Drug Testing

Research article and Analysis

Received: 6 February 2013 Revised: 6 March 2013 Accepted: 6 March 2013 Published online in Wiley Online Library: 25 April 2013

(www.drugtestinganalysis.com) DOI 10.1002/dta.1479

Detection of diabetic metabolism disorders

post-mortem – forensic case reports on cause
of death hyperglycaemia
C. Hess,* K. Wöllner, F. Musshoff and B. Madea
Diabetic coma is the most severe form of hyperglycaemic metabolic disorders. The post-mortem diagnosis of this disorder of
glucose metabolism can be difficult and vague due to a lack of characteristic morphological findings. Six death cases caused
by diabetic coma are described with special focus on biochemical (and histological) findings. The possible glycaemia markers
glucose, lactate, HbA1c, fructosamine, anhydroglucitol, and ketone bodies were measured and the usefulness of these parameters
is evaluated and discussed. Estimations of glucose concentrations in vitreous humour or cerebrospinal fluid and of ketone
bodies in blood or other matrices are obligatory while measurements of HbA1c, fructosamine, or anhydroglucitol can only
provide additional information on the long-term adjustment of diabetes in the deceased. Lactate concentrations (addition of
glucose and lactate levels to form the sum formula of Traub) do not give more information than the glucose concentration itself
and can be therefore omitted. Copyright © 2013 John Wiley & Sons, Ltd.

Keywords: diabetes; post-mortem; ketoacidosis

Introduction
Diabetes mellitus is a disease with a disordered glucose metabolism
and constant hyperglycaemia caused by either deficient insulin
secretion (Type 1) or a combination of insulin resistance and
inadequate insulin secretion (Type 2). Diabetes mellitus is being
underreported; it is thought that 8% of individuals have
undiagnosed diabetes mellitus.[1] Diabetic coma is the most
severe form of a hyperglycaemic metabolic disorder. It can be
differentiated between diabetic ketoacidosis (DKA) and non-
ketoacidotic hyperosmolar crisis. Diabetic ketoacidosis (DKA)
results from severe insulin deficiency and can be diagnosed
at autopsy despite unknown history of the disease. DKA goes
along with high blood glucose levels and higher concentrations
ketone bodies (acetone, acetoacetate, b-hydroxybutyrate) in
blood. However, nearly one-third of all deaths from DKA occurred
in individuals who had no known history of diabetes.[2]
The post-mortem diagnosis of glucose metabolism disorders
can be difficult and vague caused by missing characteristic
morphological findings. Therefore, histological and particularly
biochemical measurements have to complement autopsy and
case history in case of fatal hyperglycaemic dysregulations.[3,4]
Six case reports are presented and discussed with special focus on
the usefulness of biochemical markers including glucose and lactate,
the sum formula of Traub, HbA1c, fructosamine, anhydroglucitol,
and ketone bodies.
Material and methods
Samples for chemical-toxicological analyses
Forensic samples were obtained from autopsies at the Institute of
Forensic Medicine at Bonn, Germany. Blood was taken from the
autopsy. Vitreous humour (VH) from the right eye was cautiously
aspirated by puncture of the eyeball with a smooth syringe.
Cerebrospinal fluid (CSF) was obtained by sub-occipital puncture.
In addition to the presented case reports with death due to
diabetic coma, control cases were measured. Information about
the diabetes was taken from the health records or the court
records. Anhydroglucitol concentrations were measured in non-
diabetic deceased (n = 88) and in diabetic deceased (n = 71).
Fructosamine concentrations were determined in 81 non-diabetic
deceased and 19 diabetic deceased.
For analyses, samples were centrifuged and the supernatants were
taken for chemical-toxicological analyses. For lactate, concentrations
were often higher than the calibration range. Samples then had to
be diluted with sodium chloride solution (9 g/l) prior to analyses.
Fructosamine was measured in femoral vein blood which was
precipitated with acetone (1:1) and HbA1c was measured in whole
blood. Therefore, 20 ml of blood were fortified with 1 ml of a
haemolytic agent (sodium azide solution). After 5 min, haemolysis
was complete. The sum formula of Traub was calculated by an
addition of the concentration of glucose (mg/dl) and the half of
the concentration of lactate (mg/dl).
Analytical methods
Glucose was determined by an enzymatic test from Labor und
Technik (Berlin, Germany) on an Olympus AU 400 Immunoanalyzer.
Glucose is oxidized by the enzyme glucosedehydrogenase to
gluconolatone while added NAD is reduced to NADH, the amount
* Correspondence to: Cornelius Hess, Institute of Forensic Medicine, University of
Bonn, Stiftsplatz 12, 53111 Bonn, Germany. E-mail: cohess@uni-bonn.de
Institute of Forensic Medicine, University of Bonn, Stiftsplatz 12,53111 Bonn,
795

