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

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 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.

Sudden Death in Adults: A Practical Flow Chart for Pathologist Guidance

“…Even if rare, endocrine diseases should be closely related to nc-SD. Notably, when other causes are excluded, this tragic event may be related to different pathological statuses such as adrenal insufficiency (although infrequent, it may occur in individuals treated for other critical conditions where impairment of corticoadrenal function often happen) [ 98 , 99 ], diabetic coma [ 100 ], severe hypothyroidism (myxedema) [ 101 ], parathyroid crisis [ 102 , 103 ], thymoma [ 104 ], etc.…”

Biodistribution of Insulin Following Massive Insulin Subcutaneous Injection

“…The higher insulin level in the pericardial fluid than in the myocardial tissue was probably because a specific insulin level was maintained in the venous system rather than due to insulin acting on the heart in the early stage, given the high insulin level in iliac vein blood compared to right heart blood. In the liver ( 31 ) and brain ( 32 , 33 ), where insulin action is notable, the insulin level was low in the case subject, showing no notable difference from control cases. The high insulin level in the CSF was probably due to influx from the venous system in the choroid plexus ( 34 ).…”

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

“…The presence of hemorrhage in the gastric lumen is at least interesting, and we have the courage to say that if death would have occurred later, there would have been the possibility for the Wischnewsky spots to appear or even for acute esophageal necrosis to develop [12,13]. Many autopsies performed on DKA cases that have been reported in the literature speak about the absence of characteristic macro and microscopic changes [6,36]. Additionally, in this case, the pancreas was characterized only by autolysis.…”