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.