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Suresh D, Rastogi P, Bal A, Lad D, Naseem S, Jain A, Khadwal AR, Malhotra P. Bridging the gap: understanding contemporary autopsies in acute leukemia by comparing ante-mortem and post-mortem profiles. Leuk Lymphoma 2024:1-16. [PMID: 38949830 DOI: 10.1080/10428194.2024.2372408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 06/20/2024] [Indexed: 07/02/2024]
Abstract
This study investigates acute myeloid leukemia/lymphoblastic leukemia (AML/ALL) through a 14-year analysis (2009-2022) of 46 autopsied cases (age >12 years). B-ALL was the dominant subtype (34.8%). Liver and spleen were the common sites of active leukemia (63% cases). Symptoms like dyspnea and altered sensorium associated significantly with heart (p = .031) and brain leukostasis (p = .006). Measurable residual disease (MRD) negativity correlated with disease-free status outside the bone marrow, while MRD-positive cases displayed leukemic infiltrates. Infections were identified in 23 autopsied cases, notably linked to post-induction and post-transplant fatalities. Surprisingly, 18 of these 23 cases had unexpected infections mainly fungal (13 cases) with Aspergillus species as the most common. Diagnostic discrepancies were identified in 48% of cases. Malignant infiltration (46%) and infections (25%) were the leading causes of death. This research sheds light on leukemia in extra-medullary tissues, uncovers novel clinical-pathological associations, and highlights overlooked therapy side effects, offering insights for future case management.
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Affiliation(s)
- Deepthi Suresh
- Department of Pathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pulkit Rastogi
- Department of Haematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amanjit Bal
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepesh Lad
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shano Naseem
- Department of Haematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arihant Jain
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Alka Rani Khadwal
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Malhotra
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Leulseged H, A Rees C, Alemu A, A Tippett Barr B, Dheresa M, Madrid L, Scott A, Assefa N. The discrepancy of antemortem clinical diagnosis and postmortem autopsy diagnosis of lung pathologies in under-five deaths and the reasons for discrepancies: a case series analysis. BMC Pediatr 2024; 24:365. [PMID: 38807044 PMCID: PMC11131180 DOI: 10.1186/s12887-024-04854-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 05/23/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND Diagnostic autopsy is the most reliable approach to definitively ascertain the cause of death and evaluate the accuracy of antemortem clinical diagnoses. Identifying diagnostic discrepancies is vital to understanding common gaps in antemortem clinical diagnoses and modifying antemortem diagnostic approaches to increase the accuracy of clinical diagnosis. The objective of this study was to determine the frequency of diagnostic discrepancies between antemortem clinical diagnoses and postmortem autopsies on lung pathologies and to understand the reasons for diagnostic discrepancies among cases included in Child Health and Mortality Prevention Surveillance (CHAMPS) in Ethiopia. METHODS A clinical case series study of deaths among children under-five in the CHAMPS study at three sites in Ethiopia between October 2019 and April 2022 was conducted. The antemortem clinical diagnoses and postmortem pathological diagnoses of the lung were compared for each case. Two senior physicians assessed the findings for both agreement and disagreement. McNemar's test was used to assess for statistically significant differences between antemortem and postmortem diagnoses. RESULTS Seventy-five cases were included (73.3% male). Over half (54.7%) died between the 1st and 7th day of life. Sepsis (66.7%), pneumonia (6.7%), and meconium aspiration syndrome (5.0%) were the most common immediate causes of death. Half (52%) of cases were correctly diagnosed antemortem. The magnitude of diagnostic discrepancy was 35% (95% CI: 20-47%). The most common contributing factors to diagnostic discrepancy were gaps in knowledge (22/75, 35.5%) and problems in consultation and teamwork (22/75, 35.5%). CONCLUSIONS Misdiagnoses were common among young children who died with positive lung pathology findings. In-service education initiatives and multidisciplinary collaboration are needed to mitigate high rates of diagnostic discrepancies among young children to potentially prevent future deaths.
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Affiliation(s)
- Haleluya Leulseged
- Hararghe Health Research Partnership, Haramaya University, Harar Town, Jineala District, PO. BOX: 235, Diredawa, Ethiopia.
- College of Health and Medical Science, Haramaya University, Diredawa, Ethiopia.
- London School of Hygiene and Tropical Medicine, London, UK.
