Sudden death from diseases of the pancreas generally involve two entities, acute fulminating pancreatitis and diabetes mellitus. Deaths from acute
pancreatitis in which the patient is mobile and walking around are uncommon. As in instances of unsuspected peritonitis, they are associated with alcoholism and individuals on high doses of antipsychotic medications, which can mask or obscure symptoms.
Sudden, unexpected death due to the acute onset of diabetes mellitus is relatively rare.69 The classic symptoms of diabetes are polydipsia, polyuria, polyphagia, and loss of weight. In some instances however, diabetic coma may be the initial symptom. If the individual dies without medical attention or if the cause of the coma is not diagnosed before death, these cases become medical examiner cases.
Diabetes is a metabolic disorder characterized by hyperglycemia and a failure to a greater or lesser extent to secrete insulin. Approximately one third of all diabetics are juvenile onset diabetics. In this condition, the lack of insulin may be complete. This type of diabetes is differentiated from the mature onset diabetes by the tendency of the juvenile diabetic to develop ketoacidosis. Most individuals with juvenile onset diabetes present with the classical symptoms of diabetes previously mentioned. Approximately one third, however, initially present in acidosis or diabetic coma. In a number of instances, the onset of diabetes seems to be triggered by an infective illness. In diabetic ketoacidosis, blood glucose levels are seldom under 300 mg/dL or over 1000 mg/dL, with an average blood level reported as 736 mg/dL.
The biochemical derangement in diabetic ketoacidosis may be extremely severe with increased metabolism of fatty acids, resulting in the formation of ketone bodies and acidosis. There is loss of large quantities of electrolytes and water. The hyperglycemia produces osmotic diuresis with hypertonic dehydration. Free acetone is elevated in the blood in cases of coma. Levels of free acetone in normal individuals are generally less than 0.17 mg/dL. In diabetic coma, levels have been reported as ranging from 14.5 to 74.95 mg/dL.70
There is an aketotic form of diabetic coma that differs in several respects from the classical form of ketoacidosis. The patients tend to be older and blood glucose levels in this condition are extremely high, with an average level of 1949 mg/dL. Dehydration is intense, with serum sodium and potassium usually normal or high. Free acetone is only mildly elevated (up to 5.81 mg/dL) if at all.70
Sudden, unexpected death due to the acute onset of diabetes is a problem to the forensic pathologist in that postmortem blood glucose levels are generally of no value because of the great fluctuation in the level of glucose after death. Elevated blood acetone levels, while suggestive of diabetes, are not diagnostic, because they may be the result of another condition, such as malnutrition. In addition, in the aketotic form of diabetic coma, elevated levels of ketones may not be present. Glucose in the urine is also not diagnostic, because it can occur in many conditions. The presence of glycogen in the cells of the proximal convoluted tubules of the kidney (Armanni-Ebstein lesion) is said to be diagnostic of uncontrolled diabetes. Unfortunately, this lesion is often absent.
The most reliable indicator of diabetes mellitus in the postmortem state is elevated glucose in the vitreous humor. Vitreous humor provides an easily obtainable fluid for the postmortem diagnosis of diabetic coma. An elevated vitreous glucose level is an accurate reflection of an elevated antemortem blood glucose level. Fortunately, marked agonal rises in blood glucose level, a not uncommon occurrence, do not manifest themselves as rises in the vitreous glucose. Thus, in studying 102 nondiabetics in whom perimortem peripheral blood glucose concentrations exceeding 500 mg/dL resulted from a terminal rise in blood sugar from a variety of causes, Coe found the vitreous glucose in all of these cases was below 100 mg/dL.71 Even if intravenous glucose infusions are administered for hours prior to death, the vitreous glucose level in normal subjects is generally less than 200 mg/dL. Thus, glucose levels significantly above 200 mg/dL are diagnostic of diabetes mellitus even if intravenous glucose infusions are being administered. Of course, as the time between the death and autopsy increases, there will be a fall in the glucose level of the vitreous. This decrease, however, is relatively gradual in the diabetic because of the markedly elevated levels of glucose present, and significantly elevated levels of glucose will remain for prolonged periods of time.72
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