What is the recommended treatment for a 17-year-old boy presenting with symptoms of infectious mononucleosis (mono)?

Symptoms and Management of Infectious Mononucleosis in a 17-Year-Old Boy

Infectious mononucleosis in adolescents should be managed with supportive care, adequate rest, and symptom relief while avoiding contact sports for 4-8 weeks to prevent splenic rupture. 1

Clinical Presentation

The classic symptoms of infectious mononucleosis in a 17-year-old boy include:

• Characteristic triad:

  • Fever (typically high and persistent)
  • Severe, prolonged sore throat with tonsillar pharyngitis
  • Prominent lymphadenopathy (especially posterior cervical)

• Other common symptoms:

  • Profound fatigue that may last weeks to months
  • Periorbital/palpebral edema (in about one-third of patients)
  • Splenomegaly (in approximately 50% of cases)
  • Hepatomegaly (in approximately 10% of cases)
  • Possible maculopapular rash (in 10-45% of cases)
  • Nasal congestion and rhinorrhea may be present 1, 2

Diagnostic Approach

• Laboratory findings:

  • Peripheral blood leukocytosis with lymphocytosis (lymphocytes ≥50% of WBC count)
  • Atypical lymphocytes >10% of total lymphocyte count
  • Heterophile antibody testing (Monospot test) - most widely used initial test 2, 3
  • If Monospot is negative but clinical suspicion remains high, test for EBV-specific antibodies (particularly IgM antibodies to viral capsid antigen) 4, 3

• Differential diagnosis:

  • Other viral infections causing mononucleosis-like syndrome:
    • Cytomegalovirus (CMV)
    • Human herpesvirus-6 (HHV-6)
    • Adenovirus
    • Coxsackievirus
  • Bacterial pharyngitis 1

Treatment Recommendations

1. Supportive care is the mainstay of treatment:

   • Adequate hydration
   • Analgesics and antipyretics (acetaminophen or ibuprofen) for fever and pain relief
   • Rest guided by the patient's energy level 1, 2

2. Activity restrictions:

   • Avoid contact sports or strenuous exercise for 4-8 weeks or while splenomegaly is present
   • This is crucial to prevent splenic rupture, which occurs in 0.1-0.5% of cases 1, 2

3. Medication considerations:

   • Antiviral agents are not recommended for routine treatment
   • Antibiotics should only be used if bacterial co-infection is suspected
   • Avoid ampicillin/amoxicillin due to high risk of rash in EBV infection
   • Corticosteroids (prednisone 1-2 mg/kg/day for short duration) may be considered only for severe complications such as:
     • Significant pharyngeal edema with airway compromise
     • Severe thrombocytopenia
     • Hemolytic anemia
     • Neurological complications 1

Monitoring and Follow-up

• Monitor for red flags requiring immediate medical attention:

  • Signs of airway compromise or severe pharyngeal edema
  • Severe abdominal pain (potential splenic rupture)
  • Neurological symptoms
  • Significant respiratory symptoms 1

• Most patients recover completely within 2-4 weeks, though fatigue may persist for several months

• Athletes may take 3-6 months to regain top physical form 5

Complications to Watch For

• Splenic rupture (0.1-0.5% of cases) - most serious complication
• Hepatitis
• Neurological complications (rare)
• Airway obstruction from severe tonsillar hypertrophy
• Chronic fatigue syndrome (in some cases) 2, 6

Patient Education

• Explain that EBV is transmitted primarily through saliva
• Reassure that most cases resolve without long-term consequences
• Emphasize the importance of avoiding contact sports during recovery
• Explain that fatigue may persist for weeks to months but will eventually resolve
• Advise returning for evaluation if symptoms worsen or new symptoms develop 1, 2