| | - Chris A Rees
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Addisu Alemu
- Hararghe Health Research Partnership, Haramaya University, Harar Town, Jineala District, PO. BOX: 235, Diredawa, Ethiopia
- College of Health and Medical Science, Haramaya University, Diredawa, Ethiopia
| | - Beth A Tippett Barr
- Nyanja Health Research Institute, Salima, Malawi
- London School of Hygiene and Tropical Medicine, London, UK
| | - Merga Dheresa
- Hararghe Health Research Partnership, Haramaya University, Harar Town, Jineala District, PO. BOX: 235, Diredawa, Ethiopia
- College of Health and Medical Science, Haramaya University, Diredawa, Ethiopia
| | - Lola Madrid
- Hararghe Health Research Partnership, Haramaya University, Harar Town, Jineala District, PO. BOX: 235, Diredawa, Ethiopia
- London School of Hygiene and Tropical Medicine, London, UK
| | - Anthony Scott
- Hararghe Health Research Partnership, Haramaya University, Harar Town, Jineala District, PO. BOX: 235, Diredawa, Ethiopia
- London School of Hygiene and Tropical Medicine, London, UK
| | - Nega Assefa
- Hararghe Health Research Partnership, Haramaya University, Harar Town, Jineala District, PO. BOX: 235, Diredawa, Ethiopia
- College of Health and Medical Science, Haramaya University, Diredawa, Ethiopia
- London School of Hygiene and Tropical Medicine, London, UK
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Ogbuanu IU, Otieno K, Varo R, Sow SO, Ojulong J, Duduyemi B, Kowuor D, Cain CJ, Rogena EA, Onyango D, Akelo V, Tippett Barr BA, terKuile F, Kotloff KL, Tapia MD, Keita AM, Juma J, Assefa N, Assegid N, Acham Y, Madrid L, Scott JAG, Arifeen SE, Gurley ES, Mahtab S, Dangor Z, Wadula J, Dutoit J, Madhi SA, Mandomando I, Torres-Fernandez D, Kincardett M, Mabunda R, Mutevedzi P, Madewell ZJ, Blau DM, Whitney CG, Samuels AM, Bassat Q. Burden of child mortality from malaria in high endemic areas: Results from the CHAMPS network using minimally invasive tissue sampling. J Infect 2024; 88:106107. [PMID: 38290664 DOI: 10.1016/j.jinf.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 12/07/2023] [Accepted: 01/17/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND Malaria is a leading cause of childhood mortality worldwide. However, accurate estimates of malaria prevalence and causality among patients who die at the country level are lacking due to the limited specificity of diagnostic tools used to attribute etiologies. Accurate estimates are crucial for prioritizing interventions and resources aimed at reducing malaria-related mortality. METHODS Seven Child Health and Mortality Prevention Surveillance (CHAMPS) Network sites collected comprehensive data on stillbirths and children <5 years, using minimally invasive tissue sampling (MITS). A DeCoDe (Determination of Cause of Death) panel employed standardized protocols for assigning underlying, intermediate, and immediate causes of death, integrating sociodemographic, clinical, laboratory (including extensive microbiology, histopathology, and malaria testing), and verbal autopsy data. Analyses were conducted to ascertain the strength of evidence for cause of death (CoD), describe factors associated with malaria-related deaths, estimate malaria-specific mortality, and assess the proportion of preventable deaths. FINDINGS Between December 3, 2016, and December 31, 2022, 2673 deaths underwent MITS and had a CoD attributed from four CHAMPS sites with at least 1 malaria-attributed death. No malaria-attributable deaths were documented among 891 stillbirths or 924 neonatal deaths, therefore this analysis concentrates on the remaining 858 deaths among children aged 1-59 months. Malaria was in the causal chain for 42.9% (126/294) of deaths from Sierra Leone, 31.4% (96/306) in Kenya, 18.2% (36/198) in Mozambique, 6.7% (4/60) in Mali, and 0.3% (1/292) in South Africa. Compared to non-malaria related deaths, malaria-related deaths skewed towards older infants and children (p < 0.001), with 71.0% among ages 12-59 months. Malaria was the sole infecting pathogen in 184 (70.2%) of malaria-attributed deaths, whereas bacterial and viral co-infections were identified in the causal pathway in 24·0% and 12.2% of cases, respectively. Malnutrition was found at a similar level in the causal pathway of both malaria (26.7%) and non-malaria (30.7%, p = 0.256) deaths. Less than two-thirds (164/262; 62.6%) of malaria deaths had received antimalarials prior to death. Nearly all (98·9%) malaria-related deaths were deemed preventable. INTERPRETATION Malaria remains a significant cause of childhood mortality in the CHAMPS malaria-endemic sites. The high bacterial co-infection prevalence among malaria deaths underscores the potential benefits of antibiotics for severe malaria patients. Compared to non-malaria deaths, many of malaria-attributed deaths are preventable through accessible malaria control measures.
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Affiliation(s)
| | - Kephas Otieno
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Rosauro Varo
- ISGlobal - Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça [CISM], Maputo, Mozambique
| | - Samba O Sow
- Centre pour le Développement des Vaccins (CVD-Mali), Ministère de la Santé, Bamako, Mali
| | | | - Babatunde Duduyemi
- University of Sierra Leone Teaching Hospital Complex, Freetown, Sierra Leone
| | | | | | - Emily A Rogena
- School of Medicine, Jomo Kenyatta University of Agriculture and Technology, Juja, Kenya
| | | | - Victor Akelo
- US Centers for Disease Control and Prevention--Kenya, Kisumu, Kenya
| | | | - Feiko terKuile
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Karen L Kotloff
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Milagritos D Tapia
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Adama Mamby Keita
- Centre pour le Développement des Vaccins (CVD-Mali), Ministère de la Santé, Bamako, Mali
| | - Jane Juma
- Centre pour le Développement des Vaccins (CVD-Mali), Ministère de la Santé, Bamako, Mali
| | - Nega Assefa
- College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia; Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Nardos Assegid
- College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Yenework Acham
- College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Lola Madrid
- College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia; Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - J Anthony G Scott
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom; KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Shams El Arifeen
- International Center for Diarrhoeal Diseases Research (ICDDR,B), Dhaka, Bangladesh
| | - Emily S Gurley
- International Center for Diarrhoeal Diseases Research (ICDDR,B), Dhaka, Bangladesh; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sana Mahtab
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit; Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ziyaad Dangor
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit; Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jeannette Wadula
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit; Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jeanie Dutoit
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit; Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Shabir A Madhi
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit; Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Wits Infectious Diseases and Oncology Research Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Inácio Mandomando
- ISGlobal - Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça [CISM], Maputo, Mozambique; Instituto Nacional de Saúde, Ministério de Saúde, Maputo, Moçambique
| | - David Torres-Fernandez
- ISGlobal - Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça [CISM], Maputo, Mozambique
| | - Milton Kincardett
- Centro de Investigação em Saúde de Manhiça [CISM], Maputo, Mozambique
| | - Rita Mabunda
- Centro de Investigação em Saúde de Manhiça [CISM], Maputo, Mozambique
| | - Portia Mutevedzi
- Emory Global Health Institute, Emory University, Atlanta, GA, USA
| | - Zachary J Madewell
- Global Health Center, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Dianna M Blau
- Global Health Center, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Aaron M Samuels
- Global Health Center, Centers for Disease Control and Prevention, Atlanta, GA, USA; Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Quique Bassat
- ISGlobal - Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça [CISM], Maputo, Mozambique; ICREA, Pg. Lluís Companys 23, 08010 Barcelona, Spain; Pediatrics Department, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues, Barcelona, Spain; CIBER de Epidemiología y Salud Pública, Instituto de Salud Carlos III, Madrid, Spain.