femoral vein. Urine was gained by puncture of the bladder at Germany

Drug Test. Analysis 2013, 5, 795–801 Copyright © 2013 John Wiley & Sons, Ltd.
 Drug Testing
and Analysis
of which is proportional to the original glucose concentration and
which can be detected photometically. LoQ is 3 mg/dl, linearity
given up to 700 mg/dl, intra-day precision 1.56 % (at 96.7 mg/dl,
n = 20), 1,4 % (at 165 mg/dl, n = 20) and 0.83 % (at 236 mg/dl,
n = 20); inter-day precision 1.63 % (at 96.7 mg/dl, n = 20), 1.90 %
(at 165 mg/dl, n = 20) and 1.28 % (at 236 mg/dl, n = 20).
Lactate was determined by an enzymatic test LOX-PAP from
Labor und Technik (Berlin, Germany) on an Olympus AU 400
Immunoanalyzer. The test relies on the conversion of lactate
by the enzyme lactateoxidase to pyruvate. H2O2 which is
also formed in this reaction oxidizes a colourant (4-Chinoimine
colourant) and the colour change can be detected photometrically.
LoQ is 1 mg/dl, linearity is given up to 200 mg/dl, cross reactivity
only with ascorbic acid > 20 mg/dl; intra-day precision 1,44 %
(at 15,3 mg/dl, n = 20), 1,44 % (at 22,8 mg/dl, n = 20) and 0,67 %
(at 27,8 mg/dl, n = 20); inter-day precision 0,54% (at 15.0 mg/dl,
n = 20), 2.01 % (at 21.9 mg/dl, n = 20) and 1.31 % (at 24.4 mg/dl,
n = 20).
HbA1c was determined by an immunturbidimetric test from
Labor und Technik (Berlin, Germany) on an Olympus 400 AU
Immunoanalyzer. The determination works without measurement
of the total haemoglobin level. Total haemoglobin and HbA1c
both bind with the same affinity to latex particles. A murinary
anti-human HbA1c antibody then binds to particle bound HbA1c.
A polyclonal anti-mouse IgG-antibody then reacts with the anti-
human HbA1c antibody and leads to agglutination. The measured
extinction is proportional to the bound HbA1c which is proportional
to the percentage of HbA1c in the sample. The unit of HbA1c
is given in mmol HbA1c / mol total haemoglobin. LoQ ist
10 mmol/mol, linearity is given up to 150 mmol/mol. No interferences
are described by the manufacturer, intra-day precision is 7 %
(at 35 mmol/mol, n = 20), 1.36 % (at 80.7 mmol/mol, n = 20) and
1.8 % (at 114 mmol/mol, n = 20); inter-day precision 1,82 %
(at 36.5 mmol/mol, n = 20), 1.67 % (at 83.3 mmol/mol, n = 20) and
1.58 % (at 116 mmol/mol, n = 20). The test is standardized to the IFCC
reference method.[5] For HbA1c measurement, 20 ml of whole blood
were fortified with 1000 ml of a haemolytic agent (sodium azide; Labor
und Technik; Berlin, Germany). After 5 min, the sample is haemolyzed.
The test is standardized to the IFCC reference method.[6]
Fructosamine was determined by the testkit from Labor und
Technik (Berlin, Germany). Fructosamine exists in the enaminolic
form in an alkaline milieu. This form reduces nitro blue tetrazolium
to formazane. The kinetics of the colour formation (at 546 nm) then
is proportional to the fructosamine concentration. LOQ is 10 mmol/l,
linearity is given up to 1000 mmol/l; glucose concentrations up to
800 mg/dl do not interfere; intra-day precision is 0,90 %
(at 286 mmol/l, n = 21), 0.70 % (at 270 mmol/l, n = 21) and 0.8 %
(at 521 mmol/l, n = 21); inter-day precision is 3.0 % (at 296 mmol/l,
n = 21), 1.4 % (at 273 mmol/l, n = 21) and 1.7 % (at 512 mmol/l, n = 21).
Ketone bodies were quantified according to the head space
gas chromatographic method with flame ionization detection
by Felby et al.[7] at our institute.
For the detection of acetone, 1 ml of femoral vein blood was
fortified with 100 ml of the internal standard tert.-butanol
(100 mg/ml) in a 20-ml head-space sample. Afterwards the sample
was analyzed at a head-space temperature of 60  C, with a head-
space time of 20 min.
For the detection of acetoacetate, 1 ml of femoral vein blood was
