An epidemic of deaths attributed to fatty liver in Baltimore

The postmortem diagnosis of alcoholic ketoacidosis

AIMS

The aim of this article is to review the forensic literature covering the postmortem investigations that are associated with alcoholic ketoacidosis fatalities and report the results of our own analyses.

METHODS

Eight cases of suspected alcoholic ketoacidosis that had undergone medico-legal investigations in our facility from 2011 to 2013 were retrospectively selected. A series of laboratory parameters were measured in whole femoral blood, postmortem serum from femoral blood, urine and vitreous humor in order to obtain a more general overview on the biochemical and metabolic changes that occur during alcoholic ketoacidosis. Most of the tested parameters were chosen among those that had been described in clinical and forensic literature associated with alcoholic ketoacidosis and its complications.

RESULTS

Ketone bodies and carbohydrate-deficient transferrin levels were increased in all cases. Biochemical markers of generalized inflammation, volume depletion and undernourishment showed higher levels. Adaptive endocrine reactions involving insulin, glucagon, cortisol and triiodothyronine were also observed.

CONCLUSIONS

Metabolic and biochemical disturbances characterizing alcoholic ketoacidosis can be reliably identified in the postmortem setting. The correlation of medical history, autopsy findings and biochemical results proves therefore decisive in identifying pre-existing disorders, excluding alternative causes of death and diagnosing alcoholic ketoacidosis as the cause of death.

Sudden unexpected death in alcohol misuse--an unrecognized public health issue?

Sudden arrhythmic cardiac death can occur in chronic misusers of alcohol. The only findings at post mortem are fatty liver and a negative or low blood alcohol. This is an under-recognized entity. Coroner's post mortems in a typical UK city were studied. Seven out of 1,292 (0.5%) post mortems were deemed to have died of alcohol associated arrhythmic death. Applying this study to the UK as a whole, alcohol related arrhythmic death or as we have termed it SUDAM (Sudden Unexpected Death in Alcohol Misuse) probably accounts for around 1,000 deaths, many of which are misattributed to other causes.

Alcoholic intemperance, coronary heart disease and mortality in middle-aged Swedish men

High alcohol consumption is one of the major risk indicators for premature death in middle-aged men. An indicator of alcohol abuse--registration with the social authorities for alcoholic problems--was used to evaluate the role of alcohol in relation to general and cause-specific mortality in a general population sample. Altogether 1,116 men (11%) out of a total population of 10,004 men were registered for alcoholic problems. Total mortality during 11.8 years' follow-up was 10.4% among the non-registered men, compared to 20.5% among men with occasional convictions for drunkenness and 29.6% among heavy abusers. Fatal cancer as a whole was not independently associated with alcohol abuse, but oropharyngeal and oesophageal cancers together were seven times more common in the alcohol-registered groups. Total coronary heart disease (CHD) was significantly and independently associated with alcohol abuse, but nearly all the excess CHD mortality among the alcohol-registered men could be attributed to sudden coronary death. Cases with definite recent myocardial infarction were not more common in the alcoholic population. A combined effect of coronary arteriosclerosis and heart muscle damage secondary to alcohol abuse is suggested. Other causes of death strongly associated with registration for alcohol abuse include pulmonary embolism, pneumonia and peptic ulcer, as well as death from liver cirrhosis and alcoholism. Of the excess mortality among alcohol-registered subjects, 20.1% could be attributed to CHD, 18.1% to violent death, 13.6% to alcoholism without another diagnosis and 11.1% to liver cirrhosis.

Fat replacement of the glycogen in the liver as a cause of death: seventy-five years later

Seventy-five years ago, E. R. LeCount and H. A. Singer published a report in the first issue of the Archives of Pathology & Laboratory Medicine entitled "Fat Replacement of the Glycogen in the Liver as a Cause of Death." The report described 11 patients with chronic alcoholism who died suddenly. Markedly enlarged fatty livers were the only abnormality noted at postmortem examination in each of the subjects. Groups in this country and abroad subsequently repeated the authors' observation. The mechanism of sudden death in patients with fatty livers due to chronic alcoholism is currently understood to be an abnormality in the conduction system of the heart, manifested as a prolonged QT interval. The triggering event leading to the conduction defect has been suggested to be hypoglycemia complicated by hypopotassemia and hypomagnesemia. In this review we will summarize the changes that have taken place in this field since the initial publication by LeCount and Singer.

