Autopsy Review Research Articles

Intramedullary spinal cord metastases of malignant melanoma: an autopsy case report and review of the literature

Compared with brain metastasis of malignant melanoma (MM), spinal metastasis, and in particular intramedullary spinal cord metastasis (ISCM), is extremely rare. A 78-year-old female patient suffered from disturbance of gait and mild dementia. Radiological investigations revealed multiple hemorrhagic lesions in the brain. She underwent surgical resection of a right parietal lesion, the diagnosis of which was MM. Re-examination of her past history revealed that the patient had undergone surgical resection of a nevus on her left cheek 3 years previously, the diagnosis of which had been MM. After she had died of the tumor 3 months later, complete autopsy was performed. Multiple ISCMs with hemorrhage were detected in the cervical, thoracic, and lumbar cord. We found 9 cases of ISCM of MM in the literature, 5 of which were located in the cervical cord, 3 in the thoracic cord, and 1 in the lumbar cord. One difference between the findings noted in the literature and those in the present case involved the cross-sectional location of metastases in the spinal cord. In the present case, it appeared that postoperative management for the left buccal melanoma, which did not include adjuvant therapy, affected the postoperative clinical course. The prognosis was also affected by overlooking of ISCM. The brain metastases in the present case induced deterioration of her neurological symptoms rapid enough that the possibility of ISCM was not considered. On evaluation of tumor spread from MM, it is important to take into account not only intracranial metastases but ISCM as well.

Pulmonary tumor thrombotic microangiopathy in patients with gastric carcinoma: An analysis of 6 autopsy cases and review of the literature

Pulmonary tumor thrombotic microangiopathy (PTTM) is a rare clinicopathological entity causing severe pulmonary hypertension (PH). Its histological features include widespread tumor emboli of the small arteries and arterioles of the lung, associated with thrombus formation and fibrocellular and fibromuscular intimal proliferation. Although PTTM has drawn increased attention as a fatal complication of gastric carcinoma (GC), comprehensive studies are still lacking. In order to clarify clinical and pathological features of GC-induced PTTM, recent autopsy cases were analyzed with a review of the literature. Of 36 autopsy cases with GC, 6 (16.7%) were affected by PTTM. Four were male and 2 female, with a mean age of 72.7 years. Three patients presented with PTTM-related clinical manifestations and died of PTTM. They showed clear morphological evidence of PH. The other 3 patients had PTTM as an incidental finding irrespective of clinical manifestations or PH. No patient was diagnosed antemortem as PTTM. All PTTM cases were associated with advanced GC, with a histology of adenocarcinoma of poorly differentiated type ( n = 4) or signet-ring cell type ( n = 2). Expression of tissue factor and vascular endothelial growth factor was confirmed immunohistochemically in tumor cells in all cases. The results were all in line with previous studies. In addition, the current study revealed vascular lesions characteristic of PTTM morphology to be present exclusively in the lung. In conclusion, our study shows a 16.7% incidence of PTTM in GC patients, with half of them developing PH and dying of PTTM, confirming a clinical significance as a non-negligible lethal complication of GC. In addition to many known clinicopathological characteristics of PTTM, the current study pointed to some PTTM issues requiring clarification, including the pathogenesis of the exclusive pulmonary distribution of vascular lesions of PTTM. Since details remain to be elucidated, interdisciplinary research is a high priority with a close collaboration between pathologists and clinicians in order to overcome this lethal condition.

