Case ReportUsefulness of postmortem biochemistry in identification of ketosis: Diagnosis of ketoacidosis at the onset of autoimmune type 1 diabetes in an autopsy case with cold exposure and malnutrition
Introduction
Diabetes mellitus (DM) may cause severe metabolic disturbances, which that can be fatal. These can be difficult to diagnose based on macroscopic and histological findings alone at autopsy [1], [2], [3]. In such cases, postmortem biochemical markers can provide supporting information [1]. When investigating on metabolic and endocrin disorders, a number of postmortem biochemical laboratory procedures have been reported to be useful for autopsy diagnoses [1], [4], [5]. Particularly in the postmortem diagnosis of DM, a common metabolic disease, the main evidence for the diagnosis can be derived from postmortem biochemical parameters [3], [6], [7].
Diabetic ketoacidosis (DKA) at the onset of autoimmune type 1 diabetes (AT1D) is a complication of DM characterized by extreme and rapid progression of hyperglycemia and ketoacidosis due to the destruction of the pancreatic β cells [8], [9]. The clinical diagnosis of DKA at the onset of AT1D can be made when the following biochemical parameters are found: (1) elevation of urinary and/or serum ketone bodies; (2) high plasma and urinary glucose levels (>250 mg/dL and >100 mg/dL, respectively); (3) an anion gap of >12 mEq/L and arterial blood pH of <7.3; and (4) elevation of plasma blood urea nitrogen (BUN) and creatinine levels [8]. Patients diagnosed with DKA at the onset of AT1D are likely to die within 24 h of the onset of hyperglycemia unless they receive immediate treatment for DKA [8]. In forensics, DKA at the onset of AT1D has become more widely recognized as a cause of sudden death [2], [10]. However, methods for the postmortem diagnosis of DKA at the onset of AT1D have not yet been fully established because there are no characteristic anatomical findings.
Here, we report on a postmortem biochemical diagnosis of DKA at the onset of AT1D, which was made in spite of considerable autopsy findings that were suggestive of hypothermia as being the cause of death. We compared these findings to postmortem cases of other ketotic conditions, namely hypothermia and malnutrition. We also considered whether it was possible to use the postmortem biochemical profile for DKA diagnosis and compare it to other ketotic conditions, such as hypothermia and malnutrition.
Section snippets
Case history
A Japanese female in her twenties was found dead in her apartment bathroom by her boyfriend at 7:30 a.m. in early February morning.
Five days earlier, she had had a bicycle accident and received a blow to the right inguinal region, after which she experienced nausea and general malaise. She was absent from work for the following 3 days. On the 4th day, she was found dead in her apartment bathroom. She was nude from the waist down and had fallen while taking a cold-water shower. A gas safety
Discussion
In the present case, most of the macropathological findings on internal examination suggested possible hypothermia (cold exposure) as the cause of death. However, according to the postmortem biochemistry, postmortem HbA1c levels were markedly increased and the glucose levels in the blood of the right heart and urine glucose levels were extremely elevated. HbA1c levels have been reported to stabilize within 72 h postmortem [28], while blood glucose concentrations have been reported to decrease
Conflict of interest statement
The authors declare that they have no proprietary, financial, professional, or other personal interest of any kind in any product, service, and/or company that could be construed as influencing this current manuscript entitled “Usefulness of postmortem biochemistry in forensic autopsy: diagnosis of ketoacidosis at the onset of autoimmune type 1 diabetes in an autopsy case with cold exposure and malnutrition.”
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