Towards a direct definition of an alcohol-related death: an analysis in Aboriginal adults

This paper addresses the conceptual and methodological difficulties in obtaining reliable information on alcohol-related mortality in Aboriginal communities. A working definition is proposed; this requires an alcohol-positive history together with a consistent mode of death, and is applied retrospectively to a series of 29 adult deaths in a large Aboriginal community. An informant history of alcohol abuse was found to be the most sensitive indicator of an alcohol-positive history and correlated well with autopsy findings and medical records. Alcohol-positive histories were found for 17 of 29 deaths by informant history, for 9 of 29 by autopsy findings, and for 12 of 29 by medical record review. These indicators were combined with a mode of death categorisation to arrive at an estimate of 5 of 29 definite, 5 of 29 probable, and 1 of 29 possible alcohol-related deaths. We conclude by examining the process by which such a definition might be further developed and the context in which resulting information might then be used.

Causes of sudden unexpected deaths in young and middle-aged persons

The incidence and causes of sudden and/or unexpected deaths in the 15-49-year old population were investigated. The material was collected from 1492 cases in which either a medico-legal or a medical autopsy had been carried out. The necropsy rate was 42% of all deaths. There were 77 sudden deaths in this age-group, involving 64 males (82%) and 13 females (18%). This is 2% of all deaths and 5% of autopsied cases. The incidence per 100,000 persons in 1 year was 19.3 for males and 3.1 for females. Cardiovascular illnesses were the cause of death in 83% of cases. Coronary artery disease was the most common cause, accounting for almost half of these (49.3%). The next most common vascular cause was subarachnoidal haemorrhage (10.4%). The incidence of coronary deaths per 100,000 inhabitants in 1 year was 8.7 for males and 0.7 for females. In all cases the coronary stenosis was due to atheromatosis or more advanced atherosclerosis. Severe stenosis was located in the left descending artery in 58%, and in 52% the disease was only in one vessel. Thrombosis was found in 52%. Alcoholism (5.2%) was the next most common cause after the cardiovascular diseases. Coronary disease was very rare in age-matched victims of violent death. Deaths due to infections were rare, only 3.9%. Other solitary causes of sudden death were carcinomas, epilepsy, diabetes mellitus, intestinal occlusion and atopic dermatitis via sepsis.

Objective psychological measurement and alcoholism: survey of the literature 1974

This survey is the third in a series examining objective psychological test data or behavioral measurements on alcoholics published in the United States during a specific year. The 131 articles published in 1974 are divided into two broad categories, treatment orientation and behavior and attitudes of alcoholics. Findings are further divided into subcategories, briefly described, and cross indexed. The resume and conclusion section includes references to current findings.

Fatty liver and sudden death. A review

Alcoholism is associated with increased mortality from violent and nonviolent causes. The increase in nonviolent deaths is usually ascribed, at least in part, to "cirrhosis." In the majority of these deaths this implies fatty liver rather than true Laennec's cirrhosis. Studies of sudden nonviolent deaths illustrate the largely unrecognized and frequent occurrence of sudden death with autopsy findings limited solely to fatty liver. The mechanism(s) of these sudden fatty liver deaths is unknown. Several attractive theories attribute such deaths to ethanol withdrawal induced hypoglycemia or hypomagnesemia, pulmonary fat embolization from fatty liver, or other facets of the alcohol withdrawal syndrome, including ethanol dependent maladaptive derangements of neurotransmitters. All the theories of fatty liver death remain essentially untested, however, owing to uncontrolled postmortem conditions and the lack of awareness of fatty liver deaths within the scientific community.