Value of limited necropsy in HIV-positive patients

Infectious diseases and the role of needle biopsy post-mortem

Post-mortem examinations continue to play a crucial role in understanding the epidemiology and pathogenesis of infectious diseases. However, the perceived infection risk can preclude traditional, invasive, complete diagnostic autopsy. Post-mortem examination is especially important in emerging infectious diseases with potentially unknown infection risks, but rapid acquisition of good quality tissue samples is needed as part of the scientific and public health response. Needle biopsy post-mortem is a minimally invasive, rapid, closed-body autopsy technique that was originally developed to minimise the infection risk to practitioners. Since its inception, needle biopsy post-mortem has also been used as a technique to support complete diagnostic autopsy provision in poorly resourced regions and to facilitate post-mortem examinations in communities that might have religious or cultural objections to an invasive autopsy. This Review analyses the evolution and applicability of needle biopsy post-mortem in investigating endemic and emerging infectious diseases.

The evolution of minimally invasive tissue sampling in postmortem examination: a narrative review

BACKGROUND

Because of low acceptance rates and limited capacity, complete diagnostic autopsies (CDAs) are seldom conducted in low- and middle-income countries (LMICs). There have been growing investments in less-invasive postmortem examination methodologies, including needle-based autopsy, known as minimally invasive autopsy or minimally invasive tissue sampling (MITS). MITS has been shown to be a feasible and informative alternative to CDA for cause of death investigation and mortality surveillance purposes.

OBJECTIVE

The aim of this narrative review is to describe historical use and evolution of needle-based postmortem procedures as a tool to ascertain the cause of death, especially in LMICs.

METHODS

Key word searches were conducted in PubMed and EBSCO in 2018 and 2019. Abstracts were reviewed against inclusion and exclusion criteria. Full publications were reviewed for those abstracts meeting inclusion criteria and a start set was established. A snowball search methodology was used and references for all publications meeting inclusion criteria were manually reviewed until saturation was reached.

RESULTS

A total of 1,177 publications were initially screened. Following an iterative review of references, 79 publications were included in this review. Twenty-nine studies, published between 1955 and 2019, included MITS as part of postmortem examination. Of the publications included, 76% (60/79) have publication dates after 2010. More than 60% of all publications included addressed MITS in LMICs, and a total of nine publications compared MITS with CDA.

CONCLUSIONS

Although there is evidence of less-invasive postmortem sampling starting in the 1800s, more structured needle-based postmortem examination publications started to appear in the mid-twentieth century. Early studies were mostly conducted in high-income countries but starting in 2010 the number of publications began to increase, and a growing number of studies were conducted in LMICs. Initial studies in LMICs were disease-specific but since 2015 have evolved to include more expansive postmortem examination.

Autopsy Prevalence of Tuberculosis and Other Potentially Treatable Infections among Adults with Advanced HIV Enrolled in Out-Patient Care in South Africa

Background

Early mortality among HIV-positive adults starting antiretroviral therapy (ART) remains high in resource-limited settings, with tuberculosis (TB) the leading cause of death. However, current methods to estimate TB-related deaths are inadequate and most autopsy studies do not adequately represent those attending primary health clinics (PHCs). This study aimed to determine the autopsy prevalence of TB and other infections in adults enrolled at South African PHCs in the context of a pragmatic trial of empiric TB treatment (“TB Fast Track”).

Methods and Findings

Adults with CD4 ≤150 cells/μL, not on ART or TB treatment, were enrolled to TB Fast Track and followed up for at least six months. Minimally invasive autopsy (MIA) was conducted as soon as possible after death. Lungs, liver, and spleen were biopsied; blood, CSF, and urine aspirated; and bronchoalveolar lavage fluid obtained. Samples underwent mycobacterial, bacterial, and fungal culture; molecular testing (including Xpert® MTB/RIF); and histological examination. 34 MIAs were conducted: 18 (53%) decedents were female; median age was 39 (interquartile range 33–44) years; 25 (74%) deaths occurred in hospitals; median time from death to MIA was five (IQR 3–6) days. 16/34 (47%) had evidence of TB (14/16 [88%] with extrapulmonary disease; 6/16 [38%] not started on treatment antemortem); 23 (68%) had clinically important bacterial infections; four (12%) cryptococcal disease; three (9%) non-tuberculous mycobacterial disease; and two (6%) Pneumocystis pneumonia. Twenty decedents (59%) had evidence of two or more concurrent infections; 9/16 (56%) individuals with TB had evidence of bacterial disease and two (13%) cryptococcal disease.

