What is the management and treatment of infectious mononucleosis?

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

Core Management Principles

• Symptomatic relief with antipyretics for fever control is recommended 1
• Activity modification is essential: patients must avoid contact sports and strenuous exercise for 8 weeks or until splenomegaly resolves to prevent splenic rupture 2
• Bed rest as tolerated with gradual return to normal activities 1

Medications That Do NOT Work

• Acyclovir has no benefit in treating uncomplicated infectious mononucleosis in immunocompetent patients, despite inhibiting EBV replication in vitro 3, 1
• Routine antiviral therapy is not indicated for standard cases 1

Corticosteroid Use: Reserved for Specific Complications Only

Corticosteroids should NOT be used routinely but are indicated only for severe, life-threatening complications. 1, 4

Specific Indications for Corticosteroids

• Severe upper airway obstruction from tonsillar enlargement 4
• Neurologic complications including encephalitis or severe encephalomyelitis 3
• Hematologic emergencies such as immune-mediated hemolytic anemia or severe thrombocytopenia 4
• Cardiac complications 1

Important caveat: Corticosteroids should be used judiciously as they may increase risk of secondary complications and do not alter the overall disease course 4

Management in Immunocompromised Patients: A Different Approach

Immunocompromised patients require aggressive management with reduction or discontinuation of immunosuppressive therapy when possible. 3, 1

Specific Considerations for Immunosuppressed Patients

• Primary EBV infection in patients on thiopurines carries risk of fatal lymphoproliferative disorders, particularly in those under 50 years 3
• Reduce or discontinue immunomodulator therapy (azathioprine, thiopurines) if primary EBV infection is suspected 3, 1
• Consider antiviral therapy with ganciclovir or foscarnet in severe primary EBV infection in immunocompromised patients, despite limited supporting evidence 3, 1
  • Combination therapy (ganciclovir 5 mg/kg IV every 12 hours plus foscarnet 60 mg/kg IV every 8 hours) may be used in severe cases 3
  • These agents are more potent than acyclovir for replicative EBV infection but significantly more toxic 3

Post-Transplant Lymphoproliferative Disorder (PTLD) Risk

• Discontinuation of immunosuppression may result in spontaneous regression of EBV-associated lymphoproliferative disease 3, 1
• Specialist consultation is mandatory for suspected lymphoproliferative disease or lymphoma 3
• EBV DNA surveillance should be implemented in high-risk transplant recipients 3

Critical Complications Requiring Specific Management

Splenic Rupture: The Most Feared Complication

• Occurs in 0.1-0.5% of cases and is potentially life-threatening 2, 5
• Early diagnosis is critical as mortality is rare when diagnosed promptly 6
• Splenectomy is the preferred treatment in most cases of documented rupture 6
• Prevention through activity restriction for 8 weeks is essential 2

Neurologic Complications

• Encephalitis or encephalomyelitis may benefit from corticosteroids based on anecdotal reports, particularly when increased intracranial pressure is present 3
• Antiviral therapy provides little to no benefit for CNS complications 3

Common Pitfalls to Avoid

• False-negative heterophile tests occur early in infection (first 6-10 days) and in children under 10 years; consider EBV-specific serology if clinical suspicion remains high 7, 1
• Do not prescribe antibiotics empirically as this may cause rash, particularly with ampicillin/amoxicillin (occurs in 10-45% of cases) 2
• Symptoms in immunocompromised patients may be minimal, particularly in those receiving corticosteroids, requiring high index of suspicion 1
• Fatigue may persist for 3 months but is generally self-limited 2

Return to Activity Guidelines

• Athletes tend to recover faster than non-athletes but may require 3-6 months to regain peak performance 6
• Contact sports clearance requires documented resolution of splenomegaly, typically at 8 weeks minimum 2, 6
• Gradual return to normal activities as tolerated, with close monitoring 1