Clinico-pathological discrepancies in the diagnosis of causes of death in adults in Mozambique: A retrospective observational study

PLoS One. 2019 Sep 6;14(9):e0220657. doi: 10.1371/journal.pone.0220657. eCollection 2019.

Abstract

Background: Clinico-pathological discrepancies are more frequent in settings in which limited diagnostic techniques are available, but there is little information on their actual impact.

Aim: We assessed the accuracy of the clinical diagnoses in a tertiary referral hospital in sub-Saharan Africa by comparison with post-mortem findings. We also identified potential risk factors for misdiagnoses.

Methods: One hundred and twelve complete autopsy procedures were performed at the Maputo Central Hospital (Mozambique), from November 2013 to March 2015. We reviewed the clinical records. Major clinico-pathological discrepancies were assessed using a modified version of the Goldman and Battle classification.

Results: Major diagnostic discrepancies were detected in 65/112 cases (58%) and were particularly frequent in infection-related deaths (56/80 [70%] major discrepancies). The sensitivity of the clinical diagnosis for toxoplasmosis was 0% (95% CI: 0-37), 18% (95% CI: 2-52) for invasive fungal infections, 25% (95% CI: 5-57) for bacterial sepsis, 34% (95% CI: 16-57), for tuberculosis, and 46% (95% CI: 19-75) for bacterial pneumonia. Major discrepancies were more frequent in HIV-positive than in HIV-negative patients (48/73 [66%] vs. 17/39 [44%]; p = 0.0236).

Conclusions: Major clinico-pathological discrepancies are still frequent in resource constrained settings. Increasing the level of suspicion for infectious diseases and expanding the availability of diagnostic tests could significantly improve the recognition of common life-threatening infections, and thereby reduce the mortality associated with these diseases. The high frequency of clinico-pathological discrepancies questions the validity of mortality reports based on clinical data or verbal autopsy.

Publication types

  • Observational Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Cause of Death*
  • Communicable Diseases / diagnosis*
  • Communicable Diseases / mortality
  • Diagnostic Errors / statistics & numerical data*
  • Female
  • Humans
  • Male
  • Middle Aged
  • Mozambique
  • Tertiary Care Centers / statistics & numerical data

Grants and funding

The CaDMIA research project (Validation of the minimally invasive autopsy tool for cause of death investigation in developing countries) was funded by the Bill & Melinda Gates Foundation (Global Health grant numbers OPP1067522; QB) (http://www.gatesfoundation.org/) and by the Spanish Instituto de Salud Carlos III (FIS, PI12/00757; CM) (https://portalfis.isciii.es). Data analysis has been supported by the CaDMIA plus research project, funded by the Bill & Melinda Gates Foundation (Global health grant numbers OPP1128001; JO) (http://www.gatesfoundation.org/) and the Spanish Instituto de Salud Carlos III (Acciones CIBER; CM) (http://www.ciberisciii.es/). ISGlobal is included in the CERCA Programme / Generalitat de Catalunya (http://cerca.cat/en/suma/). CISM is supported by the Government of Mozambique and the Spanish Agency for International Development (AECID). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.