Mononucleosis is an infection that comes from the Epstein-Barr Virus. The virus is spread through body fluids, the most common being saliva. Due to how the virus is caught it was given the nickname the kissing disease. Mono can also be spread through the sharing of drinks and utensils. When contracted, the virus typically incubates for four to eight weeks before causing manifestations. The virus works by infecting the B lymphocytes. The infection can affect everyone in different ways. Some people may have minor signs and symptoms, while others may be affected severely. Most common signs and symptoms include fatigue, malaise, severe sore throat, fever, cervical node swelling, and splenomegaly. Patients are tested for mono by checking the white blood cell differential for increased B and T cells in the blood. They also test using a monospot to check whether you are positive for the Epstein-Barr virus. The disease is self-limiting and typically resolves with rest, fluids, and treatment of symptoms.
In the United States, there are many conflicting opinions on whether corticosteroids should be used to control symptoms in people who have tested positive for mono. Every doctors has a different opinion and preference about prescribing steroids to help control symptoms of mononucleosis. Steroids can cause a variety of negative side effects which causes the hesitation among health professionals. The differences in practice can become problematic in the hospital when patients doctors are changed from day to day. The controversy brings up whether mono patients benefit from the use of corticosteroids to decrease symptoms in patients who were treated with no intervention.
Search Methods
When compiling research studies, there was difficulty finding studies that had been completed recently. Many of the studies had been completed many years ago. Databases were searched through the UNH health and wellness tab through the research department. The two databases utilized where Medline and PubMed. The search engine used with Medline was EbscoHost. The two keywords used to help narrow down the search were, “infectious mononucleosis,” and, “corticosteroids.” When using PubMed, the MeSh search engine compiled articles using the words, “steroids,” and “infectious mononucleosis.” Before applying limits, there were many studies that could have applied to the question. Only full articles that could be requested through the UNH databases were used. Any articles that were not completed after the year 2000 were removed. Using the inclusion and exclusion criteria there were three research studies found to apply to the question.
Critical Appraisal of the Evidence
A retrospective case series looked at the effects of systemic corticosteroid therapy on the course of infectious mononucleosis and there effect on treatment patterns and patient outcomes (Thompson, Doerr & Hengerer, 2005). The studies included patient records of people who were diagnosed with infectious mononucleosis from January 1998 until March 2003. The diagnosis was made using a monospot test or elevated Epstein-Barr virus IgM levels. Patients also had to have at least three clinical findings appropriate with lymphocytosis including; pharyngitis, fever, cervical lymphadenopathy, tonsillar hypertrophy or exudate, and hepatosplenomegaly. The exclusion criteria used were patients who were chronically immunocompromised. The also excluded a patient who came back with a positive monospot but exhibited no other evidence of infectious mononucleosis. When the inclusion and exclusion criteria were applied 206 patients met the criteria (Thompson, Doerr & Hengerer, 2005).
Researchers looked at and analyzed patient findings at the time of diagnosis, the time of treatment, and the patient outcome. Almost all patients included had a positive antibody test. People who came back negative had three or more of the clinical findings appropriate with the diagnostic criteria. Of these patients, ninety-two of them received corticosteroids during their illness. Patients were treated with steroids for indications of airway concern, idiopathic thrombocytopenic purpura, poor oral intake/severe dysphasia, persistent symptoms, or repeat visits (Thompson, Doerr & Hengerer, 2005).
When comparing clinical course and outcomes between the group that received steroids and the group that did not researchers looked at the rate of hospital admission, the length of stay, and the incidence of complications. The outcome comparison between the groups showed no statistical differences when analyzed. The study concluded that while steroids have been implicated for use previously there is little evidence to support the claim. There was no difference in complications seen in the study despite suspicions (Thompson, Doerr & Hengerer, 2005).
The study was retrospective which allowed one of its strengths to be a large sample size. The research compiled data to create a large pool of patients to look at. Another strength is that the sample was chosen randomly based on their inclusion and exclusion criteria. A retrospective study does, however, come with weaknesses. The researchers must look back on patients charts to find information, thus relying on others for accurate records. In retrospective studies selection bias, can be a problem and certain characteristics may be hard to study based on the chart (Thompson, Doerr & Hengerer, 2005).
