Armanni-Ebstein lesion, ketoacidosis and starvation in a child

Deaths From Alcoholic and Diabetic Ketoacidosis at Autopsy-A Comparison Study

Diabetes mellitus and alcoholism are common disorders that may result in sudden death. Ketoacidosis may occur in both conditions. Diagnosis is based on history, and post-mortem findings including biochemistry and toxicology. This study compares deaths from alcoholic and diabetic ketoacidosis from two centres with large autopsy workloads. In the study period 9332 deaths were autopsies with 151 deaths diagnosed as ketoacidosis (1.6%) with 82 (0.9 %) being diabetic ketoacidosis (DKA) and 48 (0.5%) alcoholic ketoacidosis (AKA) deaths. There were more male deaths in each group. The median age for DKA deaths was 51 years (range 19-79). The median age for AKA deaths was 55 years (range was 34-78). The BMI range in DKA deaths was 12.5 to 40.4 kg/m2, with a median of 21.9. The comparative figures for AKA deaths was a range of 11.3 - 38.3 with a median of 20.2. Acetone concentrations were statistically higher in diabetic compared with alcoholic deaths, mean of 33.7 mg/100 mL in DKA cases versus mean of 16.9 mg/100 mL in AKA cases. Both DKA and AKA deaths are seen more commonly in males than female and are typically people with low BMIs in their 50s.

Renal Tubular Epithelial Subnuclear Vacuolization in Hypothermia and Diabetic Ketoacidosis-A Retrospective Autopsy Study

ABSTRACT

Subnuclear vacuolization of the renal tubular epithelium refers to discrete lipid vacuoles displacing the nuclei toward the lumen. This phenomenon has been associated with conditions sharing fatal ketoacidosis as a common denominator. This retrospective study aimed to investigate renal tubular epithelial subnuclear vacuolization and other postmortem examination findings in fatal hypothermia and diabetic ketoacidosis (DKA) cases.Fourteen cases with hypothermia and 19 cases with DKA were included. More cases with DKA had focal or diffuse subnuclear vacuolization compared with hypothermia cases (89% vs 43%; P = 0.007). In 6 cases with DKA, formalin pigment was detected within subnuclear vacuoles, whereas no case with hypothermia had formalin pigment deposition. Comparative analyses of hypothermia and DKA cases revealed further differences: Vitreous beta-hydroxybutyrate was higher in the DKA group compared with the hypothermia group (P = 0.044), whereas blood ethanol concentrations were higher in the latter (P = 0.008). Hypothermia cases were older compared with the DKA cases (P = 0.022).When all cases were included in the statistical analysis, cases with subnuclear vacuolization had higher vitreous beta-hydroxybutyrate and blood ethanol concentrations (P = 0.029 and 0.023, respectively). The findings corroborate the results of previous studies suggesting a link between subnuclear vacuolization and increased levels of ketoacidosis.

Characterization and outcome of 11 children with non-diabetic ketoacidosis

OBJECTIVES

To study the clinical and laboratory features, management, and outcome of pediatric non-diabetic ketoacidosis (NDKA).

METHODS

Between May 2018 and April 2020, we prospectively collected children under 18 years who presented with ketoacidosis, defined as ketosis (urinary ketones ≥++ and/or serum β-hydroxybutyrate level ≥3 mmol/L) and metabolic acidosis (pH <7.3 and HCO₃ ^- <15 mmol/L). Children with HbA1c level ≥6.5% at initial presentation and those meeting the diagnostic criteria for DM during follow-up were excluded. Data were collected on demographics, clinical and laboratory features, management, and outcome.

RESULTS

Eleven children with 19 episodes of NDKA were identified. The median age was 12 months (range from 5 months to 5 years). They manifested dehydration and disturbed conscious level (all cases), convulsions (n=6), hypoglycemia (n=6), hyperglycemia (n=2) and significant hyperammonemia (n=4). Most cases required intensive care management. Death or neurodevelopmental impairment occurred in six cases. Seven cases had inborn errors of metabolism (IEMs). Other cases were attributed to starvation, sepsis, and salicylate intoxication.

CONCLUSIONS

This is the largest case series of pediatric NDKA. Ketoacidosis, even with hyperglycemia, is not always secondary to diabetes mellitus. IEMs may constitute a significant portion of pediatric NDKA. Increased awareness of this unfamiliar condition is important for prompt diagnosis, timely management, and better outcome.

