Postmortem diagnosis of unsuspected diabetes mellitus established by determination of decedent's hemoglobin A1c level.

Although approximately 15.7 million Americans have diabetes mellitus, with the vast majority having type 2 diabetes, it is estimated that as many as 5.4 million are undiagnosed. The present case illustrates that undiagnosed diabetes can be a factor in otherwise unexplained deaths. A 39-year-old white male with no significant past medical history other than alcohol abuse was found deceased at his residence. The manner of death appeared to be natural, but no anatomic cause was found. Toxicological analysis revealed a blood ethanol level of 0.02 g/dL and was negative for drugs of abuse. Analysis of the vitreous fluid revealed a glucose level of 502 mg/dL. The blood glucose level was 499 mg/dL, and the hemoglobin A1c (HbA1c) level was 10.6%. Only trace urine ketones were detected, suggesting that the death was the result of hyperglycemic hyperosmolar non-ketosis (HHNK) from unsuspected diabetes. The postmortem HbA1c value serves as a definitive indicator of prolonged hyperglycemia. In order to aid the interpretation of the clinical data, this case is discussed in conjunction with a similar case of a known diabetic patient.     

Glucose and lactate in vitreous humor compared with the determination of fructosamine for the postmortem diagnosis of diabetes mellitus

Diabetes mellitus is a chronic metabolic illness responsible for a great number of deaths. In postmortem diagnosis, because of the difficulty involved in interpreting blood glucose levels and relatively nonspecific pathologic features, biochemical markers in vitreous humor are useful. The aim of this study was to compare the results obtained for the combined determination of lactate and glucose with fructosamine levels recorded in the vitreous humor of two diagnostic groups (one diabetic and the other nondiabetic). The authors intended to ascertain the capacity of different markers measured in vitreous humor to diagnose diabetes mellitus. Fifty-one cadavers (mean age, 58.7 years; standard deviation, 17.09) were studied. The mean postmortem interval was 16.4 hours (standard deviation, 9.05). Cases were assigned to two diagnostic groups according to whether they were previously diagnosed as either diabetic or nondiabetic. Statistically significant differences for glucose, fructosamine, and the sum values of glucose and lactate were found between the two diagnostic groups. The highest levels were obtained in the group of cases with a previous diagnosis of diabetes mellitus. After the comparison of receiver operating characteristic curves, the sum values of glucose and lactate in vitreous humor is a better predictor of antemortem diabetes mellitus than the fructosamine.     

Postmortem vitreous humor beta-hydroxybutyrate: its utility for the postmortem interpretation of diabetes mellitus

Ketoacidotic coma is one of the most serious complications arising from diabetes mellitus, especially type I, and may be the cause of sudden death especially in diabetes type I. Since beta-hydroxybutyrate (beta-OHB) serum concentrations might provide more information on the severity of ketoacidosis, the aim of this study was to evaluate the concentrations of beta-OHB in vitreous humor and its correlation with other biochemical parameters during postmortem examination. We intended to ascertain the sensitivity and the specificity of these markers for diagnosing diabetes mellitus and the presence of ketoacidosis. This study involved 453 cadavers with a mean age of 57.6 years (S.D. 20.7) and a mean postmortem interval of 17.8 h (S.D. 9.6, range 2-61 h). Cases were assigned to two diagnostic groups according to the antemortem diagnosis of diabetes mellitus, based on the patients' medical records. In vitreous humor statistically significant differences were found in biochemical marker concentrations between the two diagnostic groups, the highest values being obtained in the group of subjects with a previous diagnosis of diabetes mellitus. The measurement of beta-OHB in vitreous humor may be a useful alternative to using blood during postmortem analysis. The presence of high levels of beta-OHB may help interpret the cause of death in diabetics when the autopsy result is negative.     

