eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Mononucleosis and Epstein-Barr Virus Infection: Treatment & Medication

Author: Nicholas John Bennett, MB, BCh, PhD, Fellow in Pediatric Infectious Disease, Department of Pediatrics, State University of New York Upstate Medical University
Coauthor(s): Joseph Domachowske, MD, Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York-Upstate Medical University
Contributor Information and Disclosures

Updated: Oct 20, 2009

Treatment

Medical Care

  • Infectious mononucleosis is a self-limited illness that does not usually require specific therapy.
  • Because of low transmissibility of Epstein-Barr virus (EBV), isolation is not indicated.
  • Most affected individuals can be evaluated and treated as outpatients. Inpatient therapy of medical and surgical complications may be required.
  • Patients with chronic post–Epstein-Barr virus fatigue may benefit from psychological and behavioral approaches.12

Surgical Care

Splenic rupture is an acute abdominal emergency that usually requires surgical intervention.

  • Rupture may occur with trauma as minor as palpation, and is occasionally the presenting symptom.
  • Diagnosis can be confirmed using imaging procedures or peritoneal lavage in an unstable patient.
  • Splenectomy is usually required.
  • Occasionally, observation and supportive measures are adequate treatment for a hemodynamically stable patient.
  • Although partial splenectomy or suturing the capsular tear has been advocated to preserve splenic function, the acute changes that led to rupture militate against the success of this approach.

Consultations

  • Surgical consultation should be sought when the patient has abdominal pain or evidence of shock.
  • Consultation with the appropriate subspecialist is indicated for management of significant complications.

Diet

  • No dietary modifications are required.

Activity

  • Acceptable activity level during the acute illness depends on severity of the patient's symptoms.
  • Extreme fatigue may require bed rest for 1-2 weeks.
  • Malaise may persist for 2-3 months, and activity can increase as tolerated.
  • Patients should not participate in contact sports or heavy lifting for at least 2-3 weeks, although some authors recommend avoiding activities that may cause splenic trauma for 2 months.

Medication

Acute infectious mononucleosis is treated symptomatically. Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to treat fever and discomfort. Corticosteroids do not significantly alter the course of infectious mononucleosis. Although they ameliorate symptoms, corticosteroids should not be used in the treatment of uncomplicated disease. They are used in patients with significant upper airway obstruction due to tonsillar or lymph node hypertrophy and in patients with severe thrombocytopenia or hemolytic anemia.

Numerous drugs inhibit Epstein-Barr virus (EBV) replication in vitro. Nonetheless, antiviral agents are not beneficial in patients with uncomplicated infectious mononucleosis. However, antiviral agents are used in the treatment of patients with interstitial pneumonitis, X-linked lymphoproliferative syndrome, PTLD, and other lymphoproliferative disorders. Intravenous immunoglobulin may be considered to modulate immune function in the presence of disease complications due to autoantibodies.

New therapies, including the use of interferon alpha and the infusion of donor T cells or Epstein-Barr virus–specific cytotoxic T cells, are being studied.

Glucocorticoids

Corticosteroids are potent anti-inflammatory drugs that also modify the immune response. They are used to decrease the size of tonsils and upper airway lymph nodes in the presence of airway compromise and possible upper airway obstruction. They may be useful to treat severe thrombocytopenia or hemolytic anemia. Whether prednisone should be used for myocarditis, pericarditis, or CNS system involvement is unclear.


Prednisone (Deltasone, Liquid Prep, Meticorten, Orasone, Prednicen-M, Sterapred)

May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity.

Adult

60-80 mg/d PO divided bid for 5-7 d; taper over 1-2 wk

Pediatric

1 mg/kg/d PO divided bid, not to exceed 60-80 mg; administer for 5-7 d, then taper over 1-2 wk

Immune response to vaccinations may be impaired; phenytoin, rifampin, or drugs that induce hepatic enzymes can decrease serum concentration

Systemic fungal infections; varicella; vaccination with live or live-attenuated vaccines

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Associated with multiple adverse reactions, including fluid and electrolyte disturbances and musculoskeletal abnormalities, including muscle weakness, steroid myopathy, and osteoporosis; GI adverse effects include peptic ulcer disease, pancreatitis, and an increase in LFTs; steroid use has been associated with increased intracranial pressure, seizures, headache, growth suppression, adrenal cortical suppression, menstrual irregularities, hyperglycemia, negative nitrogen balance, glaucoma, and cataracts

Antiviral drugs

Numerous drugs inhibit Epstein-Barr virus replication in vitro. These include acyclovir, desciclovir, ganciclovir, interferon-alfa, interferon-gamma, adenine arabinoside, and phosphonoacetic acid. Acyclovir, which inhibits viral shedding from the oropharynx, is the only antiviral drug used to treat infectious mononucleosis in placebo-controlled clinical trials. However, the clinical course is not significantly affected in patients with uncomplicated infectious mononucleosis.


