Conceived and designed the experiments: JAC RLL AMN HMK RC YCM. Performed the experiments: JAC RLL AMN EM. Analyzed the data: JAC RLL RC YCM. Contributed reagents/materials/analysis tools: AMN HMK RC EM YCM. Wrote the paper: JAC RLL AMN HMK RC EM YCM.
The authors have declared that no competing interests exist.
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.
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.
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.
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.
Although the roll-out of antiretroviral therapy (ART) in 2004 has decreased mortality among the HIV-infected, HIV mortality rates in Sub-Saharan Africa remain high. Globally, an estimated 1.8 million HIV/AIDS-related deaths occurred in 2009, with 72% of the deaths in Africa (1.3–1.8 million)
The autopsy studies performed on HIV-infected patients in Sub-Saharan Africa have highlighted the central contribution of opportunistic infectious diseases to mortality
We conducted a prospective autopsy study among individuals dying on a combined infectious diseases gastroenterology ward of Mulago National Referral Hospital in Kampala, Uganda. We sought to describe and compare the clinical and autopsy causes of death and contributory findings in HIV-positive and HIV-negative patients.
Mulago National Tertiary Referral Hospital is located in Kampala, Uganda and is a university teaching centre. Over the last 10 years, approximately 6800 patients died annually in Mulago Hospital including maternal and child deaths. Based on data from the mortuary, the autopsy rate in Mulago Hospital over the past decade has been stable at 5%. This study was conducted on a combined infectious diseases and gastroenterology ward. The study team included clinical doctors and pathologists.
Next of kin of all patients that died on weekdays in the period from May–September 2009 on the study ward were asked for written informed consent to participate in the study. Both verbal and written information about the research and the autopsy procedure was provided in English and Luganda, the main local language. If needed, a translator was asked to assist. Clinical information was collected by interviewing the next of kin using a standardized questionnaire and by reviewing the medical chart of the deceased. After informed consent was obtained, the autopsy was performed within 12 hours. The body was embalmed free of charge afterwards. Patients that died without an available adult relative were excluded from the study.
The doctor on the ward was asked for the clinical cause of death and any contributory condition(s). Afterwards the study team reviewed all medical charts to collect diagnostic evidence. Four groups of clinical diagnoses were defined:
confirmed: microbiologic or histologic evidence supporting the diagnosis (e.g. smear (+) tuberculosis (TB))
highly suspected: radiologic findings suggestive of a specific disease (e.g. an x-ray or abdominal ultrasound suggestive for TB), a highly suggestive clinical presentation (e.g. cutaneous lesions suggestive of KS) or patients referred from elsewhere while on disease-specific treatment.
considered: suspicion based on the clinical presentation with negative and/or unavailable results from investigations or without additional investigations performed at the time of death.
not considered: not mentioned by the ward doctor or in the medical chart.
HIV status was abstracted from the medical chart. For those unaware of their serological status on admission, provider-initiated, free, opt-out HIV testing had been offered according to the hospital guidelines. The algorithm for rapid testing involved 3 sequential HIV tests: Determine TM (Abbot Laboratories by Abbot Japan CO. LTD, Minato-KU, Tokyo, Japan), HIV 1/2 Stat-Pak (Chembio Diagnostics Systems, 3661 Horseblock Road, Med Ford, New York, 11763, USA) and Unigold TM (Trinity Biotech PLC, IDA Business Park, Bray, Cowicklow, Ireland).
After informed consent was obtained, a complete autopsy examination was performed, eviscerating all organs including the brain. Standard tissue sections were taken from every organ and from any macroscopically detected lesion. All samples were fixed in 10% formalin solution. Fixed tissue samples were processed for routine hematoxylin and eosin stain (H&E) following standard protocols.
The H&E stained slides were examined by light microscopy by three experienced pathologists (R. Lukande, E. Van Marck and A. Nelson). When indicated, special stains for organisms were done including Ziehl-Neelsen (ZN), Grocott-Methenamine Silver, Brown-Hopps Gram, Periodic-Acid Schiff and mucicarmine. Acid fast bacilli seen after ZN staining were classified as
The study received ethical approval from the Makerere University Research and Ethics Committee, the Mulago Internal Review Board and the Infectious Diseases Institute Scientific Review Committee. The study received final approval and registration by the Uganda National Council of Science and Technology (ADM 154/212/01).
Data were analyzed using STATA version 11.0 (Stat Corp., College Station, TX, Texas, USA). Data are expressed as mean with a 95% confidence interval (95% CI) or as median with a range.