Postmortem diagnosis of sepsis

Human sepsis is a spectrum of pathophysiological changes in the host system resulting from a generalized activation and systemic expression of the host's inflammatory pathways in response to infection. Since autopsy findings and routine histology in cases of suspected fatal sepsis are most often unspecific and unconvincing, a number of studies has recently dealt with different methods and markers to better define criteria for the postmortem diagnosis of sepsis. Research carried out on specimens obtained postmortem from sepsis-associated fatalities is an important tool to improve our understanding of inflammatory organ changes and the associated underlying pathophysiological mechanisms. One pitfall the investigator has to be aware of is how to select appropriate case material that constitutes the basis for the setting-up of reference values that derive from such studies. Since no scientific studies have investigated the value of cardiac blood samples in the present context, autopsy blood samples for the determination of biochemical sepsis markers have to derive from the femoral vein. In both sepsis cases as well as controls, the time of death has to be well defined.     

Postmortem diagnosis of cerebral malaria

Human cerebral malaria is a frequent encephalopathy that occurs in the endemic tropical-subtropical zones. There are a smaller number of imported cases in continental zones where the diagnosis sometimes remains difficult to establish. Fifteen days after the death of a 36-year-old male French citizen in Africa, an investigation to determine the cause of death was conducted. Histologic examination of the brain permitted the diagnosis of cerebral malaria. Because of the popularity of overseas tourism and because this disorder may appear as "sudden death," these victims may be referred to a forensic pathologist. This case demonstrates the role a forensic pathologist may play in determining the cause of death in cerebral malaria.     

On the possibility of postmortem diagnosis of diabetes mellitus

The present study has demonstrated that elevated level of glycated haemoglobin in cadaveric blood may be regarded as an absolute diagnostic criterion for diabetes mellitus irrespective of other macro- and/or micropathomorphological signs of this disease.     

Postmortem roentgen diagnosis of the skull]

In this prospective study, skulls of 164 dead bodies were x-rayed in two different planes. The findings were assessed independent to the results of the subsequent autopsy, however afterwards compared with the autopsy findings. In 86 cases (53.4%) x-ray findings were significant. Dislocated calvarium fractures were clearly visible on the x-rays, however non-dislocated calvarium fractures as well as fractures of the visceral cranium and skull base were difficult to detect. Gas and foreign bodies could easily be observed. Similar to the clinical assessment the indication for a post-mortem x-ray of the skull must consider the case history and the respective condition of the corpse (for example putrefaction, charred body).     

Postmortem diagnosis of meningococcemia by detection of capsular polysaccharides

Detection of specific meningococcal capsular polysaccharide (CPS) in postmortem blood permits rapid diagnosis of meningococcemia and differentiation from pneumococcemia and septicemia caused by Haemophilus influenzae Type b. We present studies validating application of latex agglutination assay for CPS on blood samples collected at autopsy, delineate the circumstances when CPS testing is indicated, and illustrate the usefulness of this procedure by several recent cases. Blood samples from victims dying of injury or disease other than infection were examined to determine whether the postmortem interval, bacterial contamination, anticoagulants, or delay in testing would result in false positive assays. Series 1 samples, collected so as to minimize bacterial contamination, were immediately submitted for assay. Series 2 evaluated the effect of adverse conditions of collection, anticoagulation, and prolonged sample storage. Despite extended postmortem intervals of up to 14 days, heavy bacterial contamination, prolonged storage at 4 degrees C, deep hemolysis, and presence of anticoagulants, false positive assays were seldom observed.     

Sudden and unexpected deaths after the acute onset of diabetes mellitus.

Four cases of sudden and unexpected death caused by the acute onset of diabetes mellitus are reported. Three are examples of acute juvenile diabetes while the fourth demonstrated the aketotic form of diabetic coma. Such instances can present a diagnostic problem to the forensic pathologist. The usefulness of vitreous humor glucose analysis to diagnose such a condition is stressed.     