fortified with the internal standard in a 20-ml head-space sample.
However, the sample was heated for 60 min at 100  C in the
head-space oven. At this temperature, acetoacetate decarboxlates
796
and can be detected as acetone in the chromatogram.
wileyonlinelibrary.com/journal/dta Copyright © 2013 John Wiley & Sons, Ltd.
C. Hess et al.
For the detection of the third ketone body, b-hydroxybutyrate
has to be transformed enzymatically into acetoacetate for 30 min
at 45  C. Therefore, 1 ml of femoral vein blood was fortified
with 10 mmol pyruvate, 0.5 mmol NAD and 10 ml of the enzymes
b-hydroxybutyrate dehydrogenase and lactate dehydrogenase.
Afterwards, acetoacetate was decarboxylated for 60 min at
100  C in the head-space oven and could then also be detected
as acetone. Figure 1 shows the conversion of b-hydroxybutyrate
and acetoacetate into acetone.
The head-space conditions for the detection of acetone were as
follows: needle temperature 90  C, transfer temperature 90  C. The
head-space conditions for the detection of acetoacetate were as
follows: needle temperature 110  C, transfer temperature 115  C.
The temperature of the injector was 150  C, temperature of the
detector 250  C. Gaschromatographic separation was achieved by
the following temperature program: start: 40  C, hold 15 min; with
4  C/min to 200  C; hold 10 min; with 15  C/min to 230  C, hold 10 min.
The following validation parameters were determined:
linearity: 0–3,000 mgl/l (acetone); 0–1000 mmol/l (acetoacetate);
0–30,000 mmol/l (b-hydroxybutyrate); LOQ 0,6 mg/l (acetone);
9,5 mmol/l (acetoacetat); 85 mmol/l (b-hydroxybutyrate). Precision
data was in accordance with the guidelines.[8]
The enzymes were obtained from Roche Diagnostics (Mannheim,
Germany, acetone, lithiumacetoacetate, sodium-b-hydroxybutyrate,
pyruvate, nicotinamideadenindinucleotide (NAD) and tert.-butanol
were obtained from Sigma (Steinheim, Germany).
Anhydroglucitol was detected by a validated liquid chroma-
tography mass spectrometry after a protocol published by Hess
et al.[9] at our institute. For sample preparation, briefly, 50 ml of
serum were fortified with 10 ml of internal standard (200 mg/ml
1,5-Anhydro-D-[13C6] glucitol). Afterwards, the proteins were
precipitated by addition of 200 ml of methanol. After 10 s vortexing
for 10 s and centrifugation for 10 min the supernatant was diluted
1:5 with acetonitrile. 10 ml of the extract were injected into the
chromatographic system. Chromatographic separation was achieved
with a LunaW NH2 (150*2 mm, 3 mm particle size) analytic column
from Phenomenex (Aschaffenburg, Germany) and a NH2 (4*2 mm)
precolumn. An isocratic flow (0.5 ml/min) with acetonitrile/water
(80:20, v/v) for 6 min was used. Molecules were ionized by
atmospheric pressure chemical ionization 8APCI) in the negative
mode. Optimized ion transitions in multiple reaction monitoring
mode were 162.8–112.7 (target) und 162.8–101.0 (qualifier) for
anhydroglucitol and 168.9–105.0 for the IS. LoQ was 0.55 mg/ml,
linearity range was given up to 50 mg/ml, precision data was in
accordance with the guidelines.
Case reports dealing with hyperglycaemia
Case 1
Case history
According to information from his neighbours, a man (66 years)
was straying on the street at 2 am wearing only a t-shirt and
underwear. At 2.30 am his wife let him in to their shared flat;
afterwards he drank a glass of cola. Next morning the wife entered
Figure 1. Conversion of b-hydroxybutyrate (left) and acetoacetate(middle)
into acetone (right) during sample preparation.
Drug Test. Analysis 2013, 5, 795–801
 Drug Testing
Detection of diabetic metabolism disorders post mortem – forensic case reports on cause of death hyperglycaemia and Analysis

