Forensic Sci Med Pathol 2017 Jul 1. Epub 2017 Jul 1.

CRY Department of Cardiovascular Pathology, St George's, University of London, Cranmer Terrace, London, SW17 0RE, UK.

There is growing awareness of sudden unexplained death in alcohol misuse (SUDAM) in which there is no obvious cause of death, no evidence of acute alcohol toxicity or alcoholic ketoacidosis, and the heart is morphologically normal. This study describes the characteristics of a cohort with SUDAM from a tertiary cardiovascular referral center and compares the findings with those of individuals who died from sudden arrhythmic death syndrome (SADS). Cases in this retrospective cross-sectional study were identified from a database of referrals to our center spanning approximately 40 years. Read More

J Endocrinol 2017 Jul 20;234(1):R1-R21. Epub 2017 Apr 20.

School of Animal and Comparative Biomedical SciencesUniversity of Arizona, Tucson, Arizona, USA

Fatty liver can be diet, endocrine, drug, virus or genetically induced. Independent of cause, hepatic lipid accumulation promotes systemic metabolic dysfunction. By acting as peroxisome proliferator-activated receptor (PPAR) ligands, hepatic non-esterified fatty acids upregulate expression of gluconeogenic, beta-oxidative, lipogenic and ketogenic genes, promoting hyperglycemia, hyperlipidemia and ketosis. Read More

J Gen Intern Med 2017 Jun 21;32(6):714-717. Epub 2017 Feb 21.

Department of Pathology, Loyola University Stritch School of Medicine, Room 7612, 2160 S 1st Avenue, Maywood, IL, 60153, USA.

Glycogenic hepatopathy (GH) is an underdiagnosed complication of uncontrolled type 1 diabetes mellitus (T1DM). It appears as an acute relapsing hepatitis with reversible transaminase elevations secondary to excessive hepatic glycogen accumulation. Patients are often asymptomatic but can present with abdominal pain, nausea and vomiting. Read More

Scand J Clin Lab Invest 2017 Apr 2;77(2):149-152. Epub 2017 Feb 2.

a Department of Pharmacology , Oslo University Hospital , Oslo , Norway.

A rapid gas chromatographic mass spectrometric method for measuring anions associated with acute anion gap metabolic acidosis is described. The method is an extension of a previous method. The method quantifies glycolic acid, beta-hydroxybutyric acid with good linearity and pyroglutamic acid with a reproducible curvature relation between 1 and 20 mmol/L and can help the clinician distinguish effectively between ethylene glycol poisoning, alcoholic and diabetic ketoacidosis and cysteine deficiency so early that it will have clinical consequences. Read More

J Forensic Sci 2017 May 30;62(3):681-685. Epub 2017 Jan 30.

School of Medicine, The University of Adelaide, Frome Road, Adelaide, SA, 5005, Australia.

Basal vacuolization of renal tubular epithelial cells is a useful postmortem marker for ketoacidosis. To investigate its incidence and relationship to the severity of ketoacidosis, 158 autopsy cases with elevated β-hydroxybutyrate (>1 mmol/L) over a 7-year-period were retrospectively reviewed. Sixty-eight cases (43%) exhibited basal vacuolizations (vitreous β-hydroxybutyrate: 1. Read More

J Clin Med Res 2016 Dec 26;8(12):919-920. Epub 2016 Oct 26.

Department of Medicine, Centre Hospitalier de l'Universite de Montreal (CRCHUM), Montreal, QC, H2W 1T8, Canada.

Although much more rare than its diabetic counterpart, ketoacidosis secondary to alcohol withdrawal in the context of fasting has its own complex pathophysiology and can easily mimic the acute insulin deficiency presentation. We present here a rare case of a non-diabetic alcoholic patient who presented in ketoacidosis after a period of reduced intake. Read More

J Emerg Med 2016 Oct;51(4):447-449

Division of Medical Toxicology, Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

Background: Alcoholic ketoacidosis (AKA) is a complex syndrome that results from disrupted metabolism in the setting of excessive alcohol use and poor oral intake. Dehydration, glycogen depletion, high redox state, and release of stress hormones are the primary factors producing the characteristic anion gap metabolic acidosis with an elevated β-hydroxybutyrate (β-OH) and lactate.