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Knappett M, Hooft A, Maqsood MB, Lavoie PM, Kortz T, Mehta S, Duby J, Akech S, Maina M, Carter R, Popescu CR, Daftary R, Mugisha NK, Mwesigwa D, Kabakyenga J, Kumbakumba E, Ansermino JM, Kissoon N, Mutekanga A, Hau D, Moschovis P, Kangwa M, Chen C, Firnberg M, Glomb N, Argent A, Reid SJ, Bhutta A, Wiens MO. Verbal Autopsy to Assess Postdischarge Mortality in Children With Suspected Sepsis in Uganda. Pediatrics 2023; 152:e2023062011. [PMID: 37800272 PMCID: PMC11006254 DOI: 10.1542/peds.2023-062011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Reducing child mortality in low-income countries is constrained by a lack of vital statistics. In the absence of such data, verbal autopsies provide an acceptable method to determining attributable causes of death. The objective was to assess potential causes of pediatric postdischarge mortality in children younger than age 5 years (under-5) originally admitted for suspected sepsis using verbal autopsies. METHODS Secondary analysis of verbal autopsy data from children admitted to 6 hospitals across Uganda from July 2017 to March 2020. Structured verbal autopsy interviews were conducted for all deaths within 6 months after discharge. Two physicians independently classified a primary cause of death, up to 4 alternative causes, and up to 5 contributing conditions using the Start-Up Mortality List, with discordance resolved by consensus. RESULTS Verbal autopsies were completed for 361 (98.6%) of the 366 (5.9%) children who died among 6191 discharges (median admission age: 5.4 months [interquartile range, 1.8-16.7]; median time to mortality: 28 days [interquartile range, 9-74]). Most deaths (62.3%) occurred in the community. Leading primary causes of death, assigned in 356 (98.6%) of cases, were pneumonia (26.2%), sepsis (22.1%), malaria (8.5%), and diarrhea (7.9%). Common contributors to death were malnutrition (50.5%) and anemia (25.7%). Reviewers were less confident in their causes of death for neonates than older children (P < .05). CONCLUSIONS Postdischarge mortality frequently occurred in the community in children admitted for suspected sepsis in Uganda. Analyses of the probable causes for these deaths using verbal autopsies suggest potential areas for interventions, focused on early detection of infections, as well as prevention and treatment of underlying contributors such as malnutrition and anemia.
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Affiliation(s)
- Martina Knappett
- Institute for Global Health, British Columbia Children’s & Women’s Hospital, Vancouver, Canada
| | - Anneka Hooft
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Muhammad Bilal Maqsood
- Division of Neonatology, Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Pascal M. Lavoie
- Division of Neonatology, Department of Pediatrics, University of British Columbia, Vancouver, Canada
- British Columbia Children’s Hospital Research Institute, Vancouver, Canada
| | - Teresa Kortz
- Division of Critical Care, Department of Pediatrics, University of California, San Francisco, San Francisco, California
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, California
| | - Sonia Mehta
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Jessica Duby
- Department of Pediatrics, McGill University, Montreal, Canada
| | - Samuel Akech
- Kenya Medical Research Institute/Wellcome Trust Research Programme, Centre for Geographic Medicine Research–Coast, Kilifi, Kenya
| | - Michuki Maina
- Health Services Research Group, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Rebecca Carter
- Division of Neonatology, Department of Pediatrics, University of California San Diego, La Jolla, California
| | - Constantin R. Popescu
- British Columbia Children’s Hospital Research Institute, Vancouver, Canada
- Division of Neonatology, Department of Pediatrics, Université Laval, Québec, Canada
| | - Rajesh Daftary
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | | | | | - Jerome Kabakyenga
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Elias Kumbakumba
- Department of Pediatrics and Child Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - J. Mark Ansermino
- Institute for Global Health, British Columbia Children’s & Women’s Hospital, Vancouver, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
| | - Niranjan Kissoon
- Institute for Global Health, British Columbia Children’s & Women’s Hospital, Vancouver, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | | | - Duncan Hau
- Department of Pediatrics, Weill Cornell Medical College, New York, New York
| | - Peter Moschovis
- Division of Global Health, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Mukuka Kangwa
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Carol Chen
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Maytal Firnberg
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Nicolaus Glomb
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Andrew Argent
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Stephen J. Reid
- Department of Family, Community and Emergency Care, University of Cape Town, Cape Town, South Africa
| | - Adnan Bhutta
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Matthew O. Wiens
- Institute for Global Health, British Columbia Children’s & Women’s Hospital, Vancouver, Canada
- Walimu, Kampala, Uganda
- Mbarara University of Science and Technology, Mbarara, Uganda
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
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Subedi N, Bhattarai S, Ranabhat S, Sharma BK, Baral MP. Determination of causes of adult deaths using minimally invasive tissue sampling in Gandaki province of Nepal: a multicenter hospital-based study. Eur J Med Res 2023; 28:407. [PMID: 37805504 PMCID: PMC10559450 DOI: 10.1186/s40001-023-01392-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 09/23/2023] [Indexed: 10/09/2023] Open
Abstract
BACKGROUND Minimally Invasive Tissue Sampling (MITS) has been successfully used to establish the cause of death in low- and middle-income countries, mostly in stillbirths and neonates. The objective of this study was to determine the causes of death among adults using MITS in the Gandaki province of Nepal and to find out the contribution of MITS to identify the causes of death. METHODS A multicentric hospital-based pilot study was conducted to enroll 100 cases of adult deaths. The specimens of cerebrospinal fluid, blood, brain, lungs, and liver tissue were collected utilizing MITS. These specimens underwent standard histopathological, serological, and microbiological analyses. The findings from MITS, and if available, clinical records and forensic autopsy findings were compiled and the cause of death panel identified the causes of death. The final cause of death allocated to each case was based on the WHO International Medical Certificate of Death. RESULTS Among a total of 100 cases enrolled during the study period, infectious cause attributed to the immediate cause of death in 77 (77%), cardiovascular in 10 (10%), neurological in 8 (8%), malignancy in two (2%), and gastrointestinal and hepatobiliary cause in one (1%) case. The mean age of the cases was 50.8 ± 15.9 years and 76 (76%) were males. MITS established the cause of death in the causal chain of events in 81(81%) cases and identified the cause of death significantly more with infectious than non-infectious causes (p < 0.001). CONCLUSIONS MITS was useful in establishing the cause of death in the majority of adult deaths and the most common cause was infectious disease. Our findings suggest that MITS can be a valuable and alternative tool for mortality surveillance in low-resource settings, where complete diagnostic autopsies are less accepted or less prioritized.