During the 5 month-study period 290 patients died on the study ward. An autopsy was requested in 158 (54%) and performed in 59 (37%) of them. In this paper we present the autopsy data of 53 patients; 66% HIV-positive, 21% HIV-negative and 13% patients with an unknown serological status (
HIV-positives (n = 35) | HIV-negatives (n = 11) | Unknown serological status (n = 7) | |
Mean age in years (95% CI) | 38 (35–42) | 41 (32–49) | 45 (24–66) |
Sex (% male) | 48 | 64 | 71 |
Mean Karnofsky score (95% CI) | 38 (30–46) | 31 (25–37) | 28 (12–45) |
Average admission duration | 7.4 days | 5.8 days | 2.0 days |
Percentage admitted on gastroenterology ward | 14% | 73% | 71% |
On admission 16 (30%) of the 53 patients were unaware of their HIV serological status. Six (38%) tested HIV-positive and 4 (25%) HIV-negative during hospitalization. One patient tested HIV-negative according to the medical chart, however according to the relatives he was HIV-positive. He was classified as a patient with unknown serological status for the analysis. All patients, except one, with an unknown HIV serological status died within 48 hours after admission. The median duration of hospitalization before death was 5 days (range <1–30 days). According to relatives, 61% of patients had symptoms of the current illness for more than one month. Ninety-one percent of patients had sought medical care prior to admission and 55% had done so 30 days or more before admission. Of the 16 patients with unknown HIV serological status on admission, 88% had sought medical care prior to admission.
A CD4 T-cell count was available for 13 (36%) HIV-positive patients. Their mean CD4 T-cell count was 50 cells/mm3 (95% CI 14–87). Ten (27%) patients were reported to be on ART before they died. Six patients had been on ART for less than 2 months; the other 4 were on ART for 8, 12, 36 and 48 months respectively. All were on a NNRTI-based regimen. No patient was started on ART during the admission in Mulago Hospital. For 6 of the patients on ART, CD4 T-cell counts were known. In one patient on ART for 12 months, the CD4 T-cell count was only 29 cells/mm3. In another patient on ART for 36 months the CD4 T-cell count was only 26 cells/mm3. In 4 patients who started ART less than 2 months before admission, the CD4 T-cell count pre-ART ranged from 2 to 82 cells/mm3. No pre-death ascertainment of HIV viral loads was available to assess non-adherence or viral failure. Of the 30 patients aware of their HIV-positive serological status on admission, 93% were on cotrimoxazole prophylactic treatment.
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×).
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).
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).
HIV-positive (n = 35) | HIV-negative (n = 11) | Unknown serological status (n = 7) | ||||
Cause of death | Contributory finding | Cause of death | Contributory finding | Cause of death | Contributory finding | |
|
||||||
Disseminated TB | 13 (36%) | 3 (9%) | 1 (9%) | - | - | - |
7 (20%) | 1 (3%) | - | - | - | - | |
Bacterial meningitis | 3 (9%) | - | - | - | 1 (14%) | - |
Septicemia | - | - | 1 (9%) | - | 1 (14%) | - |
Bacterial pneumonia | 2 (6%) | 3 (9%) | - | - | - | - |
1(3%) | - | - | - | - | - | |
Disseminated cytomegalovirus | 1(3%) | - | - | - | - | - |
Disseminated candidiasis | - | - | - | - | 1 (14%) | - |
Cerebral abscess | 1 (3%) | - | - | - | - | - |
Progressive multifocal leucoencephalopathy | 1 (3%) | - | - | - | - | - |
Malaria | - | - | 1(9%) | - | - | - |
|
||||||
Gastrointestinal bleeding | - | - | - | - | 2 (34%) |
- |
Liver failure with cirrhosis | 2 (6%) |
1 (3%) |
3 (27%) |
1 (9%) |
1 (14%) |
1 (14%) |
Cardiac failure | 1 (3%) | - | 1 (9%) | - | - | - |
Pulmonary thromboembolism | - | - | 1 (9%) | - | - | - |
Chronic renal disease | - | 3 (9%) |
- | - | - | - |
Goitre | - | 1 (3%) | - | - | - | - |
Atherosclerosis | - | 1 (3%) | - | - | - | - |
Ischemic cardiomyopathy | - | 1 (3%) | - | - | - | 1 (14%) |
Perforated duodenal ulcer | - | - | 1 (9%) | - | 1 (14%) | - |
|
||||||
Kaposi's sarcoma | 3 (9%) | - | - | - | - | - |
Small cell lung carcinoma | - | - | 1 (9%) | - | - | - |
Adenocarcinoma of the stomach | - | - | 1 (9%) | - | - | - |
1 secondary to
of unknown origin.
secondary to
2 alcoholic, 1 of unknown origin.
cardiac liver cirrhosis.