the kitchen at 8 am where her husband was sitting on a chair and

Table 1. Glucose and lactate concentrations and the sum formula of Traub in VH and CSF, HbA1c, fructosamine, anhydroglucitol, and ketone body levels in all cases presented (VH: vitreous humour, CSF:
mumbling something incomprehensible. The door of the flat was

333 (VH), 286 (CSF), 169 (FVB)

open; again he was only wearing his t-shirt and underwear. He
wanted to stand up; however, he fell down to the floor. Lying on

fructosamine

< LoD (VH), 383 (CSF)

[mmol/l]
the floor, he was unresponsive and only slightly breathing. His wife

222 (VH), 99.6 (FVB)

did not alert the emergency service; however, she called their son,
who immediately phoned the emergency doctor. Upon arrival, the
emergency service ascertained the death of the man. The wife

512 (FVB)

110 (FVB)
128 (FVB)
seemed to have had drunk alcohol when the police arrived and
could not present a good reason for not having called the
emergency service. She informed the police about her husband’s

anhydroglucitol
diseases: he was suffering from lung disease and diabetes. The week
prior to his death he had refused to eat and to take his medication.

[mg/ml]
FVB

1.02
0.58
3.15
Autopsy findings
Two days later, an autopsy took place revealing pale mucous
membranes and organs; dry tissues; yellow skullcap; moderate and

b-hydroxybuyrate
non-stenosing coronary artery sclerosis; concentric increase of the
thickness of the left heart chamber; chronic obstructive lung disease

[mmol/l]

41400

6761
24190
18540
9896
(COPD) with chronic pulmonary emphysema; arteriosclerosis;

FVB
cerebral oedema; atrophy of a frontal lobe. Disease history and
the yellow skullcap gave hints to perform toxicological analyses.
Histological results

acetone
Glomerulosclerosis; glycogen nephrosis; arteriosclerosis; microvesicular

[mg/l]

25709

855
3280
6132
5023
FVB
hepatic steatosis.
The results of the toxicological analyses are shown in Table 1.

[mmol/mol]
Case 2
HbA1c

97.9
108.9
87.1
85.5

88.6
FVB

74
Case history
A man was found dead in his truck. His jeans were dragged down
to the lower legs. He was a type 1 diabetic and had injected his
glucose
[mg/dl]
urine

4202
261
2559
insulin only irregularly.
Autopsy findings
Four days later an autopsy took place revealing melaena in the
[mg/dl]
Traub

CSF

648
741
557

464
757
small intestine; scratches in the oesophagus; coffee-ground like
particles in the stomach; aspiration of gastric fluid in the medium
bronchi with acute lung emphysema; plethora of the internal
[mg/dl]
lactate

organs; pale kidneys; moderate lung oedema; severe cerebral

CSF

293
435
472

495
465

oedema; initial fatty degeneration of the liver; reduced pancreas;

and initially trabeculated bladder. The disease history resulted in
toxicological analyses.
glucose
[mg/dl]
CSF

501
524
321

216
524

Histological results
Glomerulosclerosis; slight glycogen nephrosis; microvesicular
[mg/dl]
cerebrospinal fluid, FVB: femoral vein blood)

Traub

steatosis of the liver; pancreas completely autolytic.

