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