What is the treatment for mononucleosis?

Treatment of Mononucleosis

Supportive care is the mainstay of treatment for infectious mononucleosis, with adequate rest and hydration, gradual return to normal activities as tolerated, and avoidance of contact sports for at least 8 weeks or while splenomegaly is present. 1, 2

Diagnosis Confirmation

Before initiating treatment, confirm the diagnosis with:

• Clinical presentation: fever, tonsillar pharyngitis, lymphadenopathy
• Laboratory findings:
  • Heterophile antibody test (Monospot)
  • EBV-specific antibody panel (VCA IgM, VCA IgG, EBNA IgG) if Monospot is negative
  • Complete blood count showing lymphocytosis with >10% atypical lymphocytes

Treatment Approach

First-Line Management

1. Supportive Care

   • Adequate hydration
   • Analgesics for pain relief (acetaminophen or NSAIDs)
   • Antipyretics for fever
   • Rest as needed, guided by patient's energy level 3
   • Gradual return to normal activities as symptoms improve

2. Activity Restrictions

   • Avoid contact sports or strenuous exercise for at least 8 weeks or while splenomegaly is present 1, 2, 4
   • This restriction is critical to prevent splenic rupture, which occurs in 0.1-0.5% of cases 2

Medications NOT Routinely Recommended

• Acyclovir: Does not improve outcomes in otherwise healthy individuals 5, 1
• Antivirals: No proven role in treatment of established infectious mononucleosis 5, 3
• Corticosteroids: Not recommended for routine treatment 3

Special Circumstances for Medication Use

• Corticosteroids: May be indicated only for:
  • Airway obstruction due to significant tonsillar hypertrophy 5, 1, 6
  • Severe hematological complications 7
  • Impending respiratory compromise 3

Monitoring and Follow-up

1. Clinical Monitoring

   • Monitor for resolution of symptoms (typically 2-3 weeks)
   • Assess for splenomegaly at follow-up visits
   • Be aware that fatigue may persist for several months 3

2. Complications to Watch For

   • Splenic rupture (most feared complication)
   • Upper airway obstruction
   • Hepatitis
   • Neurological complications

Special Considerations

Immunocompromised Patients

• Patients on immunosuppressive therapy, particularly anti-TNF agents, are at higher risk for EBV reactivation 5, 1
• Consider reducing or discontinuing immunomodulator therapy if possible during severe primary EBV infection 5
• Monitor closely for development of lymphoproliferative disorders 1

Prolonged Symptoms

• If symptoms persist beyond 3 months, consider evaluation for chronic fatigue syndrome 1
• Approximately 5-6% of patients may develop post-infectious fatigue syndrome 1

Pitfalls to Avoid

1. Unnecessary Steroid Use: Avoid prescribing corticosteroids for uncomplicated cases as they may lead to severe complications including increased risk of secondary infections 7

2. Premature Return to Contact Sports: This increases risk of splenic rupture, which can be life-threatening

3. Enforced Bed Rest: Allow activity as tolerated based on the patient's energy level 3

4. Antivirals: Do not prescribe acyclovir or other antivirals routinely as they do not improve outcomes in immunocompetent individuals 5, 1

By following these evidence-based guidelines, most patients with infectious mononucleosis will recover completely without complications. The key is supportive care while monitoring for and preventing the rare but serious complications that can occur.