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Affiliation(s)
- Nuwadatta Subedi
- Department of Forensic Medicine, Gandaki Medical College Teaching Hospital and Research Center, Gandaki, Pokhara, Nepal.
- DECODE MAUN Research Project, Gandaki Medical College Teaching Hospital and Research Center, Pokhara, Nepal.
| | - Suraj Bhattarai
- DECODE MAUN Research Project, Gandaki Medical College Teaching Hospital and Research Center, Pokhara, Nepal
- Global Health Research & Medical Interventions for Development (GLOHMED), Kathmandu, Nepal
| | - Sunita Ranabhat
- DECODE MAUN Research Project, Gandaki Medical College Teaching Hospital and Research Center, Pokhara, Nepal
- Department of Pathology, Gandaki Medical College Teaching Hospital and Research Center, Pokhara, Nepal
| | - Binita Koirala Sharma
- DECODE MAUN Research Project, Gandaki Medical College Teaching Hospital and Research Center, Pokhara, Nepal
- Department of Microbiology, Tribhuvan University Prithvi Narayan Campus, Pokhara, Nepal
| | - Madan Prasad Baral
- DECODE MAUN Research Project, Gandaki Medical College Teaching Hospital and Research Center, Pokhara, Nepal
- Department of Forensic Medicine, Pokhara Academy of Health Sciences, Western Regional Hospital, Pokhara, Nepal
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Nhantumbo AA, Comé CE, Maholela PI, Munguambe AM, da Costa P, Mott M, Cunha GR, Chambal L, Dias C, Cantarelli VV, Gudo ES. Etiology of meningitis among adults in three quaternary hospitals in Mozambique, 2016-2017: The role of HIV. PLoS One 2022; 17:e0267949. [PMID: 35544535 PMCID: PMC9094547 DOI: 10.1371/journal.pone.0267949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 04/19/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Meningitis remains an important cause of morbi-mortality in adults in sub-Saharan Africa. Data on the etiological investigation of meningitis in adults in Mozambique is limited and most studies were conducted in southern Mozambique. Identification of the etiology of meningitis in adults are crucial to guide prevention and treatments strategies. In this study, we determine the burden of fungal and bacterial meningitis among adults at the three largest hospitals in Mozambique. METHOD We performed analysis of data from the routine sentinel surveillance system for meningitis in Mozambique from January 2016 to December 2017. Cerebrospinal fluid (CSF) samples were collected from eligible adults (≥18 years old) who met World Health Organization (WHO) case definition criteria for Meningitis. All samples were tested by cryptococcal antigen (CrAg) lateral flow assay (LFA), culture and triplex real-time polymerase chain reaction (qPCR) assay and all patients were tested for human immunodeficiency virus (HIV) using the national algorithm for HIV testing. RESULTS Retrospective analysis of 1501 CSF samples from adults clinically suspected of meningitis revealed that 10.5% (158/1501) were positive for bacterial and fungal meningitis. Of these 158 confirmed cases, the proportion of Cryptococcal meningitis and pneumococcal meningitis was38.6% (95% CI: 31.0% to 46.7%) and 36.7% (95% CI: 29.2% to 44.7%), respectively. The other bacterial agents of meningitis identified include Neisseria meningitidis (8.9%; 14/158), Escherichia coli (6.3%; 10/158), Haemophilus influenzae (5.1%; 8/158) and S. aureus (4.4%; 7/158), which represent (24.7%; 39/158) of the total confirmed cases. CONCLUSION Altogether, our findings show a high burden of Cryptococcal meningitis among adults in Mozambique, especially in people living with HIV, followed by pneumococcal meningitis. Our findings suggest that rollout of CrAg Lateral Flow Assay in the health system in Mozambique for early detection of cryptococcus neoformans is necessary to improve overall patient care.