Conclusions

TB, followed by bacterial infections, were the leading findings at autopsy among adults with advanced HIV enrolled from primary care clinics. To reduce mortality, strategies are needed to identify and direct those at highest risk into a structured pathway that includes expedited investigation and/or treatment of TB and other infections.

Opportunistic Infections in HIV-Infected Patients Differ Strongly in Frequencies and Spectra between Patients with Low CD4+ Cell Counts Examined Postmortem and Compensated Patients Examined Antemortem Irrespective of the HAART Era

Objective

AIDS-related mortality has changed dramatically with the onset of highly active antiretroviral therapy (HAART), which has even allowed compensated HIV-infected patients to withdraw from secondary therapy directed against opportunistic pathogens. However, in recently autopsied HIV-infected patients, we observed that associations with a broad spectrum of pathogens remain, although detailed analyses are lacking. Therefore, we focused on the possible frequency and spectrum shifts in pathogens associated with autopsied HIV-infected patients.

Design

We hypothesized that the pathogens frequency and spectrum changes found in HIV-infected patients examined postmortem did not recapitulate the changes found previously in HIV-infected patients examined antemortem in both the pre- and post-HAART eras. Because this is the first comprehensive study originating from Central and Eastern Europe, we also compared our data with those obtained in the West and Southwest Europe, USA and Latin America.

Methods

We performed autopsies on 124 HIV-infected patients who died from AIDS or other co-morbidities in the Czech Republic between 1985 and 2014. The pathological findings were retrieved from the full postmortem examinations and autopsy records.

Results

We collected a total of 502 host-pathogen records covering 82 pathogen species, a spectrum that did not change according to patients’ therapy or since the onset of the epidemics, which can probably be explained by the fact that even recently deceased patients were usually decompensated (in 95% of the cases, the last available CD4⁺ cell count was falling below 200 cells*μl^-1) regardless of the treatment they received. The newly identified pathogen taxa in HIV-infected patients included Acinetobacter calcoaceticus, Aerococcus viridans and Escherichia hermannii. We observed a very limited overlap in both the spectra and frequencies of the pathogen species found postmortem in HIV-infected patients in Europe, the USA and Latin America.

Conclusions

The shifts documented previously in compensated HIV-infected patients examined antemortem in the post-HAART era are not recapitulated in mostly decompensated HIV-infected patients examined postmortem.

Needle autopsy to establish the cause of death in HIV-infected hospitalized adults in Uganda: a comparison to complete autopsy

INTRODUCTION

Minimal invasive but accurate methods to establish the cause of death in HIV-infected patients are needed. We studied the agreement in cause of death between blind and ultrasound-guided needle autopsy and complete autopsy in HIV-infected patients in Uganda.

METHODS

We subsequently performed a blind and ultrasound-guided needle autopsy followed by a complete autopsy in HIV-infected adults who died during hospitalization. Two teams of pathologists reviewed the tissue from either the needle autopsies or the complete autopsy and formulated the major diagnoses, that is, diseases directly contributing to death. The primary outcome was concordance in major diagnosis between needle and complete autopsies.

RESULTS

We performed 96 blind needle and complete autopsies and 95 ultrasound-guided needle autopsies. Concordance in major diagnosis between blind needle and complete autopsy was 50%. For the main major diagnosis, tuberculosis (TB) concordance was higher (71%; P < 0.01). Blind needle autopsy identified at least 1 major diagnosis in 60% of patients; and in 46%, there was complete concordance for all major diagnoses. The main reason for discordance was sampling error of the lesion. Concordance with the addition of ultrasound guidance was 52% for all major diagnoses and 79% for TB. Major diagnoses were mainly identified in tissue cores from the liver (76%) and the spleen (82%).

