Diabetic ketoacidosis--a possible complicating factor in deaths associated with drug overdose: two case reports.

Two cases are described where diabetic ketoacidosis was found in conjunction with significant levels of prescription drugs. Case 1: A 45-year-old woman with a history of insulin-dependent diabetes mellitus was found to have Armanni-Ebstein nephropathy characteristic of hyperglycaemia with a vitreous humour glucose level of 63.1 mmol/L and a beta-hydroxybutyrate level of 14.25 mmol/L. Ancillary toxicological evaluation revealed a lethal level of sertraline (2.5 mg/L), with an elevated level of methadone (0.23mg/L). Death was due to diabetic ketoacidosis complicating mixed drug toxicity. Case 2: A 27-year-old man with a history of insulin-dependent diabetes mellitus was found to have Armanni-Ebstein nephropathy with a vitreous humour glucose level of 51.7 mmol/L and a beta-hydroxybutyrate level of 18.6mmol/L. Ancillary toxicological evaluation revealed a potentially lethal level of methadone of 0.39mg/L. Death was attributed to diabetic ketoacidosis complicating methadone toxicity. These cases demonstrate a situation where drug toxicity led to diabetic ketoacidosis resulting in death most likely from a combination of factors. Measuring vitreous humour glucose and beta-hydroxybutyrate levels is important in individuals with histories, or scene evidence, of insulin-dependent diabetes mellitus, in addition to toxicological screening when there is evidence of possible drug taking. It appears that drug intoxication in both cases had impaired the ability to administer insulin, resulting in the development over time of diabetic ketoacidotic states. Lethal mechanisms were, therefore, more complex than simple drug toxicity or diabetic ketoacidosis in isolation.

Volatile substance use in sexual asphyxia.

A 38-year-old man was found dead in bed dressed in female clothing with a mouth gag, handcuffs and bindings around the genitals and limbs. A respirator was also covering the mouth and nose. There were no suspicious circumstances and a diagnosis of death due to sexual asphyxia was made. Following the subsequent discovery of bottles of chloroform in the bedroom, head space analysis of blood confirmed the presence of chloroform, with a blood level of 33 mg/L. Death was, therefore, attributed to a combination of chloroform toxicity and upper-airway obstruction. Headspace analysis with follow-up quantitation may, therefore, be a useful adjunct to the investigation of such cases when devices such as respirators or gas masks are found with the body.