Abstract
Diabetic ketoacidosis (DKA) is a frequent and life-threatening complication, whose diagnosis remains challenging in forensic practice. We aimed at assessing the performance of a commercially available blood glucose and ketone monitoring device (BGMD) in measuring glucose and ketone levels in post-mortem vitreous (VH) and blood samples, in order to determine if such a device can be used for screening lethal cases of DKA at autopsy. VH and blood samples were collected in cases of unexplained causes of death at autopsy. Glucose and β-hydroxybutyrate (BHB) were measured in VH and BHB in blood using the BGMD. The values were compared to those obtained with validated enzymatic methods. Values ≥ 10 mmol/L were considered to be elevated for glucose, and BHB values ≥ 2.5 mmol/L were considered to indicate ketoacidosis. There was a strong and significant correlation between VH glucose and blood BHB concentrations measured with the BGMD and the validated method (r = 0.78 and r = 0.80, p < 0.0001, respectively), whereas no correlation was found for VH BHB values (r = 0.19, p = 0.19). The sensitivity and specificity of the BGMD were both excellent (1.0) to detect elevated VH glucose levels with a threshold of 14.4 mmol/L, and to detect elevated blood BHB levels with a threshold of 2.85 mmol/L. In contrast, the specificity of the BGMD to detect high BHB levels in VH was poor (0.50) with an optimal threshold of 2.5 mmol/L. We showed that a commercially available BGMD is suitable for identifying cases of lethal DKA and other metabolic disorders at autopsy, through the investigation of vitreous glucose and blood BHB. We therefore recommend the systematic use of a BGMD for screening these conditions in cases of unexplained deaths.
References
Boulagnon C, Garnotel R, Fornes P, Gillery P (2011) Post-mortem biochemistry of vitreous humor and glucose metabolism: an update. Clin Chem Lab Med 49:1265–1270. https://doi.org/10.1515/CCLM.2011.638
Rousseau G, Simard G, Homedan C, Reynier P, Rouge-Maillart C (2017) Exploration biologique des décès par acidocétose diabétique : revue de la littérature. Rev Med Leg 8:116–122. https://doi.org/10.1016/j.medleg.2017.05.002
Zhou C, Byard RW (2018) An analysis of the morbidity and mortality of diabetes mellitus in a forensic context. J Forensic Sci 63:1149–1154. https://doi.org/10.1111/1556-4029.13674
Goullé J-P, Lacroix C, Bouige D (2002) Glycated hemoglobin: a useful post-mortem reference marker in determining diabetes. Forensic Sci Int 128:44–49. https://doi.org/10.1016/s0379-0738(02)00152-4
Palmiere C, Mangin P (2012) Postmortem chemistry update part I. Int J Legal Med 126:187–198. https://doi.org/10.1007/s00414-011-0625-y
Palmiere C, Mangin P, Werner D (2014) Postmortem distribution of 3-beta-hydroxybutyrate. J Forensic Sci 59:161–166. https://doi.org/10.1111/1556-4029.12265
Palmiere C (2015) Postmortem diagnosis of diabetes mellitus and its complications. Croat Med J 56:181–193. https://doi.org/10.3325/cmj.2015.56.181
Osuna E, Vivero G, Conejero J, Abenza JM, Martínez P, Luna A, Pérez-Cárceles MD (2005) Postmortem vitreous humor beta-hydroxybutyrate: its utility for the postmortem interpretation of diabetes mellitus. Forensic Sci Int 153:189–195. https://doi.org/10.1016/j.forsciint.2004.09.105
Walta A-M, Keltanen T, Lindroos K, Sajantila A (2016) The usefulness of point-of-care (POC) tests in screening elevated glucose and ketone body levels postmortem. Forensic Sci Int 266:299–303. https://doi.org/10.1016/j.forsciint.2016.06.003
(2019) Classification of diabetes mellitus. World Health Organization, Geneva
Lebossé D, Clément R, Gratas C (2017) Diagnostic post-mortem d’acidocétose diabétique. Rev Med Leg 8:73–79. https://doi.org/10.1016/j.medleg.2017.02.001
Iten PX, Meier M (2000) Beta-hydroxybutyric acid--an indicator for an alcoholic ketoacidosis as cause of death in deceased alcohol abusers. J Forensic Sci 45:624–632
Zilg B, Alkass K, Berg S, Druid H (2009) Postmortem identification of hyperglycemia. Forensic Sci Int 185:89–95. https://doi.org/10.1016/j.forsciint.2008.12.017
Palmiere C, Sporkert F, Vaucher P, Werner D, Bardy D, Rey F, Lardi C, Brunel C, Augsburger M, Mangin P (2012) Is the formula of Traub still up to date in antemortem blood glucose level estimation? Int J Legal Med 126:407–413. https://doi.org/10.1007/s00414-011-0659-1
Palmiere C, Bardy D, Mangin P, Werner D (2013) Postmortem diagnosis of unsuspected diabetes mellitus. Forensic Sci Int 226:160–167. https://doi.org/10.1016/j.forsciint.2013.01.004
Heimer J, Gascho D, Madea B, Steuer A, Martinez RM, Thali MJ, Zoelch N (2020) Comparison of the beta-hydroxybutyrate, glucose, and lactate concentrations derived from postmortem proton magnetic resonance spectroscopy and biochemical analysis for the diagnosis of fatal metabolic disorders. Int J Legal Med 134:603–612. https://doi.org/10.1007/s00414-019-02235-6
Lin LI (1989) A concordance correlation coefficient to evaluate reproducibility. Biometrics 45:255–268
Sturner WQ, Gantner GE (1964) Postmortem vitreous glucose determinations. J Forensic Sci 9:485–491
Gagajewski A, Murakami MM, Kloss J, Edstrom M, Hillyer M, Peterson GF, Amatuzio J, Apple FS (2004) Measurement of chemical analytes in vitreous humor: stability and precision studies. J Forensic Sci 49:371–374
Uemura K, Shintani-Ishida K, Saka K, Nakajima M, Ikegaya H, Kikuchi Y, Yoshida KI (2008) Biochemical blood markers and sampling sites in forensic autopsy. J Forensic Legal Med 15:312–317. https://doi.org/10.1016/j.jflm.2007.12.003
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical approval
This article does not contain any studies with live human participants or animals performed by any of the authors. Ethical approval was obtained from the Ethics Committee of the University Hospital of Montpellier, Nr. 2018_IRB-MTP_05–08.
Additional information
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Peyron, PA., Plawecki, M., Lossois, M. et al. Usefulness of a blood glucose and ketone monitoring device as a screening tool for lethal diabetic ketoacidosis. Int J Legal Med 135, 293–299 (2021). https://doi.org/10.1007/s00414-020-02343-8
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00414-020-02343-8