clinico-pathological discrepancies in the diagnosis of ... · - 1 - clinico-pathological...

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Clinico-pathological discrepancies

in the diagnosis of causes of death

in adults in Mozambique

Natalia Rakislova

Departments of Pathology, Hospital Clínic and IsGlobal,

Barcelona

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Background

Complete Diagnostic Autopsy:

Determination of cause of death (gold standard

diagnosis)

Tool for clinical quality control to analyze diagnostic

discrepanies

Observation of disease and treatment effects

Training residents and physicians

Information & closure for families

Tissue banking/research

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Background

Complete Diagnostic Autopsy:

Determination of cause of death (gold standard

diagnosis)

Tool for clinical quality control to analyze diagnostic

discrepanies

Observation of disease and treatment effects

Training residents and physicians

Information & closure for families

Tissue banking/research

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Background

• Medical errors persist over time despite all the progress..

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Background

• Medical errors persist over time despite all the progress..

• Hospitals with limited resources: medical errors are likely to

be more frequent

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Background

• Medical errors persist over time despite all the progress..

• Hospitals with limited resources and diagnostic tools:

clinical errors are likely to be more frequent

• Very few studies on clinico-pathological discrepancies at

these settings

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Aims

1. Analyze the concordance clinical vs autopsy main

diagnosis in a tertiary hospital in sub-Saharan Africa

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Aims

1. Analyze the concordance clinical vs autopsy main

diagnosis in a tertiary hospital in sub-Saharan Africa:

Complete Diagnostic Autopsy: Gold Standard Diagnosis

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Aims

1. Analyze clinical vs autopsy diagnoses concordance in a

tertiary hospital in sub-Saharan Africa:

Complete Diagnostic Autopsy: Gold Standard Diagnosis

Major discrepancies

(clinically missed diagnosis involving primary cause of

death)

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Aims

1. Analyze the accuracy of Clinical main diagnoses in a

tertiary hospital in sub-Saharan Africa:

Complete Diagnostic Autopsy: Gold Standard Diagnosis

Major discrepancies

(missed diagnosis involving primary cause of death)

2. Identify potential risk factors for Major discrepancies

Risk Factors vs Major error

Demographics Clinical signs Symptoms Analytics Other

age at death dehydration fever hemoglobin alcoholism

sex (M vs F ) hepatomegaly, splenomegaly cough leucocytes smoking

time admission-

death

pallor, jaundice, petechia,

exantema

headache GGT, GPT

nutritional

status

ethnic group oliguria, dysuria, hematuria abdominal pain diabetes

origin (urban vs

rural)

edema dyspnea hypertension

coma diarrhea antiretrovirals

axillar t vomit HIV status

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Study design

A series of 112 autopsies*:

Maputo Central Hospital, Mozambique

Nov 2013-March 2015

Clinical records

Autopsy findings

>15 years

57 males/55 females

median age: 37 years (range 15-76)

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Study design

Inclusion criteria:

autopsy requested by clinician

autopsy consented by relatives

Exclusion criteria:

maternal deaths

traumatic deaths

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Autopsy procedure

Histology/Microbiology:

Liver, lungs, CNS, kidneys, spleen, intestine, bone marrow, any

grossly visible lesions

Microbiology:

Blood

Cerebrospinal fluid

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Histology

H&E all the samples

Special and/or IHC stains if suspicion

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Microbiology analysis

All the samples:

PCR for Plasmodium falciparum

(HIV)-1/2 antibodies; viral load

HIV+ cases:

real time PCR in CSF, Brain and Lung: Toxoplasma gondii,

Mycobarcterium tuberculosis, Cryptococcus spp

real time PCR in Lung: Pneumocystis jirovecii

Blood and CSF:

bacterial/fungal culture

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Autopsy results

Gross examination

Histological report

Microbiological results

Clinical records

ICD-10

Final cause of death

Clinical error analysis

Autopsy: final cause of death

n=112

Autopsy: final cause of death

n=112

Clinical diagnosis accuracy

n=112

Clinical vs Autopsy diagnosis

n=112

Clinical diagnostic errors

56% of all the cases

Clinical diagnostic errors

Knowledge of correct diagnosis before death would

have led to survival or cure!

