Elsevier

Legal Medicine

Volume 17, Issue 6, November 2015, Pages 475-482
Legal Medicine

Comprehensive investigation of postmortem glucose levels in blood and body fluids with regard to the cause of death in forensic autopsy cases

https://doi.org/10.1016/j.legalmed.2015.08.004Get rights and content

Highlights

  • Fatal insults induce hyperglycemia involved in stress responses.

  • This study investigated postmortem glucose levels in blood and body fluids.

  • Glucose levels were higher in diabetic cases, showing site-to-site correlations.

  • Stress-induced hyperglycemia was evident in acute death of non-diabetic subjects.

  • Characteristic findings were also detected in alcohol abuse and thermal disorders.

Abstract

The serum glucose level is regulated within a narrow range by multiple factors under physiological conditions, but is greatly modified in the death process and after death. The present study comprehensively investigated glucose levels in blood and body fluids, including pericardial fluid (PCF), cerebrospinal fluid (CSF) and vitreous humor, reviewing forensic autopsy cases (n = 672). Right heart blood glucose level was often higher than at other sites, and the CSF glucose level was the lowest, showing greater dissociation in acute/subacute death cases. The glucose level was higher in the diabetic (high HbA1c) than in the non-diabetic (low HbA1c) group at each site (p < 0.01–0.0001). Fatal diabetic ketoacidosis cases had evidently high glucose levels at each site; whereas in the non-diabetic group, blood glucose level was higher in fatal alcohol abuse, saltwater drowning, electrocution, cerebrovascular disease and sudden cardiac death due to ischemic heart disease. Fatal methamphetamine (MA) abuse, sepsis, malnutrition (starvation) and hypoglycemia due to antidiabetics showed markedly lower blood glucose levels. Ketones in bilateral cardiac blood and PCF were increased in diabetic ketoacidosis and fatal alcohol abuse as well as in most cases of hyperthermia (heatstroke), hypothermia (cold exposure) and malnutrition. These findings suggest that combined analysis of glucose, HbA1c and ketones in blood and body fluids is useful to investigate not only fatal diabetic metabolic disorders but also death processes due to other causes, including alcohol and MA abuse, as well as thermal disorders, sepsis and malnutrition.

Introduction

Serum glucose is regulated within a narrow range by multiple factors in physiological conditions, but the disorders involving hyperglycemia in diabetes mellitus cause serious complications, including systemic vascular disorder leading to ischemic heart disease, cerebrovascular disease and nephropathy, as well as severe metabolic disorders involving electrolyte disturbances [1], [2], [3], [4], [5], [6]. Since these diabetic complications are often involved in the causes of sudden death or contributors to accidental casualties, postmortem diagnosis of diabetes mellitus is important in routine forensic autopsy [7], [8], [9]. In addition, hypoglycemia caused by misuse or abuse of antidiabetic drugs or in other pathological conditions may be related to unexpected or violent death [10], [11]. Essential biochemical markers for a clinical diagnosis of hyperglycemia and hypoglycemia in diabetes mellitus and other metabolic disorders include serum glucose, hemoglobin A1c (HbA1c) and ketones [12], [13], [14], [15]. In forensic biochemistry, previous studies suggested the usefulness of vitreous humor as postmortem material for glucose measurement to investigate metabolic disorders in diabetes mellitus since serum glucose level is modified in the death process and after death, while HbA1c is substantially stable [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26].

Glucose metabolism may also be disturbed in other functional causes of death, including alcohol abuse and undernutrition or wasting illness, involving ketosis [5], [26], [27], [28], [29], [30], [31]. In addition, it is known that serum glucose is transiently elevated as part of mental and physical stress responses [32], [33], [34], [35], [36], [37], [38]. Thus, postmortem glucose level may be a useful indicator to investigate these causes and modes of death when diabetic disorders are excluded; although there are insufficient data for postmortem glucose levels in blood and body fluids with regard to the cause of death.

Against the above-mentioned background, the present study comprehensively investigated glucose and ketone levels in blood and body fluids, including pericardial fluid (PCF), cerebrospinal fluid (CSF) and vitreous humor (VH), reviewing forensic autopsy cases within 2 days postmortem, to examine their efficacy in diagnosis of the cause and mode of death.

Section snippets

Autopsy materials

Biochemical data of serial medicolegal autopsy cases 0–100 years of age with a postmortem time within 48 h (n = 672: 473 males and 199 females) over a period of 7 years (2007–2014) were reviewed. Bilateral VHs and blood samples from bilateral cardiac chamber and external iliac vein, as well as PCF, CSF and urine, were collected using sterile syringes at autopsy; blood, PCF, CSF and urine were drawn after opening the body cavities. The serum was immediately separated by centrifugation, and all

Topological distribution

For all cases, there were no gender-related differences, or age-, survival time- or postmortem interval-dependent patterns in glucose and ketones levels at each site, as well as HbA1c level, without an evident difference between cases with and without critical medical care involving cardiopulmonary resuscitation (CPR) in hospital at the time of death. In individual cause-of-death groups, slight postmortem increases in glucose levels were partly detected in mechanical asphyxiation (external

Discussion

In forensic biochemistry, previous studies established the validity of using blood HbA1c and vitreous humor glucose in the postmortem diagnosis of diabetes mellitus [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], which was confirmed in the present study of forensic autopsy cases. In addition, although it has been believed that the blood glucose level is of poor diagnostic value due to its rapid decrease after death [57], the site-to-site correlation of the glucose level and

Conflict of interest

The authors have no conflict of interest to declare.

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