Discussion
We have presented a case of disseminated cryptococcosis in a HIV infected female of 35 years age. Neither HIV nor cryptococcosis had been diagnosed during her lifetime. Therefore, our finding highlights the importance of performing proper laboratory and pathology investigations at the time of autopsy to determine the cause of death. In Nepal and in many low-and-middle income countries, clinical autopsies are usually not conducted, so the cause of death remains undiagnosed in many cases. Forensic autopsies are conducted only when there is an official request from the Law enforcement agencies, mostly in unnatural and sudden or suspicious deaths. Even forensic autopsies are not routinely backed up with ancillary investigations which leads to undetermined cause of deaths. In such cases, histopathological, microbiological and other relevant tests in human specimens could have contributed to establish the cause of death. From microbiological perspective, this gap in evidence indicates the need for taking proper precautions to potentially contagious infections like HIV during an autopsy and regard every case as potentially infectious unless proven otherwise. The diagnosis of HIV in the married female with two children can have significant implications to the family members, as the husband could have also contracted the disease and there could also have been vertical transmission to her children too. In this context, our team has counselled the family members to perform HIV test and seek treatment if needed according to the protocol. The condition of disseminated cryptococcosis implies that the deceased could be in immunocompromised state for a long time.
The periorbital contusions and the contusions on the thighs in the absence of any internal injuries rules out significant trauma. Gross examination during the autopsy failed to attribute the cause of death, but the ancillary investigations were useful to establish disseminated cryptococcosis as the final or direct cause of death with HIV/AIDS as underlying cause. Cryptococcus causes meningoencephalitis and disseminated cryptococcosis usually in immunocompromised hosts,4, 5 though cases of cryptococcal meningitis have also been reported in immunocompetent patients.6-8 The research on the prevalence of cryptococcosis is very sparse in literature from Nepal. In a record review of one fiscal year in the major tertiary center of Nepal, among 15 patients with Cryptococcal meningoencephalitis, the majority (9, 60%) had HIV infection.5
The involvement of cryptococcus in causing death among HIV infected patients was demonstrated in approximately 10% cases by an autopsy study in low-income settings in Mozambique.9 The pathology of cryptococcal meningoencephalitis with minimal inflammatory infiltrates and gelatinous pseudocysts produced by abundant C. neoformans was shown in most of the cases in an autopsy study in HIV-infected patients.1
There are several ways of diagnosing cryptococcosis. CSF culture is regarded as gold standard method and microscopy can be added to aid in the diagnosis. In the recent years, there has been evolution of cryptococcal antigen (CrAg) testing which has proven to be relatively inexpensive and more sensitive method. In order to facilitate easy visualization of the fungus in the specimens, stains like India ink are also used.11 The India ink staining for fungus detected cryptococcus in our case as well. The sensitivity of India ink staining to detect cryptococcus is up 80% in HIV-positive patients.12
Postmortem examination should be done meticulously, and the use of ancillary tests should be made available to attribute mortality to specific pathogens. The accurate diagnosis of cause of death is important as it informs the burden of disease in the region and supports the surveillance system of the country. Moreover, it can make a great impact to public health policies and helps in the prophylaxis and treatment modalities, particularly in infectious diseases.