Postmortem biochemistry in suspected starvation-induced ketoacidosis

A Guide to the Postmortem Investigation of Starvation in Adults

ABSTRACT

Starvation is a rare cause of death in developed countries and is a complex multifaceted pathological process. To complicate the forensic investigation of starvation further, many medical conditions independent of starvation may cause wasting. This article provides one of the first comprehensive guides to the postmortem investigation of starvation in adults, with reference tables on organ-specific macroscopic and microscopic features, as well as features for excluding alternative causes of wasting. The eclectic literature on this complex topic is summarized in an accessible and easily referenced format, including mechanisms of death and ancillary postmortem investigations.

The Future of Analytical and Interpretative Toxicology: Where are We Going and How Do We Get There?

(Forensic) toxicology has faced many challenges, both analytically and interpretatively, especially in relation to an increase in potential drugs of interest. Analytical toxicology and its application to medicine and forensic science have progressed rapidly within the past centuries. Technological innovations have enabled detection of more substances with increasing sensitivity in a variety of matrices. Our understanding of the effects (both intended and unintended) have also increased along with determination and degree of toxicity. However, it is clear there is even more to understand and consider. The analytical focus has been on typical matrices such as blood and urine but other matrices could further increase our understanding, especially in postmortem (PM) situations. Within this context, the role of PM changes and potential redistribution of drugs requires further research and identification of markers of its occurrence and extent. Whilst instrumentation has improved, in the future, nanotechnology may play a role in selective and sensitive analysis as well as bioassays. Toxicologists often only have an advisory impact on pre-analytical and pre-interpretative considerations. The collection of appropriate samples at the right time in an appropriate way as well as obtaining sufficient circumstance background is paramount in ensuring an effective analytical strategy to provide useful results that can be interpreted within context. Nevertheless, key interpretative considerations such as pharmacogenomics and drug-drug interactions as well as determination of tolerance remain and in the future, analytical confirmation of an individual's metabolic profile may support a personalized medicine and judicial approach. This should be supported by the compilation and appropriate application of drug data pursuant to the situation. Specifically, in PM circumstances, data pertaining to where a drug was not/may have been/was contributory will be beneficial with associated pathological considerations. This article describes the challenges faced within toxicology and discusses progress to a future where they are being addressed.

Starvation Ketoacidosis Induced by Ketogenic Diet and Consumption of Ketone Supplement

The ever-changing landscape of dieting and its correlation with health outcomes have continued to evolve with time. New diets appear and disappear just as quickly as they gain notoriety. This is a rare case of a 67-year-old female with a history of type II diabetes who presented with generalized weakness, nausea, and vomiting, and was found to have severe anion gap metabolic acidosis. In an effort to lose weight, she was combining a ketogenic diet with prolonged fasting and exogenous ketone supplement use that she purchased online. The patient reported drinking an exogenous ketone ester supplement that contained 30 g of D-beta hydroxybutyrate (BHB) per serving, three times per day. This case is unique in that the patient was initially thought to be in diabetic ketoacidosis upon arrival, but after further investigation into her initial labs, medication, and social history, the underlying factor for hospitalization became evident; that is, a combination of a ketogenic diet with prolonged fasting and exogenous BHB-induced ketoacidosis in the setting of type II diabetes. Thus, this case highlights the importance of thorough history taking, the dangers of over-the-counter supplement consumption, and the risks consumers inherit with trend dieting.

