Clinical Presentation and Management of Sore Throat in Infectious Mononucleosis

Sore throat is one of the most common and characteristic symptoms of infectious mononucleosis, occurring in 70-92% of patients with the disease, according to the American College of Rheumatology 1
The sore throat of infectious mononucleosis can be difficult to distinguish from bacterial pharyngitis based on clinical appearance alone, but features such as more generalized lymphadenopathy, significant fatigue, and absence of cough and rhinorrhea can help differentiate it, as suggested by the Infectious Diseases Society of America 2, 3
The absence of cough, rhinorrhea, and other upper respiratory symptoms that are more common in viral pharyngitis can also help differentiate mono-related sore throat from streptococcal pharyngitis, as noted by the Infectious Diseases Society of America 2, 3
The sore throat of infectious mononucleosis may be mistaken for streptococcal pharyngitis, leading to unnecessary antibiotic treatment, highlighting the importance of accurate diagnosis, as emphasized by the Infectious Diseases Society of America 2, 3

Infectious Mononucleosis and Oral Manifestations

Oral manifestations of infectious mononucleosis include erythema and diffuse injection of the oral and pharyngeal mucosae, as well as changes in the lips and oral cavity, such as erythema, cracking lips, and a "strawberry tongue", according to the American Academy of Pediatrics guidelines 4
EBV-related oral lesions do not typically present with exudates, unlike bacterial pharyngitis, as noted by the Centers for Disease Control and Prevention 4

For painful oral lesions, the American Dental Association recommends considering topical analgesics such as benzydamine hydrochloride rinses 5
The American Academy of Dermatology suggests using warm saline mouthwashes to cleanse the oral cavity, as well as topical anesthetics and antiseptic oral rinses to reduce bacterial colonization of affected mucosa 6

Patients with infectious mononucleosis may be GAS carriers experiencing concurrent viral mononucleosis, highlighting the importance of differential diagnosis 7

If laboratory testing confirms both infectious mononucleosis and Group A Streptococcus, the American Academy of Pediatrics and the Infectious Diseases Society of America recommend treating the streptococcal infection appropriately while managing mononucleosis supportively 7