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Luo S, Ma X, Li X, Xie Z, Zhou Z. Fulminant type 1 diabetes: A comprehensive review of an autoimmune condition. Diabetes Metab Res Rev 2020; 36:e3317. [PMID: 32223049 DOI: 10.1002/dmrr.3317] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 03/17/2020] [Accepted: 03/19/2020] [Indexed: 12/18/2022]
Abstract
Fulminant type 1 diabetes (FT1D) is a subset of type 1 diabetes characterized by extremely rapid pancreatic β-cell destruction with aggressive progression of hyperglycaemia and ketoacidosis. It was initially classified as idiopathic type 1 diabetes due to the absence of autoimmune markers. However, subsequent studies provide evidences supporting the involvement of autoimmunity in rapid β-cell loss in FT1D pathogenesis, which are crucial for FT1D being an autoimmune disease. This article highlights the role of immunological aspects in FT1D according to the autoimmune-associated genetic background, viral infection, innate immunity, adaptive immunity, and pancreas histology.
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Affiliation(s)
- Shuoming Luo
- Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Diabetes Immunology (Central South University), Ministry of Education; National Clinical Research Center for Metabolic Diseases, Changsha, China
| | - Xiaoxi Ma
- Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Diabetes Immunology (Central South University), Ministry of Education; National Clinical Research Center for Metabolic Diseases, Changsha, China
| | - Xia Li
- Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Diabetes Immunology (Central South University), Ministry of Education; National Clinical Research Center for Metabolic Diseases, Changsha, China
| | - Zhiguo Xie
- Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Diabetes Immunology (Central South University), Ministry of Education; National Clinical Research Center for Metabolic Diseases, Changsha, China
| | - Zhiguang Zhou
- Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Diabetes Immunology (Central South University), Ministry of Education; National Clinical Research Center for Metabolic Diseases, Changsha, China
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Kjærulff MLBG, Astrup BS. Sudden death due to diabetic ketoacidosis following power failure of an insulin pump: Autopsy and pump data. J Forensic Leg Med 2019; 63:34-39. [PMID: 30856551 DOI: 10.1016/j.jflm.2019.02.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 02/11/2019] [Accepted: 02/22/2019] [Indexed: 02/05/2023]
Abstract
PURPOSE To report a case in which autopsy findings and data from an insulin pump illustrate the course up to the death of a 31-year-old man with a history of type 1 diabetes mellitus who was found dead in his apartment with his insulin pump disassembled and placed in another room. METHODS Autopsy findings including histological, toxicological and biochemical examination are presented. Postmortem download of data from the insulin pump gave the history of the pump, which included blood glucose, insulin bolus, carbohydrate intake and the time course in the days to death, and the pump settings were recorded. For this case report, police reports on the death as well as hospital records were also reviewed. RESULTS At the patch for the insulin pump, nothing abnormal was found. Biochemical analysis showed glucose of 35 mmoL/L in vitreous humor fluid indicating antemortem hyperglycemia, and ketone bodies in the blood of 11.0 mmoL/L indicating ketoacidosis. Acute pulmonary hemostasis, chronic fat accumulation in the liver and acute fat accumulation in the kidneys were histological detected. There were no signs of late diabetic complications such as nephropathy or cardiovascular disease in the tissues. Insulin pump data showed that after three alarms, a power failure of the pump occurred leading to discontinuing insulin delivery, and about 48 h before the deceased was found dead, his body was depleted of insulin. CONCLUSION The cause of death is believed to be diabetic ketoacidosis due to completely lack of insulin because of power failure of the insulin pump, which therefore has been a decisive factor in the cascade of events that led to death. The case is, to our knowledge, the first to illustrate a death caused by diabetic ketoacidosis which is supported by autopsy findings and by data of an insulin pump up to the time of power failure. It is a strong example of usefulness of postmortem download of data from insulin pumps to help determine the cause of death among diabetics. Forensic pathologists should therefore review data and history of the pump systematically.
