Treatment for Acute Infectious Mononucleosis with Elevated Liver Enzymes

Initial Management

The American Society of Anesthesiologists recommends providing supportive care with adequate hydration and electrolyte management to maintain physiologic homeostasis, and monitoring blood glucose parameters at least every 2 hours as hypoglycemia is a well-known complication of severe liver dysfunction, and providing adequate nutritional support as patients with liver dysfunction and organ failure have increased energy expenditure 1
The American Society of Anesthesiologists also recommends stress ulcer prophylaxis in this at-risk population, using agents with minimal hepatic metabolism, and avoiding the use of osmotic laxatives or non-absorbable antibiotics to lower ammonia levels 1

The American Association for the Study of Liver Diseases recommends checking complete liver panel every 2-4 weeks to establish a clear trend, and including complete blood count and serum creatinine in follow-up laboratory testing to assess for systemic effects, and monitoring electrolytes, particularly serum sodium, targeting levels between 140-145 mmol/L, with corrections not exceeding 10 mmol/L per 24 hours 1, 2, 3
The American Association for the Study of Liver Diseases also recommends continuing monitoring until liver enzymes completely return to normal range, as 84% of abnormal tests remain abnormal on retesting after 1 month 2, 3

The European Association for the Study of the Liver recommends avoiding hepatotoxic medications, including certain antibiotics, NSAIDs, and statins that may worsen liver injury, and discontinuing statins if ALT/AST levels exceed 3 times the upper limit of normal 4, 5

The American Gastroenterological Association recommends providing antiemetics for nausea and vomiting, preferably those with minimal hepatic metabolism, and maintaining hydration and considering symptomatic treatment with careful medication selection for diarrhea 6, 7

The Infectious Diseases Society of America recommends considering empirical broad-spectrum antibiotics if there are signs of sepsis and/or worsening clinical status, as patients with acute liver dysfunction have increased susceptibility to infections, and monitoring for potential secondary infections, which occur in 60-80% of patients with acute liver dysfunction 1

The American College of Gastroenterology recommends considering hepatology consultation for patients with persistent elevation of liver enzymes beyond 12 weeks 8, 2

The American Association for the Study of Liver Diseases recommends considering liver biopsy to rule out other causes of liver injury if liver enzymes continue to rise or do not improve within 2-4 weeks, and watching for signs of hepatic encephalopathy, which may manifest as altered mental status or confusion 8, 9, 1