When are corticosteroids (steroids) indicated for patients with infectious mononucleosis?

Corticosteroids for Infectious Mononucleosis

Corticosteroids should be reserved exclusively for life-threatening complications of infectious mononucleosis—specifically impending airway obstruction or increased intracranial pressure from neurologic complications—and should not be used for routine symptom control. 1

Primary Treatment Approach

• Supportive care alone is the recommended management for uncomplicated infectious mononucleosis, as antiviral therapy provides no clinical benefit 1
• The vast majority of patients (>90%) do not require corticosteroids despite widespread inappropriate use in clinical practice 2

Specific Indications for Corticosteroid Use

Corticosteroids are indicated ONLY in the following scenarios:

Life-Threatening Complications

• Airway obstruction or impending airway compromise from severe tonsillar hypertrophy 1
• Increased intracranial pressure in patients with neurologic complications such as encephalitis or meningitis 1

Hematologic Emergencies

• Severe thrombocytopenia with active bleeding or platelet counts requiring intervention 3
• Other severe hematologic complications (though evidence is limited) 4

Evidence Against Routine Use

Lack of Efficacy

• A Cochrane systematic review of 7 trials (362 participants) found no sustained benefit for symptom control with corticosteroids 5
• While two trials showed transient improvement in sore throat at 12 hours, this benefit was not maintained beyond the initial period 5
• Across 10 assessments of health improvement, 8 showed no benefit from steroid therapy 5

Safety Concerns

• Prolonged steroid use has been associated with severe infectious complications including polymicrobial bacteremia, septic shock, pulmonary septic emboli, empyema, and orbital cellulitis 4
• Corticosteroids increase susceptibility to bacterial superinfection through defects in lymphocyte signaling 6
• Respiratory infections occur in approximately 40% of patients receiving corticosteroids for other conditions 6
• Risk of invasive fungal infections, particularly aspergillosis, is elevated with corticosteroid use 6

Clinical Practice Patterns

• Despite clear guidelines, 44.7% of patients receive corticosteroids at one tertiary center, with 92% receiving them for indications outside traditional criteria 2
• Only 8% of patients in this cohort actually qualified for corticosteroid therapy by evidence-based criteria 2

When Corticosteroids Are Used: Critical Safeguards

If corticosteroids are deemed necessary for true complications:

• Screen carefully for active infection before initiating therapy 6
• Ensure any baseline infection is well-controlled with appropriate antibiotics before starting steroids 6
• Administer concurrent antibiotic therapy when infection risk is high—this approach reduced mortality from 52% to 13% in one high-risk population 6
• Use the minimum effective dose for the shortest duration necessary 6
• Monitor continuously for infectious complications during treatment and follow-up 6

Special Populations

Immunocompromised Patients

• Perform comprehensive assessment including full blood count, blood film, liver function tests, and EBV serology 1
• Consider reducing or discontinuing immunomodulator therapy if feasible 1
• For severe primary EBV infection, antiviral therapy with ganciclovir or foscarnet may be considered despite lack of supporting evidence 1
• Seek specialist consultation for suspected lymphoproliferative disease 1

Common Pitfalls to Avoid

• Do not prescribe corticosteroids for routine symptom control including fever, sore throat, or general malaise—these symptoms resolve with supportive care alone 1, 5
• Do not use corticosteroids to hasten recovery—there is insufficient evidence of efficacy and clear evidence of potential harm 5
• Avoid prolonged courses even when initiated for appropriate indications, as this significantly increases infectious complications 4
• Do not assume safety when combined with antibiotics—while one retrospective study suggested relative safety with concurrent antibiotics 7, this should not encourage broader use given lack of demonstrated efficacy and documented severe complications 4