What are the recommended treatments for resolving symptoms of mononucleosis?

Management of Infectious Mononucleosis Symptoms

Supportive care is the mainstay of treatment for infectious mononucleosis, as it is typically a self-limited disease that resolves spontaneously within 2-3 weeks, though symptoms may occasionally persist for several months.

Clinical Presentation and Diagnosis

• Classic triad: fever, tonsillar pharyngitis, and lymphadenopathy
• Additional common symptoms:
  • Profound fatigue (typically resolves within 3 months)
  • Periorbital/palpebral edema (occurs in ~33% of patients)
  • Splenomegaly (~50% of cases)
  • Hepatomegaly (~10% of cases)
  • Skin rash (10-45% of cases) - typically maculopapular
• Laboratory findings:
  • Leukocytosis with lymphocytosis (lymphocytes >50% of WBC count)
  • Atypical lymphocytes (>10% of total lymphocyte count)
  • Positive heterophile antibody test (Monospot)
  • If Monospot negative but clinical suspicion high: test for antibodies to viral capsid antigens 1

Recommended Treatment Approach

First-Line Management

1. Supportive care:

   • Adequate hydration and nutrition
   • Acetaminophen or NSAIDs for fever and pain control
   • Reduction of activity and bed rest as tolerated 1
   • Allow patients to resume activity as soon as they feel able (improves recovery time compared to imposed bed rest) 2

2. Activity restrictions:

   • Avoid contact sports or strenuous exercise for 8 weeks or while splenomegaly is present to prevent splenic rupture (occurs in 0.1-0.5% of cases) 1

Specific Symptom Management

• Sore throat: Saltwater gargles, throat lozenges, adequate hydration
• Fatigue: Gradual return to normal activities as tolerated; avoid prolonged inactivity
• Fever: Acetaminophen or NSAIDs as needed

Medications to Consider or Avoid

• Corticosteroids: Not recommended for routine use in uncomplicated infectious mononucleosis

  • Evidence does not support their use for symptom control in most cases
  • No benefit found in 8/10 assessments of health improvement across trials
  • Limited evidence showed short-term benefit for sore throat at 12 hours, but benefit was not maintained
  • Potential for serious adverse effects, including increased risk of complications 3
  • Should be reserved only for severe complications such as impending airway obstruction or significant hematological complications 4

• Antivirals: No proven benefit in uncomplicated infectious mononucleosis 1

Monitoring and Follow-up

• Clinical follow-up to assess resolution of symptoms
• Physical examination to monitor for resolution of splenomegaly before clearing patient for contact sports
• Monitor for potential complications:
  • Splenic rupture (most feared complication)
  • Airway obstruction
  • Hepatitis
  • Neurological complications
  • Hematological complications

Special Considerations

• Post-infectious fatigue: A distinct fatigue syndrome can follow infectious mononucleosis

  • Risk factors for prolonged illness include poor physical functioning and lengthy initial convalescence
  • Gradual increase in physical activity as tolerated may help prevent chronic fatigue 2

• Immunocompromised patients: May develop more severe disease with potential for serious complications, including:

  • Diffuse interstitial pneumonia
  • Disseminated disease 5
  • Require closer monitoring and earlier intervention

Common Pitfalls to Avoid

1. Unnecessary use of corticosteroids for uncomplicated cases, which may increase risk of complications 4

2. Prolonged bed rest - allowing patients to resume activity as soon as they feel able leads to quicker recovery 2

3. Premature return to contact sports before resolution of splenomegaly, increasing risk of splenic rupture

4. Failure to recognize complications requiring specific interventions (airway obstruction, severe hematologic abnormalities)

5. Overuse of antibiotics for the pharyngitis, which is viral in nature

The majority of patients with infectious mononucleosis will have an uneventful recovery with supportive care alone. Focus should be on symptom management, appropriate activity restrictions to prevent splenic rupture, and monitoring for rare but serious complications.