Management and Treatment of Infectious Mononucleosis
Supportive care is the mainstay of treatment for infectious mononucleosis, as antiviral agents like acyclovir provide no benefit in otherwise healthy individuals. 1, 2
General Management Approach
Symptomatic treatment forms the foundation of care:
- Antipyretics for fever management 2
- Activity reduction and bed rest as tolerated 3
- Patients must avoid contact sports or strenuous exercise for 8 weeks or while splenomegaly persists to prevent splenic rupture 3
- Spontaneous splenic rupture occurs in 0.1-0.5% of cases and represents the most feared, potentially life-threatening complication 3, 4
Antiviral Therapy: Not Recommended
Acyclovir does not ameliorate the course of infectious mononucleosis in immunocompetent patients despite inhibiting EBV replication in vitro. 5, 1, 2 A meta-analysis of 5 clinical trials demonstrated no clinical benefit, and its use is not recommended for uncomplicated cases. 5
Corticosteroid Use: Reserved for Specific Complications
Corticosteroids should NOT be used routinely but are indicated only for severe complications: 1, 2
- Severe upper airway obstruction 6
- Neurologic complications (encephalomyelitis, increased intracranial pressure) 5, 6
- Immune-mediated hematologic complications (severe anemia, thrombocytopenia) 6
- Cardiac complications 2
The evidence for corticosteroid efficacy comes primarily from anecdotal reports, and they should be used judiciously given limited supporting data. 5, 6
Management in Immunocompromised Patients: A Different Approach
In immunocompromised patients with primary EBV infection, immunomodulator therapy should be reduced or discontinued if possible. 1, 2
For severe primary EBV infection in immunocompromised patients, consider antiviral therapy with ganciclovir or foscarnet despite limited supporting evidence: 1, 2
- This population has increased risk of lymphoproliferative disorders and hemophagocytic syndrome 1
- Primary EBV infection poses particular threat in patients on thiopurines, with reports of fatal infectious mononucleosis-associated lymphoproliferative disorders 1
- Specialist consultation should be sought for suspected lymphoproliferative disease 1
- Discontinuation of immunosuppressive therapy may result in spontaneous regression of EBV-associated lymphoproliferative disease 2
Critical Pitfalls to Avoid
Splenic rupture prevention is paramount:
- Enforce strict activity restrictions for minimum 8 weeks 3
- Athletes may take 3-6 months to regain top form despite clinical recovery 7
- Contact sports must be avoided until spleen returns to normal size 3, 7
Diagnostic considerations:
- False-negative heterophile tests are common early in infection (first 6-10 days) and in children under 10 years 1, 2
- If clinical suspicion remains high with negative heterophile test, proceed to EBV-specific serologic testing (VCA IgM, VCA IgG, EBNA) 1, 2
Immunocompromised patients may present with minimal symptoms, particularly those on corticosteroids, requiring higher index of suspicion. 2