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Affiliation(s)
- Aquino Albino Nhantumbo
- Laboratório de Bacteriologia e Patógenos de Alto Risco, Instituto Nacional de Saúde, Ministério da Saúde, Maputo, Mozambique
| | - Charlotte Elizabeth Comé
- Laboratório de Bacteriologia e Patógenos de Alto Risco, Instituto Nacional de Saúde, Ministério da Saúde, Maputo, Mozambique
| | | | - Alcides Moniz Munguambe
- Laboratório de Bacteriologia e Patógenos de Alto Risco, Instituto Nacional de Saúde, Ministério da Saúde, Maputo, Mozambique
| | - Paulino da Costa
- Unidade de Gestão de Dados, Instituto Nacional de Saúde, Ministério da Saúde, Maputo, Mozambique
| | - Mariana Mott
- Universidade Federal de Ciências de Saúde de Porto Algre (UFCSPA), Porto Alegre, Brazil
| | - Gabriella Rosa Cunha
- Universidade Federal de Ciências de Saúde de Porto Algre (UFCSPA), Porto Alegre, Brazil
| | - Lúcia Chambal
- Departamento de Medicina at the Hospital Central de Maputo, Ministério da Saúde, Maputo, Mozambique
| | - Cícero Dias
- Universidade Federal de Ciências de Saúde de Porto Algre (UFCSPA), Porto Alegre, Brazil
| | - Vlademir Vicente Cantarelli
- Universidade Federal de Ciências de Saúde de Porto Algre (UFCSPA), Porto Alegre, Brazil
- Universidade Feevale, Novo Hamburgo, RS, Brazil
| | - Eduardo Samo Gudo
- Instituto Nacional de Saúde, Ministério da Saúde, Maputo, Mozambique
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Subedi N, Bhattarai S, Mremi A, Ntakirutimana G, Ndayisaba MC, Rugwizangoga B, Mbarushimana D, Hategekimana E, Tuyizere V, Paganelli C. Building Capacity and Infrastructure at Hospitals Implementing Minimally Invasive Tissue Sampling: Experience and Lessons Learned From Nepal, Rwanda, and Tanzania. Clin Infect Dis 2021; 73:S396-S400. [PMID: 34910170 PMCID: PMC8672746 DOI: 10.1093/cid/ciab780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Minimally invasive tissue sampling (MITS) is a useful tool to determine cause of death in low- and middle-income countries (LMICs). In 2019 the MITS Surveillance Alliance supported the implementation of small-scale postmortem studies using MITS in several LMICs. METHODS In this article we describe the preparations, challenges, and lessons learned as part of implementing MITS across 4 study sites in 3 countries: Nepal, Rwanda, and Tanzania. We describe the process for building capacity to conduct MITS, which consisted of training in MITS sample collection, individual site assessment to determine readiness and gaps prior to implementation, site visits as sites began implementation of MITS, and feedback based on remote evaluation of histology slides via an online portal. RESULTS The 4 study sites each conducted 100 MITS, for a total of 400. All 4 sites lacked sufficient infrastructure and facilities to conduct MITS, and upgrades were required. Common challenges faced by sites included that clinical autopsies were neither routinely conducted nor widely accepted. Limited clinical records made cause of death determination more difficult. Lessons learned included the importance of sensitization of the community and medical staff to MITS to enhance understanding and increase consent. CONCLUSIONS The study sites accomplished MITS and utilized the available support systems to overcome the challenges. The quality of the procedures was satisfactory and was facilitated through the organized capacity-building programs.
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Affiliation(s)
- Nuwadatta Subedi
- Gandaki Medical College Teaching Hospital and Research Center, Gandaki Province, Pokhara, Nepal
| | - Suraj Bhattarai
- Gandaki Medical College Teaching Hospital and Research Center, Gandaki Province, Pokhara, Nepal
- Global Institute for Interdisciplinary Studies, Kathmandu, Nepal
| | - Alex Mremi
- Department of Pathology, Kilimanjaro Christian Medical Centre and Kilimanjaro Christian Medical University College, Moshi, Tanzania
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8
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Bhattarai S, Sharma BK, Subedi N, Ranabhat S, Baral MP. Burden of Serious Bacterial Infections and Multidrug-Resistant Organisms in an Adult Population of Nepal: A Comparative Analysis of Minimally Invasive Tissue Sampling Informed Mortality Surveillance of Community and Hospital Deaths. Clin Infect Dis 2021; 73:S415-S421. [PMID: 34910184 PMCID: PMC8672751 DOI: 10.1093/cid/ciab773] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Bacterial diseases are the leading cause of mortality globally, and due to haphazard use of antibiotics, antimicrobial resistance has become an emerging threat. METHODS This cross-sectional observational study utilized a minimally invasive tissue sampling procedure to determine the cause of death among an adult population. Bacterial cultures (blood, cerebrospinal fluid, lung tissue) and antibiotic susceptibility were evaluated, and the results were compared between community and hospital deaths. RESULTS Of 100 deceased persons studied, 76 (76%) deaths occurred in the community and 24 (24%) in the hospital. At least 1 bacterial agent was cultured from 86 (86%) cases; of these, 74 (86%) had a bacterial disease attributed as the primary cause of death, with pneumonia (35, 47.3%), sepsis (33, 44.6%), and meningitis (3, 4.1%) most common. Of 154 bacterial isolates (76.6% from the community and 23.4% from the hospital) detected from 86 culture-positive cases, 26 (16.8%) were multidrug-resistant (MDR). Klebsiella species were the most common (13 of 26) MDR organisms. The odds of getting an MDR Klebsiella infection was 6-fold higher among hospital deaths compared with community deaths (95% confidence interval [CI], 1.37-26.40; P = .017) and almost 23-fold higher (CI, 2.45-213.54; P = .006) among cases with prior antibiotic use compared to those without. CONCLUSIONS High incidence of serious bacterial infections causing death of adults in the community, with most MDR organisms isolated from hospitalized cases, calls for robust surveillance mechanisms and infection prevention activities at the community level and evidence-driven antibiotic stewardship in healthcare settings.