DISCUSSION

Blind needle autopsy identified half of the major diagnosis. The addition of ultrasound guidance did not significantly improve the performance of needle autopsy. Needle autopsy is a valuable method to confirm causes of death in HIV-infected patients, especially for highly prevalent diseases like TB.

Practice of percutaneous needle autopsy; a descriptive study reporting experiences from Uganda

BACKGROUND

Percutaneous needle autopsy can overcome a number of barriers that limit the use of complete autopsies. We performed blind-and ultrasound guided needle autopsies in HIV-infected adults in Uganda. In this study we describe in detail the methods we used, the ability of both procedures to obtain sufficient tissue for further examination and the learning curve of the operators over time.

METHODS

If written informed consent was granted from the next of kin, we first performed a blind needle autopsy, puncturing brain, heart, lungs, liver, spleen and kidneys using predefined surface marking points. We then performed an ultrasound guided needle autopsy puncturing heart, liver, spleen and kidneys. The number of attempts, expected success and duration of the procedure were noted. A pathologist read the slides and indicated if the target tissue was present and of sufficient quality for pathological review. We report the predicted and true success rates, compare the yield of blind to ultrasound guided needle biopsies and evaluate the failure rate over time.

RESULTS

Two operators performed 96 blind needle autopsies and 95 ultrasound guided needle autopsies. For blind needle biopsies true success rates varied from 56-99% and predicted success rates from 89-99%. For ultrasound guided needle biopsies true success rates varied from 72-100% and predicted success rates from 84-98%. Ultrasound guidance led to a significantly higher success rate in heart and left kidney. A learning curve was observed over time with decreasing failure rates with increasing experience and a shorter duration of the needle autopsy.

CONCLUSION

Needle autopsy can successfully obtain tissue for further pathological review in the vast majority of cases, with a decrease in failure rate with increasing experience of the operator. The benefit of ultrasound guidance will depend on the population, the disease and organ of interest and the local circumstances. Our results justify further evaluation of needle autopsies as a method to establish a cause of death.

Causes of death on antiretroviral therapy: a post-mortem study from South Africa

Background

Mortality in the first months of antiretroviral therapy (ART) is a significant clinical problem in sub-Saharan Africa. To date, no post-mortem study has investigated the causes of mortality in these patients.

Methods

HIV-positive adults who died as in-patients at a Johannesburg academic hospital underwent chart-review and ultrasound-guided needle autopsy for histological and microbiological examination of lung, liver, spleen, kidney, bone marrow, lymph node, skin and cerebrospinal fluid. A clinico-pathologic committee considered all available data and adjudicated immediate and contributing causes of death.

Results

Thirty-nine adults were enrolled: 14 pre-ART, 15 early-ART (7–90 days), and 10 late-ART (>90 days). Needle sampling yielded adequate specimen in 100% of kidney, skin, heart and cerebrospinal fluid samples, 97% of livers and lungs, 92% of bone marrows, 87% of spleens and 68% of lymph nodes. Mycobacterial infections were implicated in 69% of deaths (26 of 27 of these due to M. tuberculosis), bacterial infections in 33%, fungal infections in 21%, neoplasm in 26%, and non-infectious organ failure in 26%. Immune reconstitution inflammatory syndrome (IRIS) was implicated in 73% of early-ART deaths. Post-mortem investigations revealed previously undiagnosed causes of death in 49% of cases. Multiple pathologies were common with 62% of subjects with mycobacterial infection also having at least one other infectious or neoplastic cause of death.

Conclusions

Needle biopsy was efficient and yielded excellent pathology. The large majority of deaths in all three groups were caused by M. tuberculosis suggesting an urgent need for improved diagnosis and expedited treatment prior to and throughout the course of antiretroviral therapy. Complex, unrecognized co-morbidities pose an additional challenge.

