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Diabetic Ketoacidosis: A Silent Death

Ali, Zabiullah MD; Levine, Barry PhD; Ripple, Mary MD; Fowler, David R. MD

The American Journal of Forensic Medicine and Pathology: September 2012 - Volume 33 - Issue 3 - p 189–193
doi: 10.1097/PAF.0b013e31825192e7
Original Articles

Diabetic ketoacidosis (DKA) results from severe insulin deficiency and can be diagnosed at autopsy despite no known history of the disease. Diabetic ketoacidosis may be the initial manifestation of type 1 diabetes or may result from increased insulin requirement in type 1 diabetic patients. The purpose of this study was to determine the percentage of DKA death investigated by the Office of Chief Medical Examiner that was not associated with a known history of diabetes.

Cases investigated by the Office of Chief Medical Examiner during a 6-year period whose cause of death was DKA were identified using a centralized database. To determine the percentage with known history of diabetes, investigation reports were reviewed for any documentation of this history. The toxicology reports of all DKA deaths were reviewed together with histologic slides, if available, for possible microscopic changes. Concentrations of vitreous glucose, vitreous acetone, and blood acetone were used to diagnose DKA in these autopsied cases.

Nearly a third of all death from DKA (32 of 92 during a 6-year period) occurred in individuals who had no known history of diabetes, emphasizing the importance of regular physicals that include a check of glucose concentration, and especially if any warning signs are present. In a case of sudden death, it is recommended that the volatile toxicology analysis at a medical examiner’s office should include tests for acetone concentration, which when elevated, together with an elevated vitreous glucose, indicates DKA.

From the Office of the Chief Medical Examiner, State of Maryland, Baltimore, MD.

Manuscript received January 21, 2009; accepted June 11, 2009.

The authors report no conflicts of interest.

Reprints: Zabiullah Ali, MD, Office of the Chief Medical Examiner, State of Maryland, 900 West Baltimore St, Baltimore, MD. E-mail:

© 2012 Lippincott Williams & Wilkins, Inc.