• Rest as tolerated (activity guided by patient's energy level)
• Monitor vital signs and airway status regularly 1, 2

2. Management of Specific Complications

Airway Obstruction

• Corticosteroids: Only indicated for significant tonsillar hypertrophy with impending airway obstruction
  • Prednisone or methylprednisolone (dosing based on severity)
  • Short course only (3-5 days) to minimize risk of complications 3, 4
• Continuous airway monitoring
• Potential need for airway intervention in severe cases

Hematologic Complications

• For immune-mediated anemia or severe thrombocytopenia:
  • Consider short-course corticosteroids
  • Monitor blood counts closely 3
• Transfusion support if clinically indicated

Splenic Complications

• Strict bed rest for patients with significant splenomegaly
• Serial abdominal examinations to monitor spleen size
• Immediate surgical consultation for suspected splenic rupture (0.1-0.5% of cases) 1
• Advise against contact sports or strenuous exercise for at least 8 weeks after discharge 1, 2

Neurological Complications

• Neurological monitoring for patients with CNS involvement
• Seizure precautions if appropriate
• Note: Corticosteroids may be beneficial in selected patients with neurological complications, though evidence is limited 5, 3

3. Antiviral Therapy

• Not recommended for routine treatment of infectious mononucleosis
• Acyclovir and other antivirals have shown no significant benefit in immunocompetent patients with uncomplicated infectious mononucleosis 5, 2, 6
• Acyclovir inhibits EBV replication in vitro but meta-analysis of clinical trials shows no benefit in treatment 5

Important Considerations and Pitfalls

Corticosteroid Use - Exercise Caution

• Do not use corticosteroids routinely for symptom control in uncomplicated cases
• Prolonged steroid therapy can lead to severe complications including secondary infections 4
• Reserve for specific indications: significant airway obstruction, severe hematologic complications, or selected neurological complications 3, 2

Monitoring During Hospitalization

• Daily assessment of:
  • Airway patency and respiratory status
  • Hydration status
  • Spleen size
  • Neurological status
  • Laboratory parameters as indicated

Discharge Planning

• Patients can be discharged when:

  • Airway is stable
  • Adequate oral intake is maintained
  • Complications are resolving
  • Patient and family understand activity restrictions and follow-up needs

• Clear instructions regarding:

  • Activity restrictions (no contact sports for 8 weeks or while splenomegaly persists) 1
  • Signs and symptoms that warrant return to medical care
  • Expected duration of fatigue (may persist for several months) 2

Special Considerations for Immunocompromised Patients

In immunocompromised patients with EBV infection:

• More aggressive monitoring may be needed
• Consider EBV viral load monitoring 6
• Higher risk for progression to lymphoproliferative disorders 5
• Reduction of immunosuppression when possible 5

Remember that most cases of infectious mononucleosis resolve spontaneously without specific antiviral therapy, and the focus should be on supportive care and managing complications when they arise.