The second research study analyzed was a systematic review (McGee, 2008). The authors searched Medline up until July 2007 for English publications. All the articles were independently reviewed to assess whether they were relevant. Any studies using topical corticosteroids were omitted. The systematic review found six studies that considered the use of corticosteroids in patients with infectious mononucleosis. The studies together enrolled 268 patients. They included primarily ambulatory patients with a mild to moderate symptoms of the disease. Patients with airway obstruction were excluded. The study broke down the participants by their age and which steroid they were placed on. The study also looked at whether people who were infected were hospitalized. The steroids given included prednisolone, prednisone, dexamethasone, and paramethasone. The study concluded that steroid therapy had very little resolution of a sore throat, lymphadenopathy, malaise, and difficult concentration. There was no significant reduction in the duration of the illness or days missed from work or school. When the 286 patients were looked at a year later there was no difference in relapse rate or late onset complications (McGee, 2008).
A systematic review is one of the highest levels of research that can be done. The review synthesizes all the previous research done on a topic to provide a definitive answer. The conclusions that come out can be more reliable than individual studies done. However, the study does still come with weaknesses. The study does not give us the exact p-values of each outcome per symptom. The study also did not state at which point in time the symptoms resolved (McGee, 2008).
The third research study evaluated was a randomized, double-blind, placebo-controlled clinical based trial (Roy et al., 2004). The trial looked at patients between the age of 8 and 18 years old. Patients admitted to the hospital during the day received a monospot test. However, the test was not available at night so patients were also included based on clinical features consistent with mononucleosis. Patients were not included in the study if the steroids were indicated because of airway obstruction or if they had a history of pregnancy, suspected pregnancy, cancer, liver disease, HIV, AIDS, history of peptic ulcer disease, invasive bacterial infection, osteoporosis, varicella, neurologic disease, malabsorption, or patients who had receives steroids in the seven days leading up to admission. There was a total of 40 patients included in the study from October 2001 to November 2002. Half of the patients were given dexamethasone, while the other half were given a placebo. A computer number generator was used to ensure randomization. The randomization code was only revealed to the researchers once recruitment, data collection, and lab analyses had been fully completed. The diagnosis was based on a sore throat, odynophagia, respiratory distress, fatigue, and fever. General appearance, temperature, weight, tonsil size, tonsil redness, tonsil exudate cervical lymphadenopathy, and size of the liver and spleen were also examined. All of the analyzed information showed that dexamethasone was only effective in providing more pain relief at 12 hours. After that, there was no statistical significance in the pain rating between both groups (Roy et al., 2004).
The fact that the study had a double-blind design was a strength. The researchers and healthcare workers were unsure of who had gotten the steroid or not which took away room for biases. However, the study comes with limitations. The patients were asked to rate their pain using a visual analog scale, but pain is a very subjective thing. One person’s pain might be completely different from another patient. Another limitation was the inclusion of patients who were clinically suspected of having infectious mononucleosis but were not specifically tested. Researchers also only looked at outcomes related to pain, not any other symptoms that the patient was experiencing (Roy et al., 2004).
Clinical and Research Recommendations
While the studies that were conducted are reliable, there needs to be much more research conducted on the topic with a larger pool of subjects. There are not a lot of recent studies to look at, as many of them are very old. In the future, more specific studies need to done to look at the effects of the steroids on specific symptoms. All the studies observed were either looking at many symptoms at once or just one in particular. Another interesting theory to test would also be looking to see if there was a difference in symptoms based on the types of steroids used. If more studies were done on how corticosteroids affected mono it could help all providers come to a universal decision on the topic.
Based on the research findings of the three articles, the evidence presented does not statistically show that corticosteroids do not help symptoms regarding infectious mononucleosis. The evidence seems to show that the inconclusive benefits of using steroids are not worth the risks to improve symptoms. There are other less harmful medications that can be used to keep patient symptoms under control. However, there was one exception that all the authors said would call for the use of the medication. Providers agree that steroids should be used with secondary upper airway obstruction in patients with mononucleosis.