Management and Treatment of Infectious Mononucleosis
Primary Treatment Approach
Supportive care is the mainstay of treatment for infectious mononucleosis, with no role for antiviral therapy in otherwise healthy individuals. 1, 2
Core Management Strategy
Symptomatic Treatment
- Antipyretics for fever control (acetaminophen or NSAIDs) 2
- Rest as tolerated with activity reduction during acute illness 3
- Adequate hydration and nutrition 3
- Throat lozenges or analgesics for pharyngitis 3
Activity Restrictions
- Avoid contact sports and strenuous exercise for 8 weeks or until splenomegaly resolves 3
- This restriction is critical given the 0.1-0.5% risk of spontaneous splenic rupture, which is the most feared and potentially life-threatening complication 3, 4
- Athletes may return to contact sports only when the spleen returns to normal size, though elite athletes may require 3-6 months to regain peak performance 5
Medications: What NOT to Use
Antiviral Agents
- Aciclovir does NOT ameliorate the course of infectious mononucleosis in otherwise healthy individuals 1, 2
- Antiviral therapy has no proven benefit in uncomplicated cases 6
Corticosteroids
- NOT recommended for routine treatment 2, 6
- Reserve corticosteroids only for specific severe complications: 1, 2, 6
- Severe upper airway obstruction with impending respiratory compromise
- Severe neurologic complications (e.g., encephalitis, Guillain-Barré syndrome)
- Immune-mediated severe anemia or thrombocytopenia
- Severe cardiac complications (e.g., myocarditis)
- Use corticosteroids judiciously as they should not be given for uncomplicated disease 6
Special Population: Immunocompromised Patients
Critical Management Differences
Immunocompromised patients require aggressive intervention with reduction or discontinuation of immunosuppressive therapy when primary EBV infection occurs. 7, 1, 2
Specific Interventions
- Reduce or discontinue immunomodulator therapy (e.g., thiopurines, anti-TNF agents) if clinically feasible 7, 1, 2
- Consider antiviral therapy with ganciclovir or foscarnet in severe primary EBV infection in immunocompromised patients, despite limited supporting evidence 7, 1, 2
- These agents are more potent than aciclovir for replicative EBV infection but carry greater toxicity 7
- Seek specialist consultation for suspected lymphoproliferative disease 7
Risk Context
- Patients on thiopurines have a 5.28-fold increased hazard ratio for lymphoproliferative disorders 7
- Primary EBV infection during immunosuppression poses particular threat, with reported fatal cases of infectious mononucleosis-associated lymphoproliferative disorders in young patients on azathioprine 7
- Discontinuation of immunosuppressive therapy may result in spontaneous regression of EBV-associated lymphoproliferative disease 7, 2
Monitoring and Follow-Up
Clinical Monitoring
- Monitor for complications including splenic rupture, airway obstruction, neurologic manifestations, and hematologic abnormalities 3, 4
- Fatigue typically resolves within 3 months but can be profound 3
- Infectious mononucleosis is a risk factor for chronic fatigue syndrome 3
Laboratory Monitoring
- Routine laboratory monitoring is not necessary in uncomplicated cases 3
- In immunocompromised patients with primary EBV infection, obtain full blood count, blood film, liver function tests, and EBV serology 7
Common Pitfalls to Avoid
- Do not prescribe ampicillin or amoxicillin as these cause a characteristic maculopapular rash in 90% of patients with infectious mononucleosis 3
- Do not allow premature return to contact sports before splenomegaly resolves, as splenic rupture can be fatal if not diagnosed early 3, 4
- Do not use corticosteroids for uncomplicated disease despite patient or family pressure for faster recovery 6
- Do not assume negative heterophile test excludes diagnosis early in illness (first 6-10 days) or in children under 10 years 1, 2