M1394 How Common is Crohn's Pancreatitis? A 14 Year Autopsy Review

G A A b st ra ct s pancreatic EUS TCB with or without additional FNA (n=37) by 5 endosonographers in our group. All specimens were interpreted by dedicated GI pathologists blinded to the clinical data. All complications were prospectively tracked and logged in the database. Results: AIP patients undergoing EUS TCB (38 male, 10 female; mean age 59.7 years (range 18-87)) had a mean of 2.9 TCBs (range 1-7) per patient. AIP was histologically diagnosed on EUS TCB in 35 (73%) patients; the diagnostic sensitivity varied among the 5 endosonographers from 33% to 90%. Non-diagnostic cases were found to have chronic pancreatitis (n=8), nonspecific histology (n=2), and failed tissue acquisition (n=3). EUS FNA (mean 3.4 passes, range 1-7 passes) failed to establish or suggest the diagnosis in any patient (n=37). Complications of EUS TCB included mild transient abdominal pain (n=3) and self-limited intraprocedural bleeding (n=1). No patient required hospitalization or therapeutic intervention. The diagnosis of AIP was strongly suspected prior to EUS in 14 patients as a result of their clinical, laboratory, and imaging findings. For 22 patients the diagnosis was considered preEUS as part of a broader differential, and in 12 patients the EUS appearance alone led to the initial suspicion of AIP. Serum IgG4 was ≥1x ULN in 42%, and ≥2xULN in only 23% of patients. None of the patients with EUS TCB diagnosis of AIP underwent surgery. In the patients with false negative EUS TCB, diagnosis was made by HISORt criteria. Over a mean follow-up of 2.6 years no false negative diagnoses of pancreatic cancer were identified. Conclusions: In a large cohort with AIP undergoing EUS TCB we show that pancreatic biopsy is safe and provides sufficientmaterial to definitively diagnose AIPwith high sensitivity. EUS TCB obviates the need for surgical intervention in this medically treatable disease.

POEMS syndrome with idiopathic portal hypertension: Autopsy case and review of the literature

Polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes (POEMS) syndrome is a rare multi-system disease. Reported herein is an autopsy case of POEMS syndrome in a subject who developed idiopathic portal hypertension (IPH). The patient was a 38-year-old woman who was initially admitted to the Saiseikai Central Hospital because of polyneuropathy and edema. Diagnosis of POEMS syndrome was established on additional symptoms (splenomegaly and papilloedema) and serum M-protein. Corticosteroid was given for 10 years. The patient was admitted again at the age of 48 years because of gastrointestinal bleeding due to portal hypertension. The patient died of hepatoencephalopathy at 58 years of age. The liver at autopsy demonstrated dense portal fibrosis and obliteration of small portal vein branches, which are characteristic histological findings of IPH. Portal hypertension is a rare symptom in POEMS syndrome. Only three cases of IPH associated with POEMS syndrome (including the present one) have been reported so far. In the previous two reports, liver biopsy failed to determine the cause of portal hypertension. This is the first report on the occurrence of histological findings compatible with IPH in the liver. Although it is not confirmed whether IPH is related to POEMS syndrome, elevated serum cytokines such as vascular endothelial growth factor and coagulation abnormality could have contributed to the development of IPH in the present case.

Fatal renal failure due to the Chinese herb “GuanMu Tong” ( Aristolochia manshuriensis): Autopsy findings and review of literature

Herbal remedies have been used since ancient times and it is now known that they are not completely free of adverse effects. We present the case of a 41-year-old Chinese man, who died in renal failure because he consumed a herbal preparation called “Fen Qing Wu Lin Wan”, having GuanMu Tong as main ingredient, for about 1 month. GuanMu Tong is derived from the plant Aristolochia manshuriensis which contains aristolochic acid. Aristolochic acid is being reported as the causative agent of what is now called aristolochic acid nephropathy (AAN) which includes Chinese herb nephropathy (CHN) and Balkan endemic nephropathy (BEN), all having renal impairment as hallmark for the disease. The gross autopsy showed multiple punctate hemorrhages over the limbs, pleural effusion, and edematous lungs with consolidation, mild myocardial hypertrophy and normal-looking kidneys. Microscopic renal tissue examination showed severe degeneration, necrosis and desquamation of renal tubular epithelial cells, presence of protein cast and a widened, edematous interstitium with interstitial fibrosis. We also provide the clinical presentation of the deceased as reported in the medical records and briefly review the literature pertinent to similar cases.

Safety assessment of recalled Haemophilus influenzae type b (Hib) conjugate vaccines—United States, 2007–2008