Case Report: We present the case of a 47-year-old man who presented to the emergency department with metabolic acidosis and profoundly elevated lactate levels who had AKA. Read More

J Forensic Leg Med 2016 Aug 4;42:51-5. Epub 2016 May 4.

Laboratory of Clinical Chemistry, Lausanne University Hospital, Lausanne, Switzerland.

Significantly increased blood ketone body levels can be occasionally observed in the forensic setting in situations other than exposure to cold, diabetic or alcoholic ketoacidosis. Though infrequent, these cases do occur and deserve thorough evaluation in order to establish appropriate differential diagnoses and quantify the role that hyperketonemia may play in the death process. Starvation ketoacidosis is a rare cause of metabolic acidosis and is a phenomenon that occurs normally during fasting, as the body switches from carbohydrate to lipid energy sources. Read More

J Forensic Leg Med 2016 Jul 19;41:49-57. Epub 2016 Apr 19.

Toxicology Unit, Department of Clinical Biochemistry, King's College Hospital NHS Foundation Trust, London SE5 9RS, UK; Toxicology Unit, Dept of Pathology, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK.

The results of biochemical analyses in specimens obtained postmortem may aid death investigation when diabetic and alcoholic ketoacidosis is suspected, when death may have been the result of drowning, anaphylaxis, or involved a prolonged stress response such as hypothermia, and in the diagnosis of disease processes such as inflammation, early myocardial infarction, or sepsis. There is often cross-over with different disciplines, in particular with clinical and forensic toxicology, since some endogenous substances such as sodium chloride, potassium chloride, and insulin can be used as poisons. The interpretation of results is often complicated because of the likelihood of postmortem change in analyte concentration or activity, and proper interpretation must take into account all the available evidence. Read More

Crit Care Med 2016 Aug;44(8):1545-52

1Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY. 2Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY. 3Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kentucky College of Medicine, Lexington, KY.

Objective: Patients with a chronic alcohol use disorder presenting to the ICU may be deficient in important vitamins and electrolytes and are often prescribed a "banana bag" as a reflexive standard of therapy. The difficulty of diagnosing Wernicke's encephalopathy in the critical care setting is reviewed. Furthermore, whether the contents and doses of micronutrients and electrolytes in standard banana bags meet the needs of critically ill patients with an alcohol use disorder is assessed based on available evidence. Read More

Oxf Med Case Reports 2016 Mar 3;2016(3):31-3. Epub 2016 Mar 3.

Department of Gastroenterology , West Suffolk Hospital , Bury St Edmunds , UK.

Alcoholic ketoacidosis (AKA) is a cause of severe metabolic acidosis usually occurring in malnourished patients with a history of recent alcoholic binge, often on a background of alcohol dependency. AKA can be fatal due to associated electrolyte abnormalities and subsequent development of cardiac arrhythmias. This is a diagnosis that is often delayed or missed, in patients who present with a severe lactic and ketoacidosis. Read More

Perm J Spring 2016;20(2):71-3. Epub 2016 Feb 22.

Consultant in Medicine at the Dunedin Hospital; and an Honorary Clinical Senior Lecturer at the University of Otago School of Medicine in Dunedin, New Zealand; Clinical Assistant Professor of Medicine at Stanford University School of Medicine; and a Hospitalist at the Santa Clara Medical Center in CA.

A 31-year-old woman presented to the hospital with symptoms of nausea, malaise, and emesis. She was breastfeeding her 10-month-old infant. She was found to have severe ketoacidosis. Read More

Fa Yi Xue Za Zhi 2015 Aug;31(4):287-92, 297

Postmortem chemistry is becoming more and more essential in routine forensic pathology and has made considerable progress over the past years. Biochemical analyses of vitreous humor, blood, urine and cerebrospinal fluid may provide important information in determining the cause of death or in elucidating forensic issues. Postmortem chemistry may be essential for the determination of cause of death when morphological methods (diabetes mellitus, alcoholic ketoacidosis and electrolytic disorders) cannot detect the pathophysiological changes involved in the death process. Read More

