Beta-Hydroxybutyric Acid—An Indicator for an Alcoholic Ketoacidosis as Cause of Death in Deceased Alcohol Abusers

Abstract

We analyzed the postmortem blood of a total of 100 fatal cases for beta-hydroxybutyric acid (BHBA). In 25 cases of sudden and unexpected death of alcoholics we found pathologically increased levels of BHBA of 1260 to 47 200 (median 8000) µmol/L. This led us to the diagnosis of an alcoholic ketoacidosis (AKA) as cause of death in these cases. The control group of 69 postmortem cases revealed that BHBA concentrations below 500 can be regarded as normal, and values up to 2500 µmol/L as elevated. Our study shows that BHBA values over 2500 µmol/L could lead to death, if no medical attention is sought. During storage we did not find any indication of postmortem formation or decomposition of BHBA in blood in vitro or in the corpses. In our opinion, BHBA should be considered the diagnostic marker of choice for the postmortem determination of alcoholic ketoacidosis (AKA) as the cause of death. The classical indications of such deaths are: unexpected death of a chronic alcoholic; none or only traces of ethanol in the blood; increased acetone blood concentration; and neither autopsy, histology, microbiology, nor toxicology reveal the cause of death. In six further cases a diabetic ketoacidosis (DKA) was diagnosed as the cause of death.

Vitreous Humor: A Short Review on Post-mortem Applications

“…However, a vitreous biochemical threshold for the diagnosis of significant ketosis is less clear. Threshold BHB levels of 2.5 mmol/L, 5 mmol/L and 6.0 mmol/L in the vitreous has been proposed [62,71,[83][84][85]. Post-mortem vitreous BHB is a useful marker for DKA when levels are elevated and accompanied by an above threshold vitreous glucose level concentration [62].…”

“…Post-mortem vitreous BHB is a useful marker for DKA when levels are elevated and accompanied by an above threshold vitreous glucose level concentration [62]. The argument for the higher thresholds are because the median ketone levels in blood are generally over 5 mmol/L in patients with diabetic ketoacidosis [86,87] and blood ketone levels correlate with VH ketone concentrations [71,73,83,86,87].…”

Postmortem chemistry update part I

“…The possible role of alcoholic ketoacidosis as cause of death has been investigated by several authors [35,[46][47][48][63][64][65][66].…”

Determination of Volatile Substances in Forensic Samples by Static Headspace Gas Chromatography

“…Ketone bodies are present in biochemical altered states known as diabetic ketoacidosis, related to diabetics and alcoholic ketoacidosis, a consequence of chronic abuse of alcohol. Studies (Iten & Meier, 2000;Pounder, et al, 1998;Thomsen, et al, 1995) indicate that alcoholic ketoacidosis could be the cause of death in alcoholics, in cases of sudden and unexpected death, where alcohol determination was negative and that an alcoholic ketoacidosis state can be diagnosed with the determination of ketone bodies in postmortem blood samples. Ketone bodies (acetone, acetoacetate and -hydroxybutyrate) can be measured separately by gas chromatography headspace.…”