Can 'death by diabetes' be determined months later?

Factual Questions
1

I was watching (another) old TV program made in 1968 or 1969. Part of the story about a quack doctor is to determine whether the person died of diabetes, as the family thought, not from “vitamin deficiency” as the quack had determined.

The body is exhumed, but because “water had seeped in,” the doctor could make no ruling.

Regardless of the “water contamination,” can ‘death by diabetes’ (specifically, uncontrolled blood sugar levels, resulting in a coma, then death) be determined (months) after the fact?

2

Diabetes is usually the secondary cause of death, not the primary. You always hear about people dying from *the complications of *diabetes (cardiovascular disease, kidney failure, etc.), not from diabetes directly.

3

People sometimes die directly from diabetes when they die in diabetic ketoacidosis.

It is hard to figure out if a person has died from diabetes because of the following odd quirk of Nature. When anyone dies, the blood stops moving. Blood that stops moving clots. Some of the red cells caught up in the clots break open. (No one can predict how many of the cells will break open - lots of them do - the amount variable from case to case.) The red cells are basically little bags of hemoglobin, glucose, and potassium. If I take a sample of blood from a dead person, and measure its electrolytes, the glucose is always 400 or higher (normal is 80 to 100), and the potassium is generally 8 to 14 (normal is 3 to 5). The pH is always acid, too - usually about 6.8 (normal tightly regulated at about 7.4).

So I can’t use the blood to decide if the person died from ketoacidosis. However, sometimes I can use the vitreous humor. This is known to laymen as the eyeball juice. I am quite good at sucking out the eyeball juice with a 21 gauge needle on a 5 cc syringe. An interesting feature of the eyeball juice is that it seems to keep the eyeball lining cells alive for as long as it contains glucose and oxygen. So the normal vitreous glucose is 2. Which would be a fatal level in a live person.

So if I get postmortem values of blood glucose of 600, eyeball juice glucose of 2, I know the person probably died with a normal blood sugar in the 80 to 100 range. But. If they died in DKA, I will get a greatly elevated vitreous glucose. I have seen 400, 600, 800, even 1000. That is proof that there was hyperosmotic hyperglycemia. Add that to very pale urine in the bladder (the glucose of which can also be tested, and should be high) and acetone or ketones on the blood screen, and there’s my proof that the person died from diabetes.

However. This would be very difficult with a long-decomposed body, as the eyeball juice gradually goes away with weeks after death, and the blood does too. Embalmed blood is no good, and is diluted anyway with embalming fluid.

But. If the body was well embalmed, and the kidneys were still reasonably well preserved, I could look under the microscopic at a section of cortex, and diagnose diabetic hyperglycemia by the Armanni-Ebstein lesion. Which is something I bet the TV writers didn’t know. Even some doctors don’t know that.

Gabriela, proudly tweaking her bow tie

4

This is interesting to me … why do the readings change? Is it because the material from within ruptured red blood cells gets mixed into the plasma? Or something else?

5

Yes, the material from the ruptured red blood cells gets mixed with the plasma, exactly right. They’re floating in it anyhow and when I take a 60 cc sample with a 12-gauge needle (dead people don’t get distressed at the sight of a horse needle), it’s well and truly homogenized by the time I squirt it into the tubes.

6

gabriela- I love reading your posts, I learn something new everyday.
Now I get to look up Armanni-Ebstein lesions!
Questions- and I know this is a weird one, what if the person died in HONK, or from a hypoglycaemic coma? I assume HONK would give you the elevated glucose in the vitreous without the ketones, would there be a way to discover hypoglycaemia?

I’m just asking, because I had a 160kg patient with type 2 diabetes who was septic and had BMs of 1.6 (using the European values where normal is 4-7) and I spent all last Friday night running in large amounts of 50% dextrose and glucagon- you don’t see severe hypoglycaemia that often, but it’s a PITA when you do.

7

Dear Colleague,

Aww.

I gotta tell you one little cute history of medicine thing about Armanni - He was a right arsehole. He was a shouter and a screamer who was miserable to everyone around him. He was the head of the Anatomy Department at an Italian university for decades until his death. The guy who worked for him all those years as second in command, who succeeded him, was later named a Saint by the Roman Catholic Church - the only pathologist who was ever canonized. I think it was for putting up with Armanni all those years.

Armanni had no bedside manner but he loved dissection. He did a lot of work on TB and diabetes. Since his century was the nineteenth century, and Banting and Best didn’t come up with insulin until the early 1920s, all the diabetes he saw was fatal. The diabetics (mostly Type I) would eat and eat because they were starving, but waste away while they ate. The wards were full of living skeletons. Not living for long.

So when they died, their proximal tubules were so packed with glucose that it formed a vacuole at the base of every proximal tubular epithelial cell. I have picked up two or three cases of unsuspected diabetes this way at forensic autopsy. It’s a hard lesion to see because it’s everywhere. Kind of like that old map game, where two people challenge eachother to fiind a name on the map as fast as possible. Beginners choose a little tiny name of an obscure street. Experienced players take a name that’s so huge it’s emblazoned across the entire map…

Hypoglycaemic coma would be absolutely impossible to diagnose. Insulin and other natural substances are very, very difficult to quantify at autopsy (don’t know why). This may be why rich devious people try to use it as a method of murder. Murder is usually established anyway in such cases by other clues.