However, if EBNA antibody is present, EBV is NOT the likely cause of the current problem. I use an EBNA mnemonic, “EB Not Active.” Occasionally an anti-EBNA-positive patient is entering recovery even if they don't feel well quite yet. We can assure them that they will feel better soon.
If EBV serology indicates recovery from a past EBV infection (positive for both IgG to VCA and anti-EBNA) or it is completely negative, a different cause for current symptoms could be sought by testing for cytomegalovirus, adenovirus, or Toxoplasma gondii.
EBV-mono patients should expect to have symptoms for at least 4–6 weeks before recovery. Reactivation may occur, but is nearly always asymptomatic or involves short-lived nonspecific symptoms. Chronic mono is so rare as to not be considered in primary care.
▸ Pitfall 4. Avoid having the patient stay too long on bed rest. Patients infected with EBV should be on bed rest only for the highly febrile stage, usually less than a week. We no longer recommend that they stay home from school or away from routine activities while riding out mononucleosis. Once the fever goes away, encourage patients to return to as much activity as their energy level will allow. The important exception is to refrain from contact sports as long as the spleen is palpable (and perhaps a little longer) to minimize chance of splenic rupture. I tell athletes to hang up the current sports season.
Patients kept in bed too long have more difficulty readjusting to normal life routines. Some may even experience clinical depression. It's important to consider how a patient with mono is coping psychologically when fatigue remains the main complaint.
▸ Pitfall 5. Active treatment is not usually helpful. Unfortunately, antivirals such as acyclovir don't work. Current consensus is not to give patients corticosteroids during acute mononucleosis. Steroids were postulated to speed recovery, and subjective mood improvement is possible due to the “steroid high” effect. However, in controlled trials they do not improve recovery other than reducing pain in first 12 hours (Cochrane Database Syst. Rev. 2006;3:CD004 402).
Further, steroids kill off defensive T cells that hold EBV-driven expansion of potentially malignant B cells in check. Such an imbalance could lead to later lymphoma. Although I don't think this is a huge risk, transient symptom relief does not seem worth the risk to me and I don't believe it's something we should do routinely. However, there are a few exceptions: The risk/benefit ratio changes in favor of corticosteroids if tonsillar swelling compromises the airway, or if there are other life-threatening EBV complications such as severe thrombocytopenia, neutropenia, or encephalitis.
But for uncomplicated EBV-mono, our best tools are ibuprofen, supportive care, and the tincture of time.