Optimizing the postmortem diagnosis of alcoholic ketoacidosis

Alcoholic ketoacidosis (AKA) is an underreported and underrecognized complication of chronic alcohol use disorder, which may present as a sudden death with few diagnostic clues. The most frequent history is that the affected individual stops eating and uses alcohol as one's primary source of nutritional intake, with the subsequent development of nausea, vomiting, and general malaise. Chronic alcoholics may also stop drinking days or weeks before death, precipitating a terminal ketoacidotic state, of which beta-hydroxybutyrate (BHB) is the principal ketoacid. The postmortem toxicology and chemistry findings may be low to absent (undetectable) blood and vitreous ethanol concentrations, elevated blood and vitreous acetone, and elevated BHB levels. We present a case series of 19 deaths of AKA at the Franklin County, Ohio Forensic Science Center that is characterized by an essentially bimodal distribution due to the introduction of an algorithm designed to facilitate the detection of ketoacids, and specifically, BHB, by two principal measures: (1) substantially lowering the detection threshold of acetone; and (2) prompting reflex testing for BHB when that threshold has been achieved. The result of this change in laboratory protocol has been a noticeably enhanced ability to make the diagnosis of AKA and to offer a feasible mechanism by which chronic alcoholics die suddenly, over the purely morphologic but mechanistically vacuous designation of "fatty liver".