Evaluation of the Compatibility of Ethyl Glucuronide and Ethyl Sulphate Levels to Assess Alcohol Consumption in Decomposed and Diabetic Postmortem Cases

The aim of the study is to evaluate the contribution of ethanol metabolite detection in postmortem cases by showing the connection between the presence of ethanol metabolites, which are indicators of alcohol consumption, and the detection of potential postmortem ethanol formation in decomposed and diabetic cases. Determination of ethanol consumption before death is often one of the most important questions in death investigations. Postmortem ethanol formation or degradation products in the blood make it difficult to distinguish antemortem consumption or postmortem formation of ethanol and eventually may lead to misinterpretation. Decomposed bodies and diabetic cases are vulnerable to postmortem ethanol formation due to putrefaction, fermentation or other degradations. Ethyl glucuronide (EtG) and ethyl sulphate (EtS) are two metabolites of ethanol produced only in the antemortem time interval. In this study, EtG and EtS levels in urine and vitreous humor samples of 27 postmortem cases, including diabetic and degraded bodies were compared to ethanol results of their blood, urine, and vitreous humor samples. EtG and EtS in urine and vitreous humor were analyzed by liquid chromatography-tandem mass spectrometry (LC-MS-MS) and ethanol was assayed by routine headspace gas chromatography-flame ionization detector (GC-FID). These cases were devoid of other influences from forensically relevant drugs, so ethanol and/or glucose were among the only positive findings in these cases. The results of this pilot study indicate the postmortem ethanol concentrations do not correlate with the measured EtG and EtS values but are beneficial in rulings of accidental or natural deaths. This preliminary study gives additional data to help distinguish between antemortem ethanol intake and postmortem formation. EtG and EtS were well correlated positively with antemortem ethanol use instead of forming spontaneously in samples from decedents who are decomposing or have a history of diabetic hyperglycemia.

Starvation Ketoacidosis With Hypoglycemia in a Patient With Chronic Pancreatitis

Chronic pancreatitis is a pancreatic inflammation that can result in endocrine pancreatic insufficiency. We present a case of starvation ketoacidosis in a 44-year-old Japanese man with chronic alcoholic pancreatitis. On admission, he exhibited hypoglycemia and severe acidosis. Intravenous glucose and vitamin B1 were administered in the emergency department, and nutritional management for presumed starvation ketoacidosis was begun. Because the patient did not have diabetes mellitus, his insulin secretion and insulin resistance were examined. A diagnosis of pancreatic diabetes caused by chronic pancreatitis was made based on decreased insulin secretion, normal insulin resistance, and negative anti-glutamic acid decarboxylase antibody. Intensive insulin therapy was initiated, and he was discharged 15 days after hospitalization. Although starvation rarely causes hypoglycemia and severe ketoacidosis, they can be induced by short-term fasting in patients with decreased pancreatic function.

Death from diabetic ketoacidosis in the Eastern part of Denmark in 2016-2018. Beta-hydroxybutyrate as a marker

Diabetes mellitus is a disease caused by a deficiency in (type 1) or inability to use insulin (type 2). Untreated it can lead to diabetic ketocidosis (DKA) – state with high levels of ketone bodies (acetone, acetoacetate, beta-hydroxybutyrate (BHB)). This state can be life threatening. Measurement of ketone bodies together with vitreous/urine glucose and glycosylated hemoglobin (HbA1C) are therefore essential to diagnose DKA-related deaths.

All autopsy samples received at our department in the period 2016-2018 for toxicological investigations were analyzed for acetone, BHB, and vitreous glucose (N = 1394). In case of a high level of BHB, HbA1C and urine glucose were measured. Thirty two cases (2.3%) were concluded to be DKA-related deaths. Eleven (34%) of these had no known history of diabetes.

BHB accounts for the major part of ketone bodies and is directly associated with the acidosis effect. Therefore, BHB is preferred to acetone when evaluating DKA and other ketoacidosis-related deaths. We compared acetone and BHB levels to evaluate if the easy acetone measurement could cover our needs for screening. We found that high BHB levels (>2000 µmol/L) were detected if the acetone cut off was set to 0.01 g/L. But, many samples would have low BHB < 3-500 µmol/L with this cut off, and many samples with raised BHB (500-1,200 µmol/L) would not be detected. We therefore recommend to screen all samples for BHB. In case of a high BHB (>1,000 µmol/L) vitreous/urine glucose and HbA1C must be measured to distinguish DKA from other types of ketoacidosis.

