Treatment of Infectious Mononucleosis
Treatment for infectious mononucleosis is entirely supportive, as antiviral medications like aciclovir do not improve outcomes in otherwise healthy individuals. 1
Supportive Care Measures
The cornerstone of management involves symptom relief and activity modification:
- Adequate hydration, analgesics, and antipyretics are the primary interventions for symptom control 2
- Rest should be guided by the patient's energy level rather than enforced bed rest 2
- Fatigue may persist for several months after acute infection resolves, which is normal and expected 2, 3
Activity Restrictions
Patients must avoid contact sports and strenuous exercise for 8 weeks from symptom onset or while splenomegaly persists, whichever is longer 4, 2. This is critical because splenic rupture, though rare (0.1-0.5% of cases), is the most feared and potentially fatal complication 4, 3.
Role of Corticosteroids
Corticosteroids should be reserved exclusively for airway obstruction or severe pharyngeal edema causing respiratory compromise 1. Despite their common use in practice, the evidence does not support routine steroid use:
- A Cochrane systematic review of seven trials (362 participants) found no sustained benefit for symptom control with steroids 5
- While two trials showed transient improvement in sore throat at 12 hours, this benefit was not maintained 5
- Serious complications have been documented with prolonged steroid use, including septic shock, polymicrobial bacteremia, and septic emboli 6
- The risk-benefit ratio does not favor routine steroid use in uncomplicated cases 5
What Does NOT Work
Aciclovir and other antiviral agents are ineffective and should not be prescribed for infectious mononucleosis in immunocompetent patients 1. Similarly, antihistamines have no role in routine treatment 2.
Special Populations
For immunocompromised patients with suspected primary EBV infection:
- Reduce or discontinue immunomodulator therapy if clinically feasible 1
- Obtain complete blood count, blood film, and liver function tests 1
- These patients require specialist consultation due to increased risk of EBV-associated lymphoproliferative disease 1
Common Pitfalls to Avoid
- Do not prescribe antibiotics empirically for pharyngitis without confirming streptococcal infection, as the classic maculopapular rash occurs in 10-45% of mononucleosis patients and is dramatically worsened by ampicillin or amoxicillin 4, 2
- Do not use steroids for routine symptom control despite patient or family pressure, as evidence shows no benefit and potential harm 5, 6
- Do not clear patients for contact sports prematurely, even if they feel better, as splenic rupture can occur weeks after symptom onset 4, 2