How do corticosteroids help alleviate symptoms of infectious mononucleosis (mono)?

Corticosteroid Use in Infectious Mononucleosis

Corticosteroids should NOT be used routinely for symptom management in infectious mononucleosis (mono) but are specifically indicated for patients with severe complications such as impending airway obstruction, severe pharyngeal edema, or respiratory compromise. 1, 2

Mechanism of Action in Mono

Corticosteroids work in infectious mononucleosis by:

1. Reducing inflammation: They suppress the inflammatory response that causes many of the uncomfortable symptoms of mono, particularly in the throat and lymphoid tissues
2. Decreasing cytokine production: They inhibit the release of pro-inflammatory cytokines that contribute to symptoms
3. Reducing lymphoid tissue swelling: This is particularly important in cases of severe tonsillar hypertrophy that may compromise the airway

Appropriate Indications for Corticosteroid Use

Corticosteroids should be reserved for specific complications:

• Airway obstruction: When tonsillar hypertrophy threatens the airway 3
• Severe pharyngeal edema: When swelling significantly impairs swallowing or breathing 1
• Respiratory compromise: When inflammation affects respiratory function 1

Evidence on Efficacy

The evidence for routine use of corticosteroids in uncomplicated mono is limited:

• A Cochrane systematic review found insufficient evidence to support routine use of steroids for symptom control 2
• Two trials found short-term benefit in reducing sore throat at 12 hours, but this benefit was not maintained 2
• Effects on other common symptoms were less clear across trials 2

Clinical Practice Reality

Despite limited evidence for routine use:

• A retrospective study found that 44.7% of mono patients received systemic corticosteroid therapy, with only 8% qualifying by traditional criteria (impending airway obstruction) 4
• No significant differences in disease complications, hospital admission rates, or length of stay were observed between steroid and non-steroid groups 4

Recommended Approach

1. For uncomplicated mono:

   • Focus on symptomatic treatment with adequate hydration, analgesics, antipyretics, and rest
   • Activity should be guided by the patient's energy level
   • Avoid enforced bed rest

2. For severe complications:

   • Consider prednisone 0.5-1.0 mg/kg daily for 1-2 weeks in tapering doses for severe cases with respiratory compromise or severe pharyngeal edema 5
   • Monitor closely for potential adverse effects

Potential Risks and Considerations

• Corticosteroids may increase the risk of secondary infections 6
• There is concern about potential delay in viral clearance 6
• Rare but serious adverse events have been reported, including respiratory distress and acute onset of diabetes 2
• Patients should be withdrawn from contact or collision sports for at least four weeks after symptom onset regardless of steroid use 1

Clinical Pearls

• Fatigue, myalgias, and increased need for sleep may persist for several months after the acute infection resolves, with or without steroid treatment 1
• When steroids are indicated, short courses with tapering doses are preferred to minimize potential adverse effects
• Patients with severe thrombocytopenia related to mono may benefit from alternative treatments like intravenous immunoglobulin if they are refractory to corticosteroid therapy 7