Validity of a Minimally Invasive Autopsy for Cause of Death Determination in Adults in Mozambique: An Observational Study

Abstract

Background: There is an urgent need to identify tools able to provide reliable information on the cause of death in low-income regions, since current methods (verbal autopsy, clinical records, and complete autopsies) are either inaccurate, not feasible, or poorly accepted. We aimed to compare the performance of a standardized minimally invasive autopsy (MIA) approach with that of the gold standard, the complete diagnostic autopsy (CDA), in a series of adults who died at Maputo Central Hospital in Mozambique.

Methods and findings: In this observational study, coupled MIAs and CDAs were performed in 112 deceased patients. The MIA analyses were done blindly, without knowledge of the clinical data or the results of the CDA. We compared the MIA diagnosis with the CDA diagnosis of cause of death. CDA diagnoses comprised infectious diseases (80; 71.4%), malignant tumors (16; 14.3%), and other diseases, including non-infectious cardiovascular, gastrointestinal, kidney, and lung diseases (16; 14.3%). A MIA diagnosis was obtained in 100/112 (89.2%) cases. The overall concordance between the MIA diagnosis and CDA diagnosis was 75.9% (85/112). The concordance was higher for infectious diseases and malignant tumors (63/80 [78.8%] and 13/16 [81.3%], respectively) than for other diseases (9/16; 56.2%). The specific microorganisms causing death were identified in the MIA in 62/74 (83.8%) of the infectious disease deaths with a recognized cause. The main limitation of the analysis is that both the MIA and the CDA include some degree of expert subjective interpretation.

Conclusions: A simple MIA procedure can identify the cause of death in many adult deaths in Mozambique. This tool could have a major role in improving the understanding and surveillance of causes of death in areas where infectious diseases are a common cause of mortality.

Fig 1. Overall study plan showing the procedures performed in the study, the investigators involved, and site and timing of each procedure.

CDA, complete diagnostic autopsy; MIA, minimally invasive autopsy.

Fig 2. Three representative cases of cause of death identification by minimally invasive autopsy.

(A–C) Cryptococcal encephalitis: (A) Cryptococcus spp. infecting the central nervous system (hematoxylin and eosin, 200×); (B) Cryptococcus spp. (methenamine silver stain, 200×); (C) real-time PCR positive for Cryptococcus spp. in the cerebrospinal fluid. (D–F) Acinetobacter baumannii pneumonia: (D) A. baumannii pneumonia infecting the lung (hematoxylin and eosin, 100×); (E) A. baumannii isolated (left side of the plate) and subjected to antibiotic susceptibility testing; (F) A. baumannii 16S RNA PCR amplification from tissue samples. (G–I) Disseminated Kaposi sarcoma: (G) Kaposi sarcoma involving the lung (hematoxylin and eosin, 100×); (H) Kaposi sarcoma involving the lung positive for human herpesvirus 8 (herpesvirus 8 antibody, 100×); (I) disseminated Kaposi sarcoma lesions in the lung (red areas on the pleural surface of the two lungs and the trachea; macroscopic image from the complete diagnostic autopsy).