Treating acute ischemic strokes with antidepressants

Depression is common after strokes. This is something that we can all relate to intuitively because a catastrophic event like a stroke is bound to affect one's emotions. A study published in the Medical Journal of Malaysia (April 2, 2013) reinforces this point and made me look up an article that had caught my attention a few months ago. In February 2011, the Lancet Neurology had published a study involving 113 patients with ischemic strokes and hemiplegia / hemiparesis, 57 of whom were treated with 20mg of Fluoxetine daily within five to eleven days of the stroke. At the end of three months, the researchers noted that those who had been treated with Fluoxetine (and physiotherapy) showed better motor recovery than those who received only physiotherapy.

When patients are depressed, they are unlikely to be motivated to do the post-stroke exercises that will help them recover motor function. While this may be a good reason to diagnose and treat depression after a stroke, the authors of this study also postulate that fluoxetine may have direct beneficial effects on neurons. It may turn out that antidepressants like fluoxetine are good for stroke recovery irrespective of whether the affected person is clinically depressed or not.


References:
1. Prevalence of depression in stroke patients with vascular dementia in University Kebangsaan Malaysia Medical Centre.

2. Fluoxetine for motor recovery after acute ischemic stroke (FLAME): a randomised placebo-controlled trial. 

Atypical pneumonia

Atypical pneumonia is often due to Mycoplasma or Chlamydia infections when the pneumonia is community-acquired. This type of atypical pneumonia responds well to macrolide antibiotics. In this week's issue of the New England Journal of Medicine (article), there is a report about a healthy young woman who developed a form of atypical pneumonia that rapidly progressed to respiratory failure. Hence this is a good opportunity to discuss some clinical aspects of severe atypical pneumonia acquired from the community.

Atypical pneumonia - other than Mycoplasma and Chlamydia - should be suspected when the respiratory illness does not respond to treatment with the usual antibiotics for community acquired pneumonia.

1. Think of Legionella pneumophilia when there are associated symptoms and signs of involvement of the CNS and / or gastrointestinal tract.

2. Think of Leptospiral infection when there is associated severe myalgia, headache or neck pain. Involvement of the liver and kidney and the presence of a skin rash are further points in favour of suspecting this condition.

3. Think of fungal pneumonia if the patient is immunocompromised and if there is exposure to an enviroment where fungi are likely - mouldy and damp places like caves, for example.  

4. Think of Toxoplasma and Pasteurella infections if there is close exposure to cats.

5. Think of Lyme disease, Rickettsial infections and Tularemia if there is a history or physical evidence of tick bites.

A woman with diarrhoea