HIV associated nephropathy.
Immediate cause of death | Contributing pathology |
Bacterial meningitis | Hepatic schistosomiasis |
Disseminated cryptococcosis | Bacterial pneumonia |
Disseminated cryptococcosis | TB in the lymph nodes |
Disseminated Kaposi's sarcoma | Disseminated cryptococcosis |
Disseminated TB | Chronic pyelonephritis |
Disseminated TB | Pneumonia |
Disseminated TB | Esophageal candidiasis |
Bacterial meningitis | Disseminated TB |
Bacterial meningitis | Bacterial pneumonia |
The 22 diagnoses that were clinically not considered consisted mainly of TB (23%) and bacterial pneumonia (18%) together accounting for 9 unconsidered diagnoses. Of these, 4 patients appeared to have two postmortem diagnoses: TB and liver failure, TB and bacterial meningitis, pneumonia and TB, pneumonia and cryptococcal meningitis. In all 4 patients, the second diagnosis was either highly suspected (n = 2) or considered (n = 2). Three patients diagnosed postmortem with disseminated TB without cerebral or meningeal involvement, presented with central nervous system symptoms. One patient with postmortem pneumonia presented with diarrhea and a CD4 cell count of 1 cell/mm3. Another patient with postmortem bilateral bronchopneumonia was clinically highly suspected for TB based on a chest x-ray.
When considering only cause of death, 14% had a confirmed diagnosis, 34% a highly suspected diagnosis, 20% a considered diagnosis and 31% of diagnoses were not considered.
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
We found that more than 80% of HIV-positive patients died of infectious diseases with disseminated TB as the most common diagnosis (36%). Furthermore, the spectrum of illness and causes of death were substantially different from those in HIV-negative patients. These findings are similar to those reported in autopsy studies performed in the pre-ART era in sub-Saharan Africa in which infectious diseases caused nearly all deaths with (disseminated) TB as the main cause of death
In our study, the patients on ART died from the same diseases as those not yet on treatment. This is in line with the observational data on early mortality after the start of ART
Eighty-eight percent of patients unaware of their HIV serological status had been to a health facility prior to admission. This implies that despite World Health Organization and national guidelines, provider-initiated HIV testing in health care facilities is not yet part of standard medical care in Uganda
Overall, only 7% of postmortem diagnoses were confirmed and another 21% highly suspected during life. This highlights the difficulty of establishing a certain diagnosis in a resource-constrained setting
In HIV-positive patients, almost half of postmortem diagnoses were not considered. Main reasons were presentation with dual infections, atypical disease presentation or misinterpretation of the results from additional examination e.g. chest x-ray. Dual diagnoses appear prevalent in HIV-positive hospitalized patients, and high suspicion of a second diagnosis is indicated
Because of all the diagnostic difficulties mentioned above, the use of preemptive treatment for highly prevalent conditions like TB or cryptococcal infection should be explored further pending the widespread availability of more sensitive rapid point-of-care diagnostic tests. At this moment, the only preemptive treatment widely used in the Mulago Hospital setting is broad-spectrum antibiotics. More information on the benefits and risks of such treatment strategies is needed.
Our study had several limitations. We enrolled only patients from one ward of a single hospital. This certainly created a selection bias leading to over- and underreporting of some diseases e.g. a patient with focal neurologic complaints due to toxoplasmosis might have been admitted to the neurology ward instead of the infectious diseases ward. Therefore the results should be generalized cautiously. HIV-status was derived from the medical chart and was missing in 11%. In addition, we could not analyze all the patients due to incomplete post mortem data (10%).
In conclusion, our results show that patients continue to die of treatable diseases, especially the HIV-infected patients, and that the clinical diagnosis is often not confirmed prior to death. HIV testing should be performed earlier and at lower level health facilities. As more point-of care diagnostics are developed, empiric algorithms should be traded for diagnosis-based targeted treatment which clinicians alert for multiple pathogens in severely immunosuppressed HIV-infected patients. Finally, our study demonstrates the importance of autopsy examination to ascertain causes of death particularly in settings with limited access to diagnostic testing during life.
The authors would like to thank all the relatives that have participated in this study. Moreover, we would like to thank the staff of the study ward in particular Dr. Pauline Byakika and Dr. Kenneth Opio for facilitating the study and Dr. Martin Opio for collecting data. We also want to thank the staff of the Pathology Department of Mulago Hospital in particular Dr. Sam Kalungi and the mortuary staff of Mulago Hospital. We would like to thank Charles Luswata for his support in the data handling.