1210
1006
1108
688
VH

The results of the toxicological analyses are shown in Table 1.

Case 3
[mg/dl]
lactate

315
291
582
398
VH

Case history
A man (73 years) was found dead at home lying in front of an
glucose
[mg/dl]

open window. He had had adiposity, hypertension, and had worn

1053
860
817
489
VH

a cardiac pacemaker.
Autopsy findings
Case no.

Three days later, an autopsy took place. It revealed a muscular

increase in the size of the heart (700 g); moderate coronary
797
1
2
3
4
5
6

sclerosis; muscular thickening of the oesophagus; liquid gastric

Drug Test. Analysis 2013, 5, 795–801 Copyright © 2013 John Wiley & Sons, Ltd. wileyonlinelibrary.com/journal/dta
 Drug Testing
and Analysis
content with little black flakes; little melaena in the small
intestine; few mucous membrane erosions; cerebral and lung
oedema; signs of COPD; crackling noise of lung tissue while
palming; minimal pulmonary sclerosis. Pictures from the scene
of death showed pills and blisters with the drugs torasemide
and glimepiride (antidiabetic medication). Since no obvious
cause of death was assumable, a toxicological analysis took place.
Histological results
Glomerulosclerosis; advanced artherosclerosis; focal nephritis;
macrovesicular steatosis of the liver; autolysis of the pancreas.
The results of the chemical toxicological analyses are shown in
Table 1.
Case 4
Case history
A man (57 years) was suffering from insulin-dependent diabetes
mellitus and prostate cancer. According to his doctor, he was also
suffering from depression. He was found dead in his bed by his wife.
Autopsy findings
Six days later, an autopsy took place. It revealed an atrophy of
cerebral tissues; cerebral and lung oedema; plethora of the internal
organs; narrowness of a fat-marbled pancreas; prostate with small
lumps and calcifications in the passage to the semen vesicles; signs
of COPD; crackling noise of lung tissue while palming; and fatty
degeneration of the liver. Calcifications of small vessels pointed
to a long-lasting diabetes mellitus.
Histological results
Advanced autolysis; hlomerulosclerosis of the kidneys; microvesicular
steatosis of the liver; advanced atherosclerosis, especially of the
coronary arteries.
The results of the toxicological analyses are shown in Table 1.
Case 5
Case history
A son found his mother (80 years) dead in the corridor in front of the
bathroom, lying in a prone position. Two days earlier, he had talked
to her for the last time. The deceased was diabetic. A few weeks
prior to her death, she had fallen from a ladder and since then
had suffered from back pain and dizziness. She did not have any
fractures; however, her doctor gave her some ‘injections’ in the weeks
before her death. Two days prior to her death she was suffering from
dizziness, had problems with her hearing and went to her doctor
again. Further illnesses were known: hypertension; noticeable
problems with the thyroid gland and urinary incontinence.
Autopsy findings
Eight days later, an autopsy took place revealing a thrombus at
the wall of the right carotid artery; arteriosclerosis of the arterial
circle at the brain base; no cerebral oedema; no signs of recent
or older cerebral infarction; strong coronary sclerosis without
recent or older infarctions.
Histological results
Glomerulosclerosis; arterial sclerosis; slight glycogen nephrosis;