A minimally invasive technique for the detection and analysis of pulmonary fat embolism: a feasibility study

We investigated the feasibility of postmortem percutaneous needle biopsy (PNB) for obtaining pulmonary samples adequate for the study of pulmonary fat embolism (PFE). Samples of both lungs were obtained from 26 cadavers via two different methods: (i) PNB and (ii) the double-edged knife technique, the gold standard at our institute. After water storage and Sudan III staining, six forensic pathologists independently examined all samples for the presence and severity of PFE. The results were compared and analyzed in each case regarding the vitality of the PFE and its relationship to the cause of death. The results showed that PFE was almost identically diagnosed and graded on the samples obtained via both methods. The discrepancies between the two techniques did not affect the diagnoses of vitality or cause of death related to PFE. This study demonstrates the feasibility of the PNB sampling method for the diagnosis and interpretation of PFE in the postmortem setting.

HIV-negative drug addict diagnosed with AIDS and tuberculosis at autopsy: a case report and brief review of literature

Human Immunodeficiency Virus (HIV) infection is a true plague and a major health concern globally. It is one of the most significant pandemics in recorded history. Despite worldwide efforts to fight the pandemic, and now with the re-emergence of tuberculosis, those clinicians, personnel performing autopsies and medical caregivers are again at risk in the work place, especially in developing countries. We describe a case where a drug abuser, whose addiction was concealed by his parents, died in hospital. He was tested HIV-negative there. A medical tangle ensued and forensic autopsy was carried out. Autopsy confirmed he was an intravenous drug addict and had tuberculosis. Post-mortem blood was positive for HIV antibodies and he was diagnosed with AIDS. Due to social stigmas, lack of knowledge or inefficient medical laboratory procedures etc, such type of cases can become a hazard to those attending the sick and to autopsy pathologists alike. We provide the case description, autopsy findings and review of pertinent literature.

The prevalence and drug sensitivity of tuberculosis among patients dying in hospital in KwaZulu-Natal, South Africa: a postmortem study

BACKGROUND

Tuberculosis is the leading cause of death in South Africa by death notification, but accurate diagnosis of tuberculosis is challenging in this setting of high HIV prevalence. We conducted limited autopsies on young adults dying in a single public hospital in the province of KwaZulu-Natal between October 2008 and August 2009 in order to estimate the magnitude of deaths attributable to tuberculosis.

METHODS AND FINDINGS

We studied a representative sample of 240 adult inpatients (aged 20-45 years) dying after admission to Edendale Hospital. Limited autopsies included collection of respiratory tract secretions and tissue by needle core biopsies of lung, liver, and spleen. Specimens were examined by fluorescent microscopy for acid-fast bacilli and cultured in liquid media; cultures positive for M. tuberculosis were tested for drug susceptibility to first- and second-line antibiotics. Ninety-four percent of our study cohort was HIV seropositive and 50% of decedents had culture-positive tuberculosis at the time of death. Fifty percent of the participants were on treatment for tuberculosis at the time of death and 58% of these treated individuals remained culture positive at the time of death. Of the 50% not receiving tuberculosis treatment, 42% were culture positive. Seventeen percent of all positive cultures were resistant to both isoniazid and rifampin (i.e., multidrug resistant); 16% of patients dying during the initiation phase of their first ever course of tuberculosis treatment were infected with multidrug-resistant bacilli.

CONCLUSIONS

Our findings reveal the immense toll of tuberculosis among HIV-positive individuals in KwaZulu-Natal. The majority of decedents who remained culture positive despite receiving tuberculosis treatment were infected with pan-susceptible M. tuberculosis, suggesting that the diagnosis of tuberculosis was made too late to alter the fatal course of the infection. There is also a significant burden of undetected multidrug-resistant tuberculosis among HIV-coinfected individuals dying in this setting. New public health approaches that improve early diagnosis of tuberculosis and accelerate the initiation of treatment are urgently needed in this setting. Please see later in the article for the Editors' Summary.

