Follow-up and Management of Mononucleosis
Patients with mononucleosis should be followed up at 6 months after diagnosis, with subsequent monitoring based on symptom resolution, and should avoid contact sports for at least 8 weeks or while splenomegaly is present to prevent complications. 1, 2
Initial Management
Supportive care is the mainstay of treatment:
- Adequate rest and hydration
- Acetaminophen or NSAIDs for fever and pain relief
- Gargling with salt water for sore throat
- No routine use of antivirals or corticosteroids 2
Activity restrictions:
- Avoid contact sports or strenuous exercise for at least 8 weeks or while splenomegaly is present
- Gradual return to normal activities based on symptom improvement 1
Follow-up Schedule
First Follow-up Visit (4-6 weeks after diagnosis)
- Assess for resolution of acute symptoms
- Physical examination focusing on:
- Lymphadenopathy
- Hepatosplenomegaly (palpation for spleen size)
- Pharyngitis resolution
- Skin rash resolution
Second Follow-up Visit (3 months after diagnosis)
- Evaluate for persistent symptoms, particularly fatigue
- Laboratory tests if symptoms persist:
- Complete blood count with differential
- Liver function tests if previously abnormal
Additional Follow-up (6 months and beyond)
- Only necessary for patients with:
- Persistent symptoms beyond 3 months
- Development of complications
- Immunocompromised status
Monitoring for Complications
Common Complications to Monitor
Splenic rupture (0.1-0.5% of cases) 1
- Most common in first 3 weeks but risk extends to 8 weeks
- Assess for left upper quadrant pain, referred left shoulder pain
Airway obstruction
- Due to significant tonsillar hypertrophy
- Monitor for difficulty breathing, stridor
Hepatitis
- Follow liver function tests if initially abnormal
- Usually resolves without intervention
Post-infectious fatigue syndrome (5-6% of patients) 3
- Persistent fatigue beyond 3 months
- May require additional supportive care
Special Considerations for High-Risk Patients
Immunocompromised patients:
Patients with severe initial presentation:
- More frequent follow-up (every 2-4 weeks until resolution)
- Monitor for neurological, hematological complications
Laboratory Monitoring
Routine follow-up labs generally not required unless:
- Persistent symptoms beyond expected timeframe
- Abnormal initial labs (e.g., elevated liver enzymes)
- Development of new symptoms
If symptoms persist beyond 3 months:
- Complete blood count with differential
- Comprehensive metabolic panel
- Consider EBV serological testing (VCA IgM, VCA IgG, EBNA IgG) 3
Return to Activities Guidelines
- School/work: Return when fever-free for 24 hours and symptoms improving
- Non-contact physical activities: Resume gradually based on energy levels
- Contact sports/strenuous exercise: Avoid for at least 8 weeks or while splenomegaly persists 1, 2
- Shared decision-making for timing of return to full activity 2
Patient Education
- Inform about potential for prolonged fatigue (weeks to months)
- Educate about signs of splenic rupture requiring immediate medical attention
- Advise on preventing transmission:
- Avoid sharing utensils, glasses, toothbrushes
- Avoid kissing or intimate contact during acute phase
- Practice good hand hygiene 3
When to Refer to Specialists
- Hematology referral: For persistent cytopenias beyond 4 weeks
- Infectious disease consultation: For severe or unusual presentations, or complications
- Otolaryngology referral: For significant tonsillar hypertrophy or airway concerns
Pitfalls to Avoid
- Unnecessary antibiotic use for pharyngitis (ineffective against viral infection)
- Prolonged steroid therapy in uncomplicated cases (may lead to serious complications) 4
- Premature return to contact sports (risk of splenic rupture)
- Inadequate follow-up of persistent symptoms (may miss complications)
By following these guidelines, clinicians can effectively manage patients with infectious mononucleosis while minimizing complications and optimizing outcomes.