slight microvesicular keratosis of the liver; autolysis of the pancreas.
798
The results of the chemical analyses are shown in Table 1.
wileyonlinelibrary.com/journal/dta Copyright © 2013 John Wiley & Sons, Ltd.
C. Hess et al.
Case 6
Case history
A female diabetic (58 years) left her work because of nausea and
indisposition. She was found dead in her bathroom by her
neighbour who had not seen her for 8 days. The woman had been
living very isolated and talking confusedly and was suffering
from a schizophrenic disorder and alcoholism. An autopsy was
conducted to exclude third party negligence.
Autopsy findings
Five days later, an autopsy took place. It revealed a fatty liver with
fibrosis and two cherry-sized haemangiomas; chronically calcificated
pancreatitis; cerebral atrophy. The suspected cause of death was
cardiac infarction.
Histological results
Advanced putrefaction; glomerusclerosis; artherosclerosis; Armanni-
Ebstein-cells (glycogen nephrosis); macrovesicular fatty liver disease.
The results of the toxicological analyses are shown in Table 1.
Discussion
Six cases of death due to diabetic ketoacidosis are presented. On
the basis of these cases, several biochemical parameters are
discussed in the following section.
In the case of a suspected diabetic coma post-mortem, knowledge
about existing diabetes mellitus, its duration and course, its
therapy and the therapeutic discipline of the patient is important.
Symptoms prior to death pointing to diabetic ketoacidosis are
polyuria or dysuria, polydipsia, polyphagia, abdominal pain,
emesis, fever, dyspnoea, hypotonia, tachycardia, and neurologic
deficits. Physical signs are dehydration, dry mucosal membranes,
and the so-called Kussmaul-respiration (fast and deep breathing
with a smell of acetone).[10]
At autopsy, fatty degeneration of the kidneys with a yellow-
reddish cloudiness of the renal parenchyma can be noted. Further
specific diabetic organ changes are diabetic glomerulosclerosis
Kimmelstiel-Wilson or a fatty liver.[11] All of the presented cases
(cases 1–6) showed a fatty liver. Beckmann[12] also showed this
finding; however he associated this fact to a higher incidence
of obesity in diabetics. Most of the described cases showed
arteriosclerotic changes in peripheral, coronary, iliac or cerebral
arteries.[13] Xanthochromia of the cranium is a relatively frequent
autopsy finding in diabetics.[14]
Histological examinations often provide helpful results such as
glycogen accumulation in the kidneys with so-called Armanni-
Ebstein cells, which are very specific for a long-lasting hyperglycaemia
with glucose concentrations > 500 mg/dl.[12] Figure 2 shows
typical histological findings of case 6.
Biochemical measurements complete the range of findings.
After death, blood glucose concentrations alone do not have
high validity. The maximum concentration at the moment of
death decreases rapidly (about 13 mg/dl per hour[15]), so that
the absolute blood glucose concentration does not give any
indication of its concentration at the moment of death. Glucose
underlies anaerobe glycolysis so that lactate concentrations
increase until ten hours after death with 10–15 mg/dl/h.[16]
According to Traub’s hypothesis,[17,18] the combined concentrations
of glucose and lactate in vitreous humour (VH) or cerebrospinal
fluid (CSF) can better indicate high glucose concentrations ante
Drug Test. Analysis 2013, 5, 795–801

