What are the management strategies for infectious mononucleosis (mono)?

Management of Infectious Mononucleosis

Infectious mononucleosis management is primarily supportive, with adequate rest, hydration, and analgesics, as aciclovir therapy does not ameliorate the course in otherwise healthy individuals. 1, 2

Diagnostic Approach

• Heterophile antibody test (Monospot) is the most widely used initial test, becoming positive between the sixth and tenth day after symptom onset 1, 2
• Complete blood count typically shows lymphocytosis (≥50% of white blood cells) with atypical lymphocytes (>10% of total lymphocyte count) 3, 4
• If heterophile test is negative but clinical suspicion remains high, EBV serologic testing should include:
  • IgM antibodies to viral capsid antigen (VCA)
  • IgG antibodies to VCA
  • Antibodies to Epstein-Barr nuclear antigen (EBNA) 1, 2
• Presence of VCA IgM (with or without VCA IgG) antibodies without EBNA antibodies indicates recent primary infection 1, 2
• False-negative heterophile results are common early in infection and in children under 10 years 1, 2

General Management

• Supportive care is the mainstay of treatment 1, 5:
  • Adequate hydration
  • Analgesics for pain relief
  • Antipyretics for fever
  • Rest as needed, guided by patient's energy level 5, 4
• Activity should be limited based on symptoms, but strict bed rest is not necessary 5, 6
• Patients should avoid contact sports or strenuous exercise for at least 3-8 weeks or while splenomegaly is present to prevent splenic rupture 3, 4

Medication Considerations

• Corticosteroids are not recommended for routine treatment but may be indicated for:
  • Airway obstruction or severe pharyngeal edema
  • Severe neurologic, hematologic, or cardiac complications 1, 7
• Antiviral agents:
  • Aciclovir does not improve outcomes 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, 2

Special Considerations for Immunocompromised Patients

• Immunomodulator therapy should be reduced or discontinued if possible in patients with primary EBV infection 1, 2
• Patients on immunosuppressive therapy (especially thiopurines) have increased risk of lymphoproliferative disorders 1
• Careful monitoring with full blood count, blood film, liver function tests, and EBV serology is recommended 1
• Discontinuation of immunosuppressive therapy may result in spontaneous regression of EBV-associated lymphoproliferative disease 1

Complications and Monitoring

• Spontaneous splenic rupture occurs in 0.1-0.5% of patients and is potentially life-threatening 3, 4
• Fatigue may persist for several months after the acute infection has resolved 5, 6
• Infectious mononucleosis is a risk factor for chronic fatigue syndrome 3
• Neurologic complications can occur and may require specific management 7

Pitfalls to Avoid

• Do not enforce strict bed rest as this may prolong recovery 5
• Avoid premature return to contact sports due to risk of splenic rupture 3, 4
• Do not routinely prescribe corticosteroids or antivirals without specific indications 1, 6
• Be aware that false-negative heterophile antibody tests are common early in the course of infection 1, 2
• Remember that symptoms of EBV infection in immunocompromised patients may be minimal, particularly in those receiving corticosteroids 1