Postmortem diagnosis of ketoacidosis: Levels of beta-hydroxybutyrate, acetone and isopropanol in different causes of death

Isopropyl Alcohol Intoxication Treated With Hemodialysis: A Case Report and Short Review

Isopropyl alcohol (IPA) is a common constituent of rubbing alcohol, household cleaning agents, and antiseptic agents. Ingestion of IPA usually leads to self-resolving mild symptoms in most cases but can result in severe symptoms, including central nervous system depression or hemodynamic instability. Treatment is mainly supportive, and hemodialysis is generally reserved for severe intoxication. Limited data are available on the use of hemodialysis to treat IPA intoxication. We are presenting a case of accidental ingestion of IPA in an elderly female with dementia leading to severe intoxication requiring hemodialysis at relatively non-toxic serum levels of IPA. The patient had a prompt recovery without any post-procedural or hospital-acquired complications.

Non-Destructive and Non-Invasive Measurement of Ethanol and Toxic Alcohol Strengths in Beverages and Spirits Using Portable Raman Spectroscopy

The measurement of ethanol and toxic alcohol (methanol and isopropanol) strengths in beverages and spirits is crucial for health reasons but also for the identification of adulterated products. Many methodologies have been reported in the literature, based mainly on chromatographic and on spectroscopic techniques. Chromatographic techniques are laborious and time-consuming, while spectroscopic techniques are rapid and need no special sample pretreatment. All techniques were only applied to off-line or at-line manner. In the present work, Raman spectroscopy was used for fast and non-destructive measurements. A "through the container" method was developed for a non-invasive analysis, i.e., analysis without unsealing the bottles. This method, coupled with a miniature portable Raman, can serve for in-line measurements in a production line. The optimum laser focus for maximum spirit signal and minimum glass-wall signal was investigated. Calibration curves for the alcohols of interest were constructed and validated. The limits of detections were calculated and proved to be lower than the legitimate values. The influences of the liquor color and the bottle color, shape, and thickness were checked. Twenty-eight alcoholic products were studied. The concentrations found were compared against the nominal values (from the bottle labels).

Examination of Postmortem β-Hydroxybutyrate Increase in Forensic Autopsy Cases

Ketoacidosis is one of the common diseases that sometimes result in death. In forensic autopsy cases, the measuring of ketone bodies, especially β-hydroxybutyrate (BHB), is useful in diagnosing postmortem ketoacidosis as a cause of death. However, increased BHB values are not always indicative of ketoacidosis. Other causes of death, such as hypothermia, are known to increase BHB values. In addition, sometimes, we experience cases of increased BHB values that are unlikely to be associated with the pathophysiology or the cause of death resulting in an increase in BHB values. In this study, autopsies were performed to determine the relationship between blood BHB values and the postmortem interval (PMI). The patients were divided into four groups: PMI ≤ 24 h, PMI ≤ 48 h, PMI ≤ 72 h, and PMI > 72 h. The BHB values for each group were then compared. Based on the analysis, patients with a PMI ≤ 72 h and those with a PMI > 72 h had significantly higher BHB values than patients with a PMI ≤ 24 h. In conclusion, there remains a possibility that the BHB values increase after death. Forensic pathologists should consider PMI when diagnosing ketoacidosis as the cause of death.

Postmortem Diagnosis of Ketoacidosis by Determining Beta-Hydroxybutyrate Levels in Three Types of Body Fluids by Two Different Methods

Background: Postmortem assessment of endogenous ketoacidosis is primarily focused on the determination of 3-beta-hydroxybutyrate (BHB). The aim of our study was to identify the most adequate body fluid and postmortem quantification method for assessing ketoacidosis status immediately prior to death. Material and method: We performed a prospective study on 53 cases of sudden death or in-hospital death that were considered forensic cases and could present a state of ketoacidosis prior to death, the autopsies being performed at a post-mortem interval of 24–72 h. BHB analysis was performed by Multi-Functional Monitoring System XPER Technology analyzer (method A—portable analyzer) for peripheral blood, and by BHB Assay MAK041 Kit (method B) for vitreous humor (VH) and cerebrospinal fluid (CSF). Results: We identified 11 ketoacidosis cases using method A and 9 ketoacidosis cases using method B. All nine cases of ketoacidosis identified using the MAK041 kit were confirmed with the portable analyzer. For the 2 cases of ketoacidosis identified only with the portable analyzer, the values obtained by method B were at the diagnostic limit. BHB concentrations determined in VH and CSF by method B were statistically significantly correlated with each other and with peripheral blood BHB concentration. Conclusion: BHB, a marker of ketoacidosis, should be determined post-mortem whenever a metabolic imbalance is suspected irrespective of known risk factors or obvious morphological substrate to help establish the thanatogenic mechanism. BHB quantification can easily be performed using a handheld automatic analyzer and a sample of peripheral blood as BHB levels in various body fluids correlate with each other.

