Page 279 - AIDSBK23C

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CHAPTER 7 - MEDICOLEGAL ISSUES AND AIDS

DEATH INVESTIGATION AND CERTIFICATION IN AIDS

The medical examiner-coroner may need to conduct a comprehensive investigation,
including an autopsy, in some deaths of HIV-infected persons. When an established diagnosis of
AIDS by definitional criteria can be documented, an autopsy with histological confirmation of
diagnosis may not always be necessary.[391,392] However, in cases in which the diagnosis is in
doubt or in which death occurred under suspicious circumstances, an autopsy should be
performed. Investigation of deaths with HIV infection from job-related or accidental parenteral
exposure to blood or blood products require an autopsy with histopathologic and/or laboratory
confirmation of findings to prepare for possible litigation by surviving family who may
challenge the medical examiner's determination of the cause and mode of death.
A thorough external examination of the body may reveal typical findings with AIDS such
as cachexia, needle tracks of intravenous narcotism, onychomycosis of nails, or skin lesions
typical of Kaposi's sarcoma. However, not all skin lesions appearing to be KS on gross
examination are confirmed by microscopy. Use routine CDC criteria for AIDS as a guide in
death investigation to search for data to confirm or exclude AIDS.[391,392] The presence of a
medical record may document specific clinical findings, laboratory testing, or tissue diagnoses.
In some states, reporting of laboratory testing for HIV may be strictly regulated, limiting
availability of medical data. In the absence of definitive documented findings in available
records, an internal examination should still be performed when doubt exists concerning either
mode or underlying cause of death.[1092]
Additional information may be obtained either from autopsy with microscopic
examination and/or postmortem microbiologic cultures of tissues or fluids or from postmortem
laboratory testing for HIV infection, or both. Postmortem testing for HIV infection can be done
on sera from blood, vitreous humor from the eye, and bile from gallbladder. Samples are stable
at room temperature for at least one month. Testing by enzyme immunoassay and Western blot
(WB) for antibodies to HIV is performed similarly to screening pre mortem samples.[1103,1104]
Viral culture of blood, fluids, or tissues for HIV is definitive for diagnosis of infection,
but is difficult to perform and has very limited availability. If specimens for enzyme
immunoassay or other serologic testing are not obtained at the time of autopsy, then HIV
detection by in situ hybridization, polymerase chain reaction, and immunohistochemical methods
can be carried out in formalin-fixed and paraffin embedded tissues--even years later.
Microbiologic culture of opportunistic infectious agents in tissues or fluids is typically available
in many laboratories for all agents except Pneumocystis jiroveci (carinii), Toxoplasma gondii,
Isospora belli, and Cryptosporidium. Most of the remaining agents require special media,
complex procedures, and several weeks' time for definitive results.[379,380,364]

DETERMINATION OF CAUSE AND MODE OF DEATH WITH HIV INFECTION

Not all deaths in which HIV is present are caused by HIV. The proportion of deaths from
AIDS-related causes has decreased when antiretroviral therapy (ART) is widely available, and
non-AIDS conditions may account for at least a third of deaths, and may include non-natural