Detection of diabetic metabolism disorders post mortem – forensic case reports on cause of death hyperglycaemia and Analysis
Figure 2. Typical pathomorphological observations post mortem in case 6: upper left: A shrunken kidney of a diabetic; upper right: Armanni-Ebstein-
cells in the kidney (x 400); bottom left: A diabetic glomerulosclerosis Kimmelstiel-Wilson (x 100); bottom right: glycogen accumulation in a diabetic liver.
mortem. A number of cut-offs for the determination of a diabetic
coma for this ‘sum formula of Traub’ have been described: >
410 mg/dl,[19] >427 mg/dl,[20] >450 mg/dl[21] or >650 mg/dl[22]
in VH and >362 mg/dl,[20] >400 mg/dl,[23] >415 mg/dl,[19]
>422 mg/dl[21] or >500 mg/dl[24] in CSF. However, some authors[25]
asked themselves, due to the fact that lactate concentrations
increase after death in diabetic metabolism disorders, whether
the sum formula of Traub does not result in an overestimation of
diabetic metabolic disorders with a fatal outcome. In a collective
of 80 deceased, glucose concentration in VH and in CSF correlated
well (R2 = 0,922). The inclusion of lactate concentrations did not
lead to a better correlation (R2 = 0,815), which leads to the
conclusion that glucose but not lactate concentrations are
influenced differently after death. Palmiere et al.[25] showed the
same phenomenon for a bigger collective (n = 470) and proposed
glucose concentration cut offs of > 180 mg/dl in VH or > 144 mg/dl
in CSF. All six cases in our study revealed concentrations above this
cut-off and above the proposed cut-offs for the sum formula of
Traub. Therefore, the sum formula of Traub does not provide
more information than the glucose concentration itself. Glucose
concentrations of non-diabetic deceased in VH were 20 mg/dl
(mean value),[26] 30–80 mg/dl,[27,28] 4–60 mg/dl,[17] 0–75 mg/dl[29]
or 0–108 mg/dl,[18] so that a cut-off of 180 mg glucose per dl
promises good sensitivity. Palmiere et al.[30] showed vitreousglucose
concentrations in 12 cases of DKA always > 342 mg/dl. Zilg et al.[31]
postulated that after an initial decrease in VH-glucose concentrations
during the early post-mortem phase they remained constant
while lactate concentrations increased. The decrease of glucose
concentrations is probably due to the metabolic activity of the
surviving hyalocytes and the inner retina cells. Our cases show
that the sum formula of Traub in cases of diabetic coma is
basically composed of the glucose concentration while, for other
causes of death, the lactate concentrations overbalance.
Glucose concentrations in urine are less reliable. Glucose is
reabsorbed in the renal tubuli. Although glucose is detectable
in patients with high blood glucose concentrations, it does not
give indications for blood glucose concentrations below the very
Drug Test. Analysis 2013, 5, 795–801 Copyright © 2013 John Wiley & Sons, Ltd.
Drug Testing
variable renal glucose barrier (about 180 mg/dl).[23,24] During
diabetic coma, values > 500 mg/dl were detected.[32] Other studies
quoted that urine concentrations > 100 mg/dl indicate abnormal
blood glucose concentrations.[33] Unpublished results of our
research group demonstrate that glucose concentrations in urine
are only of low significance in the post mortem detection of
diabetic coma. Urine glucose weakly correlates with glucose
concentrations in VH (R2 = 0,682; p < 0,0001; n = 20) and in CSF
(R2 = 0,260; p = 0,036; n = 17). High glucose concentration,
however, were only demonstrated in cases of diabetic coma, so
that high urine glucose concentrations can be indicative of
diabetic coma. Conversely, low urine glucose concentrations are
not a criterion to exclude diabetic coma.
The determination of the HbA1c is also of importance for the
post-mortem diagnosis of fatal diabetic coma. HbA1c is stable
for several weeks after death.[23,34] HbA1c concentrations of
diabetics after death conform to concentrations in living diabetics
and are 8.7–15.4%[33,35] or 7.5–19.6%.[34] HbA1c concentrations
correlate with glucose concentrations in VH (R2 = 0.499; p < 0.0001;
n = 63) or in CSF (R2 = 0.419; p < 0.0001; n = 36) after death. High
HbA1c concentrations (> 10%) correlate even better.[36] HbA1c
concentrations are only influenced by hyperglycaemia lasting
for 12 h minimum[34]; short hyperglycaemias do not have an effect
on HbA1c. Therefore, it does not allow a conclusion on the actual