Post-mortem tissue sampling using computed tomography guidance

PURPOSE

Currently, in forensic medicine cross-sectional imaging gains recognition and a wide use as a non-invasive examination approach. Today, computed tomography (CT) or magnetic resonance imaging that are available for patients are unable to provide tissue information on the cellular level in a non-invasive manner and also diatom detection, DNA, bacteriological, chemical toxicological and other specific tissue analyses are impossible using radiology. We hypothesised that post-mortem minimally invasive tissue sampling using needle biopsies under CT guidance might significantly enhance the potential of virtual autopsy. The purpose of this study was to test the use of a clinically approved biopsy needle for minimally invasive post-mortem sampling of tissue specimens under CT guidance.

MATERIAL AND METHODS

ACN III biopsy core needles 14 gauge x 160 mm with automatic pistol device were used on three bodies dedicated to research from the local anatomical institute. Tissue probes from the brain, heart, lung, liver, spleen, kidney and muscle tissue were obtained under CT fluoroscopy.

RESULTS

CT fluoroscopy enabled accurate placement of the needle within the organs and tissues. The needles allowed for sampling of tissue probes with a mean width of 1.7 mm (range 1.2-2 mm) and the maximal length of 20 mm at all locations. The obtained tissue specimens were of sufficient size and adequate quality for histological analysis.

CONCLUSION

Our results indicate that, similar to the clinical experience but in many more organs, the tissue specimens obtained using the clinically approved biopsy needle are of a sufficient size and adequate quality for a histological examination. We suggest that post-mortem biopsy using the ACN III needle under CT guidance may become a reliable method for targeted sampling of tissue probes of the body.

Multiple, severe lung infiltrates due to Mycobacterium avium-intracellulare in a patient with decompensated liver cirrhosis: Spontaneous resolution after a two-year follow-up

A unique case of severe, multiple, microbiologically-confirmed pulmonary Mycobacterium avium-intracellulare lesions occurred in a female with decompensated liver cirrhosis, and went to cure after around 2 y despite the impossibility to deliver an effective antimicrobial chemotherapy, owing to the patient's intolerance. From an extensive literature review, we underline a possible mechanism prompting mycobacterial disease during advanced liver disease, while we retrieved only 2 described cases of possible spontaneous resolution of Mycobacterium terrae lung disease, although both were reported in patients without end-organ liver disease, who received a specific combined chemotherapy for an appreciable time period. On the other hand, while decompensated liver cirrhosis is more frequently complicated by a peritoneal localization of bacteria and very infrequently mycobacteria, the reported case represents the first severe pulmonary localization of multiple lesions due to Mycobacterium avium-intracellulare. Moreover, this extraordinary episode resolved spontaneously within the 2-y follow-up, as documented by bronchoalveolar lavage, culture, high-resolution CT scans, and scintigraphic examination.

Unnatural causes of sudden unexpected deaths initially thought to be sudden infant death syndrome

The aim of this clinicopathological study was to determine the frequency of infant deaths due to unnatural causes among cases of sudden and unexpected infant death. Nine institutes of legal medicine in Germany that took part in the German study on Sudden Infant Death Syndrome (GeSID), representing 35% of the German territory, investigated in a 3-year period (from 1998 to 2001) 339 cases of infant death that were not expected to be due to unnatural causes from the first external examination. All cases were investigated by complete, standardised, post-mortem examination including death scene investigation, autopsy, histology, toxicology and neuropathology. The frequency of unnatural deaths was 5.0% (n=17). The causes of death were head injury (n=7), suffocation (n=5), poisoning (n=2), neglect (n=2) and septicaemia due to aspiration of a foreign body (n=1). Two deaths were unsuspected accidents and 12 were due to infanticide. In 3 cases, it was not possible to differentiate between accidental death and infanticide. A complete postmortem examination including an analysis of the clinical history, death scene investigation, autopsy, histology, toxicology, and neuropathology is mandatory to differentiate sudden and unexpected deaths due to natural causes (e.g. SIDS) and cases of unnatural death.

