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causes such as drug overdose, suicide, and violence.[1105] The mode or manner in which HIV
was acquired is of particular importance. Always investigate for risk factors for HIV infection
along with information obtained from scene investigation and postmortem examination of tissues
and fluids.[1092]
Deaths of HIV-infected persons who have not developed the clinical syndromes of HIV
infection and AIDS by definitional criteria are usually due to causes other than HIV. HIV-
infected persons with a CD4 lymphocyte count >200/µL, or those with stages A and B of HIV-
infection, are generally not at increased risk for death from HIV. As a rule, HIV infection should
lead to clinically apparent consequences of immune deficiency meeting diagnostic criteria for
AIDS in order to cause death.
The proximate causes of death in 565 cases with AIDS in a large autopsy series of
patients dying prior to widespread use of antiretroviral therapy are given in Table 10. Over half
of these deaths were due to pneumonia, either from Pneumocystis jiroveci (carinii) pneumonia,
cytomegalovirus pneumonia, or bacterial bronchopneumonias. Cryptococcus neoformans,
Kaposi's sarcoma, and malignant lymphomas also frequently involved the lungs.
The leading causes of death in persons with AIDS in a series from New York for the
years 1999-2004 were non-HIV related in a fourth of cases, mainly substance abuse-related,
cardiovascular, and cancer. Of HIV-related causes, 41.4% were due to infection and 6.8% were
due to AIDS-defining neoplasms. Of HIV-related infections causing death, 23.8% were due to
bacteria and 12% were due to Pneumocystis pneumonia.[1106]
A study of HIV-infected persons living in Europe, Israel, and Argentina tracked deaths
occurring from 2001 to 2009 and found that there was a 4-fold increase in risk for death
following an AIDS-defining event, but the risk was 7-fold following a non-AIDS event such as
malignancies, cardiovascular disease, and renal disease. a doubling of the CD4 count was
associated with a 37% reduction in the incidence of AIDS events. For non-AIDS events, a liver-
related event such as hepatitis B or C viral infection was associated with the worst prognosis,
over a 22-fold increased risk of death. Development of anemia was a very strong risk factor for
both AIDS and non-AIDS events.[1107]
st
Continuing into the 21 century, as over the past 500 years, autopsy remains a useful tool
for quality assurance, identifying the true prevalence of disease, and for research. A study of
HIV-infected persons at autopsy showed that the findings from autopsy altered the primary
diagnosis in 70% of cases, and that 36% of opportunistic infections were not diagnosed prior to
death. Both false positive as well as false negative premortem diagnoses occurred despite
sophisticated diagnostic techniques. Infections most likely to be missed prior to death were
cytomegalovirus and tuberculosis.[1108]
The single most important organ to examine at autopsy is lung, and the commonest
mechanism of death in AIDS is respiratory failure (in two thirds of cases). Central nervous
system lesions lead to death in one fifth of AIDS patients, so it is important to remove and
examine the brain at autopsy. Gastrointestinal diseases lead to death in one seventh of cases.
Over 90% of the immediate causes of death in AIDS can be determined from histological
examination alone.[417]
The differentiation of natural versus accidental mode of death with HIV infection and
AIDS is made primarily by risk factors. If HIV was a sexually transmitted disease, including
perinatal deaths in which the mother acquired HIV sexually, then the mode is natural.
Identification of intravenous narcotism as the source of HIV infection establishes an accidental
mode of death. If transmission occurred from administration of blood or blood products in the