On 13 December 2007, Merck & Co., Inc. voluntarily recalled 1.2 million doses of Haemophilus influenzae type b (Hib) vaccines that had been distributed since April 2007 for concerns regarding potential Bacillus cereus contamination. Enhanced postrecall surveillance was conducted to detect vaccine-associated B. cereus infections. We reviewed reports involving recalled Hib vaccines received by the Vaccine Adverse Event Reporting System (VAERS) during 1 April 2007-29 February 2008. For each reported death, autopsy review sought evidence of B. cereus infections. For each specified outcome, the proportional reporting ratios (PRRs) were calculated to compare the recalled Hib vaccines with the manufacturer's nonrecalled Hib vaccines in the VAERS databases. On 20 December 2007, we used the Epidemic Information Exchange (Epi-X) to solicit nongastrointestinal vaccine-associated B. cereus infections, and requested B. cereus isolates for genotyping to compare with the manufacturing facility isolate. VAERS received 75 reports involving recalled Hib vaccines; none described a confirmed B. cereus infection. Comparative analyses did not reveal disproportionate reporting of specified outcomes for recalled Hib vaccines. The Epi-X posting triggered one report of vaccine-associated B. cereus bacteremia from a child who received a nonrecalled Hib vaccine manufactured by Merck; the genotypes of isolates from the patient and the manufacturing facility differed. No evidence of vaccine-associated B. cereus infection had been found in recipients of recalled Hib vaccines. Conducting laboratory surveillance through Epi-X was feasible and may enhance public health response capacities for future vaccine safety emergencies.

Undiagnosed late-onset chylothorax accompanied by fatal acute pulmonary thromboembolism after surgical treatment of lung cancer: An autopsy case and review of the literature

Late-onset chylothorax is a relatively rare and essentially benign postoperative complication. We describe an autopsy case of undiagnosed hemi-chylothorax accompanied by fatal acute pulmonary thromboembolism after pulmonary resection and lymph node dissection for lung cancer, reviewing the literature. The patient was a 60-year-old woman. She complained of dyspnea on the 20th postoperative day, which gradually increased. The patient suddenly died 2 days later. Autopsy demonstrated right chylothorax (1000 ml), and fatal acute pulmonary thromboembolism, mainly on the left side, originating from the lower extremities. Postoperative chylothorax, causing respiratory and pulmonary circulatory disturbance, may provide an important predisposition to ward fatality due to pulmonary thromboembolism even among those showing a milder type; thus careful management is necessary.

Post-irradiation pericardial malignant mesothelioma: an autopsy case and review of the literature

We report a case of a malignant pericardial mesothelioma of the epithelioid type in a 39-year-old man. He had a history of nodular sclerosing Hodgkin's disease treated with irradiation of the cervical and mediastinal regions 24 years before, and of infarction of the anterior wall of the left ventricle, after which a percutaneous coronary intervention was carried out 7 years previously. He was admitted to a cardiology unit with progressive dyspnea. On examination, a hemorrhagic pericardial fluid collection of 600 ml was detected which was successfully drained. On the next day, the patient developed an electromechanical dissociation suggesting a pericardial tamponade, which was followed by circulatory arrest. At autopsy, the pericardial sac was found to contain 300 ml of partly clotted blood. The epicardial surface showed a diffuse thickening, suggesting a chronic fibrous pericarditis without a macroscopically evident distinct tumor mass. A rupture measuring 0.4 cm in diameter was detected in the right ventricular free wall, 1 cm below the level of the tricuspid valve. The diagnosis of a diffusely growing, malignant mesothelioma of the epithelioid type was made on the basis of histological and immunohistochemical examination of the thickened pericardium.

Anaplastic transformation in lung metastases of differentiated papillary thyroid carcinoma: an autopsy case report and review of the literature

Anaplastic transformation of papillary thyroid carcinoma is a rare condition and is associated with an aggressive behavior. Most cases described in the literature have occurred in the thyroid gland or in the surrounding cervical lymph nodes. We report a case of an 83-year-old man who, 10 years after being treated for a conventional papillary thyroid carcinoma, presented with widespread metastases in his lungs. At autopsy, he was found to have extensive metastatic deposits in both lungs, which histologically and immunohistochemically were consistent with papillary thyroid carcinoma. An unusual finding was the presence of solid pleomorphic foci within tumor deposits, consistent with anaplastic transformation.

Bilateral intravesical ureterocele associated with megacystitis, ipsilateral partial duplication and megaureters, ipsilateral segmental renal dysplasia of the upper pole and other anomalies: a perinatal autopsy report and review of literature