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Affiliation(s)
- Suraj Bhattarai
- DECODE-MAUN Research Project, GMCTHRC, Pokhara, Nepal.,Department of Global Health, Global Institute for Interdisciplinary Studies, Kathmandu, Nepal
| | - Binita Koirala Sharma
- DECODE-MAUN Research Project, GMCTHRC, Pokhara, Nepal.,Department of Microbiology, GMCTHRC, Pokhara, Nepal.,Department of Microbiology, Tribhuvan University Prithvi Narayan Campus, Pokhara, Nepal
| | - Nuwadatta Subedi
- DECODE-MAUN Research Project, GMCTHRC, Pokhara, Nepal.,Department of Forensic Medicine, GMCTHRC, Pokhara, Nepal
| | - Sunita Ranabhat
- DECODE-MAUN Research Project, GMCTHRC, Pokhara, Nepal.,Department of Pathology, GMCTHRC, Pokhara, Nepal
| | - Madan Prasad Baral
- DECODE-MAUN Research Project, GMCTHRC, Pokhara, Nepal.,Department of Forensic Medicine, Pokhara Academy of Health Sciences, Western Regional Hospital, Pokhara, Nepal
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9
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Rakislova N, Jordao D, Ismail MR, Mayor A, Cisteró P, Marimon L, Ferrando M, Hurtado JC, Lovane L, Carrilho C, Lorenzoni C, Fernandes F, Nhampossa T, Cossa A, Mandomando I, Navarro M, Casas I, Munguambe K, Maixenchs M, Quintó L, Macete E, Martinez M, Snow RW, Bassat Q, Menéndez C, Ordi J. Accuracy of verbal autopsy, clinical data and minimally invasive autopsy in the evaluation of malaria-specific mortality: an observational study. BMJ Glob Health 2021; 6:bmjgh-2021-005218. [PMID: 34083241 PMCID: PMC8183227 DOI: 10.1136/bmjgh-2021-005218] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 05/12/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Global malaria mortality estimates are hindered by the low reliability of the verbal autopsy (VA) and the clinical records, the most common sources of information used to estimate malaria-specific mortality. We aimed to determine the accuracy of these tools, as well as of the minimally invasive autopsy (MIA), a needle-based postmortem sampling method, to identify malaria-specific mortality in a large series of deceased patients from Mozambique, using complete autopsy as the gold standard. METHODS Observational study that included 264 deaths, occurring at a tertiary level hospital in Mozambique, from 1 November 2013 to 31 March 2015 (17 months-long period). Clinical data were abstracted, a computer coded VA was completed using the clinical data as source of information, and an MIA followed by a complete autopsy were performed. Screening for malaria infection was conducted postmortem to all participants using molecular and histological techniques (PCR and immunohistochemistry). FINDINGS Malaria infection was considered the cause of death in 6/264 (2.3%) cases: 2/54 children (3.7%, both less than 5 years old) and 4/57 (7.0%) maternal deaths. The sensitivity and specificity of the VA, the clinical data and the MIA to identify malaria-specific deaths were 33.3% and 96.1%, 66.7% and 96.1%, and 100% and 100%, respectively. In addition, malaria was identified as a possible contributor in 14 additional patients who died of other diseases. These cases were also accurately identified by the MIA (sensitivity 82.4%, specificity 100%). INTERPRETATION The high sensitivity and specificity of the MIA in identifying malaria may help to improve current estimates of malaria-specific mortality in endemic areas.
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Affiliation(s)
- Natalia Rakislova
- ISGLOBAL, Hospital Clinic, University of Barcelona, Barcelona, Spain.,Department of Pathology, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Dercio Jordao
- Department of Pathology, Quelimane Central Hospital, Quelimane, Mozambique
| | - Mamudo R Ismail
- Department of Pathology, Maputo Central Hospital, Maputo, Mozambique.,Faculty of Medicine, University Eduardo Mondlane, Maputo, Mozambique
| | - Alfredo Mayor
- ISGLOBAL, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Pau Cisteró
- ISGLOBAL, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Lorena Marimon
- ISGLOBAL, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Melania Ferrando
- ISGLOBAL, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Juan Carlos Hurtado
- ISGLOBAL, Hospital Clinic, University of Barcelona, Barcelona, Spain.,Department of Microbiology, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Lucilia Lovane
- Department of Pathology, Maputo Central Hospital, Maputo, Mozambique
| | - Carla Carrilho
- Department of Pathology, Maputo Central Hospital, Maputo, Mozambique.,Faculty of Medicine, University Eduardo Mondlane, Maputo, Mozambique
| | | | - Fabiola Fernandes
- Department of Pathology, Maputo Central Hospital, Maputo, Mozambique
| | - Tacilta Nhampossa
- Centro de Investigação em Saúde de Manhiça, Manhica, Mozambique.,Department of Pediatrics, Maputo Central Hospital, Maputo, Mozambique
| | - Anelsio Cossa
- Centro de Investigação em Saúde de Manhiça, Manhica, Mozambique
| | | | - Mireia Navarro
- ISGLOBAL, Hospital Clinic, University of Barcelona, Barcelona, Spain.,Department of Microbiology, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Isaac Casas
- ISGLOBAL, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Khatia Munguambe
- Faculty of Medicine, University Eduardo Mondlane, Maputo, Mozambique.,Centro de Investigação em Saúde de Manhiça, Manhica, Mozambique
| | - Maria Maixenchs
- ISGLOBAL, Hospital Clinic, University of Barcelona, Barcelona, Spain.,Centro de Investigação em Saúde de Manhiça, Manhica, Mozambique
| | - Llorenç Quintó
- ISGLOBAL, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Eusebio Macete
- Centro de Investigação em Saúde de Manhiça, Manhica, Mozambique
| | - Mikel Martinez
- ISGLOBAL, Hospital Clinic, University of Barcelona, Barcelona, Spain.,Department of Microbiology, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Robert W Snow
- Population and Health Unit, KEMRI - Wellcome Trust Research Programme, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, Nuttfield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Quique Bassat
- ISGLOBAL, Hospital Clinic, University of Barcelona, Barcelona, Spain.,Centro de Investigação em Saúde de Manhiça, Manhica, Mozambique
| | - Clara Menéndez
- ISGLOBAL, Hospital Clinic, University of Barcelona, Barcelona, Spain.,Centro de Investigação em Saúde de Manhiça, Manhica, Mozambique.,Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Jaume Ordi
- ISGLOBAL, Hospital Clinic, University of Barcelona, Barcelona, Spain .,Department of Pathology, Hospital Clínic, University of Barcelona, Barcelona, Spain
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10
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Rusu S, Lavis P, Domingues Salgado V, Van Craynest MP, Creteur J, Salmon I, Brasseur A, Remmelink M. Comparison of antemortem clinical diagnosis and post-mortem findings in intensive care unit patients. Virchows Arch 2021; 479:385-392. [PMID: 33580806 PMCID: PMC8364530 DOI: 10.1007/s00428-020-03016-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/24/2020] [Accepted: 12/30/2020] [Indexed: 12/25/2022]
Abstract
Autopsy is an important quality assurance indicator and a tool to advance medical knowledge. This study aims to compare the premortem clinical and postmortem pathology findings in patients who died in the Intensive Care Unit (ICU), to analyze if there are any discrepancies between them, and to compare the results to two similar studies performed in our institution in 2004 and 2007. Between January 1, 2016, and December 31, 2018, 888 patients died in the ICU and 473 underwent post-mortem examination (PME) of whom 437 were included in the present study. Autopsies revealed discrepancies between clinical diagnosis and pathologic findings according to in 101 cases (23.1%) according to Goldman classification. Forty-eight major discrepancies (class I and class II) were identified in 44 cases and the most frequent identified discrepancies were pulmonary embolism (3/12) as class I and malignancies (13/35) as class II. They were more frequent in patients hospitalized for less than 10 days then in the group with more than 10 days of hospitalization (13.8% vs 4.5%; p = 0.002). No statistical difference has been noticed concerning age, gender, and ICU stay. We observed an increase of performed autopsies and a total discrepancy rate similar to the studies performed in the same institution in 2004 (22.5%) and 2007 (21%). In conclusion, discrepancies between clinical and PME diagnoses persist despite the medical progress. Secondly, the autopsy after a short hospital stay may reveal unexpected findings whose diagnosis is challenging even if it may be suspected by the intensivist.
