Article

An Autopsy Study Describing Causes of Death and Comparing Clinico-Pathological Findings among Hospitalized Patients in Kampala, Uganda

Johns Hopkins Bloomberg School of Public Health, United States of America
PLoS ONE (Impact Factor: 3.23). 03/2012; 7(3):e33685. DOI: 10.1371/journal.pone.0033685
Source: PubMed

ABSTRACT

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.

Full-text

Available from: Robert Lukande
An Autopsy Study Describing Causes of Death and
Comparing Clinico-Pathological Findings among
Hospitalized Patients in Kampala, Uganda
Janneke A. Cox
1
*
.
, Robert L. Lukande
2.
, Ann M. Nelson
3
, Harriet Mayanja-Kizza
4
, Robert
Colebunders
1,5
, Eric Van Marck
5
, Yukari C. Manabe
6,7
1 Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium, 2 Department of Pathology, Makerere University, Kampala, Uganda, 3 Joint Pathology
Center, Silver Spring, Maryland, United States of America, 4 Department of Internal Medicine, Makerere University, Kampala, Uganda, 5 Faculty of Medicine, University of
Antwerp, Antwerp, Belgium, 6 Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda, 7 Division of Infectious Diseases,
Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
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.
Citation: Cox JA, Lukande RL, Nelson AM, Mayanja-Kizza H, Colebunders R, et al. (2012) An Autopsy Study Describing Causes of Death and Comparing Clinico-
Pathological Findings among Hospitalized Patients in Kampala, Uganda. PLoS ONE 7(3): e33685. doi:10.1371/journal.pone.0033685
Editor: David Sullivan, Johns Hopkins Bloomberg School of Public Health, United States of America
Received December 19, 2011; Accepted February 15, 2012; Published March 14, 2012
This is an open-access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for
any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.
Funding: The study received funding from the Directorate General for Development Cooperation (DGDC) through the Flemish Interuniversity council (VLIR-UOS):
http://www.vliruos.be/index.php?language=EN&navid=498&direct_to=Institutional_University_Cooperation_IUC. The funders had no role in study design, data
collection and analysis, decision to publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: jannekecox@xs4all.nl
. These authors contributed equally to this work.
Introduction
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) [1]. In Uganda, an
estimated 1.1 million people were HIV-infected and 61.000 deaths
were caused by HIV-related illness in 2008 [2]. Due to limited
diagnostic testing in most sub-Saharan African countries, the exact
cause of death is often difficult to ascertain. Even in developed
countries, discrepancies between clinical and autopsy diagnoses
have been reported to be as high as 50% [3,4]. Autopsy remains
the gold standard for confirming the cause of death. Previous
studies have shown that (partial) autopsy is a feasible procedure in
Sub-Saharan Africa, both in study settings and as a general
practice [5,6,7].
The autopsy studies performed on HIV-infected patients in
Sub-Saharan Africa have highlighted the central contribution of
opportunistic infectious diseases to mortality [8]. These studies did
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not include any patients on antiretroviral therapy (ART) and only
a limited number of patients taking cotrimoxazole prophylaxis.
Information on causes of death in HIV-infected patients on ART
in Sub-Saharan Africa is scarce and is derived exclusively from
observational and verbal autopsy studies [9,10,11].
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.
Methods
Study setting
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.
Study design
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.
Clinical diagnosis
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:
1. confirmed: microbiologic or histologic evidence supporting the
diagnosis (e.g. smear (+) tuberculosis (TB))
2. 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.
3. 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.
4. 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).
Autopsy and histological examination
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 mycobacterium
tuberculosis, taking into account possible errors due to mycobacterial
infections caused by other mycobacteria. When indicated we
confirmed the diagnosis of Kaposi’s sarcoma and cytomegalovirus
infection by immunohistochemistry using commercially available
mouse monoclonal antibodies; LANA1 for HHV8, Cell Marque
(reference number 265M-18) and CMV antibody, clone DDG9/
CCH2, Ventana (reference number 760-2638). The cause of death
and contributing findings were formulated based on the clinical
information combined with the macro- and microscopic post-
mortem findings.
Ethical consideration
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).
Statistical methods
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.
Results
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 (table 1, figure 1). Details of the
entire study cohort including those that did not consent to autopsy
were previously described [12]. Six patients (3 HIV-positive
patients, none on ART) were left out of the analysis due to
incomplete postmortem data.