Aim To demonstrate bilateral intravesical ureterocele associated with megacystitis, ipsilateral partial duplication and megaureters, ipsilateral segmental renal dysplasia of the upper pole, accessory spleen and incomplete fissure horizontalis pulmonis dextri. Methods A perinatal necropsy conducted on the 21+3 weeks fetus by employing the Rokitansky procedure (1) with evisceration performed in blocks1,2 revealed the aforementioned abnormalities without cardiac or neural anomalies. The amniocentesis report was normal. Results To our knowledge, bilateral intravesical ureterocele with incomplete pyeloureteral duplication and other associations described have not been reported during the perinatal period. Discussion Ureterocele is a saccular expansion of the distal ureter.3 It is most commonly observed in females and children and usually affects the upper moiety of a complete pyeloureteral duplication.4,5 Four types of ureteroceles are described: (A) ureterocele with single ureter (10%);(B) ureterocele with total duplication and intra-vesical development (10%);(C) ureterocele with total duplication and extravesical development (62%);(D) ureterocele with ectopic ureter (3%).6 Only one case in a newborn has been reported with bilateral intravesical ureterocele associated with hydrouretero-nephrosis and hyperechogenic spots in kidneys.7 To demonstrate bilateral intravesical ureterocele associated with megacystitis, ipsilateral partial duplication and megaureters, ipsilateral segmental renal dysplasia of the upper pole, accessory spleen and incomplete fissure horizontalis pulmonis dextri. A perinatal necropsy conducted on the 21+3 weeks fetus by employing the Rokitansky procedure (1) with evisceration performed in blocks1,2 revealed the aforementioned abnormalities without cardiac or neural anomalies. The amniocentesis report was normal. To our knowledge, bilateral intravesical ureterocele with incomplete pyeloureteral duplication and other associations described have not been reported during the perinatal period. Ureterocele is a saccular expansion of the distal ureter.3 It is most commonly observed in females and children and usually affects the upper moiety of a complete pyeloureteral duplication.4,5 Four types of ureteroceles are described: (A) ureterocele with single ureter (10%);(B) ureterocele with total duplication and intra-vesical development (10%);(C) ureterocele with total duplication and extravesical development (62%);(D) ureterocele with ectopic ureter (3%).6 Only one case in a newborn has been reported with bilateral intravesical ureterocele associated with hydrouretero-nephrosis and hyperechogenic spots in kidneys.7

Hemorrhage is More Prevalent than Brain Injury in Early Trauma Deaths: The Golden Six Hours.

Under the trimodal distribution, most trauma deaths occur within the first hour. Determination of cause of death without autopsy review is inaccurate. The goal of this study is to determine cause of death, in hourly intervals, in trauma patients who died in the first 24 h, as determined by autopsy. Trauma deaths that occurred within 24 h at a Level I trauma center were reviewed over a six-year period ending December 2005. Timing of death was separated into 0-1, 1-3, 3-6, 6-12 and 12-24 h intervals. Cause of death was determined by clinical course and AIS scores, and was confirmed by autopsy results. Overall, 9,388 trauma patients were admitted, of which 185 deaths occurred within 24 h, with 167 available autopsies. Blunt and penetrating were the injury mechanisms in 122 (73%) and 45 (27%) patients, respectively. Of 167 deaths, 73 (43.7%) occurred within the first hour. Brain injury, when compared to other body areas, was the most likely cause of death in all hourly intervals, but hemorrhage was as or more important than brain injury as the cause of death during the first 3 h and up to 6 h. No deaths were attributable to hemorrhage after 12 h. The temporal distribution of the cause of death varies in the first 24 h after admission. Hemorrhage should not be overlooked as the cause of death, even after survival beyond 1 h. Understanding the temporal relationship of causes of early death can aid in the targeting of management and surgical training to optimize patient outcome.

Mortality and loss to follow-up among HAART initiators in rural South Africa

A retrospective cohort study of mortality rates and potential predictors of death was conducted in public-sector patients initiating highly active antiretroviral therapy (HAART) between October 2005 and September 2007 in a rural, under-resourced region of South Africa. The aims were to determine the relative contribution of death to cohort exit and the causes and predictors of mortality among HAART initiators. A community outreach programme traced non-attenders. Patients categorised as dying at home underwent a verbal autopsy (by interviewing family members) and case-file review, and those dying in hospital a case-file review, to determine the probable cause of death. At 24 months 1131 (83.6%) patients were retained on treatment in the programme, 124 (9.2%) had died, 63 (4.7%) had transferred out, and 35 (2.6%) were lost to follow-up. The most common causes of death were tuberculosis (44.3%) and diarrhoeal diseases (24.5%). Death was the major reason for cohort exit. As experience is gained with rural HAART programmes mortality rates may decrease. These results draw attention to the need for early HIV diagnosis, increased access to HAART services with earlier treatment initiation, and routine screening and aggressive management of opportunistic infections, particularly tuberculosis.