Arch Kriminol 2015 Sep-Oct;236(3-4):103-14

Alcoholic ketoacidosis is a medical emergency, which is characterized at first by an elevated level of ketone bodies. The production of these ketone bodies is accompanied by an equimolar quantity of hydrogen ions and thus causes acidosis, which cannot be detected post-mortem due to anaerobic glycolysis, whereas the three ketone bodies beta-hydroxybutyrate, acetoacetate and acetone can be easily identified. However, the limits of ketone body concentrations mentioned in the literature for diagnosing ketoacidosis vary significantly, partly due to inhomogeneous study groups. Read More

Alcohol Alcohol 2016 May 4;51(3):268-74. Epub 2015 Nov 4.

National Hospital Organization Kurihama Medical and Addiction Center, Kanagawa 239-0841, Japan.

Aims: To identify determinants of hyperuricemia in alcoholics.

Methods: The serum uric acid (UA) levels of 1759 Japanese alcoholic men (≥40 years) were measured on their first visit or within 3 days after admission; ADH1B and ALDH2 genotyping on blood DNA samples were performed. Dipstick urinalyses for ketonuria and serum UA measurements were simultaneously performed for 621 men on their first visit. Read More

Am J Emerg Med 2016 May 23;34(5):941.e3-4. Epub 2015 Oct 23.

Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Izunokuni city, Shizuoka, Japan; Department of Emergency and Critical Care Medicine, Nerima Hospital, Juntendo University, Izunokuni city, Shizuoka, Japan. Electronic address:

A 74-year-old man noted dysarthria and right hemiparesis. His history included a gastric ulcer 2 years previously, and he had gradually lost 10 kg over a 2-year period due to appetite loss. He daily consumed 120 mg of alcohol. Read More

Minerva Endocrinol 2016 Mar 16;41(1):70-7. Epub 2015 Oct 16.

Section of Endocrinology, Diabetes and Nutrition, Department of Medicine Boston University School of Medicine and Boston Medical Center, Boston, MA, USA -

The aim of this paper is to review the relevant literature related to the epidemiology, pathophysiology, natural history, clinical features and treatment of fibrocalculous pancreatic diabetes (FCPD). We review the English-language literature on this topic published between 1956 and 2014. FCPD is a form of diabetes usually associated with chronic calcific pancreatitis. Read More

PLoS One 2015 20;10(8):e0136078. Epub 2015 Aug 20.

Institute of Animal Nutrition, Federal Research Institute for Animal Health, Friedrich-Loeffler-Institute, Braunschweig, Germany.

The inhibition of dipeptidyl peptidase-4 (DPP4) via specific inhibitors is known to result in improved glucose tolerance and insulin sensitivity and decreased accumulation of hepatic fat in type II diabetic human patients. The metabolic situation of dairy cows can easily be compared to the status of human diabetes and non-alcoholic fatty liver. For both, insulin sensitivity is reduced, while hepatic fat accumulation increases, characterized by high levels of non-esterified fatty acids (NEFA) and ketone bodies. Read More

J UOEH 2015 Mar;37(1):43-7

Department of neurology, JCHO (Japan Community Health care Organization) Kyushu Hospital.

We report a 55 year old Japanese man with a history of alcohol abuse, who was in a near fasting state for the previous few days.He was admitted to our hospital with abrupt disturbance of consciousness. He presented disturbance of consciousness with extreme hypoglycemia and ketoacidosis with high β-hydroxybutyric acid concentration. Read More

Am J Physiol Endocrinol Metab 2015 May 24;308(9):E744-55. Epub 2015 Feb 24.

Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy; Policlinico Tor Vergata Foundation, Rome, Italy;

Liver has a principal role in glucose regulation and lipids homeostasis. It is under a complex control by substrates such as hormones, nutrients, and neuronal impulses. Insulin promotes glycogen synthesis, lipogenesis, and lipoprotein synthesis and inhibits gluconeogenesis, glycogenolysis, and VLDL secretion by modifying the expression and enzymatic activity of specific molecules. Read More

J Pediatr Endocrinol Metab 2015 Mar;28(3-4):333-5

Real euglycemic diabetic ketoacidosis [DKA; blood glucose <200 mg/dL (11.1 mmol/L)] is rare, and long-lasting starvation conditions due to intervening diseases in type 1 diabetes mellitus patients may also cause it. Euglycemic DKA is also reported in insulin-dependent diabetics with depression, alcoholics, glycogen storage diseases, and chronic liver disease apart from pregnant cases. Read More

Soud Lek 2014 ;59(4):48-50

Unlabelled: Alcohol accounts for a great amount of deaths per year either due to the acute intoxication or due to the secondary impacts of acute or chronic alcoholism. Commonly, in large amount of such fatal cases blood alcohol concentration is low or absent and fatty liver disease is frequently the only pathological finding detected at the autopsy of alcohol consumer. We offer a short case report of a case with the following analysis of why we decided to consider alcoholic ketoacidosis in our differential diagnosis. Read More

Alcohol Alcohol 2014 Nov 22;49(6):687-8. Epub 2014 Sep 22.

University Centre of Legal Medicine, rue du Bugnon 21, 1011 Lausanne, Switzerland.

Alcohol Alcohol 2014 Nov 21;49(6):687. Epub 2014 Sep 21.

Institute of Forensic Medicine, University of Southern Denmark, Winsløwparken 17B, DK-5000 Odense C, Denmark

Alcohol Alcohol 2014 Nov 1;49(6):618-25. Epub 2014 Aug 1.

National Hospital Organization Kurihama Medical and Addiction Center, Kanagawa 239-0841, Japan.

Aims: Alcoholic ketosis and ketoacidosis are metabolic abnormalities often diagnosed in alcoholics in emergency departments. We attempted to identify determinants or factors associated with alcoholic ketosis.

Methods: The subjects of this cross-sectional survey were 1588 Japanese alcoholic men (≥40 years) who came to an addiction center within 14 days of their last drink. Read More

J Diabetes Res 2014 13;2014:510643. Epub 2014 Apr 13.

Department of Endocrinology & Metabolism, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong 519000, China.

Diabetic ketosis had been identified as a characteristic of type 1 diabetes mellitus (T1DM), but now emerging evidence has identified that they were diagnosed as T2DM after long time follow up. This case control study was aimed at comparing the clinical characteristic, β-cell function, and insulin resistance of ketosis and nonketotic onset T2DM and providing evidence for treatment selection. 140 cases of newly diagnosed T2DM patients were divided into ketosis (62 cases) and nonketotic onset group (78 cases). Read More

Emerg Med Clin North Am 2014 May 19;32(2):293-301. Epub 2014 Feb 19.

Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, 110 South Paca Street, 2nd Floor, Baltimore, MD, USA; Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Baltimore, MD 21201, USA. Electronic address:

Ethanol intoxication and ethanol use are associated with a variety of metabolic derangements encountered in the Emergency Department. In this article, the authors discuss alcohol intoxication and its treatment, dispel the myth that alcohol intoxication is associated with hypoglycemia, comment on electrolyte derangements and their management, review alcoholic ketoacidosis, and end with a section on alcoholic encephalopathy. Read More

Basic Clin Pharmacol Toxicol 2014 Nov 28;115(5):472-5. Epub 2014 Apr 28.

Department of Pharmacy & Pharmacology, Slotervaart Hospital, Amsterdam, The Netherlands.

An intoxication with drugs, ethanol or cleaning solvents may cause a complex clinical scenario if multiple agents have been ingested simultaneously. The situation can become even more complex in patients with (multiple) co-morbidities. A 59-year-old man with type 2 diabetes mellitus (without treatment two weeks before the intoxication) intentionally ingested a substantial amount of ethanol along with ~750 mL of laminate floor cleaner containing citric acid. Read More

BMJ Case Rep 2014 Feb 25;2014. Epub 2014 Feb 25.

Acute Medicine, Endocrinology & Diabetes, Stepping Hill Hospital, Stockport, UK.

Chronic alcoholism is a frequently unrecognised cause of ketoacidosis. Most patients with alcoholic ketoacidosis present with normal or low glucose, but this condition can present with hyperglycaemia. This can lead to misdiagnosis of diabetes ketoacidosis and, therefore, inappropriate treatment with insulin. Read More

Alcohol Alcohol 2014 May-Jun;49(3):271-81. Epub 2013 Dec 10.