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
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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/mm
3
(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/
mm
3
. In another patient on ART for 36 months the CD4 T-cell
count was only 26 cells/mm
3
. 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/mm
3
. 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.
Autopsy findings
HIV-positive patients: Overall, 83% of the HIV-positive
patients died as a result of infectious diseases (table 2). The leading
cause of death was tuberculosis (TB), which accounted for 37% of
all deaths (n = 13) (figure 2). Another 9% of patients had TB
infection that was not considered their cause of death (n = 3). In all
TB patients, the disease was disseminated beyond the lung
parenchyma. The most frequently infected organs were the spleen
(81%), liver (69%), lymph nodes (69%) and lungs (56%). The
second most common cause of death was a Cryptococcus neoformans
infection that accounted for 20% of deaths (n = 7). One additional
patient had disseminated Cryptococcus neoformans infection but died
of pulmonary haemorrhage due to disseminated Kaposi’s sarcoma
(KS). In all but one patient, the cryptococcal infection was located
in the meninges (88%). Other organs involved included the spleen
(50%), the liver (38%), the lungs (38%), the kidneys (38%) and the
lymph nodes (38%). Disseminated KS was the only identified
malignancy and caused death in 3 patients (9%) who all had
widespread involvement including the gastrointestinal tract (67%),
the lungs (67%) and the peri- and myocardium (33%) (figure 3).
Other less common causes of death included bacterial meningitis
(9%), progressive multifocal leucoencephalopathy (3%), Pneumo-
Figure 1. Study flow diagram.
doi:10.1371/journal.pone.0033685.g001
Table 1. Patient characteristics (n = 53).
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%
doi:10.1371/journal.pone.0033685.t001
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cystis jiroveci pneumonia (PJP) (3%) and disseminated cytomegalo-
virus infection (figure 4a). The latter was a patient who was tested
HIV-positive on admission and who was not on cotrimoxazole
prophylaxis. Pneumonia was found in 14% of patients, but
considered to be the cause of death in only 6%. Chronic renal
damage suggestive of HIV-associated nephropathy (HIVAN) was
found in 9%. Dual infections were common and identified in 26%
of the patients (table 3, figure 4b).
HIV-positive patients on ART: At least 8 of the 10 patients
on ART died of HIV-related conditions; 50% died of disseminated
TB, 20% of disseminated Cryptococcus neoformans infection and 10%
of disseminated KS. A 32-year-old female that started treatment
with tenofovir, emtricitabine and efavirenz 6 weeks prior to
admission possibly died of ART-induced liver failure. Liver
sections showed an eosinophilic infiltration against a background
of cirrhosis. She had a concurrent clinical undiagnosed TB
infection in the lymph nodes. One patient died of pneumonia with
Pseudomonas aeruginosa.
HIV- negative patients: The leading causes of death in HIV-
negative patients were non-infectious and accounted for 73% of all
deaths. Only one patient had TB, which was disseminated to liver,
spleen, meninges and kidneys. One patient died of decompensated
alcoholic liver cirrhosis. Two patients died of variceal bleeding
secondary to liver cirrhosis: one of alcoholic origin and the other of
unknown origin. One patient died of cardiac failure, but also had
secondary chronic liver congestion leading to cirrhosis. A patient
that died of pulmonary thromboembolism also had underlying
sickle cell disease.
Patients with unknown HIV serological status: Non-
infectious diseases accounted for 71% of all deat hs. Gastrointes-
tinal bleeding was the cause of death in 3 patients: one patient
had a variceal bleeding secondary to liver cirrhosis du e to
disseminated Schistosoma mansoni infection, in the others no
bleeding focus was identified. An accidental finding was an
Ancylostoma duodenale in the small gut of one of these two patients.
One p atient died of a perforated chronic duodenal ul cer. The
Table 2. Causes of death and contributory findings according to HIV-serological status.
