Symptomatic Treatment of Infectious Mononucleosis
Supportive care with adequate hydration, antipyretics, and analgesics is the mainstay of treatment for infectious mononucleosis, as acyclovir and other antivirals do not improve outcomes in otherwise healthy individuals. 1, 2
Core Symptomatic Management
Rest and Activity Modification:
- Allow patients to self-regulate activity based on energy levels rather than enforcing strict bed rest 2
- Advise avoidance of contact sports or strenuous exercise for 8 weeks after symptom onset or while splenomegaly persists to prevent splenic rupture (occurs in 0.1-0.5% of cases) 3
- Patients should be withdrawn from collision sports for at least four weeks after onset of symptoms 2
Fever and Pain Control:
- Use antipyretics and analgesics for symptomatic relief of fever and sore throat 1, 2
- Ensure adequate hydration, particularly important given the pharyngitis and fever 2
Medications NOT Recommended for Routine Use
Antivirals:
- Acyclovir does not ameliorate the course of infectious mononucleosis in otherwise healthy individuals 4, 1
- A Cochrane review found insufficient evidence that antivirals (acyclovir, valacyclovir, valomaciclovir) provide clinically meaningful benefit 5
- While viral shedding may be suppressed during treatment, this effect is not sustained after stopping medication 5
Corticosteroids:
- Not recommended for routine treatment 1, 2
- A Cochrane review of seven trials (362 participants) found insufficient evidence of efficacy for symptom control 6
- Two trials showed benefit for sore throat at 12 hours, but this was not maintained 6
- Reserve corticosteroids only for specific severe complications: respiratory compromise, severe pharyngeal edema with airway obstruction, or severe neurologic/hematologic/cardiac complications 1, 2
Antihistamines:
- Not recommended for routine treatment of infectious mononucleosis 2
Special Population Considerations
Immunocompromised Patients:
- Reduce or discontinue immunomodulator therapy if possible when primary EBV infection occurs 7, 1
- In severe primary EBV infection, antiviral therapy with ganciclovir or foscarnet may be considered despite limited supporting evidence 7, 1
- These patients have increased risk of lymphoproliferative disorders and require specialist consultation 7, 1
- Patients on thiopurines face particular risk, with reports of fatal infectious mononucleosis-associated lymphoproliferative disorders 7
Expected Clinical Course and Counseling
Symptom Duration:
- Most symptoms typically resolve within two to three weeks 6
- Fatigue, myalgias, and need for sleep may persist for several months after acute infection resolves 2
- Fatigue tends to resolve within three months in most cases 3
- Infectious mononucleosis is a risk factor for chronic fatigue syndrome 3
Critical Pitfall to Avoid
The most feared complication is spontaneous splenic rupture, which is potentially life-threatening 3. This underscores the critical importance of activity restriction counseling, particularly regarding contact sports and heavy lifting during the acute phase and recovery period.