Consecutive autopsies on an internal medicine service

OBJECTIVES

Autopsy rates continue to decline in the United States despite the demonstrated value of this procedure in many different settings. We sought to review clinical pathologic discordance information generated by autopsies on an internal medicine service in the urban United States and to determine whether resident services appear to influence autopsy rates.

METHODS

We reviewed consecutive deaths and autopsies on an inpatient internal medicine service during a 30-month period at a 400-bed community hospital in Baltimore, MD.

RESULTS

There were 622 deaths and 65 autopsies (10.3%). Resident teaching status correlated with a higher rate of autopsies performed (P = 0.048). Clinical pathologic discordance was common, with a major discordance rate of 39%. Major discordance was indicated by only one of nine autopsies performed on patients with human immunodeficiency virus.

CONCLUSIONS

The autopsy was a valuable educational and quality improvement tool on the urban internal medicine service. Residency influences may be a major factor in continuing this exercise. In our study, although the numbers were small, patients with human immunodeficiency virus had a very low discordance rate.

[Correlation between clinical apparatus-based differential diagnosis and neuropathological diagnosis in patients with AIDS]

BACKGROUND

During the course of HIV infection, the majority of patients develop opportunistic cerebral neuro-manifestations. If conventional diagnostic tools are not sufficient, a stereotactic biopsy is often necessary.

PATIENTS AND METHODS

In order to evaluate the correctness of the clinical diagnosis of cerebral neuro-manifestations in HIV-infected patients, we compared the results of cerebral biopsy or autopsy with the previous clinical diagnosis. A total of 19 biopsies and 49 autopsies could be analyzed.

RESULTS

Except for HIV-associated encephalopathy, we detected a very high conformity between the clinical and the neuropathological diagnoses. We obtained the best sensitivity for progressive multifocal leukoencephalopathy (PML), whereas for cerebral toxoplasmosis the worst sensitivity and specificity was identified.

CONCLUSION

We conclude that the diagnosis of PML can be made on clinical grounds alone, whereas the diagnosis of cerebral toxoplasmosis and lymphoma often requires a biopsy, which should be performed early.

The autopsy: complete or not complete?

Less invasive or non-invasive alternatives to the complete autopsy have been sought for some time, and a range of methods, ranging from needle sampling to endoscopy to magnetic resonance imaging, have been considered. Evaluations of these methods are few and far between, but generally confirm the predictable conclusion that incomplete autopsies provide incomplete information. It is not difficult to envisage a situation whereby pressure for non-invasive autopsies will allow them to become prevalent, whether properly evaluated or not. However, used appropriately, non-invasive or less invasive autopsies may be valuable tools capable of answering specific questions in situations where it is not possible to perform a complete autopsy.

Autopsy Findings in AIDS Patients from a Reference Hospital in Brazil: Analysis of 92 Cases

The aim of this work was to evaluate the opportunistic diseases and the cause of death of AIDS patients who were submitted to autopsy. We included all AIDS patients submitted to autopsy at a reference hospital of a medical school in São Paulo, Brazil, during the period of 1993 to 2000. Out of 1,478 autopsy cases in this period, 92 patients (6.22%) had the previously confirmed diagnosis of AIDS. Sixty-nine patients (75%) were men ranging in age from 19 to 68 years (mean 34.8). Eighty-five patients (92.4%) died due to infectious diseases, while only two died of neoplasia. Forty-four (48%) patients died from pulmonary infection, 14 (15%) from sepsis, 14 (15%) from disseminated mycobacteriosis, and six (7%) from Central Nervous System (CNS) infection. The opportunistic diseases found were mycobacteriosis (n = 25), Pneumocystis carinii infection (n = 16), Cytomegalovirus infection (n = 17), toxoplasmosis (8 CNS cases), candida sp infection (n = 12), histoplasmosis (n = 5), cryptococcus (n = 4), and one case of blastomycosis in the lung. Most of our AIDS patients are dying of infectious and opportunistic diseases that are not always diagnosed during their lifetime.