Management of Infectious Mononucleosis
Infectious mononucleosis is a self-limited disease requiring primarily supportive care, with no role for antiviral therapy in immunocompetent patients. 1, 2
Supportive Treatment Approach
The cornerstone of management is symptomatic treatment with activity restriction to prevent splenic rupture. 1, 3
Activity Restrictions
- Patients must avoid contact sports and strenuous exercise for 8 weeks from symptom onset or until splenomegaly resolves, whichever is longer. 1, 3
- Bed rest as tolerated is recommended during the acute phase. 3
- Splenic rupture occurs in 0.1-0.5% of cases and represents the most feared complication. 1, 3
Symptomatic Relief
- Adequate analgesia for sore throat and fever management. 4
- Hydration and rest during the acute illness phase. 3
Role of Antiviral Therapy
Antiviral agents (acyclovir, valacyclovir, valganciclovir) have no proven benefit in immunocompetent patients with infectious mononucleosis and are NOT recommended. 5, 1, 2
- A Cochrane systematic review found that while antivirals may reduce time to clinical recovery by 5 days, this difference is of questionable clinical significance given the wide confidence intervals and very low quality of evidence. 2
- Antivirals suppress viral shedding only while on treatment, with no sustained effect after discontinuation. 2
- Meta-analysis of 5 clinical trials showed no benefit of acyclovir in treating infectious mononucleosis. 5
Exception: Immunocompromised Patients
In immunocompromised patients with severe primary EBV infection, consider antiviral therapy with ganciclovir or foscarnet despite limited supporting evidence. 5, 1
- Reduce or discontinue immunomodulator therapy if possible. 5, 1
- Seek specialist consultation for suspected lymphoproliferative disease. 1
- Patients on thiopurines face particular risk of fatal infectious mononucleosis-associated lymphoproliferative disorders. 1
Corticosteroid Use
Corticosteroids should be reserved ONLY for specific life-threatening complications, not for routine management. 1, 6
Indications for Corticosteroids
- Upper airway obstruction (primary indication). 1, 6, 4
- Possibly immune-mediated severe anemia or thrombocytopenia. 6
- Selected cases of neurologic complications with increased intracranial pressure. 5
Corticosteroids should NOT be used for uncomplicated infectious mononucleosis or to hasten routine symptom resolution. 1, 6
Monitoring and Follow-Up
Clinical Monitoring
- Most patients recover within weeks to months without sequelae. 3, 6
- Fatigue may persist in approximately 10% of patients at 6-month follow-up. 2
- Monitor for complications including neurologic, hematologic, hepatic, and respiratory manifestations. 6
Important Caveats
- Avoid prescribing ampicillin or amoxicillin, as these cause a characteristic maculopapular rash in 90% of patients with infectious mononucleosis. 3
- Patients remain contagious for approximately 7-10 days from symptom onset. 7
- Advise patients to avoid sharing personal items contaminated with saliva (utensils, drinking containers, towels). 7
Key Clinical Pitfall
The most critical management error is failing to counsel patients about activity restriction, which can lead to preventable splenic rupture. 1, 3 This complication, though rare, is potentially life-threatening and entirely avoidable with proper patient education about the 8-week restriction period.