Corresponding author: University Center of Legal Medicine, Rue du Bugnon 21, 1011 Lausanne, Switzerland.

Aims: The aim of this article is to review the forensic literature covering the postmortem investigations that are associated with alcoholic ketoacidosis fatalities and report the results of our own analyses.

Methods: Eight cases of suspected alcoholic ketoacidosis that had undergone medico-legal investigations in our facility from 2011 to 2013 were retrospectively selected. A series of laboratory parameters were measured in whole femoral blood, postmortem serum from femoral blood, urine and vitreous humor in order to obtain a more general overview on the biochemical and metabolic changes that occur during alcoholic ketoacidosis. Read More

Int J Legal Med 2013 Nov 4;127(6):1131-7. Epub 2013 Oct 4.

Laboratory of Forensic Biology, Department of Forensic Medicine, Hjelt Institute, PO Box 40, FI-00014, University of Helsinki, Finland,

Diabetes and alcohol abuse may cause severe metabolic disturbances that can be fatal. These may be difficult to diagnose in autopsies based solely on macroscopical and histological findings. In such cases, metabolic markers, such as postmortem glucose and ketone levels, can provide supporting information. Read More

J Forensic Sci 2014 Jan 23;59(1):161-6. Epub 2013 Aug 23.

University Centre of Legal Medicine, Rue du Bugnon 21, 1011, Lausanne, Switzerland.

The concentrations of 3-beta-hydroxybutyrate (3HB) in femoral blood, urine, vitreous humor as well as pericardial and cerebrospinal fluids were retrospectively examined in a series of medico-legal autopsies, which included cases of diabetic ketoacidosis, hypothermia fatalities without ethanol in blood, bodies presenting mild decompositional changes, and sudden deaths in chronic alcoholics. Similar increases in 3HB concentrations were observed in blood, vitreous, and pericardial fluid, irrespective of the cause of death, suggesting that pericardial fluid and vitreous can both be used as alternatives to blood for postmortem 3HB determination. Urine 3HB levels were higher than blood values in most cases. Read More

J Forensic Leg Med 2013 May 11;20(4):305-7. Epub 2012 Aug 11.

School of Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia.

Basal vacuolization of renal epithelial cells occurs in diabetic and alcoholic ketoacidosis, hypothermia and starvation. The vacuoles contain triglycerides. Following a case where formalin pigment deposition within these vacuoles led to the identification of ketoacidosis, a retrospective review of a further 31 cases with ketoacidosis, was undertaken. Read More

J Forensic Sci 2013 May 12;58(3):693-6. Epub 2013 Mar 12.

School of Medical Sciences, The University of Adelaide Medical School, Frome Road, Adelaide, SA, 5005, Australia.

Renal cortical pallor was studied as a potential marker at autopsy of diabetic ketoacidosis in 23 cases, hyperglycemic nonketotic coma in eight cases, and alcoholic ketoacidosis in five cases (vitreous humor glucose level≥11.1 mM; β-hydroxybutyrate level≥5 mM). Renal cortical pallor was noted on macroscopic examination in 10 of 23 cases of lethal diabetic ketoacidosis (43. Read More

Clin Chim Acta 2013 Jan 13;415:245-9. Epub 2012 Nov 13.

Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, United States.

Background: Alcohol ketoacidosis is a frequently missed diagnosis, but is well described in the literature. We present a case of ketoacidosis, likely alcohol ketoacidosis, in a 40 y-old chronic alcoholic patient. The detection of trace serum isopropanol prompted a discussion of alcohol ketoacidosis versus toxic isopropanol ingestion or a combination of both, including comparisons with citations in current literature. Read More

Nutr Hosp 2012 May-Jun;27(3):936-9

Servicio de Endocrinoloxía e Nutrición, Complexo Hospitalario Universitario de Ourense, Ourense, España.

A 57-year-old man with chronic alcoholism was admitted to our hospital due to disturbance of consciousness and polyradiculitis. Laboratory examination revealed metabolic acidosis, hypokalemia and hypophosphataemia. Alcoholic ketoacidosis is a common disorder in alcoholic patients. Read More

Leg Med (Tokyo) 2013 Mar 22;15(2):72-8. Epub 2012 Oct 22.