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Affiliation(s)
| | - Birgitte Schmidt Astrup
- Institute of Forensic Medicine, University of Southern Denmark, J.B. Winsløws Vej 17B, 5000, Odense C, Denmark.
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Abstract
RATIONALE Fulminant type 1 diabetes mellitus (FT1DM) is a new subtype of type 1 diabetes mellitus that was first proposed by the Japanese scholar Imagawa in 2000. In the 2 patient cases described in this study, gastrointestinal symptoms were the first symptoms reported, and the initial blood glucose levels were very high. However, the glycosylated hemoglobin (HbA1c) levels were not very high, the islet β-cell function was almost completely lost in a short time, and the metabolic disorder was severe; the patients' islet β cells demonstrated complete and irreversible functional damage, and the prognosis was poor. PATIENT CONCERNS We report a 37-year-old and 48-year-old male patients. The first patient was addmited with emesis and diarrhea for 2 days and the second patient had stomachache for 8 days, emesis and dyspnea for half an hour before admission. Both patients had no history of hypertension, coronary heart disease, or hyperglycemia. DIAGNOSIS Two patients had same scenario: acute onset, hyperglycemia, ketoacidosis, β cell function deficiency, and HbA1c <8.5%. INTERVENTIONS After admission, the administration of adequate liquid infusion, the intravenous injection of regular insulin to reduce the blood glucose levels, and the correction of electrolyte disturbance and acid-base imbalance were conducted. OUTCOMES Subsequently, the blood glucose level of the patients was gradually reduced, the acidosis was corrected, and the disease conditions gradually stabilized. For both patients, the long-term insulin replacement therapy of "insulin aspart plus insulin glargine" was selected. LESSONS FT1DM is a new subtype of type 1 diabetes mellitus. The onset of this disease is rapid, and the function of islet β cells is almost completely lost in a short time period. This metabolic disorder is severe, and the clinical manifestations are nonspecific. Unless a timely and accurate diagnosis is made, and patients receive prompt treatment, it is difficult to control the disease and the risk of death is high.
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Mizutani T, Yoshimoto T, Ishii A. Pericardial fluid is suitable as an alternative specimen for the measurement of β-hydroxybutyrate within 96 h after death. Leg Med (Tokyo) 2018; 33:53-54. [PMID: 29859352 DOI: 10.1016/j.legalmed.2018.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 05/15/2018] [Accepted: 05/20/2018] [Indexed: 11/16/2022]
Abstract
We examined postmortem β-hydroxybutyrate (BHB) levels in the body fluids obtained from 253 forensic autopsy cases whose causes of death were determined. Postmortem changes of BHB levels according to postmortem intervals (PMI) in various body fluids (plasma, urine, vitreous humor, and pericardial fluids) were investigated to determine appropriate alternative specimens as plasma samples. Our study has indicated the following points: 1) the BHB levels in plasma specimens from three sampling sites showed no significant differences, 2) postmortem changes of BHB levels in plasma and pericardial fluids could be negligible within 96 h PMI, while urine and vitreous humor BHB levels showed postmortem changes, and 3) pericardial fluid would thus be most suitable as an alternative to plasma in postmortem BHB level. We have also proposed that BHB levels could be applicable for the diagnosis of metabolic disorders in forensic autopsy.
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Affiliation(s)
- Tatsushi Mizutani
- Department of Respiratory Medicine, Kyoto University Graduate School of Medicine, 54 Kawahara Shogoin, Sakyo-ku, Kyoto 606-8507, Japan; Department of Legal Medicine and Bioethics, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Takashi Yoshimoto
- Department of Legal Medicine and Bioethics, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Akira Ishii
- Department of Legal Medicine and Bioethics, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya 466-8550, Japan.