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
Infectious diseases
Disseminated TB 13 (36%) 3 (9%) 1 (9%) - - -
Cryptococcus neoformans infection 7 (20%) 1 (3%) - - - -
Bacterial meningitis 3 (9%) - - - 1 (14%) -
Septicemia - - 1 (9%) - 1 (14%) -
Bacterial pneumonia 2 (6%) 3 (9%) - - - -
Pneumocystis jiroveci Pneumonia 1(3%) - - - - -
Disseminated cytomegalovirus 1(3%) - - - - -
Disseminated candidiasis - - - - 1 (14%) -
Cerebral abscess 1 (3%) - - - - -
Progressive multifocal
leucoencephalopathy
1(3%)-----
Malaria - - 1(9%) - - -
Non-infectious diseases
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%) -
Malignancies
Kaposi’s sarcoma 3 (9%) - - - - -
Small cell lung carcinoma - - 1 (9%) - - -
Adenocarcinoma of the stomach - - 1 (9%) - - -
*1 secondary to Ancylostoma duodenale infection, 1 of unknown cause.
**of unknown origin.
{secondary to Schistosoma mansoni infection.
{{2 alcoholic, 1 of unknown origin.
"cardiac liver cirrhosis.
""HIV associated nephropathy.
doi:10.1371/journal.pone.0033685.t002
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infectious cause s of death were bacterial meningitis and
disseminated candidiasis.
Comparison between clinical diagnos es and autopsy
findings
HIV-positive patients: Overall, 49 postmortem diagnoses
were made. Of these 12% were clinically confirmed, 27% highly
suspected, 16% considered and 45% not considered. The 6
confirmed diagnoses were cryptococcal meningitis with a positive
Indian ink in 5 patients and disseminated TB with a positive Ziehl-
Neelsen (ZN) stain of sputum and liver tissue obtained with a liver
biopsy in 1 patient. The 13 highly suspected clinical diagnoses
consisted of TB in 8 patients: 3 patients were referred while on
anti-TB treatment, one patient had a suggestive chest x-ray, 3
patients a suggestive abdominal ultrasound and one patient had
both a suggestive chest x-ray and abdominal ultrasound. The
other highly suspected diagnoses were disseminated KS (n = 2),
liver failure on the basis of laboratory results (n = 2) and a cerebral
abscess on the basis of a computer tomography of the head. The 8
autopsy diagnoses that were clinically considered were bacterial
meningitis (n = 3), cryptococcal meningitis (n = 2), disseminated
TB (n = 2) and pneumonia (n = 1). No diagnostic work-up had
been done except in two patients: one patient with disseminated
cryptococal infection had a negative serum cryptococcal antigen
and another patient with disseminated TB had 3 negative ZN
sputum smears, high protein in cerebrospinal fluid without a ZN
performed and a normal abdominal ultrasound.
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/mm
3
. Another
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, 206 and ZN stain, 1006).
doi:10.1371/journal.pone.0033685.g002
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).
doi:10.1371/journal.pone.0033685.g003
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patient with postmortem bilateral bronchopneumonia was clini-
cally 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.
IRIS: The ward doctors reported a clinical suspicion of TB-
associated immune reconstitution inflammatory syndrome (IRIS)
in 4 patients. Three of them started anti-TB treatment 1–4 months
and ART 2 weeks–3 months prior to admission. One patient
started ART 2 weeks before and anti-TB treatment 1 week after
admission. The autopsy revealed disseminated TB in 3 of them
and disseminated cryptococcal infection in one. No signs of IRIS
(e.g. granuloma formation) were identified in any of the
postmortem specimens.
HIV-negative patients: Of the 12 autopsy diagnoses, none
were clinically confirmed, 17% highly suspected, 42% considered
and 42% not considered. TB was highly suspected on the basis of a
chest x-ray and liver cirrhosis on the basis of an abdominal
ultrasound. The clinically considered diagnoses were all based on
the clinical presentation without investigations done. Five
diagnoses were clinically not considered: small cell type broncho-
genic carcinoma in a patient with a productive cough since 3
months clinically suspected of pulmonary TB, pulmonary
embolism in a patient with sickle cell disease presenting with
back pain clinically suspected of a sickle cell crisis, ischemic cardiac
failure and liver cirrhosis with variceal bleeding and malaria in a
19-year-old male admitted with fever and jaundice diagnosed
clinically as hepatic failure of unknown origin. No malaria testing
was performed during admission.