Hjelt-Institute, Department of Forensic Medicine, PL 40, University of Helsinki, 00300 Helsinki, Finland.

Glycated hemoglobin (HbA1c) is a glycoprotein formed as a result of the non-enzymatic addition of d-glucose to the hemoglobin β-chain. The amount of HbA1c in the blood is dependent on mean glucose levels present during the 1-2 months preceding measurement, and it is an indicator of long-term glycemic levels. HbA1c is a useful marker in postmortem biochemistry in determining cause of death in acetonemic cases by allowing to distinguish diabetic ketoacidosis (DKA) from starvation or alcoholic ketoacidosis (AKA) and intoxication by acetone or isopropanol. Read More

Endocr J 2012 12;59(8):669-76. Epub 2012 May 12.

Department of Metabolism/Diabetes and Clinical Nutrition, Nagasaki University Hospital, Japan.

Glycogenic hepatopathy (GH) has been reported as a very rare and under recognized complication in long-standing poorly controlled type 1 diabetes (T1D) patients. GH is characterized by transient elevation of liver transaminase and hepatomegaly caused by reversible and excessive glycogen accumulation in hepatocytes. It has been reported that GH is indistinguishable from non-alcoholic fatty liver disease, which is more commonly seen in diabetic patients, even after a history is taken and a physical examination or imaging studies have been performed. Read More

J Forensic Sci 2012 Sep 27;57(5):1234-40. Epub 2012 Mar 27.

Fulton County Medical Examiner's Center, Atlanta, GA 30312, USA.

Vitreous beta-hydroxybutyrate (BHB) was retrospectively analyzed in 1795 forensic cases using the Pointe Scientific method. Comparison of vitreous BHB with vitreous glucose in 1781 of the cases showed moderately good correlation r = 0.731. Read More

Leg Med (Tokyo) 2012 May 25;14(3):140-6. Epub 2012 Feb 25.

Hjelt-Institute, Department of Forensic Medicine, PL 40, University of Helsinki, 00300 Helsinki, Finland.

C-reactive protein (CRP) is a widely used acute phase protein that reacts to various tissue-destroying stimuli. Its forensic applications have been established in prior studies. We show that CRP can be successfully measured even after a long postmortem period, up to 18 days, which has not previously been reported. Read More

Am J Emerg Med 2012 Nov 4;30(9):2087.e7-8. Epub 2012 Feb 4.

Department of Medicine, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan.

Alcoholism is the major cause of electrolyte and acid-base imbalance and nutrition deficiency. Ketoacidosis is one of major advised effect on alcoholism. Marchiafava-Bignami disease, a rare alcohol-related disorder, characterized by altered mental status, seizure, and multifocal central nervous system signs, which results from progressive demyelination and necrosis of corpus callosum. Read More

J Forensic Sci 2012 May 23;57(3):674-8. Epub 2012 Jan 23.

Duke Univeristy School of Medicine, Duke University Medical Center, Durham, NC 27710, USA.

Isopropanol (IPA) detected in deaths because of diabetic ketoacidosis (DKA) or alcoholic ketoacidosis (AKA) may cause concern for IPA poisoning. This study addressed this concern in a 15-year retrospective review of 260 deaths in which concentrations of acetone and IPA, as well as their ratios, were compared in DKA (175 cases), AKA (79 cases), and IPA intoxication (six cases). The results demonstrated the frequency of detecting IPA in ketoacidosis when there was no evidence of IPA ingestion. Read More

BMC Clin Pathol 2012 Jan 12;12. Epub 2012 Jan 12.

Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, 52242, USA.

Background: Patients ingesting ethylene glycol, isopropanol, methanol, and propylene glycol ('toxic alcohols') often present with non-specific signs and symptoms. Definitive diagnosis of toxic alcohols has traditionally been by gas chromatography (GC), a technique not commonly performed on-site in hospital clinical laboratories. The objectives of this retrospective study were: 1) to assess the diagnostic accuracy of the osmolal gap in screening for toxic alcohol ingestion and 2) to determine the common reasons other than toxic alcohol ingestion for elevated osmolal gaps. Read More

J Forensic Sci 2012 Jan 10;57(1):126-8. Epub 2011 Nov 10.

