What is the management and treatment for infectious mononucleosis (infectious mono)?

Management and Treatment of Infectious Mononucleosis

Infectious mononucleosis requires primarily supportive care, with avoidance of contact sports for at least 8 weeks or while splenomegaly is present to prevent splenic rupture. 1, 2

Diagnosis

• Look for the classic triad:

  • Fever
  • Tonsillar pharyngitis
  • Lymphadenopathy (particularly posterior cervical or auricular) 2, 3

• Additional common findings:

  • Fatigue (may be profound)
  • Periorbital/palpebral edema (in ~33% of cases)
  • Splenomegaly (~50% of cases)
  • Hepatomegaly (~10% of cases)
  • Maculopapular rash (10-45% of cases, more common if treated with ampicillin) 2

• Laboratory findings:

  • Atypical lymphocytosis (>10% of total lymphocyte count)
  • Positive heterophile antibody test (Monospot)
  • For negative Monospot with high clinical suspicion, test for EBV-specific antibodies:

    Pattern	Interpretation
    VCA IgM (+), VCA IgG (+), EBNA IgG (-)	Acute primary infection
    VCA IgM (-), VCA IgG (+), EBNA IgG (+)	Past infection
    VCA IgM (-), VCA IgG (-), EBNA IgG (-)	No previous EBV infection

Treatment Approach

Supportive Care (First-Line)

1. Rest and activity modification:

   • Rest as needed, guided by patient's energy level
   • Avoid contact sports or strenuous exercise for 8 weeks or while splenomegaly is present 2, 3
   • Bed rest should not be enforced 3

2. Symptomatic relief:

   • Adequate hydration
   • Analgesics (acetaminophen, NSAIDs) for pain and fever
   • Throat lozenges for symptomatic relief 1, 2

3. Monitoring:

   • Watch for complications, particularly splenic rupture (0.1-0.5% of cases) 2
   • Monitor for respiratory compromise or severe pharyngeal edema

Medications to Avoid

• Corticosteroids: Not recommended for routine treatment

  • Only consider for severe complications:
    • Impending airway obstruction
    • Severe pharyngeal edema
    • Significant hematological complications 3, 4
  • Caution: Prolonged steroid use in uncomplicated cases may lead to serious complications including sepsis 4

• Antivirals: Acyclovir and other antivirals are not recommended for routine treatment 3

• Antibiotics: Avoid unless bacterial co-infection is confirmed 1

  • Note: Ampicillin can cause rash in patients with EBV infection and should be avoided

Special Considerations

Athletes

• Serial ultrasonography may be used to assess splenic size to guide return-to-play decisions 5
• Return to non-contact activities can begin when the athlete feels able and afebrile
• Gradual return to full activity after the 8-week restriction period

Immunocompromised Patients

• Higher risk for lymphoproliferative disorders
• More vigilant monitoring may be needed 1

Complications to Watch For

• Splenic rupture (most feared complication)
• Airway obstruction
• Hepatitis
• Neurological complications
• Hematological abnormalities
• Chronic fatigue syndrome 2

Expected Course

• Most patients have an uneventful recovery
• Acute symptoms typically resolve within 2-4 weeks
• Fatigue may persist for several months after the acute infection has resolved 2, 3

Remember that infectious mononucleosis is generally a self-limited disease that requires supportive care rather than specific antiviral treatment. The focus should be on symptom management and prevention of complications, particularly splenic rupture.