Autopsy & forensics

A 40 year old man with a history of obesity, chronic alcoholism and diabetes mellitus type 1 was found unresponsive during a well being check. He was last known to be alive the night before and he was witnessed drinking large amounts of alcohol. Autopsy examination showed liver steatosis but no other significant pathologic changes. Toxicology and blood and vitreous chemistry analyses showed the following results

• Inferior vena cava blood
  • β hydroxybutyric acid: > 1,200 mcg/mL (normal: < 50 mcg/mL)
  • Ethanol: 78 mg/dL (reporting limit: 10 mg/dL)
  • Isopropanol: 6.6 mg/dL (reporting limit: 5.0 mg/dL)
  • Acetone: 42 mg/dL (normal: < 0.3 mg/dL)
  • Caffeine: presumptive pos (reporting limit: 0.20 mcg/mL)
• Vitreous
  • Creatinine: 0.875 mg/dL (normal: 0.6 - 1.3 mg/dL)
  • Sodium: 143 mmol/L (normal: < 15 mmol/L)
  • Potassium: 14.3 mmol/L (normal: < 15 mmol/L)
  • Chloride: 118 mmol/L (normal: 105 - 135 mmol/L)
  • Glucose: 327 mg/dL (normal: < 200 mg/dL)
  • Urea nitrogen: 27 mg/dL (normal: 8 - 20 mg/dL)

Which of the following causes of death is best certified?

1. Acute ethanol toxicity
2. Alcoholic ketoacidosis
3. Chronic alcoholism
4. Diabetic ketoacidosis
5. Multifactorial ketoacidosis

E. Multifactorial ketoacidosis. The deceased had a history of chronic alcoholism and diabetes mellitus. Postmortem chemistry shows a high concentration of ketones and glucose in the collected samples. Since alcohol, diabetes and starvation can result in ketoacidosis, the cause of death should be certified as multifactorial ketoacidosis (ketoacidosis alone is also an acceptable option).

Answer A is incorrect because the concentration of alcohol in peripheral blood is not enough to cause acute toxicity, even if there is a history of recent consumption of large quantities of ethanol. Answers B and D are incorrect because there is no reliable way to distinguish between alcoholic and diabetic ketoacidosis in this case since both conditions can lead to it. Answer C is incorrect because even if there is liver steatosis, suggesting chronic ethanol use, the high levels of ketones are consistent with ketoacidosis, making that the more immediate cause of death.

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Reference: Postmortem chemistry

The body of a 64 year old woman is discovered supine on the floor in her secured residence after an unknown interval. There is no available medical or social history. External and internal examination reveal a well developed and well nourished woman showing no evidence of trauma. Brown colored vitreous fluid and liver samples are collected and submitted for analysis. Blood samples could not be collected. Which of the following should be considered most important while interpreting the results of the available samples?

1. Absence or presence of glucose in vitreous fluid is of no significance
2. Color of the vitreous fluid is suspicious for trauma to the eye; a more detailed inspection is required
3. Liver tissue is the best specimen for quantitative analyses
4. Potassium concentration in vitreous fluid
5. Sodium concentration in vitreous fluid

D. Potassium concentration in vitreous fluid. Checking the concentration of vitreous potassium is the first step to determine whether the concentration of other analytes is relevant or should be considered with caution. A vitreous potassium level above 15 mmol/L suggests that decomposition changes may contribute to the observed result. In the provided history, the liver was collected and the vitreous fluid was brownish in color, further suggesting that the body was at least in an early stage of decomposition.

Answer A is incorrect because glucose concentration is a useful marker of diabetes or a hyperglycemic state. Answer C is incorrect because the best and most reliable postmortem specimen for quantitative analysis is peripheral blood. Answer B is incorrect because while in a fresh body, a red tinged vitreous fluid may suggest local trauma or sampling artifact, in a decomposed body, a darker color in the absence of clear evidence of injury should be considered a postmortem artifact. Answer E is incorrect because the sodium concentration in vitreous fluid is a useful marker of dehydration; however, its concentration should be considered after determining the potassium concentration.

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Reference: Postmortem chemistry