What is the management and treatment of infectious mononucleosis?

Management and Treatment of Infectious Mononucleosis

Treatment of infectious mononucleosis is primarily supportive, as antiviral therapy with aciclovir does not improve outcomes in otherwise healthy individuals. 1

Diagnostic Approach

• The initial diagnostic test of choice is the heterophile antibody test (Monospot), which typically becomes positive between the sixth and tenth day after symptom onset 1, 2
• When clinical suspicion remains high despite a negative heterophile test, EBV-specific serologic testing is recommended, including:
  • IgM antibodies to viral capsid antigen (VCA)
  • IgG antibodies to VCA
  • Antibodies to Epstein-Barr nuclear antigen (EBNA) 1, 2
• The presence of VCA IgM (with or without VCA IgG) antibodies in the absence of EBNA antibodies indicates recent primary EBV infection 1, 2
• The Paul-Bunnell and monospot tests are suboptimal for diagnosis in certain populations, particularly in young children who may have false-negative results 1, 2

Treatment Recommendations

• Supportive care is the mainstay of treatment:
  • Adequate hydration and rest as tolerated 3, 4
  • Antipyretics and analgesics for fever and sore throat 3
  • Reduction of activity during the acute phase 5
• Corticosteroids may be indicated in specific circumstances:
  • Airway obstruction due to significant tonsillar hypertrophy 1, 6
  • Immune-mediated complications such as severe hemolytic anemia or thrombocytopenia 6
• Antiviral therapy:
  • Aciclovir does not improve outcomes in uncomplicated infectious mononucleosis in otherwise healthy individuals 1, 6
  • In severe primary EBV infection in immunocompromised patients, ganciclovir or foscarnet may be considered despite limited supporting evidence 1

Activity Restrictions

• Patients should avoid contact sports or strenuous exercise for at least 8 weeks or while splenomegaly is present 3, 5
• This restriction is critical to prevent splenic rupture, which occurs in 0.1-0.5% of patients and is potentially life-threatening 3, 4

Special Considerations for Immunocompromised Patients

• In immunocompromised patients (particularly those on immunomodulators for IBD or post-transplant):
  • Primary EBV infection warrants careful clinical assessment with full blood count, blood film, and liver function tests 1
  • Immunomodulator therapy should be reduced or discontinued if possible 1
  • Risk of EBV-associated lymphoproliferative disorders is increased in immunosuppressed patients 1
  • Specialist advice should be sought for suspected lymphoproliferative disease 1

Monitoring and Follow-up

• Most patients recover completely within 2-4 weeks, though fatigue may persist for several months 3, 7
• Monitor for potential complications:
  • Splenic rupture (most serious acute complication) 5, 4
  • Neurological complications (rare but can include encephalitis, meningitis, Guillain-Barré syndrome) 6
  • Hematologic complications (hemolytic anemia, thrombocytopenia) 6
  • Hepatic involvement (usually mild and self-limiting) 3, 7

Prevention

• No EBV vaccine is currently available 1, 3
• Prophylaxis with antiviral agents is not recommended for general population due to low risk-benefit ratio 1
• In transplant recipients, EBV IgG testing pre-transplant can identify susceptible patients 1

Remember that infectious mononucleosis is generally a self-limited disease with good prognosis, but careful monitoring for complications and appropriate activity restrictions are essential to prevent adverse outcomes, particularly splenic rupture.