What are the treatment and precautions for mononucleosis (infectious mononucleosis)?

Treatment and Precautions for Infectious Mononucleosis

Supportive care is the mainstay of treatment for infectious mononucleosis, with activity restriction for 3-8 weeks to prevent splenic rupture, while acyclovir and routine corticosteroids are not recommended for otherwise healthy individuals. 1, 2, 3

General Treatment Approach

Supportive Care Measures

• Adequate hydration, antipyretics for fever control, and analgesics for pain relief form the foundation of treatment. 1, 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

Medications NOT Recommended for Routine Use

• Acyclovir does not ameliorate the course of infectious mononucleosis in otherwise healthy individuals and should not be used routinely. 4, 1, 2
• Corticosteroids are not recommended for routine treatment. 1, 2
• Antihistamines have no proven benefit. 2

Activity Restrictions and Splenic Rupture Prevention

Critical Precautions

• Patients must avoid contact sports and strenuous exercise for at least 3-4 weeks from symptom onset, with some guidelines recommending up to 8 weeks or until splenomegaly resolves. 1, 2, 3
• Splenic rupture occurs in 0.1-0.5% of patients and is the most feared, potentially life-threatening complication. 5
• Splenomegaly occurs in approximately 50% of cases. 5

Return to Activity Decision-Making

• Use shared decision-making to determine timing of return to athletic activity. 3
• Activity restrictions should continue while splenomegaly is still present on examination. 2

Specific Indications for Corticosteroids

Corticosteroids may be indicated only for specific severe complications: 1, 2, 6

• Severe airway obstruction or pharyngeal edema causing respiratory compromise
• Severe neurologic complications
• Severe hematologic complications (e.g., severe thrombocytopenia, hemolytic anemia)
• Severe cardiac complications

The benefits must outweigh potential risks, as corticosteroids should generally be avoided. 6

Special Populations: Immunocompromised Patients

High-Risk Considerations

• Immunocompromised patients have significantly increased risk of severe disease, lymphoproliferative disorders, and hemophagocytic syndrome. 7, 1
• These patients require more aggressive monitoring and may have minimal symptoms despite severe disease, particularly if receiving corticosteroids. 1

Management in Immunosuppressed Patients

• Immunomodulator therapy (particularly thiopurines) should be reduced or discontinued if possible during primary EBV infection. 4, 1
• Discontinuation of immunosuppressive therapy may result in spontaneous regression of EBV-associated lymphoproliferative disease. 1
• Antiviral therapy with ganciclovir or foscarnet may be considered in severe primary EBV infection in immunocompromised patients, despite limited supporting evidence. 1

Screening Before Immunosuppression

• EBV IgG screening should be considered before initiating immunomodulator therapy, particularly thiopurines. 4
• Anti-TNF monotherapy could be used in preference to thiopurines in EBV seronegative patients. 4
• Primary EBV infection in patients on thiopurines carries risk of fatal infectious mononucleosis-associated lymphoproliferative disorders. 4

Transmission Prevention

Key Precautions

• Avoid sharing items contaminated with saliva, as EBV is transmitted primarily through saliva. 8, 3
• Hand hygiene is essential during outbreaks. 8
• Close personal contact and crowded settings facilitate transmission. 8

Common Pitfalls to Avoid

Diagnostic Pitfalls

• False-negative heterophile antibody tests are common early in infection (first 6-10 days) and in children under 10 years. 7, 1, 3
• If clinical suspicion remains high despite negative heterophile test, obtain EBV-specific serologic testing (VCA IgM, VCA IgG, and EBNA antibodies). 7, 1

Treatment Pitfalls

• Do not prescribe ampicillin or amoxicillin, as these cause a maculopapular rash in 90% of patients with infectious mononucleosis. 5
• Do not enforce strict bed rest; allow patient's energy level to guide activity. 2
• Do not use antiviral therapy routinely in immunocompetent patients. 4, 6

Monitoring and Follow-Up

Expected Clinical Course

• Most patients have uneventful recovery over several weeks. 5, 6
• Fatigue, myalgias, and increased need for sleep may persist for several months. 2
• Infectious mononucleosis is a risk factor for chronic fatigue syndrome. 5

Long-Term Considerations

• EBV infection has been linked to nine types of cancer, including Hodgkin lymphoma, non-Hodgkin lymphoma, and nasopharyngeal carcinoma. 3
• Over 90% of normal adults eventually develop IgG antibodies to VCA and EBNA antigens, reflecting past infection. 7