Presentation on theme: "Autopsies in HIV: still finding missed diagnoses after 20 years Background Mortality has significantly fallen with the advent of HAART and chemoprophylaxis."— Presentation transcript:
Autopsies in HIV: still finding missed diagnoses after 20 years Background Mortality has significantly fallen with the advent of HAART and chemoprophylaxis for opportunistic infections (OI). (Palella et al, Mocroft et al.) Despite these interventions mortality remains in developed world cohorts. Reasons for this include poor/variable adherence, late presentation, changing demographics, viral resistance. (Sabin et al.) The causes include OI, co-infection with blood-borne viruses, haematologiacal malignancy and non-HIV aetiology. With HAART diversity of cause may be increasing. Post-mortem remains a highly sensitive issue. However, it can change cause of death or confirm it and ultimately could influence future clinical practice. The regional Tropical and Infectious Diseases Unit at RLUH/UHA has looked after an HIV cohort of patients since the beginning of the pandemic. We examined results of available post-mortem examinations over the last 20 years, 1983-2005. Aims To determine: The overall number of post-mortem examinations carried out between 1983-2005 as a proportion of deaths in out cohort. Causes of death and change in pre- and post-mortem primary diagnosis. Which and how many diagnoses were missed. Methods A retrospective study of all patients known to have died in the Unit between 1983-2005. Information was obtained from case notes and autopsy reports. Results Data was available on 105 of the 115 known to have died between 1983 and 2005. Age: –Median at diagnosis: 33.5 (range 21-65) –Median at death: 38 (range 24-69) Sex: –Pre- 1996: Male 93.2% (69/74)Female 6.8% (5/74) –Post 1996: Male 51.5% (17/33) Female 48.5% (16/33) –Overall: Male 80.4%Female 18.7% 1 MBJ Beadsworth, 1 D Cohen, 1 L Ratcliffe, 1 N Jenkins, 2 W Taylor, 1 NJ Beeching 1 Tropical and Infectious Disease Unit, Royal Liverpool University Hospital (RLUH), Liverpool. 2 Department of Histopathology, University Hospital Aintree (UHA), Liverpool. Ethnic origin: (n=107) –White British 80.4% –White other 1.9% –Black African 12.1% –Asian 0.9% –South American 3.7% Pre 1996 1.4% of deaths occurred in those of Black African origin. Post 1996 39.3% of deaths occurred in those of Black African origin. Likely route of transmission of HIV: (n=107) –MSM 56% –Heterosexual 12% –Sexual intercourse in Africa 18% –IDU 9% –Blood product 2% –Other/Unknown10% Post-mortem was requested in 50.4% (n=54) of patients. They were carried out in 38% (n=41). Change in Primary cause of death was seen in 51.2% (21). Of the total diagnoses 70.7% changed post-mortem. Missed Diagnoses No significant changes in diagnoses pre and post mortem were seen. However: –Lymphoma was over-diagnosed (4 pre-mortem, 1 post-mortem). CMV diagnosis was missed in 8 of 11 patients. TB was missed in 3 patients and opportunistic mycobacterial infection in 1. KS was missed in 3 of 4 patients. Pneumonia was the commonest cause pre- and post mortem. Pre-mortem diagnosis (n = 41) Post-mortem diagnosis (n = 41) Pre-mortem overall diagnoses (n = 57) Post-mortem overall diagnoses (n = 80) OI Pre-mortem% (n = 41) PCP10 (4) Crypto5 (2) CMV2 (1) Toxo2 (1) Lymphoma10 (4) KS0 (0) OI Post-mortem% (n = 41) PCP7 (3) Crypto0 (0) CMV5 (2) Toxo2 (1) Lymphoma2 (1) KS2 (1) OI (total) Pre-mortem% (n = 57) PCP7 (4) Crypto5 (3) CMV5 (3) Toxo5 (3) Lymphoma11 (6) KS2 (1) OI (total) Post-mortem% (n = 80) PCP4 (3) Crypto4 (3) CMV14 (11) Toxo5 (4) Lymphoma6 (5) KS5 (4) Number of Deaths of HIV Patients in Northwest England Conclusions Post-mortem remains a vital tool of investigation. It should and can be considered in every HIV positive patient who dies. Causes of death changed for the majority undergoing post- mortem. Current diagnostic tools are inadequate. Results cont. References Palella et al. New Eng J Med 1998; 338. Mocroft et al. Lancet 2003; 362. Sabin et al. AIDS 2006;20.