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Tani N, Michiue T, Chen JH, Oritani S, Ishikawa T. Usefulness 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. Leg Med (Tokyo) 2016; 22:23-9. [PMID: 27591535 DOI: 10.1016/j.legalmed.2016.07.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 07/04/2016] [Accepted: 07/25/2016] [Indexed: 10/21/2022]
Abstract
A severely malnourished, Japanese female in her twenties was found dead in her apartment. On autopsy, most of the findings from the internal examination were suggestive of hypothermia. Postmortem biochemistry, however, showed severely increased levels of glycated hemoglobin (HbA1c) and blood and urine glucose levels. Levels of acetone, 3-hydroxybutyric acid, and acetoacetate in various body fluids were also highly increased, indicating ketosis. The serum insulin and c-peptide levels were severely low, and subsequent testing was positive for anti-GAD antibodies. Immunohistochemical examination of the pancreatic islet cells revealed few insulin-positive cells but many glucagon-positive cells on staining. Furthermore, slight invasion of CD8-positive lymphocytes in the pancreatic islets of Langerhans was observed. Results of immunostaining of the pancreatic and bronchial epithelial tissues were partly positive for the Influenza A virus. We concluded that severe ketoacidosis associated with rapid-onset hyperglycemia due to autoimmune type 1 diabetes (AT1D) had occurred shortly before death. However, the ketosis was accompanied by hypothermia and malnutrition as well as diabetic ketoacidosis (DKA). Therefore, we retrospectively collected biochemical data on cases of hypothermia and malnutrition and compared them with the present case. Serum glucose, acetone, 3-hydroxybutyric acid, and acetoacetic acid can be used for screening and diagnosis to distinguish DKA from ketosis due to hypothermia and malnutrition. Therefore, in the present case, we diagnosed that the natural cause of death was due to AT1D. In conclusion, screening investigations for relevant biochemical markers can provide essential information for the diagnosis of metabolic disturbances, which fail to demonstrate characteristic autopsy findings.
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Affiliation(s)
- Naoto Tani
- Department of Legal Medicine, Osaka City University Medical School, Asahi-machi 1-4-3, Abeno, 545-8585 Osaka, Japan; Forensic Autopsy Section, Medico-legal Consultation and Postmortem Investigation Support Center, c/o Department of Legal Medicine, Osaka City University Medical School, Asahi-machi 1-4-3, Abeno, 545-8585 Osaka, Japan
| | - Tomomi Michiue
- Department of Legal Medicine, Osaka City University Medical School, Asahi-machi 1-4-3, Abeno, 545-8585 Osaka, Japan; Forensic Autopsy Section, Medico-legal Consultation and Postmortem Investigation Support Center, c/o Department of Legal Medicine, Osaka City University Medical School, Asahi-machi 1-4-3, Abeno, 545-8585 Osaka, Japan
| | - Jian-Hua Chen
- Department of Legal Medicine, Osaka City University Medical School, Asahi-machi 1-4-3, Abeno, 545-8585 Osaka, Japan; Forensic Autopsy Section, Medico-legal Consultation and Postmortem Investigation Support Center, c/o Department of Legal Medicine, Osaka City University Medical School, Asahi-machi 1-4-3, Abeno, 545-8585 Osaka, Japan
| | - Shigeki Oritani
- Department of Legal Medicine, Osaka City University Medical School, Asahi-machi 1-4-3, Abeno, 545-8585 Osaka, Japan
| | - Takaki Ishikawa
- Department of Legal Medicine, Osaka City University Medical School, Asahi-machi 1-4-3, Abeno, 545-8585 Osaka, Japan; Forensic Autopsy Section, Medico-legal Consultation and Postmortem Investigation Support Center, c/o Department of Legal Medicine, Osaka City University Medical School, Asahi-machi 1-4-3, Abeno, 545-8585 Osaka, Japan.
