Management of Infectious Mononucleosis
Treatment for infectious mononucleosis is entirely supportive, with no role for antiviral therapy in otherwise healthy individuals. 1, 2
Supportive Care Measures
- Provide symptomatic relief with antipyretics (acetaminophen or ibuprofen) for fever and throat pain 2, 3
- Ensure adequate hydration throughout the illness course 3
- Allow patient-guided activity levels rather than enforcing strict bed rest; patients allowed out of bed as soon as they felt able reported quicker recovery 4
- Advise rest as tolerated based on the patient's energy level, as fatigue may persist for several months 3, 5
Activity Restrictions
Patients must avoid contact sports and strenuous exercise for at least 3-4 weeks from symptom onset to prevent splenic rupture, which occurs in 0.1-0.5% of cases and is potentially life-threatening 6, 3, 5. The risk of splenic rupture persists even after clinical recovery 7.
- Restrict contact or collision sports for 4 weeks minimum after onset of symptoms 3
- Extend restrictions to 8 weeks or until splenomegaly resolves if splenomegaly is documented 6
- Use shared decision-making to determine exact timing of return to athletic activity 5
Medications to Avoid
- Do not prescribe aciclovir routinely, as it does not ameliorate the course of infectious mononucleosis in healthy individuals 1, 2
- Avoid routine corticosteroids for uncomplicated cases 2, 3
- Do not prescribe antihistamines for routine treatment 3
When Corticosteroids Are Indicated
Reserve corticosteroids exclusively for life-threatening complications 1, 3:
- Airway obstruction or impending airway compromise 1
- Severe pharyngeal edema causing respiratory compromise 1
- Severe neurologic complications 2
- Severe hematologic complications 2
- Severe cardiac complications 2
Special Instructions for Immunocompromised Patients
If the patient is on immunosuppressive therapy, reduce or discontinue immunomodulators if possible 1, 2. These patients require:
- Specialist consultation due to increased risk of EBV-associated lymphoproliferative disease 1
- Laboratory monitoring including complete blood count, blood film, and liver function tests 1
- Consider antiviral agents (ganciclovir or foscarnet) in severe primary EBV infection in immunocompromised patients, though evidence is limited 2
Infection Control Measures
- Advise avoiding sharing personal items contaminated with saliva (cups, utensils, toothbrushes) 1
- Practice hand hygiene during outbreaks in close community settings 1
- Explain that EBV is transmitted primarily through saliva and close personal contact 6, 5
Common Pitfalls to Avoid
- Do not enforce strict bed rest, as this does not improve outcomes and patient-guided activity leads to faster recovery 4
- Do not prescribe antibiotics unless there is documented bacterial superinfection; ampicillin/amoxicillin will cause a rash in 90% of mononucleosis patients 3
- Do not allow premature return to sports, as splenic rupture can occur even after clinical recovery and has resulted in fatal hemorrhage 7
- Do not dismiss persistent fatigue as it may last several months and is a risk factor for chronic fatigue syndrome 6, 3
Expected Clinical Course
- Most patients have uneventful recovery with resolution of acute symptoms within 2-4 weeks 6
- Fatigue, myalgias, and need for sleep may persist for several months after acute infection resolves 3
- Monitor for complications including splenic rupture (most feared), airway obstruction, and rarely neurologic or hematologic complications 6, 5