Polycystic kidney disease - autopsy review from the period 1987-2007

Polycystic kidney disease is an inherited kidney disease that affects both kidneys and it is characterized by diffuse replacement of renal parenchyma by thousands of microcysts. In time, renal insufficiency develops. There are two forms of PKD: ADPKD, which is detected in adults (children are rarely affected), and ARPK, which is detected in neonates (later presentations do occur, but rarely). The aim of this study was to analyse frequency of polycystic kidney disease, clinical data and morphological characteristics. At the Institute of Pathology, School of Medicine, Belgrade, there were detected 33 cases of ADPKD and 20 cases of ARPKD between 1987 and 2007. There were no differences between incidence of ADPKD in males and females. Average age of patients with ADPKD was 52 years. In 20 (66.7%) cases of ADPKD there were neither extrarenal cysts nor extrarenal manifestations detected. In other 13 cases, we detected extrarenal cysts: hepatic cysts in 8 cases, pancreatic cysts in 5 cases. In two cases, hepatic cysts were associated with intracranial (arachnoid cysts) and extracranial aneurysms. The most frequent cause of death in patients with ADPKD was end-stage disease. ARPKD affects more often male children compared to female. 70% of children with ARPKD were male. The mean age of patients with ARPKD was 1 month. 5 patients (40%) had hepatic fibrosis. The most frequent cause of death was respiratory insufficiency (75%). In 25% of patients, the cause of death was sepsis and renal insufficiency. Morphological and clinical manifestations of the analysed cases of both types of PKD are fairly consistent with literature data. Better knowing of aethiopathogenesis of PKD will facilitate early diagnosis, based on clinical and morphological characteristics and better management of the disease.

Pulmonary Capillary Hemangiomatosis: Report of an Autopsy Case and Review of the Literature

肺毛細血管腫症pulmonary capillary hemangiomatosis（PCH）は毛細血管が気管支壁や血管壁，肺胞隔壁，胸膜に増殖・浸潤し肺高血圧症を引き起こす極めて稀な疾患である．症例は86歳，女性．気道感染症，脳梗塞を発症し緊急入院した．抗生物質，脳保護薬等で治療したが第14病日に死亡した．剖検の結果，PCHと診断された．本症例では毛細血管が肺全体びまん性に増生していた．

Cardiac metastasis of tongue cancer may cause sudden death

Objective To identify cardiac metastases in a patient with a squamous cell carcinoma of the tongue and to clarify the relationship between cardiac metastases and sudden death. Study design Autopsy and retrospective chart review for a patient. Methods We studied a Japanese patient who suddenly died after the operation and radiation therapy, despite an absence of thanatoid symptoms. We performed a subsequent autopsy. Results The patient had four metastatic lesions in the heart, one of which was in the septum and infiltrated the region around the conducting system of the heart. Conclusion Cardiac metastasis of tongue cancer may cause sudden death.

Epstein–Barr Virus–associated Multifocal Leiomyosarcomas Arising in a Cardiac Transplant Recipient: Autopsy Case Report and Review of the Literature

Epstein-Barr virus (EBV) associated smooth muscle tumors (SMTs) have been described in patients with acquired immune deficiency syndrome (AIDS) and, more recently, in association with immunosuppression after solid-organ transplantation. We present the autopsy findings of multiple leiomyosarcomas (LMSs) in a 24-year old man who died 18 months after undergoing orthotopic cardiac transplantation for idiopathic cardiomyopathy. The recognition of EBV-driven LMS developing in cardiac transplant recipients in multiple unusual sites is crucial for the management of these patients and should include complete surgical removal anti-viral therapy and modulation of immunosuppression.

