Beeching NJ, Azadeh B. Autopsies in HIV

Beeching NJ, Azadeh B. Autopsies in HIV: still identifying missed diagnoses. Int J STD AIDS.

This study reviews the deaths and autopsies carried out over 23 years, 1983- 2005 , in a British Infection Unit in HIV patients. Of 115 HIV patients known to have died, Beadsworth and colleagues obtained data on 93%. Of this 80% were male, median age 38 (25-68) years; 83% were Caucasian; 12% Black African. Major risk factors were men who have sex with men, 52%; heterosexual in Africa, 17%; and injecting drug use, 8%. The commonest diagnosis pre- and post-autopsy diagnosis was pneumonia. Changes in diagnoses in the 38% who underwent autopsy were high (the authors requested autopsy in 50%). Primary diagnosis changed in 70%, and 36% of all opportunistic infections were missed. This included six of nine cytomegalovirus, all tuberculosis, and 75% of Kaposi’s sarcoma. Lymphoma was overdiagnosed. Thus, despite excellent resources, the majority of primary diagnoses were wrong, suggesting inadequacy of current diagnostics. To improve these and improve both epidemiological data and future management autopsy should be considered for all deaths.

Although HIV-related mortality has fallen dramatically due to antiretroviral therapy and chemoprophylaxis for opportunistic infections, deaths still occur and we need to better understand what causes them. Autopsy is an important tool for auditing clinical diagnoses, improving diagnostics and management, and enhancing clinical governance in HIV medical practice. This study found errors in the reported primary cause of death in 70% of the deaths occurring in this HIV practice over a 23-year period. Three cases of tuberculosis among the 41 autopsies performed had been completely missed before death. Wherever possible, both physicians and families should request an autopsy in every death of an HIV-positive person in the interests of improved care for those who are living.