Postmortem Diagnosis of Diabetic Ketoacidosis Presenting as the "Dead-in-Bed Syndrome"

Luna, Jennie; Gilliland, M. G. F.; Hewan-Lowe, Karlene; Tanenberg, Robert J.

doi:10.4158/ep13473.cr

Cited by 7 publications

(6 citation statements)

References 13 publications

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“…As acetone is often routinely measured with ethanol as part of toxicological analysis in post mortem investigations, its presence can be used as an indicator for ketoacidosis, where measurement of β-hydroxybutyrate can further confirm the diagnosis. 32 Luna et al 33 reported a case which was initially suspected as “dead in bed” syndrome, however the toxicological and biochemical assessment of the vitreous fluid revealed a ketoacidotic profile. Almost 20% of the “dead-in-bed” cases investigated by Edge et al 8 were found to have hyperglycemia and ketonemia after post-mortem toxicological investigations.…”

Section: Discussionmentioning

confidence: 99%

Diabetes Related Deaths in a Tertiary Pediatric Referral Institution in England: The Value of Biochemical Analyses in Post-Mortem Samples

2023

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Objectives: To establish the incidence of “diabetes-related death” (DRD) in children with known and unknown Diabetes Mellitus (DM) dying unexpectedly, and describe post-mortem (PM) biochemistry findings. Patients and Methods: PM reports from the previous 16-year period were reviewed. Cases of DRD were extracted. All available demographic, clinical, and autopsy data including laboratory analyses was retrieved. Results: 9/1376 (0.7%) DRD cases were identified. This was attributed to Diabetic Ketoacidosis in 7 and to Death in Bed Syndrome in 2. 4/9 cases were known diabetic and on insulin; whilst in 5/9 cases the diagnosis of DM was at PM. The mean age was 11.6 years (range 2.5–15). At PM, 4 cases were undernourished. The histology demonstrated pancreatic changes in keeping with DM in 3/9 and unremarkable pancreatic findings in 6/9. 3 cases also had autoimmune thyroiditis (1 also had myocarditis and Armanni-Ebstein nephropathy). Toxicological and biochemical analysis showed raised: β-hydroxybutyrate in 6, ketone bodies in 5 cases and raised HbA1c in 3c. Conclusion: Type 1 DM is an infrequent but yet potentially preventable cause of death in children. Our findings highlight the value of routine biochemical and toxicological analysis in all PM examinations of infants and children dying suddenly and unexpectedly.

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Section: Discussionmentioning

confidence: 99%

Diabetes Related Deaths in a Tertiary Pediatric Referral Institution in England: The Value of Biochemical Analyses in Post-Mortem Samples

2023

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“…The literature has previously reported cases with DKA as the cause of death due to, for example, intake of drugs [14,15] or undetected diabetes mellitus [16,17]. A single case report has described a death due to DKA in a type 1 diabetic with insulin pump, where the deceased had not replaced an empty ampoule of insulin [18]. In addition, a case has been described using the possibility of looking at data from an insulin pump and a continuous glucose monitoring system that showed the progress of blood glucose to death caused by hypoglycemia [19].…”

Section: Insulin Pumpsmentioning

confidence: 99%

“…The very high levels of ketone bodies in the blood (11 mmol/L) and of the vitreous glucose (35 mmol/L) indicate DKA rather than hypothermia or malnutrition. In alcoholic ketoacidosis, glucose levels are normal or low [7,18], and at sudden death due to e.g. ischemic heart disease, cerebrovascular disease or thromboembolism, there is elevated glucose levels but no elevated ketone bodies [20].…”

Section: Accepted Manuscriptmentioning

confidence: 99%

“…Sometimes, it can be complicated to determine whether DKA is the cause of death as macroscopic and microscopic findings that can be done, such as cerebral edema or Armanni-Ebstein lesions, are not specific to the diagnosis as these acute complications may also occur for other reasons. Biochemical analyzes of, for example, glucose in vitreous humor fluid and beta-hydroxybutyrate in the blood can supplement the postmortem examination and help to address the cause of death [5,7,18]. Reading the insulin pump's data and history can provide additional information in the time before death, thus giving an indication of what triggered the DKA.…”

Section: Importance Of Insulin Pump Datamentioning

confidence: 99%

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Sudden death due to diabetic ketoacidosis following power failure of an insulin pump: Autopsy and pump data

Kjærulff

Astrup

2019

Journal of Forensic and Legal Medicine

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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 hours 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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“…Diabetic ketoacidosis is the most common cause. There are multiple case reports that show death as the result of diabetic ketoacidosis [9][10][11]. Patients with type 1 diabetes are often associated with diabetic ketoacidosis.…”

Section: Introductionmentioning

confidence: 99%

Examination of Postmortem β-Hydroxybutyrate Increase in Forensic Autopsy Cases

et al. 2022

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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.

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Postmortem Diagnosis of Diabetic Ketoacidosis Presenting as the "Dead-in-Bed Syndrome"

Cited by 7 publications

References 13 publications

Diabetes Related Deaths in a Tertiary Pediatric Referral Institution in England: The Value of Biochemical Analyses in Post-Mortem Samples

Diabetes Related Deaths in a Tertiary Pediatric Referral Institution in England: The Value of Biochemical Analyses in Post-Mortem Samples

Sudden death due to diabetic ketoacidosis following power failure of an insulin pump: Autopsy and pump data

Examination of Postmortem β-Hydroxybutyrate Increase in Forensic Autopsy Cases

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