Utility of Postmortem Vitreous Beta-Hydroxybutyrate Testing for Distinguishing Sudden from Prolonged Deaths and for Diagnosing Ketoacidosis

A retrospective, cross-sectional analysis of vitreous beta-hydroxybutyrate (BHB) on 967 forensic cases over a two-year period was conducted. Cases were sorted into six categories of death: (i) sudden traumatic/non-natural (ST), (ii) sudden natural (SN), (iii) prolonged traumatic/non-natural (PT), (iv) prolonged natural (PN), (v) diabetic ketoacidosis (DKA), and (vi) alcoholic ketoacidosis (AKA). The mean BHB for all cases was 1.67 mmol/L (17.4 mg/dL; range: 0.11-18.02 mmol/L). The numbers of DKA, AKA, PN, PT, SN, and ST deaths were 21, 5, 155, 258, 275, and 253, respectively. Their mean vitreous BHBs were as follows: 11.04 mmol/L (DKA), 8.88 mmol/L (AKA), 1.56 mmol/L (PN), 1.55 mmol/L (PT), 1.26 mmol/L (SN), and 1.38 mmol/L (ST). There was a statistically significant difference between the mean BHBs of the PN and SN death groups (p < 0.001), as well as between those of the PT and ST death groups (p = 0.004). Given the overlapping ranges seen between the prolonged and sudden death groups, the identified differences did not hold clinical significance. In addition, we sought to determine a threshold value for vitreous BHB to definitely diagnose cases of ketoacidosis. BHB threshold concentrations between 2.5 and 5 mmol/L produced sensitivities >92% and specificities >96%. A receiver operator characteristic curve found 3.43 mmol/L to be the optimal cutoff value, demonstrating a specificity of 98.3% and a sensitivity of 96.2%.

Another "D" in MUDPILES? A Review of Diet-Associated Nondiabetic Ketoacidosis

Ketogenic diet or very-low-carbohydrate diet gained widespread popularity in the 1990s due to their favorable effects on weight loss and diabetes among others with good short-term safety data. People on ketogenic diets exist in a state of "dietary ketosis" in which the body production of ketone is equal to consumption and no harmful effects of ketonemia occur. However, in face of stress, the harmless "dietary ketosis" can lead to profound acid-base disturbances due to massive overproduction of ketone bodies that overwhelms the acid buffer system of the body. A handful of case reports have been published on this topic calling the safety of ketogenic diet into question. In this article, we chronicle a unique case of ketogenic (Atkins) diet-associated ketoacidosis, and we present a comprehensive literature review on the etiology of ketoacidosis.

Basal Vacuolization in Renal Tubular Epithelial Cells at Autopsy and Their Relation to Ketoacidosis

Basal vacuolization of renal tubular epithelial cells is a useful postmortem marker for ketoacidosis. To investigate its incidence and relationship to the severity of ketoacidosis, 158 autopsy cases with elevated β-hydroxybutyrate (>1 mmol/L) over a 7-year-period were retrospectively reviewed. Sixty-eight cases (43%) exhibited basal vacuolizations (vitreous β-hydroxybutyrate: 1.16-29.35 mmol/L, mean 10.28 mmol/L), and 90 cases (57%) did not (vitreous β-hydroxybutyrate: 1.03-13.7 mmol/L, mean 2.84 mmol/L). Quantitative analysis revealed on average a fourfold elevation in β-hydroxybutyrate in cases with basal vacuolizations compared to those without; 10.3% of cases with β-hydroxybutyrate concentrations between 1.01 and 2.00 mmol/L had basal vacuolizations, and this incidence increased to 33.3% with concentrations between 4.01 and 6.00 mmol/L. A marked increase in incidence to >70% was observed with concentrations >6.00 mmol/L, and basal vacuoles were invariably present (100%) with concentrations >14.01 mmol/L. This study demonstrates that basal vacuolizations are a sensitive marker for significant ketoacidosis and reaffirms its use as an indicator for likely cases of fatal ketoacidosis at autopsy.

An Isolated Perfused Rat Kidney Model for the Evaluation of the Effect of Glucose on Renal Tubular Epithelial Morphology

An isolated perfused kidney model was used to evaluate the effect of hyperglycemia on renal tubular epithelial cell morphology. Ten Sprague-Dawley rat kidneys were perfused with Krebs-Henseleit buffer containing 70 mmol/L of glucose (five for 1 h and five for 2 h). Two control groups consisted of 10 kidneys perfused with Krebs-Henseleit buffer without hyperglycemia (five for 1 h and five for 2 h), and 10 nonperfused contralateral kidneys placed in the same environment for the same duration. The hyperglycemia group had significantly increased renal tubular vacuolization (p < 0.001) compared to both control groups at 1 and 2 h. The isolated perfused kidney model recapitulates the renal tubular vacuolization phenotype found in hyperglycemia and may be a potential tool for the investigation into causal factors in renal histology. The full pattern of the Armanni-Ebstein phenomenon was not, however, reproduced, suggesting that this change requires more time or involves more complex factors.