56% (n=63) of all the cases

Diagnostic category vs Major

error

Type of error

No- or

minor

Major error Odds ratio p

Cause of death

Infectious

Malignant tumors

Other diseases

24 (51%)

11 (23%)

12 (26%)

56 (86%)

5 (8%)

4 (6%)

1

0.21 (0.07, 0.64)

0.16 (0.05, 0.51)

0.0007

n=112

Diagnostic category vs Major

error

Type of error

No- or

minor

Major error Odds ratio p

Cause of death

Infectious

Malignant tumors

Other diseases

24 (51%)

11 (23%)

12 (26%)

56 (86%)

5 (8%)

4 (6%)

1

0.21 (0.07, 0.64)

0.16 (0.05, 0.51)

0.0007

n=112

Major discrepancy in 56/80 (70%) of infection-related cause of death

Clinico-pathological discrepanciesInfections

Cause of death

Autopsy

diagnosis

Clinical error (Major

error)

n n %

Tuberculosis 23 15 65%

Bacterial pneumonia 13 7 54%

Sepsis 12 9 75%

Invasive fungal infections 11 9 82%

Toxoplasmosis 8 8 100%

Bacterial meningitis 4 3 75%

Viral pneumonia 2 2 100%

Viral meningoencephalitis 3 2 67%

Cause of death Autopsy diagnosis Clinical error (Major error)

n n %

Tuberculosis 23 15 65%

Bacterial pneumonia 13 7 54%

Sepsis 12 9 75%

Invasive fungal infections 11 9 82%

Toxoplasmosis 8 8 100%

Bacterial meningitis 4 3 75%

Viral pneumonia 2 2 100%

Viral meningoencephalitis 3 2 67%

Clinico-pathological discrepanciesInfections

Cause of death Autopsy diagnosis Missed diagnosis (Major error)

n n %

Tuberculosis 23 15 65%

Bacterial pneumonia 13 7 54%

Sepsis 12 9 75%

Invasive fungal infections 11 9 82%

Toxoplasmosis 8 8 100%

Bacterial meningitis 4 3 75%

Viral pneumonia 2 2 100%

Viral meningoencephalitis 3 2 67%

Clinico-pathological discrepanciesInfections

Cause of death

Autopsy

diagnosis

Missed diagnosis (Major

error)

n n %

Tuberculosis 23 15 65%

Bacterial pneumonia 13 7 54%

Sepsis 12 9 75%

Invasive fungal infections 11 9 82%

Toxoplasmosis 8 8 100%

Bacterial meningitis 4 3 75%

Viral pneumonia 2 2 100%

Clinico-pathological discrepanciesInfections

Autopsy diagnosis Primary clinical diagnoses (n)

Meningoencephalitis (4)Tuberculosis Hypertensive encephalopathy (1)

Cryptococcal meningitis (1)Bacterial pneumonia (2)

Pulmonary pneumocystosis (1)Gastroenteritis (1)Severe anemia (1)

Renal failure (1)

Abdominal tumor (1)Pericarditis (1)

Invasive fungal infection Meningoencephalitis (4)Cerebral malaria (1)

Hypertensive encephalitis (1)Sepsis (1)

Gastroenteritis (1)Appendicitis (1)

Toxoplasmosis Meningoencephalitis (4)Cryptococcus meningitis (2)Pulmonary pneumocystis (1)

Hemorrhagic stroke (1)

Sepsis Meningoencephalitis (3)Severe anemia (2)

Stevens Johnson syndrome (1)Uremic coma (1)Gastroenteritis (1)

Malignant tumor (1)

Bacterial pneumonia Meningoencephalitis (2)Renal failure (1)

Submandibular abscess (1)

Severe anemia (1)AIDS (1)

Disseminated Kaposi’s sarcoma (1)

Cause of death AutopsyMissed diagnosis

(Major error)

n n %

Liver carcinoma 5 0 0%

Cervical

carcinoma3 0 0%

Lymhoma 3 1 33%

Kaposi sarcoma 2 1 50%

Myeloid leukemia 11 100%

Brain tumor 1 1 100%

Undifferentiated

tumor1 1 100%

Clinico-pathological discrepanciesMalignant tumors and other diseases

5/16 (30%) missed dx

Cause of death Autopsy Missed diagnosis

(Major error)

n n %

Cardiovascular

disease11 1 9%

Renal disease 1 1 100%

Pulmonary

disease2 1 33%

Gastrointestinal

disease2 1 50%

Demographics Clinical signs Symptoms Analytics Other

age at death dehydration fever hemoglobin alcoholism

sex (M vs F ) hepatomegaly, splenomegaly cough leucocytes smoking

time admission-

death

pallor, jaundice, petechia,

exantema

headache* GGT, GPT

nutritional

status

ethnic group oliguria, dysuria, hematuria abdominal pain diabetes

origin (urban vs

rural)

edema dyspnea hypertension

coma diarrhea antiretrovirals*

axillar t vomit HIV status*

Major error vs risk factors

* p<0.05

Conclusions

• Major clinico-pathological dicrepancies have a

significant impact on mortality in health facilities in sub-

Saharan Africa

• The high frequency of major clinico-pathological

dicrepancies infectious diseases

• The validity of mortality reports based on clinical data and

verbal autopsies?

• Next Steps:

Increasing clinical awareness of the impact of infectious

diseases

Introduction of easy-to-perform tests for most common

and life-threatening infections

Thank you for your attention