How to manage a patient with infectious mononucleosis presenting with elevated Gamma-Glutamyl Transferase (GGT)?

Management of Elevated GGT in Infectious Mononucleosis

In patients with infectious mononucleosis presenting with elevated GGT, supportive care and monitoring of liver function tests every 2-4 weeks is recommended until resolution, which may take up to 6 months. 1, 2

Assessment and Workup

• Elevated GGT is common in infectious mononucleosis (IM), occurring in approximately 41% of cases, and is part of the hepatic involvement pattern 2
• Complete a comprehensive liver function panel including AST, ALT, ALP, total and direct bilirubin, albumin, and prothrombin time/INR to assess the extent of liver involvement 3, 1
• Determine if GGT elevation is isolated or accompanied by other liver enzyme abnormalities, as this helps differentiate between various causes 3, 1
• Calculate AST:ALT ratio, as a ratio >1 may indicate more advanced liver involvement 1
• Abdominal ultrasonography should be performed only if there are concerning features such as significant hepatomegaly or jaundice, as routine ultrasound is not required in immunocompetent patients with subclinical derangement of liver function tests 2

Monitoring and Follow-up

• Monitor GGT levels every 2-4 weeks initially to establish trend (increasing, stable, or decreasing) 3, 1
• Median time to resolution of liver function test abnormalities in IM is approximately 8 weeks (range 6-12 weeks), though maximum time to resolution can exceed 6 months 2
• In rare cases, elevated GGT can persist for up to 24 months after IM resolution, raising the question of persistent "post-IM" hepatitis 4
• Routine serial liver function test assessments following initial abnormalities are not required in immunocompetent patients with subclinical derangement 2

Management Approach

• Treatment of infectious mononucleosis is primarily supportive; routine use of antivirals and corticosteroids is not recommended 5
• No specific treatment is required for isolated GGT elevation in the context of IM if the patient is asymptomatic 2
• Avoid hepatotoxic medications and alcohol consumption during the recovery period 1
• Current guidelines recommend that patients with infectious mononucleosis not participate in athletic activity for three weeks from onset of symptoms 5

When to Consider Further Evaluation

• Refer to hepatology/gastroenterology if:
  • GGT elevation persists >3 months despite addressing modifiable factors 1
  • There is evidence of advanced liver involvement (significant jaundice, coagulopathy) 1
  • Imaging studies suggest structural liver or biliary disease beyond what is expected in IM 1

Special Considerations

• Immunosuppressed populations are at higher risk of severe disease and significant morbidity from IM, including more severe hepatic involvement 5
• Be aware that both AST and ALT can be normal even in the setting of significant GGT elevation 1
• Avoid attributing elevated GGT solely to alcohol without proper investigation of other causes, especially in the context of recent IM 3, 1

Prognosis

• Decompensated liver disease is extremely rare in IM-associated hepatic involvement 2
• Most patients with IM-associated elevated GGT will have complete resolution without specific intervention 2
• Long-term follow-up may be warranted in cases of persistent GGT elevation beyond 6 months 4