Pathology of maternal deaths in Rivers state (a ten year autopsy review) in a referral hospital

Pathology of maternal deaths in Rivers state (a ten year autopsy review) in a referral hospital

Preventable Deaths From Hemorrhage at a Level I Canadian Trauma Center

Studies of trauma deaths have had a tremendous impact on the quality of contemporary trauma care. We studied causes of trauma death at a Level I Canadian trauma center, and tabulated preventable deaths from hemorrhage using explicit criteria. Trauma registry data were used to identify all trauma deaths at our institution from January 1, 1999 to December 31, 2003. Demographics, mechanism, and time or location of death were recorded. Registry data analysis and selective chart or autopsy review were then performed to assign causes of death. A total of 558 consecutive trauma deaths were reviewed. Mean age was 48.7 (46.7-50.6), and mean Injury Severity Score was 38.8 (37.6-40.0); 29% were females. Blunt trauma represented 87% of all cases; penetrating injuries were only 13%. Central nervous system (CNS) injuries were the most frequent cause of death (60%), followed by hemorrhage (15%), and then combination CNS and hemorrhagic injuries (11%). Multiple organ failure caused 5% of deaths and 9% of deaths were from other causes. Of hemorrhagic deaths, 48% (n = 41) were from blunt injury, and 52% (n = 45) were from a penetrating mechanism. Of these hemorrhagic deaths, 16% were judged to be preventable because of significant delays in identifying the major source of hemorrhage. Hemorrhage from blunt pelvic injury was the major cause of exsanguination in 12 of 14 of these preventable deaths. Blunt injury is the major mechanism leading to trauma deaths. Massive bleeding from blunt pelvic injury is the major cause of preventable hemorrhagic deaths in our study.

Neuroendocrine carcinoma of the liver associated with dermatomyositis: Autopsy case and review of the literature

Reported herein is an autopsy case of primary hepatic neuroendocrine carcinoma associated with dermatomyositis. A 71-year-old Japanese man, who was diagnosed with dermatomyositis 5 months before death, had multiple tumors within a non-cirrhotic liver. Histopathologically, the tumors were composed of small- and medium-sized round cells with clear cytoplasm arranged in nests, sheets or rosettes. Immunohistochemically, the tumor cells were positive for chromogranin A, neuron-specific enolase and CD56 and were negative for synaptophysin. This tumor was diagnosed as a primary hepatic neuroendocrine carcinoma with metastasis to the lung, gallbladder and lymph nodes around the pancreas and aorta; no primary lesions were detected in any other organ. The tumor cells were also positive for cytokeratin 7, cytokeratin 19 and epithelial membrane antigen but were negative for anti-hepatocyte antibody and AFP. These findings suggest that the tumor originated in intrahepatic bile duct epithelium. Various cancers have been reported in patients with dermatomyositis, but only seven cases of dermatomyositis associated with primary liver cancer have been reported. To the best of the authors' knowledge, this is the first report of dermatomyositis associated with primary hepatic neuroendocrine carcinoma.

Causes of Death among Persons with AIDS in the Era of Highly Active Antiretroviral Therapy: New York City

Monitoring the full spectrum of causes of death among persons with AIDS is increasingly important as survival improves because of highly active antiretroviral therapy. To describe recent trends in deaths due to HIV-related and non-HIV-related causes among persons with AIDS, identify factors associated with these deaths, and identify leading causes of non-HIV-related deaths. Population-based cohort analysis. New York City. All adults (age > or =13 years) living with AIDS between 1999 and 2004 who were reported to the New York City HIV/AIDS Reporting System and Vital Statistics Registry through 2004 (n = 68,669). Underlying cause of death on the death certificate. Between 1999 and 2004, the percentage of deaths due to non-HIV-related causes increased by 32.8% (from 19.8% to 26.3%; P = 0.015). The age-adjusted mortality rate decreased by 49.6 deaths per 10,000 persons with AIDS (P < 0.001) annually for HIV-related causes but only by 7.5 deaths per 10 000 persons with AIDS (P = 0.004) annually for non-HIV-related causes. Of deaths due to non-HIV-related causes, 76% could be attributed to substance abuse, cardiovascular disease, or a non-AIDS-defining type of cancer. Compared with men who have sex with men, injection drug users had a statistically significantly increased risk for death due to HIV-related causes (hazard ratio, 1.59 [95% CI, 1.49 to 1.70]) and non-HIV-related causes (hazard ratio, 2.54 [CI, 2.24 to 2.87]). Compared with autopsy and chart review, death certificates may lack specificity in the underlying cause of death or detailed clinical and treatment-related information. Non-HIV-related causes of death account for one fourth of all deaths of persons with AIDS. Cardiovascular disease, non-AIDS-defining cancer, and substance abuse account for most non-HIV-related deaths. Reducing deaths from these causes requires a shift in the health care model for persons with AIDS from a primary focus on managing HIV infection to providing care that addresses all aspects of physical and mental health.