The surge in fatal diabetic ketoacidosis in the years of the COVID-19 pandemic: a forensic autopsy study

Abstract

Abstract Introduction/Objective Although many deaths resulting from diabetic ketoacidosis (DKA) fall outside the legal jurisdiction of the medical examiner, a forensic pathologist may identify this cause of death through ancillary testing multiple times per year. We recognized a sharp increase in deaths due to DKA at a busy metropolitan medical examiner’s office in 2020 and 2021, coinciding with the COVID-19 pandemic. We hypothesize that in the majority of these cases, fatal DKA was the presenting symptom of previously undiagnosed diabetes mellitus (DM). Methods/Case Report We performed a retrospective autopsy review of all cases with a cause of death listed as “diabetic ketoacidosis” from January 1, 2018 through June 18, 2021. We compared the number of DKA deaths to all reported deaths from the same time period. Results (if a Case Study enter NA) We identified a total 34 cases of fatal DKA. In 2018, 5 cases of DKA were identified and all decedents had a known diagnosis of DM; the average age at death was 50.6 years (range: 40- 60 years) and 2 decedents were male (40%). In 2019, 5 cases of DKA were identified and 4 decedents had a known diagnosis of DM (80%); the average age at death was 51.4 years (range: 37- 61 years), and all decedents were male (100%). In 2021, 18 cases of DKA were identified and 9 decedents had a previous diagnosis of DM (50%); the average age at death was 43.5 years (range: 22- 64 years), 13 decedents were male (72%), and 1 decedent was COVID-19 positive (5.5%). In the first 6 months of 2021, 6 cases of DKA were identified and none of these decedents had a previous diagnosis of DM (0%); the average at death was 51.8 years (range: 35- 73 years), 4 decedents were male (66%), and 1 decedent was COVID-19 positive (16.6%). Reported deaths per year to our office are as follows: 2018 = 2585 deaths, 2019 = 2658 deaths, 2020 = 3091 deaths, and 2021 to date = 1482 deaths. Conclusion Coinciding with the COVID-19 pandemic, our office experienced a 16.2% increase in all reported deaths from 2019 to 2020, and a 260% increase in fatal DKA. In 2018 and 2019, 9 of the 10 decedents who died from DKA had a known diagnosis of DM (90%). However, in 2020 and the first half of 2021, DKA was the presenting symptom of previously undiagnosed DM in 15 of 24 cases of fatal DKA (62.5%). Further investigation must be done to examine the factors driving the recent surge in fatal DKA.