Clinicopathologic Appearance of Advanced Ketoacidosis With Basal Vacuolation in Renal Tubules

CONTEXT.—

Basal vacuolization (BV) in renal tubules is a histopathologic hallmark of advanced ketoacidosis that enables us to retrospectively diagnose these cases.

OBJECTIVE.—

To clarify the pathologic background and serologic findings of ketoacidosis with BV, and to reveal the pathologic findings by each pathologic background.

DESIGN.—

We examined 664 serial autopsy cases. A systemic histopathologic examination and measurement of serum β-hydroxybutyrate concentration were performed for the cases with BV. The extent of steatosis and fibrosis in the organs and the degree of coronary artery stenosis were semiquantitatively investigated. Immunohistochemistry for adipophilin was also performed to analyze its usefulness for the pathologic diagnosis.

RESULTS.—

Basal vacuolization was found in 16 cases, all of which showed a pathologic serum β-hydroxybutyrate concentration. The main background of ketoacidosis was considered as alcohol abuse in 6 cases, diabetes in 5, malnutrition in 3, and hypothermia and infection in 1 case each. Severe hepatic fibrosis was observed only in the alcohol-abuser group. Moreover, cardiac steatosis was more severe in patients with possible alcohol abuse than in those with other causes. Immunohistochemistry for adipophilin showed immunoreactivity consistent with BV in 13 of 16 cases. There was no correlation between β-hydroxybutyrate concentration and either the postmortem or storage interval.

CONCLUSIONS.—

Basal vacuolization may be a useful finding for detecting ketoacidosis cases in a postmortem investigation. Serum β-hydroxybutyrate was a stable and reliable compound for the definitive diagnosis of ketoacidosis in such cases. The present study showed that pathologic changes in some organs may vary by each pathologic background of ketoacidosis with BV.

The Importance of BHB Testing on the Post-Mortem Diagnosis of Ketoacidosis

Although beta-hydroxybutyrate (BHB) analysis has proved its importance in forensic pathology, its effects on cause-of-death diagnostics are unaddressed. Therefore, this study aims at evaluating the effects of BHB analysis on the number of deaths by DKA (diabetes ketoacidosis), AKA (alcoholic ketoacidosis), HHS (hyperosmolar hyperglycaemic state), hypothermia, diabetes, alcoholism, and acidosis NOS (not otherwise specified). All 2900 deaths from 2013 through 2019 in which BHB was analysed at the National Board of Forensic Medicine, and 1069 DKA, AKA, HHS, hypothermia, diabetes, alcoholism, and acidosis cases without BHB analysis were included. The prevalence of BHB-positive cases for each cause of death, and trends and proportions of different BHB concentrations, were investigated. The number of BHB analyses/year increased from 13 to 1417. AKA increased from three to 66 and acidosis from one to 20. The deaths from alcoholism, DKA, and hypothermia remained stable. It is unclear why death from alcoholism remained stable while AKA increased. The increase in unspecific acidosis deaths raises the question why a more specific diagnosis had not been used. In conclusion, BHB analysis is instrumental in detecting AKA and acidosis. The scientific basis for the diagnosis of DKA and hypothermia improved, but the number of cases did not change.

Characteristics of post-mortem beta-hydroxybutyrate-positivet cases - A retrospective study on age, sex and BMI in 1407 forensic autopsies

BACKGROUND

Post-mortem biochemistry, including the analysis of beta-hydroxybutyrate (BHB), is increasingly employed in forensic medicine, especially in conditions such as diabetes and chronic alcoholism. However, not much is known about the associations between age, body mass index (BMI), and sex and BHB concentrations in ketoacidotic conditions.

AIM

To retrospectively study the association between age, BMI and sex in several conditions, such as diabetic ketoacidosis (DKA), alcoholic ketoacidosis (AKA), and elevated post-mortem BHB concentrations.

