Is steroid treatment indicated for a patient with mononucleosis?

Steroid Use in Infectious Mononucleosis

Steroids should NOT be routinely given to patients with infectious mononucleosis, but are indicated only for specific life-threatening complications including airway obstruction or impending airway compromise, and increased intracranial pressure from neurologic complications. 1

Primary Management Approach

• Supportive care alone is the recommended treatment for uncomplicated infectious mononucleosis, as this self-limiting illness typically resolves over 2-3 weeks without specific pharmacologic intervention 1, 2
• Symptomatic treatment includes adequate hydration, analgesics, antipyretics, and rest guided by the patient's energy level rather than enforced bed rest 2

When Steroids Are NOT Indicated

• Routine symptom control: Corticosteroids are not recommended for common symptoms including sore throat, fever, lymphadenopathy, or fatigue 1, 2, 3
• A Cochrane systematic review of 7 trials (362 participants) found insufficient evidence for steroid efficacy in symptom control, with only 2/10 assessments showing any benefit 4
• While two trials showed reduced sore throat at 12 hours with steroids, this benefit was not maintained beyond the initial period 4
• Corticosteroids alone or combined with antivirals should not be given to children for common IM symptoms 3

Specific Indications for Steroid Use

Steroids may be indicated in the following severe complications:

• Airway obstruction or impending airway compromise from severe pharyngeal edema or tonsillar enlargement 1, 2, 5
• Increased intracranial pressure in patients with neurologic complications 1
• Severe immune-mediated complications including autoimmune hemolytic anemia or severe thrombocytopenia (use judiciously) 5

Safety Considerations

• A retrospective cohort study of 396 patients found that corticosteroid use during IM was generally safe when combined with concomitant antibiotic therapy, with similar rates of severe complications (peritonsillar abscess, bacteremia, splenic rupture) between steroid and non-steroid groups 6
• However, adverse events have been documented including respiratory distress and acute onset of diabetes, though causality with steroids is uncertain 4
• Safety does not justify routine use, as efficacy remains unproven 6

Clinical Pitfalls to Avoid

• Do not prescribe steroids simply because patients present with severe sore throat or prolonged symptoms—these are expected features of IM 2, 3
• Avoid the temptation to use steroids to shorten illness duration or reduce school absences, as evidence shows small and inconsistent benefits at best 3
• Be particularly cautious about steroid use given the lack of long-term safety data and potential for complications 4

Special Population: Immunocompromised Patients

• Careful clinical assessment is warranted with full blood count, blood film, liver function tests, and EBV serology 1
• Consider reducing or discontinuing immunomodulator therapy if possible 1
• In severe primary EBV infection, antiviral therapy with ganciclovir or foscarnet may be considered despite lack of supporting evidence, with specialist consultation 1