Gastric Mucosal Petechial Hemorrhages (Wischnewsky Lesions), Hypothermia, and Diabetic Ketoacidosis

Abstract

For more than 100 years since their initial description, gastric mucosal petechial hemorrhages have been discovered at autopsy in cases where environmental hypothermia was determined to be the cause of death. Although these lesions are frequently seen in deaths caused by environmental hypothermia, they can also be seen in cases where hypothermia is not implicated; however, this has been seldom described. We present a series of autopsy cases where hypothermia has been conclusively ruled out as a cause of death, in which Wischnewsky lesions are found. In all of these cases, diabetic ketoacidosis (DKA) was determined to be the proximate cause of death, as confirmed through clinical history, laboratory analysis, and absence of other anatomic or toxicological findings. We provide a mechanism of Wischnewsky lesion formation and how that mechanism relates to both hypothermia and ketoacidosis. Our data show that gastric mucosal petechial hemorrhages are not specific for hypothermia-related deaths, and are likely indicative of a state in which hypothermia and DKA have a common underlying pathophysiology, most likely a coagulopathy. Our data also illustrate that in autopsy cases where Wischnewsky lesions are found, DKA should be seriously considered as the underlying cause of death, particularly in the absence of indications of environmental hypothermia.

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

“…The blood identified in the gastric lumen, the only obvious morphological change, may have two explanations. Either a synergistic effect of the DKA induced acidosis, with the manifestation of coagulation disorders and subsequent hemorrhage, or the existence of a marked physiological stress often present in agonic states [12]. Wischnewsky gastric lesions and acute esophageal necrosis were also not identified in our case.…”

“…There are authors who consider Armanni-Ebstein kidney injuries as pathognomonic for DKA [9,10]. Recent studies correlate Wischnewsky gastric lesions and acute esophageal necrosis with death caused by DKA [11][12][13].…”

Molecular mechanisms of Wischnewski spot development on gastric mucosa in fatal hypothermia: an experimental study in rats

“…In addition, differences may result from severe atrophic gastritis or Helicobacter pylori infection, which may cause a low secretion of gastric acid 31 . Wischnewski spots have been recognized in cases of non-hypothermic diabetic ketoacidosis 32 and fatal burn 33 . Nevertheless, the genesis and pathophysiology of these spots in cases of fatal hypothermia remain unclear.…”

The Evaluation of the Deaths Related to Hypothermy in Eskisehir between 1997 and 2016

“…These lesions, as described by Wischnewsky, are expressed as "Wichnewsky spot" [26,27]. Possible causes of these stains are thought to be cellular damage caused by submucosal hypoxia, which is secondary to the shift of the oxyhemoglobin dissociation curve to the left and decrease in metabolic rate [1,6,[27][28][29]. It has been reported that the incidence of hypothermia in Wischnevsky ulcers varies between 44%-90.9% [30].…”