METHODS

1407 forensic autopsy cases analysed for BHB were grouped by diagnosis: DKA, AKA, HHS [hyperosmolar hyperglycaemic state], acidosis NOS [not otherwise specified], or hypothermia. Age, sex, BMI and the concentrations of blood alcohol, vitreous glucose and blood BHB were recorded.

RESULTS

Cases of AKA and DKA were most numerous (184 and 156, respectively). In DKA and in its male subgroup, cases with severe ketosis (BHB>1000 µg/g) were younger and had a lower BMI than those with moderate ketosis (BHB 250-1000 µg/g) and controls (P<0.001). In DKA and in its female subgroup, cases with moderate ketosis cases were older (P = 0.0218 and P = 0.0083) than controls. In AKA and in its male subgroup, cases with severe ketosis had a lower BMI than those with moderate ketosis (P = 0.0391 and P = 0.0469) and controls (P<0.001). Cases with moderate ketosis had a lower BMI than controls (P<0.001).

CONCLUSIONS

BHB concentration is associated with BMI in DKA and AKA, and with both BMI and age in DKA. Constitutional factors should, therefore, be considered in potential AKA and DKA cases.

The Vital Role of Thanatochemistry in the Postmortem Diagnostic of Diabetic Ketoacidosis-Case Report

Diabetic ketoacidosis (DKA) is a lethal acute hyperglycemic complication of diabetes mellitus (DM) and it represents the initial manifestation of DM in about 15-20% of cases in adults and about 30-40% of cases in children. Postmortem diagnosis of DKA can only be made by applying thanatochemistry. Biochemistry applied postmortem is viewed with skepticism by many practitioners in the forensic field, completely lacking in many forensic services around the world, and especially in the national ones. This article aims to underline the importance of the postmortem application of biochemistry by reviewing the case of a person in the third decade of life who died suddenly at home due to diabetic ketoacidosis (DKA), whose autopsy was performed at an early PMI of approximately 24 h. Routine postmortem examinations (macroscopic, anatomopathological, and toxicological) could not establish a clear cause of death. When attention was turned to biochemical determinations (i.e., determination of glycated hemoglobin, glucose and ketone bodies (acetone, beta-hydroxybutyrate) in the blood, vitreous humor, and cerebrospinal fluid), the identified values clarified the thanatogenic mechanisms by establishing the diagnosis of DKA.

Relationship between betahydroxybutyrate (BHB) and acetone concentrations in postmortem blood and cause of death

Unexpected death caused by diabetic or alcoholic ketoacidosis is easily overlooked due to the non-specific symptoms. Although the acid betahydroxybutyrate (BHB) is the most abundant ketone body formed in conditions with ketoacidosis, routine analysis in postmortem investigations often only includes the neutral ketone body acetone. This study aims to evaluate the usefulness of implementing routine BHB analysis in postmortem cases, by investigating the relationship between BHB and acetone concentrations in postmortem blood and the main cause of death. From our database of forensic autopsy cases examined from 2012 to 2015, there were 376 cases with BHB and/or acetone detected in postmortem blood that could be paired with data from the Norwegian Cause of Death Registry. Cases were categorized into three groups based on cause of death: "Diabetes-related" (n = 38), "Alcohol-related" (n = 35) and "Other" (n = 303). Analysis of BHB in blood was performed using UHPLC-MS/MS (limit of quantification (LOQ) 52 mg/L) and of acetone using HS-GC-FID (LOQ 87 mg/L). For the purpose of the study, the acetone method was also validated for a LOQ of 23 mg/L. The median BHB concentration was significantly higher in the group of diabetes-related deaths (671 mg/L, range 68-1311 mg/L) compared to the group of alcohol-related (304 mg/L, range 65-1555 mg/L, p <0.001) and other causes of deaths (113 mg/L, range 0-1402 mg/L, p <0.001). In seven deaths (1.9%), the BHB blood concentration was above the suggested pathological threshold of 250 mg/L, without detection of acetone in blood above 23 mg/L. In 15% of deaths by other causes than diabetes or alcohol, a pathologically significant BHB blood concentration was detected. Our results indicate that BHB is a more reliable marker of pathologically significant ketoacidosis than acetone, and we suggest that BHB should be routinely analyzed in postmortem investigations.