Postmortem diagnosis of syphilitic aortitis, including serological verification on postmortem blood

304 postmortem blood samples were serologically examined for syphilis at Statens Seruminstitut. Seventy-six percent of the samples were usable and gave clear-cut results (18% positive, 34% negative and 24% borderline). Twenty-four percent were indeterminable. The blood samples originated from 304 medico-legally examined bodies, 301 of whom were autopsied. The indications for the serological examinations were suspicion of syphilitic aortitis (SA) on the basis of the macroscopical appearance of the aorta at the autopsy--or information on earlier syphilis. Ninety-seven cases of SA were verified macro- and microscopically, 53 being lethal. The serological results were positive in half of these 97 cases, negative in 15, borderline in 21 and indeterminable in 12. A little more than half of the 97 cases were known in advance in the nation-wide syphilis index at the State Serum Institute. The variegated findings in the remaining part of the material are discussed. It is concluded that serological examination of postmortem blood may be a valuable adjuvant for the pathologist for the diagnosis of SA and other syphilitic manifestations.     

Postmortem stability of lung surfactant phospholipids.

The postmortem stability of the main phospholipids of lung surfactant-phosphatidyl choline (PC), phosphatidyl ethanolamine (PE), phosphatidyl inositol (PI), phosphatidyl serine (PS) and sphingomyelin (S) in three different deaths; one caused by fresh-water drowning, one by salt-water drowning, and one from a sodium-pentobarbital overdose has been studied. The drug overdose was considered the control because there was no surfactant involvement. The results show the stability of these kinds of lipids in the first 24 h, with a progressive decrease from 48 h on until 96 h, with a significant correlation to the time of P less than 0.01 in most cases.     

Postmortem tissue embolisms. Report of 3 cases

In three cases of autopsy (cause of death - intoxication and drowning) we found in the lung intraalveolar und intravasal lymphatic tissue and bone-marrow. The results cannot be explained with violence during lifetime, but in tow cases as an effect of fracture of rips caused by external cardiacmassage, in one case by embalming with injection of conservation fluids.     

Postmortem stability and interpretation of beta 2-agonist concentrations.

This paper describes a series of stability and redistribution studies aimed at understanding the presence and significance of beta 2-agonists in asthma deaths. Salbutamol and terbutaline were shown to be stable in postmortem blood at 23 degrees C for 1 week, 4 degrees C for 6 months and -20 degrees C for 1 to 2 years. However, fenoterol was shown to degrade at 23 degrees C (83% loss), 4 degrees C (93% loss) and -20 degrees C (66% loss) over the same time. Salbutamol concentrations detected in blood taken at the time of body admission to the mortuary were not significantly different from the concentrations detected in blood taken from the same cases at the time of autopsy (45 h later). This suggests that significant postmortem redistribution of salbutamol is unlikely to occur during this period. Postmortem blood concentrations of at least salbutamol are likely to reflect the concentration of these drugs in the body at the time of death.     

Postmortem angiography of catheter-induced pulmonary artery perforation.

A case of pulmonary artery perforation by the placement of a balloon-tipped, flow-directed (Swan-Ganz) catheter, as demonstrated postmortem by angiography and confirmed by conventional autopsy method, is reported. Angiography is an effective adjunctive modality in the postmortem diagnosis and localization of pulmonary artery perforation. In cases of suspected catheter-induced pulmonary artery perforation and death, postmortem angiography may prove useful to the forensic pathologist.     

Brain amino acid abnormalities in kidney disease and diabetes mellitus

The present postmortem study examines whether specific amino acid abnormalities associated with renal diseases or diabetes mellitus in animal experiments and on clinical examination may also be found in human brain samples obtained at clinical autopsies. The material includes 12 deceased with renal insufficiency, 23 deceased with diabetes mellitus and 26 control cases with lethal cardiovascular diseases (without a history of hepatic, renal or metabolic disturbances). The autopsy and clinical records were retrospectively analyzed for age, sex, postmortem delay, cause of death, substantial preexisting diseases and histological findings. The analysis of free amino acid concentrations in human brain specimens was performed applying a Beckman amino acid analyzer. The results were evaluated using the U-test according to Mann, Willcox and Whitney. A P-value less than 0.05 was considered to be significantly different. Differences of amino acid concentrations attributable to sex, age and postmortem delay were not significant. The comparison of postmortem amino acid concentrations in the brains of patients with diabetes mellitus and controls did not reveal relevant changes. However, the patients with renal diseases, as compared to controls, showed a significant cerebral increase of urea, phenylethanolamine and gamma-aminobutyric acid. Thus, the postmortem amino acid analysis may contribute to the understanding of pathophysiological mechanisms of uremic encephalopathy and may supplement the conventional postmortem morphological diagnosis in kidney diseases by indication of functional impairment.     

