What is the treatment for infectious mononucleosis (mono)?

Treatment of Infectious Mononucleosis (Mono)

The mainstay of treatment for infectious mononucleosis is supportive care, including adequate rest, hydration, and avoidance of contact sports for at least 8 weeks or while splenomegaly is present. 1, 2

Diagnosis Confirmation

Before initiating treatment, confirm the diagnosis with:

• EBV antibody testing (VCA IgM, VCA IgG, EBNA IgG)
• Heterophile antibody test (Monospot)
• Complete blood count showing atypical lymphocytosis (>10% of lymphocytes)

Supportive Care Treatment Algorithm

First-line Management

1. Rest and Activity Management:

   • Allow activity as tolerated based on patient's energy level
   • Do NOT enforce strict bed rest as this may prolong recovery 3
   • Gradual return to normal activities as symptoms improve

2. Hydration:

   • Ensure adequate fluid intake
   • Oral hydration is preferred unless severe pharyngeal edema or inability to swallow

3. Symptomatic Relief:

   • Pain management: Acetaminophen or NSAIDs for fever, sore throat, and myalgia
   • Throat discomfort: Salt water gargles, throat lozenges
   • Sleep support: Maintain regular sleep schedule

Activity Restrictions

• Contact sports prohibition: Avoid for at least 8 weeks or while splenomegaly is present 1, 2
• Return to sports: Only after clinical resolution of splenomegaly to prevent splenic rupture
• Gradual return: Athletes may require 3-6 months to regain peak performance 4

Special Considerations

Severe Cases

For patients with significant complications:

• Airway compromise: Consider corticosteroids for severe pharyngeal edema or respiratory distress 5
• Splenic monitoring: Physical examination and possibly ultrasound if splenomegaly is suspected
• Neurological complications: Prompt neurological evaluation and appropriate specialist referral

Not Recommended Treatments

• Corticosteroids: Not recommended for routine treatment unless severe complications present 5
• Antivirals (acyclovir): Not recommended for uncomplicated infectious mononucleosis 1, 5
• Antihistamines: Not recommended for routine treatment 5

Follow-up and Monitoring

• Short-term follow-up: Assess for resolution of acute symptoms within 2-3 weeks
• Medium-term follow-up: Monitor for resolution of fatigue and return to baseline energy (may take up to 3 months)
• Long-term considerations: Approximately 5-6% of patients may develop post-infectious fatigue syndrome 1

Patient Education

• Explain the typically self-limited nature of the illness
• Discuss potential for prolonged fatigue (weeks to months)
• Emphasize importance of avoiding contact sports to prevent splenic rupture
• Advise on preventing transmission through avoiding sharing utensils, glasses, and intimate contact during acute phase

Warning Signs Requiring Urgent Evaluation

• Severe abdominal pain (concern for splenic rupture)
• Difficulty breathing
• Severe headache or altered mental status
• Persistent high fever unresponsive to antipyretics

The evidence strongly supports that infectious mononucleosis is generally a self-limited disease that resolves with supportive care alone. Pharmacological interventions beyond symptomatic relief are rarely indicated and should be reserved for specific complications.