Can an infectious disease specialist treat cases of chronic infectious mononucleosis (mono)?

Management of Chronic Infectious Mononucleosis by Infectious Disease Specialists

Yes, infectious disease specialists can and should treat cases of chronic active Epstein-Barr virus (EBV) infection, particularly when patients experience persistent symptoms, complications, or when the condition is refractory to standard supportive care. 1

Identifying Chronic Active EBV Infection

Chronic active EBV infection is characterized by:

• Prolonged or intermittent symptoms lasting beyond the typical 2-3 week course 2, 3
• Clinical manifestations including:
  • Persistent fever
  • Lymphadenopathy and/or hepatosplenomegaly
  • Recurrent fatigue
  • Sore throat
  • Lymph node tenderness
  • Headache, myalgia, arthralgia 1

Diagnostic Approach for Chronic EBV

An infectious disease specialist would employ:

1. Serological testing:

   • EBV-specific antibody panel (VCA IgM, VCA IgG, EBNA IgG) 1
   • IgG avidity testing to distinguish between recent infection and reactivation 1

2. Molecular testing:

   • Quantitative EBV viral load by PCR in peripheral blood to confirm active viral replication 1
   • PCR-based viral panels to diagnose viral infections and reactivations 4

3. Specialized testing for unclear cases:

   • Immunoblotting for specific anti-EBV antibodies
   • Testing for heterophile antibodies or anti-EA (D) antibodies 1

Treatment Strategies by Infectious Disease Specialists

For chronic active EBV infection, specialists may implement:

1. Supportive care as the foundation of treatment 3

2. Antiviral therapy considerations:

   • While not routinely recommended for uncomplicated cases, may be considered for severe or persistent cases 1
   • Monitoring EBV DNA copies in cases of persistent fever and fatigue 4

3. Immunomodulatory approaches:

   • Intravenous immunoglobulin (IVIG) therapy for patients with:
     • IgG levels <400 mg/dl
     • ≥2 severe recurrent infections
     • Life-threatening infections
     • Documented bacterial infections with insufficient response to antibiotics 4
   • Monthly IVIG treatment for the duration of immunoparesis 4

4. Advanced therapies for severe cases:

   • Corticosteroids for severe complications
   • Consideration of immunomodulative therapies
   • Autologous EBV-specific cytotoxic T lymphocytes therapy
   • Allogeneic stem-cell transplantation for severe disease 1

5. Monitoring for complications:

   • EBV-related hemophagocytic lymphohistiocytosis
   • T-cell or NK-cell lymphoproliferative disorders/lymphomas
   • Hematological abnormalities 1

Special Considerations

• Rituximab may be considered in post-allogenic HSCT patients with EBV reactivation 4

• Multidisciplinary approach is essential, particularly when complications arise:

  • Hematological complications
  • Neurological manifestations
  • Pulmonary involvement
  • Ocular, dermal, or cardiovascular disorders 1

• Avoidance of immunosuppressive medications that may worsen EBV reactivation 1

When to Refer to an Infectious Disease Specialist

Patients should be referred when:

• Symptoms persist beyond 3 months
• Complications develop
• EBV viral load remains elevated despite supportive care
• Immunocompromised status complicates management
• Atypical presentation requires specialized diagnosis 1, 3

Prognosis

While approximately 5-6% of patients may develop post-infectious fatigue syndrome after acute EBV infection 1, proper management by infectious disease specialists can help prevent progression to more severe complications and improve quality of life for those with chronic active infection.