What is the best treatment for mononucleosis?

Best Treatment for Mononucleosis

The best treatment for infectious mononucleosis is supportive care, including adequate hydration, analgesics, antipyretics, and appropriate rest guided by the patient's energy level. 1, 2, 3

Diagnosis Confirmation

Before initiating treatment, confirm the diagnosis with:

• Complete blood count with differential (looking for >40% lymphocytes and >10% atypical lymphocytes)
• Heterophile antibody test (Monospot test)
  • Note: False negatives may occur in children <5 years and adults in the first week of illness 3
• If Monospot is negative but clinical suspicion remains high, check EBV viral capsid antigen (VCA) antibodies 3
• Liver function tests (elevated enzymes support diagnosis)

Supportive Care Protocol

1. Pain and Fever Management

   • Acetaminophen or NSAIDs for fever and pain relief
   • Adequate hydration to prevent dehydration
   • Throat lozenges or warm salt water gargles for sore throat

2. Rest Recommendations

   • Rest as needed based on energy levels
   • Avoid enforced bed rest 1
   • Gradual return to normal activities as symptoms improve

3. Activity Restrictions

   • Avoid contact sports or strenuous exercise for at least 4-8 weeks to prevent splenic rupture 1, 2
   • Continue restriction while splenomegaly is present 2

Special Considerations

Airway Compromise

In rare cases of severe pharyngeal edema or respiratory compromise, corticosteroids may be considered:

• Prednisone 1-2 mg/kg/day for short duration 4
• Monitor closely for adverse effects

Antiviral Therapy

• Antiviral agents (acyclovir, valacyclovir) are not recommended for routine treatment 5, 3
• A Cochrane review found insufficient evidence for their effectiveness in infectious mononucleosis 5
• Viral shedding may be suppressed during treatment but rebounds after discontinuation 5

Immunocompromised Patients

• Patients with immunosuppression require closer monitoring
• Higher risk for severe disease and complications 2
• May develop serious consequences including disseminated disease 6

Monitoring and Follow-up

1. Clinical Monitoring

   • Follow symptoms weekly until resolution
   • Most symptoms resolve within 2-3 weeks, though fatigue may persist longer 4

2. Complications to Watch For

   • Splenic rupture (0.1-0.5% of cases) - most serious complication 2
   • Hepatomegaly (occurs in ~10% of patients) 2
   • Persistent fatigue (may last several months in some patients) 1

Patient Education

• Inform patients that fatigue may persist for several months 1
• Emphasize the importance of avoiding contact sports during recovery
• Reassure that most patients have complete recovery without long-term sequelae
• No special precautions needed to prevent transmission due to high EBV seropositivity in the population 4

Common Pitfalls to Avoid

1. Unnecessary Antibiotic Use

   • Antibiotics are ineffective against viral infections
   • Amoxicillin can cause rash in EBV infection, potentially leading to misdiagnosis of drug allergy

2. Premature Return to Contact Sports

   • Can lead to splenic rupture, the most feared complication 2

3. Overuse of Corticosteroids

   • Should be reserved for specific indications like severe pharyngeal edema
   • Routine use not supported by evidence 4, 3

4. Overreliance on Antiviral Medications

   • Despite theoretical benefits, clinical evidence does not support routine use 5