Postmortem Diagnosis of Unsuspected Diabetes Mellitus Established by Determination of Decedent's Hemoglobin A1c Level

Abstract

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.

Postmortem identification of hyperglycemia

“…Several other tests have been developed to identify diabetes or to monitor glucose levels over time. The levels of HbA1c, fructosamine, a-1-antritrypsine and glycosylated haptoglobin are used in clinical practice, and have been found to be useful even in the postmortem setting [12][13][14].…”

Sudden adult death

“…When deaths appears to be related to diabetes mellitus [469][470][471], in addition to testing the vitreous for glucose, further relevant information may be obtained by testing the vitreous for the ketone beta-hydroxbutyrate [472] and by measuring blood HbA1c levels (with elevated levels indicating the presence of diabetes mellitus [473][474][475]), as well as analysing for insulin and c-peptide [476,477]. Others have advocated measuring lactate to assist in the establishment of the presence of antemortem hyperglycemia [478].…”

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

“…World-wide, about 30 million people are thought to be affected by the disease, which is one of the leading causes of death in developed countries. A substantial percentage of individuals with diabetes are undiagnosed [1,2] and the illness is similarly under-reported on death certificates, both as an illness and cause of death [3]. The chronic complications of diabetes mellitus, mostly cardiovascular complications, followed by chronic renal disease and cerebrovascular attacks, are frequent causes of death.…”

“…Because glycosoprotein concentrations reflect mean serum glucose levels over a period of time, their determination provides a useful means of monitoring diabetic control. Hemoglobin A1c and fructosamine are fairly stable and have therefore been proposed as aids in the postmortem diagnosis of diabetes [2,[17][18][19][20][21].…”