What is the recommended dose of prednisone (corticosteroid) for infectious mononucleosis (mono) with sore throat and tonsillitis?

Prednisone Dosing for Infectious Mononucleosis with Sore Throat and Tonsillitis

A single dose of corticosteroids (30-40 mg of prednisone daily for a short, finite period) can be considered in adult patients with severe presentations of infectious mononucleosis with sore throat and tonsillitis, particularly when there is significant pharyngeal edema or respiratory compromise.

Indications for Corticosteroid Use

Corticosteroids are not routinely recommended for the treatment of infectious mononucleosis but may be beneficial in specific situations:

• Severe pharyngeal edema
• Respiratory compromise
• Significant difficulty swallowing
• Severe tonsillitis with marked inflammation

Evidence-Based Approach

The 2012 European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidelines for management of acute sore throat state that corticosteroids can be considered in adult patients with severe presentations, particularly those with 3-4 Centor criteria 1. However, they are not recommended for routine use.

Dosing Recommendations

When corticosteroids are indicated for severe symptoms:

• Initial dose: 30-40 mg of prednisone daily 1
• Duration: Short, finite period (typically 3-5 days)
• Administration: Single morning dose
• Tapering: Generally not required for short courses

For severe cases with respiratory compromise or marked tonsillar swelling:

1. Consider a single dose of corticosteroids in conjunction with appropriate supportive care
2. Monitor closely for improvement of symptoms
3. Discontinue after resolution of severe symptoms

Important Considerations

Potential Benefits

• Reduction in pharyngeal inflammation
• Decreased pain and discomfort
• Improved ability to maintain oral hydration
• Prevention of airway compromise in severe cases

Potential Risks

• May prolong viral shedding
• Possible masking of bacterial superinfection
• Short-term side effects (hyperglycemia, mood changes)

Supportive Care (Always Required)

• Adequate hydration
• Analgesics (ibuprofen or acetaminophen) for pain control 1
• Rest as needed (guided by patient's energy level) 2

Special Considerations

1. Antibiotics: Not routinely indicated unless bacterial superinfection is suspected 1

2. Monitoring: If corticosteroids are used, monitor for:

   • Improvement in swallowing and respiratory status
   • Signs of bacterial superinfection
   • Adequate oral intake

3. Safety: A retrospective cohort study found that systemic corticosteroids during EBV-induced infectious mononucleosis were generally safe, especially when used with concomitant antibiotic therapy for suspected bacterial superinfection 3

4. Evidence limitations: Cochrane reviews note insufficient evidence to routinely recommend steroid treatment for symptom control in glandular fever, with heterogeneous and sometimes poor-quality trials 4

When to Avoid Corticosteroids

• Mild to moderate symptoms without airway compromise
• Known contraindications to corticosteroid use
• Suspected bacterial infection without appropriate antibiotic coverage

While the evidence for routine use of corticosteroids in infectious mononucleosis is limited, they may be beneficial in carefully selected patients with severe symptoms, particularly when there is significant tonsillar inflammation causing respiratory symptoms or difficulty swallowing.