What is the treatment for Luke's infectious mononucleosis due to Epstein-Barr Virus (EBV)?

Treatment of Infectious Mononucleosis due to Epstein-Barr Virus (EBV)

Supportive care is the mainstay of treatment for infectious mononucleosis due to EBV, as there are no approved antiviral drugs effective against EBV infection. 1

Diagnosis Confirmation

• Look for classic triad: fever, tonsillar pharyngitis, and lymphadenopathy 2
• Laboratory findings:
  • Complete blood count showing lymphocytosis (≥50% lymphocytes)
  • Atypical lymphocytes (>10% of total lymphocyte count)
  • Heterophile antibody testing (Monospot test) - most widely used initial test 2
  • If Monospot negative but clinical suspicion high, order EBV-specific antibody testing (viral capsid antigen IgM/IgG) 3

Treatment Algorithm

First-Line: Supportive Care

1. Adequate hydration
2. Rest as tolerated (guided by patient's energy level, not enforced bed rest) 4
3. Antipyretics for fever control
4. Analgesics for pain management
5. Avoid contact sports or strenuous exercise for 8 weeks or while splenomegaly is present 2

Special Circumstances

• Significant tonsillar hypertrophy with airway compromise: Consider corticosteroids 1
• Immunocompromised patients:
  • Monitor EBV viral load
  • If significant EBV DNA-emia: Consider rituximab 375 mg/m² weekly until EBV DNA-emia negativity 1
  • Reduce immunosuppression when possible 1

NOT Recommended for Routine Treatment

• Antiviral drugs (acyclovir, ganciclovir) - ineffective against latent EBV 5, 1
• Corticosteroids - except for specific complications 4
• Antihistamines 4

Monitoring and Follow-up

• Monitor for potential complications:
  • Splenic rupture (0.1-0.5% of cases) - most feared complication 2
  • Neurological complications
  • Hematologic abnormalities (thrombocytopenia)
  • Hepatitis (elevated liver enzymes occur in ~90% of patients) 4

Special Considerations

• Prolonged fatigue may persist for several months after acute infection 4
• Return to sports: Wait at least 3-4 weeks from symptom onset; longer if splenomegaly persists 3
• Immunocompromised patients are at higher risk for severe disease and complications 3
• In patients with inflammatory bowel disease on immunomodulators who develop EBV infection:
  • Consider reducing or discontinuing immunomodulator therapy 5
  • In severe cases, consider ganciclovir or foscarnet despite limited evidence 5

Clinical Pitfalls

1. False-negative heterophile antibody tests are common early in infection course - consider repeating test if high clinical suspicion 4
2. Enforcing strict bed rest is unnecessary and not recommended - activity should be guided by patient's energy level 4
3. Premature return to contact sports increases risk of splenic rupture - ensure proper counseling 2
4. Overlooking EBV in immunocompromised patients - can lead to post-transplant lymphoproliferative disorders (PTLD) requiring more aggressive management 5, 1

The vast majority of EBV infectious mononucleosis cases resolve spontaneously with supportive care alone, though fatigue may persist for months in some patients.