Liver Pathology in First Presentation Diabetic Ketoacidosis at Autopsy

Diabetes mellitus is an enormous health burden on developed and developing nations. Eight percent of people in the United States are stated to have diabetes mellitus and 79 million people have impaired glucose tolerance. Sudden death from diabetic ketoacidosis (DKA) is common and nonalcoholic fatty liver disease (NAFLD) is a frequent finding in patients with diabetes mellitus and impaired glucose tolerance. Diabetic ketoacidosis accounts for around 1% of autopsy cases in our units and 25% of these cases did not have a previous diagnosis of diabetes mellitus. We have analyzed for the presence of NAFLD in 16 patients dying on first presentation of DKA. Some degree of NAFLD was present in all cases, with all but one case having some degree of steatosis and some degree of fibrosis was present in 14 out of 16 cases, though none where cirrhotic. Inflammation was present in nine of 13 cases and glyogenated nuclei in five of 13 cases. NAFLD can be well established in patients dying of DKA who were not known to be diabetic before death. The pathology shares features with alcoholic liver disease. They should not be mistakenly diagnosed as dying of other causes of ketoacidosis based upon the liver pathology present.

Renal tubular epithelial vacuoles-a marker for both hyperlipidemia and ketoacidosis at autopsy

Review of 15 cases of nephrotic syndrome found that eight had significant hyperlipidemia with serum cholesterol levels ranging between 10.59 and 18.60 mmol/L (mean 12.88) and serum triglyceride levels between 2.30 and 9.92 mmol/L (mean 4.58); all of these cases displayed basal lipid vacuolization. Seven of the 15 study cases had normal-mild hyperlipidemia with serum cholesterol levels ranging between 4.71 and 7.54 mmol/L (mean 6.02) and serum triglyceride levels between 0.65 and 4.1 mmol/L (mean 1.57). Six of the seven cases had basal lipid vacuoles (86%). Of these, five cases were hyperlipidemic and one case had borderline hyperlipidemia with a serum cholesterol level of 4.71 mmol/L. Although hyperlipidemia was associated with renal tubular epithelial vacuolization, the vacuoles appeared morphologically different to those found in ketoacidosis. This study has shown that while hyperlipidemia in isolation may result in basal lipid vacuolization within renal tubular epithelial cells, the phenotype differs from that observed in ketoacidosis.

The role of the Armanni-Ebstein lesion, hepatic steatosis, biochemical analysis and second generation anti-psychotic drugs in fatal diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is an acute severe complication of diabetes and characterized by a complex disordered metabolic state due to an absolute or relative insulin deficiency, leads to hyperglycaemia, ketoacidosis and ketonuria. DKA can cause sudden unexpected death and often yields minimal and/or subtle autopsy findings or a negative autopsy and the diagnosis mainly depends upon biochemical analysis of body fluids. This communication highlights the role of Armanni-Ebstein lesion, hepatic steatosis, biochemical analysis and second generation anti-psychotic drugs in 25 adult cases of fatal diabetic ketoacidosis. The study recognises and reconfirms that fatal DKA occurs in both type I and II diabetes. The macroscopic autopsy features observed in this study are non-specific and do not guide the pathologist towards the diagnosis of fatal DKA. Once other possibilities have been excluded, the Armanni-Ebstein lesion alone or the combination of hepatic steatosis and Armanni-Ebstein lesion in an otherwise negative autopsy of a sudden unexpected death should raise the suspicion of DKA as the cause of death and indicate biochemical analysis of body fluids. Our findings also remind forensic pathologists to search for fatal DKA in sudden unexpected death with a negative autopsy, where there is a history of second generation anti-psychotic treatment.

The Armanni-Ebstein Lesion and the Postmortem Diagnosis of Ketoacidosis

The diagnoses of ketoacidosis and disturbances of glucose metabolism are difficult at autopsy because of changes in glucose concentrations postmortem. The Armanni-Ebstein lesion is a histological change in the kidney that has been reported as a marker of diabetic ketoacidosis. This paper examines the specificity of the Armanni-Ebstein lesion and the diagnosis of alterations in glucose metabolism and ketoacidosis at autopsy. The Armanni-Ebstein lesion consists of subnuclear vacuolation of the proximal tubules. The vacuoles contain fat and can be demonstrated on fresh and formalin fixed tissue using standard fat stains. Recently it has been reported in other conditions associated with non-diabetic ketoacidosis. The lesion has the same appearance whatever the cause of the ketoacidosis. This review, with illustrative cases shows the Armanni-Ebstein lesion is a marker of ketoacidosis and not specific for diabetic ketoacidosis. It may be seen in cases of diabetic and alcoholic ketoacidosis and in starvation and hypothermia, in which ketoacidosis occurs. It has also been reported in isopropanol poisoning.