Cortisol levels after cold exposure are independent of adrenocorticotropic hormone stimulation

We previously showed that postmortem serum levels of adrenocorticotropic hormone (ACTH) were significantly higher in cases of hypothermia (cold exposure) than other causes of death. This study examined how the human hypothalamic-pituitary-adrenal axis, and specifically cortisol, responds to hypothermia. Human samples: Autopsies on 205 subjects (147 men and 58 women; age 15-98 years, median 60 years) were performed within 3 days of death. Cause of death was classified as either hypothermia (cold exposure, n = 14) or non-cold exposure (controls; n = 191). Cortisol levels were determined in blood samples obtained from the left and right cardiac chambers and common iliac veins using a chemiluminescent enzyme immunoassay. Adrenal gland tissues samples were stained for cortisol using a rabbit anti-human polyclonal antibody. Cell culture: AtT20, a mouse ACTH secretory cell line, and Y-1, a corticosterone secretory cell line derived from a mouse adrenal tumor, were analyzed in mono-and co-culture, and times courses of ACTH (in AtT20) and corticosterone (in Y-1) secretion were assessed after low temperature exposure mimicking hypothermia and compared with data for samples collected postmortem for other cases of death. However, no correlation between ACTH concentration and cortisol levels was observed in hypothermia cases. Immunohistologic analyses of samples from hypothermia cases showed that cortisol staining was localized primarily to the nucleus rather than the cytoplasm of cells in the zona fasciculata of the adrenal gland. During both mono-culture and co-culture, AtT20 cells secreted high levels of ACTH after 10-15 minutes of cold exposure, whereas corticosterone secretion by Y-1 cells increased slowly during the first 15-20 minutes of cold exposure. Similar to autopsy results, no correlation was detected between ACTH levels and corticosterone secretion, either in mono-culture or co-culture experiments. These results suggested that ACTH-independent cortisol secretion may function as a stress response during cold exposure.

Starvation Ketoacidosis due to the Ketogenic Diet and Prolonged Fasting - A Possibly Dangerous Diet Trend

Patient: Male, 60

Final Diagnosis: Starvation ketoacidosis

Symptoms: Nausea • syncope • vomiting

Medication: —

Clinical Procedure: —

Specialty: Metabolic Disorders and Diabetics

Euglycemic diabetic ketoacidosis in association with dapagliflozin use after gastric sleeve surgery in a patient with type II diabetes mellitus

Sodium-glucose cotransporter 2 inhibitors (SGLT2Is) can be associated with euglycemic diabetic ketoacidosis (eDKA). Severe metabolic acidosis with extreme electrolyte abnormalities can occur with nonsignificant blood glucose elevations in SGLT2I-treated patients. Additional risk factors for eDKA include prolonged fasting, major illness, large weight loss, and reductions in insulin doses.

Intra-individual alterations of serum markers routinely used in forensic pathology depending on increasing post-mortem interval

Post-mortem biochemistry of serum markers has been the subject of numerous studies, but in-situ marker stability after death has not been sufficiently evaluated yet. Such laboratory analyses are especially necessary in the cases of functional deaths without morphological evidence of the death causes and also in cardiac death cases with only very short survival times. The aim of the study was to determine the post-mortem stability of commonly-used serum markers at predefined time points. In 20 cases, peripheral venous samples were taken starting immediately after circulatory arrest and ending 48 hours after death. Serum creatinine, urea, 3-β-hydroxybutyrate, tryptase, myoglobin, troponin T, creatin kinase and creatin kinase-MB have been included. For all markers, we observed increasing marker levels for longer post-mortem intervals. Significant marker level changes began two hours after death. Excessive increases were observed for cardiac and muscle markers. Marker levels showed high intra-assay precision. Furthermore, the markers were robust enough to withstand freeze-thaw cycles. Potential contamination of arteriovenous blood did not influence the post-mortem marker levels. Post-mortem blood should be sampled as soon as possible, as increased post-mortem intervals may heavily change marker levels in-situ in individual cases, whereas the markers are mostly unaffected by laboratory conditions.