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Affiliation(s)
- Stefan Rusu
- Hôpital Erasme, Department of Pathology, Université Libre de Bruxelles, Brussels, Belgium
| | - Philomène Lavis
- Hôpital Erasme, Department of Pathology, Université Libre de Bruxelles, Brussels, Belgium
| | | | | | - Jacques Creteur
- Hôpital Erasme, Department of Intensive Care, Université Libre de Bruxelles, Brussels, Belgium
| | - Isabelle Salmon
- Hôpital Erasme, Department of Pathology, Université Libre de Bruxelles, Brussels, Belgium.,Centre Universitaire Inter Regional d'Expertise en Anatomie Pathologique Hospitalière (CurePath), Charleroi (Jumet), Belgium.,DIAPath - Center for Microscopy and Molecular Imaging, Université Libre de Bruxelles, Gosselies, Belgium
| | - Alexandre Brasseur
- Hôpital Erasme, Department of Intensive Care, Université Libre de Bruxelles, Brussels, Belgium
| | - Myriam Remmelink
- Hôpital Erasme, Department of Pathology, Université Libre de Bruxelles, Brussels, Belgium. .,Centre Universitaire Inter Regional d'Expertise en Anatomie Pathologique Hospitalière (CurePath), Charleroi (Jumet), Belgium.
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11
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Manuel L, Santos-Gomes G, Noormahomed EV. Human toxoplasmosis in Mozambique: gaps in knowledge and research opportunities. Parasit Vectors 2020; 13:571. [PMID: 33176884 PMCID: PMC7659051 DOI: 10.1186/s13071-020-04441-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/30/2020] [Indexed: 01/01/2023] Open
Abstract
Toxoplasmosis is a parasitic zoonotic disease caused by Toxoplasma gondii that afflicts humans worldwide and wild and domestic warm-blooded animals. In immunocompetent individuals, the acute phase of infection presents transient low or mild symptoms that remain unnoticed. In immunocompromised patients, T. gondii is a life-threatening opportunistic infection, which can result from the reactivation of latent infection or primary infection. Moreover, congenital toxoplasmosis, which results from the transplacental passage of tachyzoites into the fetus during a pregnant primary infection, can lead to miscarriage, stillbirth, or ocular and neurologic disease, and neurocognitive deficits in the newborns. Thus, the present review aims to address the current knowledge of T. gondii infection and toxoplasmosis in Africa and especially in Mozambique, stressing the importance of identifying risk factors and promote awareness among the health care providers and population, assessing the gaps in knowledge and define research priorities. In Mozambique, and in general in southern African countries, clinical disease and epidemiological data have not yet been entirely addressed in addition to the implications of T. gondii infection in immunocompetent individuals, in pregnant women, and its relation with neuropsychiatric disorders. The main gaps in knowledge in Mozambique include lack of awareness of the disease, lack of diagnostic methods in health facilities, lack of genetic data, and lack of control strategies.![]()
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Affiliation(s)
- Leonardo Manuel
- Faculty of Health Sciences, Universidade Lurio, Nampula, Mozambique
| | - Gabriela Santos-Gomes
- Global Health and Tropical Medicine (GHTM), Instituto de Higiene e Medicina Tropical (IHMT), Universidade Nova de Lisboa (UNL), Lisbon, Portugal
| | - Emilia V Noormahomed
- Department of Microbiology, Faculty of Medicine, Universidade Eduardo Mondlane (UEM), Maputo, Mozambique. .,Department of Medicine, Infectious Disease Division, University of California, San Diego, USA. .,Mozambique Institute for Health Education and Research (MIHER), Maputo, Mozambique.
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12
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García JI, Mambuque E, Nguenha D, Vilanculo F, Sacoor C, Sequera VG, Fernández-Quevedo M, Pierre MLL, Chiconela H, Faife LA, Respeito D, Saavedra B, Nhampossa T, López-Varela E, Garcia-Basteiro AL. Mortality and risk of tuberculosis among people living with HIV in whom TB was initially ruled out. Sci Rep 2020; 10:15442. [PMID: 32963296 PMCID: PMC7509810 DOI: 10.1038/s41598-020-71784-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 07/31/2020] [Indexed: 12/12/2022] Open
Abstract
Tuberculosis (TB) misdiagnosis remains a public health concern, especially among people living with HIV (PLHIV), given the high mortality associated with missed TB diagnoses. The main objective of this study was to describe the all-cause mortality, TB incidence rates and their associated risk factors in a cohort of PLHIV with presumptive TB in whom TB was initially ruled out. We retrospectively followed a cohort of PLHIV with presumptive TB over a 2 year-period in a rural district in Southern Mozambique. During the study period 382 PLHIV were followed-up. Mortality rate was 6.8/100 person-years (PYs) (95% CI 5.2-9.2) and TB incidence rate was 5.4/100 PYs (95% CI 3.9-7.5). Thirty-six percent of deaths and 43% of TB incident cases occurred in the first 12 months of the follow up. Mortality and TB incidence rates in the 2-year period after TB was initially ruled out was very high. The TB diagnostic work-up and linkage to HIV care should be strengthened to decrease TB burden and all-cause mortality among PLHIV with presumptive TB.