Acyclovir (Zovirax)

Strains of HSV1 are most sensitive, followed by HSV2. Also sensitive to other herpesviruses, including, in descending order, varicella zoster, EBV, and CMV.

Adult

800 mg PO 5 times/d for 10 d
10 mg/kg/dose IV q8h for 7-10 d

Pediatric

>24 months: 800 mg PO 5 times/d for 10 d, not to exceed 80 mg/kg/d in 5 divided doses; 10 mg/kg/dose IV q8h for 7-10 d

Neurotoxicity can occur when combined with zidovudine; probenecid decreases renal clearance of acyclovir; use with cyclosporine increases risk of nephrotoxicity

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution with other nephrotoxic drugs or in patients with preexisting renal disease; maintain adequate urine output for the first 2 h after IV infusion; use carefully in patients with renal, hepatic, or electrolyte disturbances and in patients with hypoxemia or underlying neurologic abnormalities

Immunoglobulins

Intravenous immunoglobulin is used to modulate immune function in the presence of autoantibodies. It has been used successfully in the treatment of immune thrombocytopenia associated with infectious mononucleosis.


Intravenous immunoglobulin (Gammagard S/D, Gammar-P, Polygam)

Neutralizes circulating myelin antibodies through antiidiotypic antibodies; down-regulates proinflammatory cytokines, including INF-gamma; blocks Fc receptors on macrophages; suppresses inducer T and B cells and augments suppressor T cells; blocks complement cascade; promotes remyelination; may increase CSF IgG (10%).

Adult

400 mg/kg/d IV for 2-5 d

Pediatric

Administer as in adults

May interfere with antibody response to live virus vaccines

Documented hypersensitivity; IgA deficiency

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Hypersensitivity reactions may occur; initiating at rate of administration may increase risk of hypotension; risk of anaphylaxis is greater in IgA-deficient individuals (procure low-titer IgA product if essential)

More on Mononucleosis and Epstein-Barr Virus Infection

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References
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Further Reading

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Keywords

mononucleosis, Epstein-Barr virus infection, EBV, acute infectious mononucleosis, infectious mononucleosis, mono, human herpesvirus 4, HHV-4, kissing disease, gamma-herpesvirus, human tumor virus, lymphoproliferative disorders, nasopharyngeal carcinoma, Burkitt lymphoma, endemic Burkitt lymphoma, acute glandular fever, non-Hodgkin lymphomas, Hodgkin lymphoma, Duncan syndrome, X-linked lymphoproliferative syndrome, fatal massive hepatitis, disseminated lymphoproliferative disorder, B-cell lymphoma, hypogammaglobulinemia, EBV-associated lymphoproliferative disorders, EBV-associated lymphomas, ataxia-telangiectasia, Chédiak-Higashi syndrome, Wiskott-Aldrich syndrome, posttransplant lymphoproliferative disorder, PTLD, lymphoproliferative syndrome, hairy leukoplakia, leiomyosarcoma, CNS lymphoma, lymphoid interstitial pneumonitis, infectious mononucleosis syndrome, sore throat, splenic rupture, pharyngitis, hepatosplenomegaly, petechiae, tonsillar enlargement, enlarged epitrochlear nodes, hepatomegaly, splenomegaly, maculopapular rash

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Contributor Information and Disclosures

Author

Nicholas John Bennett, MB, BCh, PhD, Fellow in Pediatric Infectious Disease, Department of Pediatrics, State University of New York Upstate Medical University
Nicholas John Bennett, MB, BCh, PhD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Pediatrics
Disclosure: Nothing to disclose.

Coauthor(s)

Joseph Domachowske, MD, Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York-Upstate Medical University
Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

Rosemary Johann-Liang, MD, Medical Officer, Infectious Diseases and Pediatrics, Division of Special Pathogens and Immunological Drug Products, Center for Drug Evaluation and Research, Food and Drug Administration
Rosemary Johann-Liang, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Mark R Schleiss, MD, American Legion Chair of Pediatrics, Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota Medical School
Mark R Schleiss, MD is a member of the following medical societies: American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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