What are the differences in management between acute and convalescent mononucleosis (mono)?

Management of Acute vs Convalescent Mononucleosis

The management of infectious mononucleosis differs significantly between the acute and convalescent phases, with acute management focusing on supportive care and symptom relief while convalescent management emphasizes gradual return to activity and monitoring for potential complications.

Acute Phase Management

Diagnosis and Initial Assessment

• Suspect infectious mononucleosis in patients 10-30 years old presenting with:

  • Sore throat and significant fatigue
  • Posterior cervical or auricular lymphadenopathy
  • Palatal petechiae
  • Fever 1

• Laboratory confirmation:

  • Atypical lymphocytosis ≥20% or atypical lymphocytosis ≥10% plus lymphocytosis ≥50%
  • Positive heterophile antibody test (Monospot) 1
  • If Monospot is negative but suspicion is high, test for EBV-specific antibodies (VCA IgM and IgG, EBNA) 2

Supportive Care

• Adequate hydration and nutrition
• Analgesics and antipyretics for fever and pain control
• Rest as needed, but not enforced bed rest 1, 3
• Allow patients to be out of bed as soon as they feel able (improves recovery time) 3

Activity Restrictions

• Withdraw from contact or collision sports for at least 4 weeks after symptom onset 1
• Avoid activities that might increase risk of splenic injury while splenomegaly is present (approximately 50% of cases) 4

Medications

• Corticosteroids are not recommended for routine treatment of infectious mononucleosis but may be beneficial for severe complications such as:

  • Respiratory compromise
  • Severe pharyngeal edema 1
  • Neurological complications 2

• Acyclovir and antihistamines are not recommended for routine treatment 1

• No evidence that drug therapy shortens recovery time 3

Monitoring for Complications

• Monitor for signs of:
  • Splenic rupture (0.1-0.5% of cases) - left upper quadrant pain, Kehr's sign 4
  • Airway obstruction from tonsillar enlargement
  • Hepatitis (elevated liver enzymes)
  • Neurological complications

Convalescent Phase Management

Duration and Expectations

• Acute symptoms typically resolve in 2-3 weeks 5
• Fatigue, myalgias, and increased need for sleep may persist for several months 1, 4
• Patients should be informed that prolonged fatigue is common but usually self-limiting

Activity Resumption

• Gradual return to normal activities guided by the patient's energy level 1
• Continue to avoid contact sports for a total of 8 weeks or while splenomegaly is present 4
• Physical activity should be increased gradually rather than abruptly

Monitoring and Follow-up

• Follow-up to assess resolution of lymphadenopathy and splenomegaly
• No need for routine repeat laboratory testing if symptoms are resolving
• Consider evaluation for chronic fatigue syndrome if fatigue persists beyond 3 months 4

Risk Factors for Prolonged Recovery

• Poor physical functioning and lengthy initial convalescence
• Being less physically fit or active prior to illness 3
• Consider more active support and monitoring for patients with these risk factors

Key Differences Between Acute and Convalescent Management

1. Focus of care: Acute phase focuses on symptom relief and preventing complications; convalescent phase emphasizes gradual return to normal activities and monitoring for persistent symptoms

2. Activity level: Acute phase requires more rest and strict avoidance of contact sports; convalescent phase allows progressive increase in activity based on patient tolerance

3. Monitoring: Acute phase requires monitoring for potentially serious complications; convalescent phase focuses on monitoring recovery progress and watching for chronic sequelae

4. Duration: Acute phase typically lasts 2-3 weeks; convalescent phase may extend for several months

Common Pitfalls to Avoid

• Enforcing strict bed rest, which may prolong recovery 3
• Premature return to contact sports, risking splenic rupture
• Overlooking persistent symptoms that may indicate complications
• Unnecessary use of corticosteroids, acyclovir, or antibiotics in uncomplicated cases
• Failing to counsel patients about the potentially prolonged nature of fatigue symptoms

Remember that infectious mononucleosis is generally a self-limited disease with good outcomes, but appropriate management of both phases is essential to minimize complications and optimize recovery.