What is the management approach for a patient diagnosed with mononucleosis?

Management of Mononucleosis

The management of mononucleosis is primarily supportive care, focusing on adequate hydration, analgesics, antipyretics, and appropriate rest guided by the patient's energy level, with avoidance of contact sports for at least 4 weeks after symptom onset to prevent splenic rupture.

Diagnosis and Clinical Presentation

Infectious mononucleosis should be suspected in patients aged 10-30 years presenting with:

• Fever
• Tonsillar pharyngitis
• Lymphadenopathy (particularly posterior cervical or auricular)
• Fatigue (often profound)
• Periorbital/palpebral edema (in about one-third of cases)
• Splenomegaly (in approximately 50% of cases)
• Hepatomegaly (in about 10% of cases)
• Skin rash (erythematous and maculopapular in 10-45% of cases)

Laboratory findings typically include:

• Lymphocytosis (≥50% of white blood cell count)
• Atypical lymphocytes (>10% of total lymphocyte count)
• Positive heterophile antibody test (Monospot)
  • Note: False negatives are common early in infection
  • Consider EBV viral capsid antigen antibody testing if clinical suspicion is high with negative heterophile test

Management Approach

Supportive Care (First-line)

• Adequate hydration
• Analgesics for pain control (acetaminophen, NSAIDs)
• Antipyretics for fever
• Rest as needed, guided by patient's energy level 1, 2
  • Bed rest should not be enforced
  • Activity should be guided by the patient's energy level
  • Excessive bed rest may actually delay recovery 3

Activity Restrictions

• Avoid contact or collision sports for at least 4 weeks after symptom onset 1
• Some guidelines recommend avoiding athletic activity for 3 weeks from symptom onset 4
• Continue activity restrictions while splenomegaly is present 2
• Use shared decision-making to determine timing of return to activity 4

Medications

• Not recommended for routine use:

  • Corticosteroids (insufficient evidence for routine use) 1, 5
  • Acyclovir or other antivirals 1, 2
  • Antihistamines 1

• Exception for corticosteroids:

  • May be beneficial in cases of respiratory compromise
  • May help with severe pharyngeal edema 1
  • Limited evidence suggests possible short-term benefit for sore throat relief at 12 hours, but benefit is not maintained 5

Special Considerations

Immunocompromised Patients

• Higher risk of severe disease and significant morbidity 4
• May develop serious consequences including fatal disseminated disease or diffuse interstitial pneumonia 6
• May require closer monitoring and specialist consultation

Post-transfusion Mononucleosis

• Can occur approximately 1 month after transfusion
• Presents with high fever, often leading to empirical antimicrobial therapy
• Consider when patients with spiking fevers do not respond to antimicrobial therapy or when cultures are negative 6

Complications to Monitor

• Splenic rupture (0.1-0.5% of cases) - potentially life-threatening 2
• Chronic fatigue syndrome - infectious mononucleosis is a risk factor 2
• Prolonged fatigue may persist for several months after acute infection resolves 1

Follow-up and Prognosis

• Most patients have an uneventful recovery 2
• Fatigue, myalgias, and increased need for sleep may persist for several months 1
• Monitor for resolution of splenomegaly before clearing for return to contact sports
• No specific follow-up laboratory testing is required in uncomplicated cases

By following these guidelines, most patients with infectious mononucleosis can be managed effectively with supportive care while minimizing the risk of complications.