The University of Adelaide Medical School, Adelaide, SA 5005, Australia.

Subnuclear renal tubular epithelial cell vacuolization is a marker for diabetic ketoacidosis. Whether it is because of hyperglycemia or of ketoacidosis is unclear. To examine the effect of ketoacidosis on renal cells in isolation, five cases of lethal alcoholic ketoacidosis without hyperglycemia were examined (vitreous humor β-hydroxybutyrate: 6. Read More

Int J Legal Med 2012 Mar 24;126(2):187-98. Epub 2011 Sep 24.

University Centre of Legal Medicine, Lausanne-Geneva, Rue du Bugnon 21, 1011, Lausanne, Switzerland.

Postmortem chemistry is becoming increasingly essential in the forensic pathology routine and considerable progress has been made over the past years. Biochemical analyses of vitreous humor, cerebrospinal fluid, blood and urine may provide significant information in determining the cause of death or in elucidating forensic cases. Postmortem chemistry may essentially contribute in the determination of the cause of death when the pathophysiological changes involved in the death process cannot be detected by morphological methods (e. Read More

Forensic Sci Int 2012 Jan 12;214(1-3):142-7. Epub 2011 Aug 12.

Toxicology Unit, Imperial College London, Charing Cross Hospital, London, United Kingdom.

Data from 191 post-mortem cases where post-mortem blood beta-hydroxybutyrate (βHB) and acetone concentrations and vitreous humor glucose concentrations (where available) had been measured were retrospectively investigated to determine the markers required to identify and distinguish between Alcoholic Ketoacidosis (AKA), Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycemic State (HHS). Blood βHB concentrations above 250 μg/mL were considered significant and it was shown to be the preferred marker of ketoacidosis. All cases with significant βHB detected also had acetone present (greater than 2mg/dL) demonstrating that acetone can be used as a marker to identify ketoacidosis and can be used to indicate when βHB measurement is necessary. Read More

Forensic Sci Med Pathol 2012 Mar 31;8(1):19-22. Epub 2011 Jul 31.

Division of Anatomical Pathology, Eastern Ontario Forensic Pathology Unit, Ontario Forensic Pathology Service, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON K1H8L6, Canada.

The Armanni-Ebstein lesion is a histological change in the kidney consisting of sub-nuclear vacuolation of the proximal tubules. It has been most associated with diabetic ketoacidosis. The vacuoles have been reported to contain glycogen. Read More

Am J Kidney Dis 2011 Sep 27;58(3):480-4. Epub 2011 Jul 27.

Medical and Research Services Veterans Administration Greater Los Angeles (VHAGLA) Healthcare System, Los Angeles, CA 90073, USA.

An increase in serum osmolality and serum osmolal gap with or without high-anion-gap metabolic acidosis is an important clue to exposure to one of the toxic alcohols, which include methanol, ethylene glycol, diethylene glycol, propylene glycol, or isopropanol. However, the increase in serum osmolal gap and metabolic acidosis can occur either together or alone depending on several factors, including baseline serum osmolal gap, molecular weight of the alcohol, and stage of metabolism of the alcohol. In addition, other disorders, including diabetic or alcoholic ketoacidosis, acute kidney injury, chronic kidney disease, and lactic acidosis, can cause high-anion-gap metabolic acidosis associated with an increased serum osmolal gap and therefore should be explored in the differential diagnosis. Read More

Praxis (Bern 1994) 2011 Jun;100(13):797-9

Interdisziplinäre Intensivstation, Stadtspital Waid Zürich.

We report on a 46-year-old female patient with chronic alcoholism, who presented with a severe metabolic acidosis and an increased anion gap despite repeated vomiting. In face of a dramatically increased serum-beta-hydroxybutyrate and after ruling out more common causes of acidosis, we were able to diagnose an alcoholic ketoacidosis. The epidemiology, pathophysiology, clinics and treatment of this often forgotten and misunderstood disorder of acid-base balance are discussed. Read More