Is it safe to use steroids, such as prednisone, in patients with infectious mononucleosis (mono)?

Steroids in Infectious Mononucleosis: When to Use and When to Avoid

Steroids should NOT be used routinely for symptom control in uncomplicated infectious mononucleosis (mono), but should be reserved only for specific severe complications such as significant tonsillar hypertrophy with airway obstruction.

Indications for Steroid Use in Mono

Appropriate Use:

• Severe pharyngitis with significant tonsillar hypertrophy causing:
  • Respiratory compromise
  • Difficulty swallowing
  • Airway obstruction 1

Dosing When Indicated:

• Prednisone 0.5-1.0 mg/kg daily (maximum 80 mg daily)
• Short course of 1-2 weeks with tapering
• Begin tapering after clinical improvement (typically 3-5 days)
• Reduce dose by 10-20 mg every 1-2 days 1

Evidence Against Routine Use

Current evidence shows:

• Small and inconsistent benefits for symptom relief 2
• Potential serious complications with prolonged use 3
• Insufficient evidence for efficacy in uncomplicated cases 4

Risks of Steroid Use in Mono

Potential Complications:

• Increased risk of secondary bacterial infections
• Immunosuppression that may prolong viral shedding
• Possible development of septic complications with prolonged use
• Case reports of polymicrobial bacteremia, pulmonary septic emboli, sinus thrombosis, and orbital cellulitis following prolonged steroid therapy 3

Alternative Management for Uncomplicated Mono

First-line Treatment:

• Adequate hydration
• Appropriate analgesics and antipyretics
• Rest guided by patient's energy level (not enforced bed rest)
• Supportive care 5

Monitoring Patients on Steroids

If steroids are necessary for severe complications:

• Assess for clinical improvement within 24-48 hours
• Monitor for common corticosteroid side effects:
  • Hyperglycemia
  • Mood changes
  • Insomnia
  • Increased appetite 1
• Watch for signs of secondary infection

Decision Algorithm

1. Assess severity of tonsillar hypertrophy:

   • Mild to moderate pharyngitis → supportive care only
   • Severe tonsillar hypertrophy with airway concerns → consider steroids

2. If considering steroids, evaluate for:

   • Degree of airway obstruction
   • Ability to swallow
   • Signs of respiratory distress

3. If steroids are indicated:

   • Use lowest effective dose
   • Prescribe for shortest duration possible
   • Taper appropriately
   • Monitor closely for complications

Conclusion

The evidence clearly shows that while steroids may provide temporary symptom relief, they should not be used routinely for uncomplicated infectious mononucleosis. Reserve steroid therapy only for patients with severe pharyngitis and significant tonsillar hypertrophy causing airway compromise.