Sudden Death in Diabetic Ketoacidosis Complicated by Sickle Cell Trait.

ABSTRACT: In a sudden death investigation of a service member with sickle cell trait (SCT), evidence of sickle cell crisis further complicated by coexisting, undiagnosed diabetic ketoacidosis called into question the synergistic effects of diabetic ketoacidosis on red blood cell sickling. Sickle cell trait affects more than 4 million people in the United States (US) with the highest prevalence in non-Hispanic Blacks (7%-9%; Mil Med 2017;182(3):e1819-e1824). The heterozygous state of sickled hemoglobin was previously considered a benign condition causing sickling during hypoxic, high-stress conditions such as exercise and high altitude ( Am Assoc Clin Chem 2017). However, research within the last decade shows evidence of sudden death among SCT patients ( J Forensic Sci 2011;56(5):1352-1360). It has been shown that the presence of sickled hemoglobin artificially lowers levels of hemoglobin A1c making it a less effective biomarker for red blood cell glycosylation over time in sickle cell patients ( JAMA 2017;317(5):507-515). The limited scope of medical understanding of the effects of SCT in combination with other comorbidities requires further investigation and better diagnostic criteria. The uniqueness of the US Military and its screening program for sickle cell disease (SCD) and SCT allows for more detection. Since May 2006, newborn screening for SCD/SCT has been a national requirement; however, anyone older than 14 years may not know their SCD/SCT status ( Semin Perinatol 2010;34(2):134-44). The previous absence of such national screening makes it more challenging to identify SCT and SCD patients even within high-risk populations. Furthermore, patients may not know or understand the results of their SCD/SCT status testing. International standards for the autopsy of decedents with SCD and SCT exist ( R Coll Pathol 2017). Within the US, testing of vitreous electrolytes is a common practice in suspected natural death cases, but a review of the US literature did not demonstrate any autopsy standards or recommendations for persons with SCT or high-risk persons for sickling pathologies. The identification of a new diagnosis of type 2 diabetes mellitus, as the cause of death, is not uncommon; however, this case indicates that type 2 diabetes mellitus was not the sole contributing factor. It further illustrates that the US may be underestimating the impact of SCD and SCT as a cause of death, a contributing factor to death, and its synergistic effects with other pathologic processes. We propose a stringent literature review in conjunction with a review of international autopsy standards to develop national autopsy standards and possible SCT/SCD screening recommendations for high-risk persons at the time of autopsy.

The Virtual Hydrostatic Test.

The hydrostatic test is used to help determine if there has been a live birth. Computed tomography (CT), with its ability to detect and localize air/gas in the body, offers a rapid, noninvasive tool for assessment.Four baby deaths (20 to 25 weeks' gestation) in which the hydrostatic test, radiographs, and CT were performed before autopsy are presented. In 2 cases, considered stillbirths, the lungs and liver sank, and there was no air seen in the lungs or gas in the liver on CT. Histology of the lungs showed collapsed alveoli. In 1 case, concluded to be a live birth, the lungs floated, the liver sank, and air was seen in the trachea, bronchi, and both lungs on CT. Histology of the lungs showed multiple areas of expanded alveoli. In 1 case, where both the lungs and liver floated, the CT showed gas widely distributed in the soft tissues. This reflected decomposition, and no conclusion could be made regarding birth status.Assessment of live birth is a critical and difficult decision. Postmortem CT offers another technique to consider in this determination, and it has significant advantages over radiography. Continued study and correlation with existing methods seem warranted.

Observational case series: an algorithm incorporating multidetector computed tomography in the medicolegal investigation of human remains after a natural disaster.

An algorithm incorporating multidetector computed tomography (MDCT), digital radiographs, and external examination was used to triage cases for noninvasive or complete autopsy after a natural disaster. The algorithm was applied to 27 individuals who died during or soon after the earthquake that struck the Republic of Haiti on January 12, 2010. Of the 27 cases reviewed, 7 (26%) required a complete autopsy to determine cause and manner of death. In the remaining 20 (74%), cause and manner of death were determined with a reasonable degree of medical certainty after review of circumstances, an external examination, and postmortem imaging by MDCT and digital radiography (noninvasive autopsy). MDCT was particularly useful in detecting skeletal fractures caused by blunt force injury which were not evident on digital radiographs. The algorithm incorporating postmortem MDCT can be useful in the triage of human remains for autopsy after a natural disaster.