glucose concentration prior to death; however, it gives information
about the glycaemic status during the weeks prior to death. In
all of the six described cases (74–108.9 mmol/mol equivalent
to 8.9–12.1 %), the HbA1c levels were higher than reference
values. Palmiere et al.[30] showed HbA1c-concentrations in blood
of 12 cases of DKA from 49 mmol/mol to 121 mmol/mol.
Similar to HbA1c, fructosamine represents a long time glycaemic
marker for the last 1–3 weeks before measurement. Our data
showed a difference in blood fructosamine concentrations between
diabetics (mean value 138 mmol/l; 12.3–513 mmol/l; n = 19) and
non-diabetics (mean value 78,4 mmol/l; 11.6–286 mmol/l; n = 81).
Fructosamine-concentrations > 300 mmol/l in blood, > 100 mmol/l
799
in VH and > 150 mmol/l in CSF were only detected in diabetics
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 Drug Testing
and Analysis
and are indicative of diabetic illness, not of a lethal diabetic coma.
Fructosamine blood concentrations of the described cases were
110 mmol/l, 129 mmol/l, 160 mmol/l, and 512 mmol/l and so these
concentrations would be partially lower than the cut offs. In VH
and CSF, there significant differences were not seen between
non-diabetics and diabetics in our study. This disagrees with
Osuna et al.[37] who showed significant (p < 0,0001) higher
concentrations in diabetics (mean value 880 mmol/l, n = 111)
than in non-diabetics (mean value 160 mmol/l, n = 342) in VH.
Fructosamine concentrations in the described cases were < LOD,
222 and 333 mmol/l, so that conclusions on the glucose concentra-
tions at the time of death is not possible.
A relatively new glycaemic marker is anhydroglucitol. The sugar
competes with glucose for reabsorption in the kidneys. Therefore,
in case of high blood glucose concentrations, anhydroglucitol is
excreted excessively and diabetics show lower anhydroglucitol
concentrations even after death because anhydroglucitol is
metabolically very stable. Anhydroglucitol concentrations were
significantly higher (p < 0.001) in non-diabetic deceased (mean
value 15.5 mg/ml; 3.21–40.8 mg/ml; SD 8.7 mg/ml; n = 88) than in
diabetics (mean value 4.74 mg/ml; < LoQ-25.2 mg/ml; SD 5.4 mg/ml;
n = 71). However, there was no correlation between AG in femoral
blood and glucose concentrations in VH (R = 0,414; R2 = 0,146;
p = 0,014; n = 35). Nevertheless, concentrations in femoral
blood < 10 mg/ml indicate a badly adjusted diabetes mellitus
before and after death.[9] In the actually described cases concen-
trations were very low (3.15 mg/ml and lower).
Since HbA1c, fructosamin and anhydroglucitol do not reflect
glycaemic conditions at the time of death, the detection of
high concentration ketone bodies acetone, acetoacetate and
b-hydroxybutyrate is an important tool in the post mortem
diagnosis of diabetic ketoacidosis. The main ketone bodies
hydroxybutyrat (27–86 mmol/l fasting and 11–31 mmol/l post-
prandial[38]) and acetoacetate (28–203 mmol/l[23]) can be found
in blood in aequimolar amounts. In case of diabetic ketoacidosis,
acetone concentrations > 21 mg/l were found.[15] In the presently
described cases, concentrations were much higher while
hydroxybutyrate-concentrations always exceeded 6761 mmol/l.
Palmiere et al. measured hydroxybutyrate-concentrtions in 12 cases
of DKA and described concentrations between 7900 mmol/l
and 15100 mmol/l.[30] A high hydroxybutyrate-concentration I
combination with high acetone-concentrations are enough to
diagnose ketoacidosis, therefore, in Table 1, only acetone and
hydroxybutyrate-concentrations are shown.
Conclusion
The post-mortem diagnosis of diabetic coma poses a challenge in
forensics. Apart from morphological and histological findings, a
thorough examination has to include biochemical measurements.
Glucose concentrations in VH or CSF and estimations of ketone
bodies in blood or other matrices are obligatory while measure-
ment of HbA1c, fructosamine, or anhydroglucitol can only give
additional information on the long-term adjustment of the
diabetes of the deceased. Lactate concentrations do not give
more information and can be omitted.
Acknowledgement
The authors thank Prof. Dr Kernbach-Wighton for correction of
800
the manuscript.
wileyonlinelibrary.com/journal/dta Copyright © 2013 John Wiley & Sons, Ltd.
C. Hess et al.
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