An autopsy study describing causes of death and comparing clinico-pathological findings among hospitalized patients in Kampala, Uganda

Abstract

Background: Information on causes of death in HIV-infected patients in Sub-Saharan Africa is mainly derived from observational cohort and verbal autopsy studies. Autopsy is the gold standard to ascertain cause of death. We conducted an autopsy study to describe and compare the clinical and autopsy causes of death and contributory findings in hospitalized HIV-infected and HIV-uninfected patients in Uganda.

Methods: Between May and September 2009 a complete autopsy was performed on patients that died on a combined infectious diseases gastroenterology ward in Mulago Hospital in Kampala, Uganda. Autopsy cause of death and contributing findings were based on the macro- and microscopic post-mortem findings combined with clinical information. Clinical diagnoses were reported by the ward doctor and classified as confirmed, highly suspected, considered or not considered, based on information derived from the medical chart. Results are reported according to HIV serostatus.

Results: Fifty-three complete autopsies were performed in 66% HIV-positive, 21% HIV-negative and 13% patients with an unknown HIV serological status. Infectious diseases caused death in 83% of HIV-positive patients, with disseminated TB as the main diagnosis causing 37% of deaths. The spectrum of illness and causes of death were substantially different between HIV-positive and HIV-negative patients. In HIV-positive patients 12% of postmortem diagnoses were clinically confirmed, 27% highly suspected, 16% considered and 45% not considered. In HIV-negative patients 17% of postmortem diagnoses were clinically highly suspected, 42% considered and 42% not considered.

Conclusion: Autopsy examination remains an important tool to ascertain causes of death particularly in settings with limited access to diagnostic testing during life. HIV-positive patients continue to die from treatable and clinically undiagnosed infectious diseases. Until rapid-point of care testing is available to confirm common infections, empiric treatment should be further investigated.

Figure 1. Study flow diagram.

Figure 2. Spectrum of host response to mycobacterial infection in HIV-infected patients.

a. Miliary nodule in the liver with a small granuloma in a patient with disseminated disease (H&E stain) b. Abscess in the submucosal lymph nodes of the small bowel (H&E stain) c–d. TB vasculitis in a lung vessel. The arrow indicates acid-fast bacilli in the pulmonary blood vessels (H&E stain, 20× and ZN stain, 100×).

Figure 3. Kaposi's Sarcoma.

Disseminated Kaposi's Sarcoma (KS) in a patient who was on lamivudine, zidovudine and nevirapine for 8 months and was treated for KS for 3 months. a. Note vascular proliferation of KS invading cardiac muscle (H&E) b. Kaposi's associated Herpes virus detected in the pericardium (immunophenotyping using LANA1).

Figure 4. Opportunistic infections.

a. Cytomegalovirus infection showing an “owl-eye” nuclear inclusion in an endothelial cell (H&E stain, arrow) b. Esophageal candidiasis showing yeast and pseudohyphae (PAS stain).

Figure 5. Central nervous system infections.

a. Progressive Multifocal Leukoencephalopathy due to JC-virus infection, showing viral inclusion (arrow) and loss of myelin (H&E stain) b–c. Cryptococcal meningitis, showing Cryptococcus neoformans with a polysaccharide capsule (H&E stain)(b) and multiple narrow-necked budding yeast (Grocott Methanamine Silver stain) (c) d–f. Streptococcal meningitis, showing the macroscopic image of the brain with edema and purulent exudate (d), the subarachnoid space expanded by neutrophils and fibrin (H&E stain) (e) and Gram positive diplococci (arrow) (Brown-Hopps tissue Gram stain) (f).