Cause of death assignment using minimally invasive tissue sampling in low resource settings: a cross-sectional study from the University Teaching Hospital of Kigali, Rwanda

Background: Autopsy is a postmortem examination of the body to clarify the cause of death (CoD), and complete diagnostic autopsy (CDA) is considered the gold standard. However, CDA is rarely performed in low-resource settings. Minimally invasive tissue sampling (MITS) involves the systematic collection of needle biopsies for laboratory investigations to determine the cause of death. MITS is among the possible alternative methods to CDA. We aimed to assess the usefulness of MITS in the cause of death assignment at the University Teaching Hospital of Kigali (CHUK). Methods: This was a cross-sectional study at CHUK, Rwanda. MITS included brain, lung and liver core needle tissue biopsies; nasopharyngeal (NP) and rectal swabs; and blood and CSF collection. Ascites and pus were also collected from applicable cases. Histopathology evaluation was performed on brain, lung and liver biopsies. Microbiological culture was performed on the brain, lungs, liver, CSF, blood, NP and rectal swabs, ascites and pus. The CoD was assigned for each case by a multidisciplinary team of 5 to 6 medical professionals using the ICD-10 startup mortality list, clinical data and MITS findings. Results: We enrolled 100 deceased, including 60 females and 40 males aged from 6 days to 96 years (mean=50 years, mode=26, SD=23). Most deaths occurred in the hospital (91%), and 83% of MITSs were performed within a 24-hour death‒autopsy interval. The leading immediate CoDs included certain infectious and parasitic diseases (34%), diseases of the circulatory system (16%), diseases of the respiratory system (16%), neoplasms (10%) and endocrine, nutritional and metabolic diseases (6%). HIV, diabetes mellitus, hypertension, liver cirrhosis and malnutrition were the top five underlying conditions recorded. Escherichia coli (E. coli) and Klebsiella species were the most common pathogens identified in microbiology-positive cultures. Conclusion: Interpretation of MITS autopsy findings coupled with antemortem clinical and imaging data provided useful insights into CoD among the studied deceased at CHUK. MITS autopsy is a simple, rapid method that can reduce uncertainty around the CoD. Therefore, it offers an opportunity to revive autopsy practices in low-resource settings.