Treatment of Infectious Mononucleosis
Supportive care is the mainstay of treatment for infectious mononucleosis, with no role for routine antiviral therapy or corticosteroids in immunocompetent patients. 1, 2, 3
Primary Treatment Approach
Symptomatic Management
- Provide adequate hydration, analgesics, and antipyretics for fever control 1, 2
- Activity should be guided by the patient's energy level rather than enforced bed rest 2
- Fatigue may persist for several months after acute infection resolves, but typically improves within three months 4, 2
Medications NOT Recommended for Routine Use
- Acyclovir does not ameliorate the course of infectious mononucleosis in otherwise healthy individuals 5, 1
- Antihistamines are not recommended for routine treatment 2
- Corticosteroids should NOT be used routinely 1, 2, 3
Corticosteroid Use: Reserved for Specific Complications Only
Corticosteroids may be indicated only for severe neurologic, hematologic, or cardiac complications, or for respiratory compromise with severe pharyngeal edema 1, 2
This represents a narrow therapeutic window and should not be confused with routine management.
Activity Restrictions: Critical for Splenic Rupture Prevention
Return to Sports Guidelines
- Patients must avoid contact sports or strenuous exercise for at least 3-4 weeks from symptom onset 1, 3
- Some guidelines extend this to 8 weeks or until splenomegaly resolves 4
- Splenic rupture occurs in 0.1-0.5% of cases and typically happens between days 4-21 of illness 4, 6
- Shared decision-making should determine exact timing of return to activity 3
Common Pitfall
The risk of splenic rupture is approximately 2% per hundred, making activity restriction non-negotiable during the acute phase 6. This is the most feared and potentially fatal complication 4, 7.
Special Population: Immunocompromised Patients
Management Algorithm for Immunosuppressed Individuals
If primary EBV infection occurs in an immunocompromised patient, reduce or discontinue immunomodulator therapy if possible 5, 1
- Immunocompromised patients have increased risk of severe disease, lymphoproliferative disorders, and hemophagocytic syndrome 5, 1
- In severe primary EBV infection, antiviral therapy with ganciclovir or foscarnet may be considered despite lack of strong supporting evidence 5, 1
- Seek specialist consultation for suspected lymphoproliferative disease 5
- Primary EBV infection poses particular threat in patients on thiopurines, with reports of fatal infectious mononucleosis-associated lymphoproliferative disorders 5
Important Caveat
Symptoms of EBV infection in immunocompromised patients may be minimal, particularly in those receiving corticosteroids, making diagnosis more challenging 1
Monitoring and Follow-up
- Most patients have an uneventful recovery with spontaneous resolution 4
- Infectious mononucleosis is a risk factor for chronic fatigue syndrome 4
- Long-term association exists with nine types of cancer (including Hodgkin lymphoma, non-Hodgkin lymphoma, nasopharyngeal carcinoma) and some autoimmune diseases 3