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Affiliation(s)
- Juan Ignacio García
- TB Group, Population Health Program, Texas Biomedical Research Institute, San Antonio, TX, USA
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Edson Mambuque
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
| | - Dinis Nguenha
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
| | | | - Charfudin Sacoor
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
| | | | | | | | - Helio Chiconela
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
- Manhiça District Hospital, Ministry of Health, National Tuberculosis Control Program, Maputo, Mozambique
| | - Luis A Faife
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
- Manhiça District Hospital, Ministry of Health, National Tuberculosis Control Program, Maputo, Mozambique
| | - Durval Respeito
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
- Manhiça District Hospital, Ministry of Health, National Tuberculosis Control Program, Maputo, Mozambique
| | - Belén Saavedra
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Tacilta Nhampossa
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
- Instituto Nacional de Saúde, Ministério de Saúde, Maputo, Mozambique
| | - Elisa López-Varela
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Desmond Tutu TB center, Stellenbosch University, Cape Town, South Africa
| | - Alberto L Garcia-Basteiro
- Centro de Investigação em Saude de Manhiça (CISM), Maputo, Mozambique.
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.
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13
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Bhargava A, Bhargava M. Tuberculosis deaths are predictable and preventable: Comprehensive assessment and clinical care is the key. J Clin Tuberc Other Mycobact Dis 2020; 19:100155. [PMID: 32211519 PMCID: PMC7082610 DOI: 10.1016/j.jctube.2020.100155] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The goal of reducing tuberculosis (TB) mortality in the END TB Strategy can be achieved if TB deaths are considered predictable and preventable. This will require programs to examine and address some key gaps in the understanding of the distribution and determinants of TB mortality and the current model of assessment and care in high burden countries. Most deaths in high-burden countries occur in the first eight weeks of treatment and in those belonging to the age group of 15–49 years, living in poverty, with HIV infection and/or low body mass index (BMI). Deaths result from extensive disease, comorbidities like advanced HIV disease complicated with other infections (bacterial, fungal, bloodstream), and moderate-severe undernutrition. Most early deaths in patients with TB, even with TB-HIV co-infection, are due to TB itself. Comprehensive assessment and clinical care are a prerequisite of patient-centered care. Simple independent predictors of death like unstable vital signs, BMI, mid-upper arm circumference, or inability to stand or walk unaided can be used by programs for risk assessment. Programs need to define criteria for referral for inpatient care, address the paucity of hospital beds and develop and implement guidelines for the clinical management of seriously ill patients with TB, advanced HIV disease and severe undernutrition as co-morbidities. Programs should also consider notification and audit of all TB deaths, similar to audit of maternal deaths, and address the issues in delays in diagnosis, treatment, and quality of care.
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Affiliation(s)
- Anurag Bhargava
- Department of Medicine, Yenepoya Medical College, University Road, Deralakatte, Mangalore, 575018, India.,Department of Medicine, McGill University, 1001 Decarie Boulevard, suite D05-2212, Mail Drop Number: D05-2214, Montreal, H4A 3J1, Canada.,Center for Nutrition Studies, Yenepoya (Deemed to be University), University Road, Deralakatte, Mangalore. 575018, India
| | - Madhavi Bhargava
- Department of Community Medicine, Yenepoya Medical College, University Road, Deralakatte, Mangalore. 575018, India.,Center for Nutrition Studies, Yenepoya (Deemed to be University), University Road, Deralakatte, Mangalore. 575018, India
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14
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Bomanji J, Sharma R, Mittal BR, Gambhir S, Qureshy A, Begum SM, Paez D, Sathekge M, Vorster M, Sobic Saranovic D, Pusuwan P, Mann V, Vinjamuri S, Zumla A, Pascual TN. PET/CT features of extrapulmonary tuberculosis at first clinical presentation: a cross-sectional observational 18F-FDG imaging study across six countries. Eur Respir J 2019; 55:13993003.01959-2019. [DOI: 10.1183/13993003.01959-2019] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 11/11/2019] [Indexed: 12/17/2022]
Abstract
BackgroundA large proportion of the huge global burden of extrapulmonary tuberculosis (EPTB) cases are treated empirically without accurate definition of disease sites and extent of multi-organ disease involvement. Positron emission tomography (PET) imaging using 2-deoxy-2-(fluorine-18) fluoro-d-glucose (18F-FDG) in tuberculosis could be a useful imaging technique for localising disease sites and extent of disease.MethodsWe conducted a study of HIV-negative adult patients with a new clinical diagnosis of EPTB across eight centres located in six countries: India, Pakistan, Thailand, South Africa, Serbia and Bangladesh, to assess the extent of disease and common sites involved at first presentation. 18F-FDG PET/computed tomography (CT) scans were performed within 2 weeks of presentation.Findings358 patients with EPTB (189 females; 169 males) were recruited over 45 months, with an age range of 18–83 years (females median 30 years; males median 38 years). 350 (98%) out of 358 patients (183 female, 167 male) had positive scans. 118 (33.7%) out of 350 had a single extrapulmonary site and 232 (66.3%) out of 350 had more than one site (organ) affected. Lymph nodes, skeleton, pleura and brain were common sites. 100 (28%) out of 358 EPTB patients had 18F-FDG PET/CT-positive sites in the lung. 110 patients were 18F-FDG PET/CT-positive in more body sites than were noted clinically at first presentation and 160 patients had the same number of positive body sites.Interpretation18F-FDG PET/CT scan has potential for further elucidating the spectrum of disease, pathogenesis of EPTB and monitoring the effects of treatment on active lesions over time, and requires longitudinal cohort studies, twinned with biopsy and molecular studies.
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