What is the treatment for acute infectious mononucleosis (mono) with significantly elevated liver enzymes, anorexia, nausea, cough, and fever in a hospitalized patient?

Treatment for Acute Infectious Mononucleosis with Elevated Liver Enzymes in Hospitalized Patient

Supportive care is the mainstay of treatment for acute infectious mononucleosis with significantly elevated liver enzymes (>10x ULN), with careful monitoring and management of symptoms being essential for patient recovery. 1, 2

Initial Management

• Provide supportive care with adequate hydration and electrolyte management to maintain physiologic homeostasis 3, 1
• Monitor blood glucose parameters at least every 2 hours as hypoglycemia is a well-known complication of severe liver dysfunction 3
• Administer antipyretics for fever control, preferably acetaminophen at appropriate doses with careful consideration of the impaired liver function 1
• Provide adequate nutritional support as patients with liver dysfunction and organ failure have increased energy expenditure 3

Liver Function Monitoring

• Check complete liver panel (ALT, AST, alkaline phosphatase, GGT, bilirubin, albumin) every 2-4 weeks to establish a clear trend 4, 5
• Include complete blood count and serum creatinine in follow-up laboratory testing to assess for systemic effects 4, 5
• Monitor electrolytes, particularly serum sodium, targeting levels between 140-145 mmol/L, with corrections not exceeding 10 mmol/L per 24 hours 3
• Continue monitoring until liver enzymes completely return to normal range, as 84% of abnormal tests remain abnormal on retesting after 1 month 4, 5

Specific Interventions for Liver Dysfunction

• Avoid hepatotoxic medications, including certain antibiotics, NSAIDs, and statins that may worsen liver injury 3, 6
• If the patient is on statins, discontinue if ALT/AST levels exceed 3 times the upper limit of normal 6
• Stress ulcer prophylaxis is recommended in this at-risk population, using agents with minimal hepatic metabolism 3
• Avoid the use of osmotic laxatives (lactulose) or non-absorbable antibiotics (rifaximin) to lower ammonia levels 3

Management of Gastrointestinal Symptoms

• Provide antiemetics for nausea and vomiting, preferably those with minimal hepatic metabolism 3
• For diarrhea, maintain hydration and consider symptomatic treatment with careful medication selection 3
• Monitor for abdominal pain which may indicate hepatomegaly or splenomegaly, present in approximately 50% and 10% of cases respectively 1, 7

Infection Control and Prevention

• Consider empirical broad-spectrum antibiotics if there are signs of sepsis and/or worsening clinical status, as patients with acute liver dysfunction have increased susceptibility to infections 3
• Antibiotics should cover common organisms such as enterobacteria, staphylococcal or streptococcal species 3
• Monitor for potential secondary infections, which occur in 60-80% of patients with acute liver dysfunction 3

Activity Recommendations

• Recommend bed rest as tolerated during the acute phase 1
• Advise against contact sports or strenuous exercise for at least 8 weeks or while splenomegaly is present to prevent splenic rupture 1, 7
• Gradual return to normal activities as symptoms improve and liver enzymes normalize 1

Follow-up and Monitoring

• Serial liver function tests should be performed until normalization, which typically occurs within 8-12 weeks 7
• Ultrasound abdomen is not routinely required in immunocompetent patients with subclinical derangement of liver function tests 7
• Consider hepatology consultation for patients with persistent elevation of liver enzymes beyond 12 weeks 3, 4

Special Considerations

• If liver enzymes continue to rise or do not improve within 2-4 weeks, consider liver biopsy to rule out other causes of liver injury 3
• Watch for signs of hepatic encephalopathy, which may manifest as altered mental status or confusion 3
• Monitor for potential complications such as spontaneous splenic rupture, which occurs in 0.1-0.5% of patients with infectious mononucleosis 1

Common Pitfalls to Avoid

• Don't ignore mild elevations in liver enzymes that haven't completely normalized, as they may indicate underlying liver disease 4, 5
• Avoid simply repeating the same panel of tests without a diagnostic plan to identify the underlying cause 4, 5
• Don't overlook the potential relationship between liver function and other factors that could affect liver enzymes 4, 5
• Avoid premature discontinuation of monitoring once enzymes begin to normalize, as recurrence is possible 4