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Ely SF. Sudden Death Related to Diabetes Mellitus: Current and Emerging Relevance to the Forensic Pathologist. Acad Forensic Pathol 2016; 6:154-163. [PMID: 31239887 PMCID: PMC6506998 DOI: 10.23907/2016.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 04/01/2016] [Accepted: 04/25/2016] [Indexed: 11/12/2022]
Abstract
While diabetes mellitus (DM) has historically accounted for substantial worldwide morbidity and mortality, new and evolving epidemiologic trends are forcing the scientific community to view it as a type of emerging disease. This review will summarize the pathophysiology of the disease, present an update of current national statistics and changing epidemiologic patterns, discuss how DM might specifically lead to acute deaths falling under the jurisdiction of the medical examiner/coroner, and suggest a medicolegal standard of practice to maximize their capture and reporting.
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Affiliation(s)
- Susan F. Ely
- Office of Chief Medical Examiner of the City of New York -
Forensic Medicine
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Risk factors for sudden death and cardiac arrest at the onset of fulminant type 1 diabetes mellitus. Diabetol Int 2015; 7:281-288. [PMID: 30603275 DOI: 10.1007/s13340-015-0247-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 12/01/2015] [Indexed: 01/23/2023]
Abstract
Aims The onset of fulminant type 1 diabetes mellitus is sometimes accompanied by sudden death or cardiac arrest. The aim of this study was to determine the risk factors for the development of these conditions at the onset of fulminant type 1 diabetes mellitus. Methods We conducted a search of the literature on fulminant type 1 diabetes and sudden death or cardiac arrest published up to 2012 in PubMed and Ichushi (a Japanese article database), and a questionnaire survey was administered to the authors of the articles and to diabetes specialists affiliated to the Japan Diabetes Society. We analyzed the clinical data at disease onset of 17 patients with fulminant type 1 diabetes mellitus who experienced sudden death or cardiac arrest, and those of 257 patients who did not develop these conditions. Results Patients with sudden death or cardiac arrest were younger, had a higher rate of impaired consciousness, more severe acidosis, hyperglycemia, hyponatremia, hyperkalemia, and hypochloremia, a higher serum blood urea nitrogen level, a higher serum creatinine level, and a higher plasma osmolality level than the other patients. In multiple logistic regression analyses, plasma glucose level was positively associated with sudden death or cardiac arrest. Receiver operating characteristic curve analyses showed that patients with a plasma glucose level over 1000 mg/dl (55.5 mmol/l) were at a high risk of cardiac arrest. Conclusions Severe metabolic derangement, especially a high plasma glucose level, is associated with sudden death or cardiac arrest at the onset of fulminant type 1 diabetes mellitus.
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Dong H, Liu L, Zhou Y, Mu J, Zhang J. Sudden death of a 15-year-old girl due to fulminant type 1 diabetes mellitus—Diabetic ketoacidosis induced cerebral edema? J Forensic Leg Med 2014; 26:5-9. [DOI: 10.1016/j.jflm.2014.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Palmiere C, Mangin P, Werner D. Postmortem Distribution of 3-Beta-Hydroxybutyrate. J Forensic Sci 2013; 59:161-6. [DOI: 10.1111/1556-4029.12265] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 10/02/2012] [Accepted: 10/13/2012] [Indexed: 11/28/2022]
Affiliation(s)
- Cristian Palmiere
- University Centre of Legal Medicine; Rue du Bugnon 21 1011 Lausanne Switzerland
| | - Patrice Mangin
- University Centre of Legal Medicine; Rue du Bugnon 21 1011 Lausanne Switzerland
| | - Dominique Werner
- Laboratory of Clinical Chemistry; Lausanne University Hospital; 1011 Lausanne Switzerland
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Palmiere C, Bardy D, Mangin P, Werner D. Postmortem diagnosis of unsuspected diabetes mellitus. Forensic Sci Int 2013; 226:160-7. [DOI: 10.1016/j.forsciint.2013.01.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Revised: 12/21/2012] [Accepted: 01/04/2013] [Indexed: 01/25/2023]
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