Autopsies in HIV: still finding missed diagnoses after 20 years

1. Autopsies in HIV: still finding missed diagnoses after 20 years 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. • 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% Results cont. Number of Deaths of HIV Patients in Northwest England Pre-mortem diagnosis (n = 41) Post-mortem diagnosis (n = 41) Pre-mortem overall diagnoses (n = 57) Post-mortem overall diagnoses (n = 80) • 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/Unknown 10% • 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. • 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. References Palella et al. New Eng J Med 1998;338. Mocroft et al. Lancet 2003; 362. Sabin et al.AIDS 2006;20.