What is the treatment for mono (mononucleosis) EBV (Epstein-Barr Virus) tonsillitis?

Treatment of Mononucleosis (EBV) Tonsillitis

Supportive care is the mainstay of treatment for EBV-associated mononucleosis tonsillitis, as antiviral therapy is not recommended for immunocompetent individuals. 1

Primary Treatment Approach

The treatment of EBV mononucleosis tonsillitis consists of:

1. Supportive care measures:

   • Adequate hydration
   • Rest as needed
   • Antipyretics for fever (acetaminophen or NSAIDs)
   • Analgesics for pain relief, particularly for sore throat 1, 2

2. Activity restrictions:

   • Avoid contact sports or strenuous exercise for at least 8 weeks or while splenomegaly is present to prevent splenic rupture 1, 2
   • Reduction of activity and bed rest as tolerated 2

Important Considerations

Antiviral Therapy

• Antiviral medications (acyclovir, ganciclovir, etc.) are not recommended for EBV infection in immunocompetent hosts 1
• Multiple studies have shown that antivirals lack efficacy against EBV in immunocompetent individuals 1, 3
• While viral shedding may be temporarily suppressed during antiviral treatment, this effect is not sustained after treatment cessation 3

Special Populations

For immunocompromised patients:

• First-line treatment includes Rituximab 375 mg/m² once weekly (typically 1-4 doses) until EBV DNA-emia negativity 1
• Reduction of immunosuppressive therapy whenever possible 1
• Consider EBV-specific cellular therapy or donor lymphocyte infusion as second-line options 1

Monitoring and Follow-up

• Monitor for resolution of symptoms, which may take one month or more 3
• Be aware that fatigue may persist in approximately 10% of patients at six-month follow-up 3
• Regular follow-up is recommended to assess for potential complications 1, 2

Potential Complications to Monitor

• Splenic rupture (occurs in 0.1-0.5% of patients) - the most feared complication 2
• Upper airway obstruction due to severe tonsillar hypertrophy 4
• Hepatomegaly (occurs in approximately 10% of cases) 2
• Chronic fatigue syndrome (EBV infection is a risk factor) 2

Common Pitfalls to Avoid

• Inappropriate use of antibiotics when bacterial superinfection is not present 5
• Premature return to contact sports before resolution of splenomegaly 1, 2, 6
• Relying solely on heterophile testing in children under 10 years (high false-negative rate) 1
• Inappropriate use of antiviral medications (generally ineffective against EBV) 1, 3

Recovery Timeline

• Most patients have an uneventful recovery 2
• Athletic individuals may recover faster than non-athletes, but elite athletes may require 3-6 months to regain top form 6
• Clinical signs and symptoms typically resolve within one month, though some may persist longer 3

Remember that while EBV mononucleosis is generally self-limiting, prompt diagnosis and appropriate supportive care are essential to minimize complications and ensure proper recovery.