Biochemical Differences Between Vitreous Humor and Cerebral Spinal Fluid in a Death From Diabetic Ketoacidosis

Significant ketoacidosis at autopsy: a single-centre systematic review

AIM

To examine the value of vitreous beta-hydroxybutyrate and serum acetone in the investigation of sudden unexpected death.

METHODS

Coroners' autopsy reports from a provincial UK city, with a population of approximately 900 000, over a 24-month period with significant ketoacidosis were studied. Demographic features, medical history, anatomical and histological findings, and biochemical parameters, including renal function, vitreous glucose, serum and vitreous alcohol, were analysed.

RESULTS

Forty-two cases (28 males and 14 females) were identified; 55% had a history of alcohol and/or substance misuse, and mental health problems, particularly depression and anxiety, and 16% were diabetic. In all, 50% of subjects had alcoholic ketoacidosis (AKA), 19% had diabetic ketoacidosis (DKA) and 12% had a history of both diabetes and alcohol abuse. In 19% of cases, an exact cause of ketoacidosis was established. In AKA, the subjects typically had low vitreous glucose and low or undetected blood alcohol levels. All of the subjects with raised vitreous glucose levels had DKA.

CONCLUSION

Ketoacidosis is relatively common and should be considered as a cause of sudden death, especially in alcoholic patients and patients with diabetes with no clear cause of death at autopsy.

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.

Biological Mechanisms behind Wischnewsky Spots Finding on Gastric Mucosa: Autopsy Cases and Literature Review

Hypothermia is an emergency caused by the lowering of the central body temperature with a slowdown of basic vital functions. Reduced mobility, old age, psychiatric or metabolic disorders are relevant risk factors. Diagnosis of death from hypothermia is a challenge, as there are no pathognomonic signs, and supportive findings can be inconstant. Wischnewsky Spots (WS) are blackish lesions of gastric mucosa, typically associated with hypothermic death. The pathophysiology of these lesions is still uncertain. The aim of this paper is to investigate the pathological mechanisms determining the appearance of WS by analyzing the current scientific knowledge in this area. We performed a narrative review of the literature published in the last 20 years, comparing the results with three cases of hypothermia reported from our experience. The review proved that WS show a multifactorial etiology, i.e., not only body temperature decrease, but also various extrinsic and intrinsic factors, such as physical and psychological stress, agony, causa mortis and metabolic comorbidities. The review summarizes the current knowledge in the field of incidence, pathology and morphology of WS by proposing some scientific and technical points for clinical and forensic analysis of this phenomenon.