Postmortem wound dehiscence. A report of three cases

Three cases of healing incised wounds that dehisced following death are reported. All three deaths were apparent drownings during summer months. The incised wounds had occurred from 1 week to 6 months prior to death. The length of post-mortem immersion ranged from 2 days to 3 weeks, and all three decedents exhibited significant decompositional changes. Proper recognition of this postmortem artifact eliminates undue suspicions and contributes to proper identification.     

Postmortem DNA and RNA synthesis. Preliminary studies in human cadavers

Postmortem DNA and RNA synthesis was detected in tissue specimens harvested from two cadavers at different intervals between 2.5 and 32 h postmortem. Each tissue specimen was incubated for 1 h in a 3H-thymidine or 3H-cytidine solution. DNA- as well as RNA-synthesizing cells were found in skin tissue and bone marrow throughout the interval investigated. Cytidine incorporation decreased progressively during the course of the postmortem interval. DNA and RNA synthesis was also observed in cells of the testis, which were predominantly spermatogonia cells in the case of DNA. Low-grade RNA synthesis was detected in bowel epithelial cells up to 2.5 h postmortem; DNA synthesis was not present during the interval investigated. No supravital phenomena were observable in the splenic tissues examined.     

Postmortem absorption of drugs and ethanol from aspirated vomitus--an experimental model.

Using human cadavers an experimental model was developed to simulate the agonal aspiration of drug- and alcohol-laden vomitus. By needle puncture, an acidified (N/20 HCl) 60-ml slurry of drugs (paracetamol 3.25 g, dextropropoxyphene 325 mg) and ethanol 3% w/v was introduced into the trachea. After 48 h undisturbed at room temperature, blood samples were obtained from ten sites. Ethanol and drug concentrations were highest in the pulmonary vessels in all five cases studied. Pulmonary vein mean ethanol was 58 mg% (range 13-130), paracetamol 969 mg/l (range 284-1934), propoxyphene 70 mg/l (range 11-168). Pulmonary artery mean ethanol was 53 mg% (range 10-98), paracetamol 476 mg/l (range 141-882), propoxyphene 29 mg/l (range 7.6-80). Ethanol and drug concentrations in aortic blood were higher than in the left heart and concentrations in the superior vena cava were higher than in the right heart, suggesting direct diffusion into these vessels rather than diffusion via the pulmonary and cardiac blood. Potential interpretive problems arising from this phenomenon can be avoided by using femoral vein blood for quantitative toxicological analysis.     

MDMA的死后再分布及其机制

对MDMA死后再分布及其发生机制进行的动物实验和案例研究的文献,阐述MDMA死后心血浓度升高、死后通过胃肠道和气管内MDMA的再分布、MDMA在死后代谢再分布中的作用,以及死后再分布的发生机制与死后血液流动、顺浓度梯度扩散、毒物的代谢等有关的问题。     

Postmortem redistribution of morphine and its metabolites

The postmortem redistribution of morphine, morphine-3-glucuronide, morphine-6-glucuronide and total morphine was assessed in 40 heroin-related deaths. In blood taken from subclavian, heart, and femoral regions, concentrations of morphine and its metabolites were similar. While there was a trend for higher concentrations in heart blood, when compared with femoral or subclavian blood, this was not significant. There was also no significant difference in concentrations between admission and autopsy blood in which the postmortem interval was on average 59 h. From our observations, significant postmortem redistribution of morphine and its metabolites seems unlikely.