A 28-year-old man with no significant past medical history presents with fever, pharyngitis, and bilateral cervical lymphadenopathy. Monospot test is positive. He has severe hepatitis (ALT 1200 U/L) and mild thrombocytopenia. What is the drug of choice for his condition?

Explanation

## Clinical Diagnosis The patient presents with infectious mononucleosis (IM) caused by Epstein–Barr virus (EBV). Classic features include fever, pharyngitis, cervical lymphadenopathy, and positive Monospot (heterophile antibody test). The elevated transaminases and thrombocytopenia are typical hepatic and hematologic manifestations of acute EBV infection. ## Management Approach: Supportive Care **Key Point:** Infectious mononucleosis is a self-limited viral illness. The standard of care is **supportive management alone** — no antiviral therapy is routinely indicated in immunocompetent hosts. **High-Yield:** Despite being caused by a herpesvirus (EBV), routine antiviral therapy does NOT improve clinical outcomes, reduce symptom duration, or prevent complications in immunocompetent patients. This is a critical distinction from VZV or HSV infection. ### Supportive Care Measures 1. Rest and hydration 2. NSAIDs or acetaminophen for fever and pain 3. Throat lozenges and warm salt-water gargles 4. Avoid contact sports for 4–6 weeks (risk of splenic rupture) 5. Monitor for complications (secondary bacterial infection, airway obstruction) **Clinical Pearl:** Ampicillin or amoxicillin should be **avoided** in IM because they cause a characteristic maculopapular rash in 80–90% of EBV-infected patients — this is a classic NEET PG trap. ## When Antivirals ARE Used in EBV | Scenario | Indication | Drug | |----------|-----------|------| | Immunocompromised (HIV, transplant) | Severe or disseminated disease | IV ganciclovir or acyclovir | | Post-transplant lymphoproliferative disorder (PTLD) | EBV-driven malignancy | Rituximab ± chemotherapy; consider acyclovir | | Immunocompetent with severe pharyngitis | Rare; only if airway compromise | IV acyclovir (limited evidence) | **Warning:** Acyclovir has **minimal activity** against EBV in vitro and does not reliably improve clinical outcomes in immunocompetent IM. Ganciclovir is reserved for immunocompromised hosts. **Tip:** The exam may present a patient with "severe IM" or "IM with complications" to test whether you know that even then, supportive care is the mainstay in immunocompetent hosts.