Diagnostic approach to drug-screening tests for fatal diabetic ketoacidosis: Forensic autopsy of a methamphetamine abuser

Abstract To diagnose the cause of death in autopsy cases, systematic examinations, such as macroscopic, pathological, biochemical, and toxicological are important. In this case report, drug examinations also gave very useful information to diagnose the cause of death, fatal diabetic ketoacidosis (DKA). A female methamphetamine abuser in her forties was found dead lying on a hotel bed. Diagnosing her cause of death was difficult only from the macroscopic findings because there was no fatal and/or serious injury or disease. On toxicological examination, acetone was detected at a high concentration (682μg/mL in blood, 887μg/mL in urine) using gas chromatography (GC). Using gas chromatography–mass spectrometry (GC–MS), methamphetamine was detected in the blood, urine, hair, and visceral organs; however, these concentrations were low. At the same time, GC–MS examination revealed a high glucose peak. From the results of the biochemical examination of urine, acetoacetic acid was 1940μmol/L, β-hydroxybutyric acid was 14,720μmol/L, and glucose was 4620mg/dL. Histologically, Langerhans' islets in the pancreas were fibrotic and atrophic, and no insulin-immunoreactive cells were observed. The subsequent police investigation also revealed that she had contracted diabetes mellitus type 1; therefore, we concluded that her cause of death was DKA, due to a lack of insulin injection.