Treatment of Infectious Mononucleosis

Treatment is entirely supportive, as aciclovir does not ameliorate the course of infectious mononucleosis in otherwise healthy individuals. 1

Supportive Care Measures

The mainstay of management consists of:

Adequate hydration, analgesics, antipyretics, and rest guided by the patient's energy level 2. Enforced bed rest is not recommended; patients should adjust activity based on their own fatigue levels 2.
Reduction of activity as tolerated 3. Fatigue may be profound but typically resolves within three months, though myalgias and need for sleep may persist for several months after acute infection 2.

Acyclovir has no role in routine treatment 1, 2. It does not improve clinical outcomes in immunocompetent patients 1.
Antihistamines are not recommended for routine treatment 2.
Corticosteroids should be reserved exclusively for airway obstruction or severe pharyngeal edema causing respiratory compromise 1, 2. They are not indicated for routine symptom management 2.

Patients must be withdrawn from contact or collision sports for at least 4 weeks after symptom onset 2. More recent evidence suggests avoiding contact sports or strenuous exercise for 8 weeks or while splenomegaly persists 3.
Current guidelines recommend no athletic activity for 3 weeks from symptom onset, with shared decision-making to determine timing of return to activity 4. The conservative approach of 8 weeks is safer given that spontaneous splenic rupture occurs in 0.1-0.5% of patients and is potentially life-threatening 3.

In immunocompromised patients with suspected primary EBV infection, immunomodulator therapy should be reduced or discontinued if possible 1.
These patients require specialist consultation due to increased risk of EBV-associated lymphoproliferative disease 1.
Obtain complete blood count, blood film, and liver function tests in patients on immunosuppressive therapy 1.

Primary EBV infection in children up to 10 years is usually asymptomatic or shows nonspecific courses 5. The heterophile antibody test can have false-negative results in children younger than 5 years 4.

Avoid sharing personal items contaminated with saliva and practice hand hygiene during outbreaks in close community settings 1. EBV is transmitted primarily through saliva 3, 5.

Do not prescribe antibiotics routinely, as infectious mononucleosis is viral 2, 3. If ampicillin or amoxicillin is given (often mistakenly for pharyngitis), a rash develops in 10-45% of cases 3.
Do not allow premature return to contact sports, as splenic rupture, though rare, can be fatal if not diagnosed early 3, 6.
Do not rely solely on heterophile antibody testing in the first week of illness or in young children, as false-negatives are common 2, 4.