Patients with unknown HIV serological status: Of the 9
autopsy diagnoses, none were clinically confirmed or highly
suspected, 67% considered and 33% not considered. The clinically
considered diagnoses were all based on clinical presentation. The
following diagnoses were clinically not considered: cardiac failure
in an 80-year old female with a second postmortem diagnosis of
upper gastro-intestinal bleeding probably of vascular origin and
disseminated candidiasis and liver cirrhosis of unknown etiology in
a 32 year old male with a discrepant HIV serostatus according to
the medical chart and the relatives.
Pathology of the central nervous system: The brain was
eviscerated and sampled in all 53 of the autopsies. In 15 patients
(28%), there was evidence of an infectious pathogen. Thirteen of
the 15 patients (80%) were HIV infected. Cryptococcal meningitis
was present in 6 patients, bacterial meningitis in 4, TB in 2,
candidiasis, cerebral abscess and PML each in one patient
(figure 5). In all of them, the brain pathology was considered the
cause of death except in one patient where cryptococcosis was
considered as ‘significant other pathology contributing to death’ in
a patient who died of disseminated KS. Brain pathology had been
clinically suspected in 14 of the 15 patients (93%).
Discussion
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 (dissemi-
nated) TB as the main cause of death [8,13,14,15].
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 [9,10]. The patients
on ART more than 6 months with a documented CD4 T-cell
count had little evidence of immune reconstitution. We concluded
that the patients in our cohort were either on ART for too short a
time or that they were non-adherent and/or on a failing regimen
and therefore showed similar pathology as those not yet on ART.
Coverage of cotrimoxazole prophylactic treatment was 93%.
Given the small sample size of our study it is not possible to
determine the influence of this high cotrimoxazole coverage on
disease prevalence or cause of death.
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).
doi:10.1371/journal.pone.0033685.g004
Table 3. Dual infections among HIV-infected patients.
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
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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 [16,17]. By not
being tested during an earlier encounter with a health care facility,
those that tested HIV-positive on admission missed the opportu-
nity for an earlier therapeutic intervention. Causes of death did
not seem to differ between the HIV-positive patients diagnosed on
admission and those already aware of their serological status
before. This should be considered a reflection of the very poor
immune status of the HIV-positive patients already aware of their
serological status. Therefore, both earlier diagnostic testing and
retention in care should be advocated.
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 [18]. This is partly due to the low performance
status of many patients (mean Karnofsky scores ,30 on admission)
being either too ill or dead before diagnostic testing could be
performed or results became available. Moreover, invasive
procedures to come to a diagnosis, e.g. LP, were sometimes
refused or failed. Some of the diagnostics performed gave false
negative results or were interpreted wrongly. This emphasizes the
urgent need for rapid, point-of-care diagnostics with high
sensitivity. Recent studies evaluating new techniques for diagnos-
ing TB (GeneXpert and urinary lipoarabinomannan) and
cryptococcosis (Cryptococcal AntiGene lateral flow immunoassay)
show promising results [19,20,21]. They are becoming more
available but implementation research on the best way to utilize
these tests is needed. These tests hopefully will allow us to move
from empiric algorithm-based treatment toward diagnosis-based,
targeted treatment.
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 [14,15]. Our
study shows the value of autopsy in informing empiric algorithms
of care. Making clinicians aware of missed diagnosis will lead to an
expansion of their knowledge and will inevitably improve patient
care.
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 toxoplas-
mosis 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 treat-
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).
doi:10.1371/journal.pone.0033685.g005
An Autopsy Study from Mulago Hospital, Uganda
PLoS ONE | www.plosone.org 7 March 2012 | Volume 7 | Issue 3 | e33685
Page 7
ment 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.
Acknowledgments
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.
Author Contributions
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.
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An Autopsy Study from Mulago Hospital, Uganda
PLoS ONE | www.plosone.org 8 March 2012 | Volume 7 | Issue 3 | e33685
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    • "The STRIDE trial showed a significant reduction in AIDS-defining illness or death among patients with a CD4 cell count below 50 cells/mm 3 in patients who started ART within two weeks of initiation of treatment for tuberculosis.[28] TB was the most common diagnosis in our cohort, which is consistent with prior studies showing that TB is a leading cause of death among HIV-infected patients in sub-Saharan Africa.[31, 32] Our data reflect Predictor Score for Mortality in HIV+ Ugandan Adults with Pneumonia the persistent need for timely diagnosis of HIV infection and earlier initiation of ART, which may also reduce rates of TB and other HIV-related complications in this patient population. "
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