Forensic Pathology for Police - Brainshare Public Online Library

248 10 Natural Deaths
with severe cases possibly leading to death. Vitreous electrolyte evaluation in such
cases will typically reveal a “diabetic pattern” (see Chapter 21), with glucose levels
>200 mg/dL and the presence of acetone.
Type II DM, accounting for 80–90% of DM cases, is caused by cells’ resistance
to insulin and an inadequate release of insulin from beta-cells. As a result, the body
responds by producing more glucose, with damage to kidney, eye, nerve, and blood
vessel cells. Type II DM is strongly related to obesity. Treatment includes dietary
and nutritional education and manipulation, as well as medication (hypoglycemic
drugs).
Classic autopsy findings in patients with long-standing DM include “diabetic
nephropathy” (kidney changes), with many possible findings, such as grosslyevident
granularity of the kidney surfaces and microscopic nodular glomerulosclerosis
(the “Kimmelstiel–Wilson” lesion), and vascular changes, including
atherosclerosis as well as arteriolosclerosis (thickened walls of small arterioles).
Usually, the eye and nerve changes are not evaluated in routine forensic autopsies.
Diabetics are at risk for atherosclerotic cardiovascular disease-related death.
In fact, from a clinical standpoint, diabetics may experience a “silent” myocardial
infarct, with no recognizable symptoms. Diabetics are also more likely to experience
“subendocardial” myocardial infarcts (infarcts involving the inner aspects of
the myocardium) compared to the non-diabetic population, but they also can experience
the more typical “transmural” (full thickness) infarcts. Diabetic patients are at
risk for nasal infections (with fungi called “mucormycosis”) as well as urinary tract
infections. In deaths related to ketoacidosis, the “Armanni–Ebstein” change can be
seen as microscopic clearing of the cytoplasm of proximal convoluted tubule cells.
Persons on long-term insulin replacement therapy will frequently develop antiinsulin
antibodies, which can be measured in postmortem blood samples. When
present, much of the insulin that is present in the blood is actually bound to these
antibodies, and therefore not available to function at the cellular level. Consequently,
it is not unusual for these persons to have elevated “total insulin” levels. Their “free
insulin” levels should be within normal limits. In endogenous insulin (that produced
by the beta-cells of the pancreas), a substance called “C-peptide” is produced along
with insulin. C-peptide levels can also be measured. If there is a very low C-peptide
level in the presence of a normal or high insulin level, this indicates that the insulin is
exogenous (injected). In deaths involving insulin-dependent DM patients, questions
sometimes arise regarding whether the individual may have purposefully taken an
insulin overdose, or whether a non-diabetic patient was injected with insulin. These
questions are addressed in Chapter 11 (Drug and Toxin-Related Deaths).
Sickle Cell Disease
Sickle cell disease is a type of disorder referred to as a “hemoglobinopathy” (a disease
characterized by the production of abnormal hemoglobin). More specifically,
sickle cell disease is an autosomal recessive genetic disorder involving the gene that
codes for the beta-globin chain that is part of the hemoglobin A (HbA) molecule.