Management and Treatment of Infectious Mononucleosis
Infectious mononucleosis is a self-limited disease requiring supportive care only, with no role for antiviral therapy in immunocompetent patients. 1
Primary Treatment Approach
Supportive Care (Mainstay of Treatment)
- Provide antipyretics for fever control and analgesics for pain relief 1
- Ensure adequate hydration throughout the illness 2
- Allow activity as tolerated based on the patient's energy level rather than enforcing strict bed rest 2
- Advise patients that fatigue may persist for several months after acute symptoms resolve 2
Activity Restrictions
- Patients must avoid contact sports and strenuous exercise for 8 weeks from symptom onset or until splenomegaly resolves, whichever is longer 3
- This restriction is critical to prevent splenic rupture, which occurs in 0.1-0.5% of cases and represents the most feared complication 3, 4
- Athletes typically recover faster than non-athletes, though elite athletes may require 3-6 months to regain peak performance 5
Medications NOT Recommended for Routine Use
Antiviral Agents
- Acyclovir does not ameliorate the course of infectious mononucleosis in immunocompetent individuals and should not be used 6, 1
- Despite inhibiting EBV replication in vitro, a meta-analysis of 5 clinical trials showed no clinical benefit 7
- Antiviral agents (ganciclovir, foscarnet) have no proven role in established disease in immunocompetent patients 6
Corticosteroids
- Corticosteroids are NOT recommended for routine treatment 1, 2
- Reserve corticosteroids only for specific severe complications including: 6, 1
- Severe neurologic complications (encephalomyelitis, increased intracranial pressure)
- Severe hematologic complications
- Severe cardiac complications
- Respiratory compromise or severe pharyngeal edema threatening airway patency 2
- Anecdotal reports suggest benefit in neurologic complications of EBV infection, but this requires confirmation 7
Management in Immunocompromised Patients
Critical Differences in Approach
- Reduce or discontinue immunomodulator therapy if possible when primary EBV infection is diagnosed 6, 1
- This is particularly important for patients on thiopurines, where fatal infectious mononucleosis-associated lymphoproliferative disorders have been reported 6
- Discontinuation of immunosuppressive therapy may result in spontaneous regression of EBV-associated lymphoproliferative disease 1
Antiviral Therapy Consideration
- In severe primary EBV infection in immunocompromised patients, consider antiviral therapy with ganciclovir or foscarnet despite limited supporting evidence 6, 1
- This represents an exception to the general rule against antivirals, reserved only for severe cases in immunosuppressed individuals
- Seek specialist consultation for suspected lymphoproliferative disease 6
Important Clinical Pitfalls
Diagnostic Considerations
- Symptoms in immunocompromised patients may be minimal, particularly in those receiving corticosteroids 1
- Immunocompromised patients have increased risk of severe disease, lymphoproliferative disorders, and hemophagocytic syndrome 6
- Monitor these high-risk patients more aggressively 6
Splenic Rupture Recognition
- Splenic rupture is rare but potentially life-threatening, occurring in 0.1-0.5% of cases 3, 4
- Almost never fatal if diagnosed early 5
- Maintain high clinical suspicion in patients with abdominal pain during the acute illness or recovery period