Treatment of Infectious Mononucleosis
Supportive care is the mainstay of treatment for infectious mononucleosis, as antiviral agents like acyclovir do not improve outcomes in otherwise healthy individuals. 1, 2
General Management Approach
Symptomatic treatment forms the foundation of care:
- Provide antipyretics for fever management 2
- Recommend adequate analgesia for throat pain and discomfort 3
- Advise reduction of activity and bed rest as tolerated 4
- Patients must avoid contact sports or strenuous exercise for 8 weeks or while splenomegaly persists to prevent splenic rupture, which occurs in 0.1-0.5% of cases 4
When NOT to Use Antivirals
Acyclovir and other antiviral agents have no proven role in established disease in immunocompetent patients and should not be routinely prescribed. 1, 5 Multiple studies confirm that acyclovir does not ameliorate the clinical course in otherwise healthy individuals. 1, 2
Corticosteroid Use: Reserved for Specific Complications Only
Corticosteroids are NOT recommended for routine treatment but may be indicated for specific severe complications: 2, 3
- Severe upper airway obstruction (primary indication) 3, 5
- Severe neurologic complications 2, 3
- Severe hematologic complications (e.g., thrombocytopenic purpura) 2, 3
- Cardiac complications 2, 3
Important caveat: Corticosteroids should be avoided unless benefits clearly outweigh potential risks, as they may mask symptoms in immunocompromised patients. 2, 5
Special Population: Immunocompromised Patients
Management differs significantly in immunocompromised patients:
- Reduce or discontinue immunomodulator therapy if possible when primary EBV infection is diagnosed 1, 2
- Antiviral therapy with ganciclovir or foscarnet may be considered in severe primary EBV infection, despite limited supporting evidence 1, 2
- Seek specialist consultation for suspected lymphoproliferative disease 1
- Monitor closely for severe disease manifestations, as symptoms may be minimal in patients receiving corticosteroids 2
Critical consideration: Primary EBV infection poses particular threat in patients on thiopurines, with reports of fatal infectious mononucleosis-associated lymphoproliferative disorders. 1
Activity Restrictions
Specific guidelines for return to activity:
- Avoid contact sports for minimum 8 weeks from symptom onset 4
- Continue activity restriction while splenomegaly is still present on examination 4
- This prevents splenic rupture, the most feared and potentially life-threatening complication 4
Clinical Pitfalls to Avoid
- Do not prescribe antibiotics like ampicillin or amoxicillin, as they commonly cause a maculopapular rash in patients with infectious mononucleosis 4
- Do not use antiviral therapy routinely—it has no proven benefit in immunocompetent patients 5
- Do not allow early return to sports without confirming resolution of splenomegaly 4