Autopsy case of a possible enigmatic triad accompanied by black esophagus and Wischnewsky spots

The coexistence of diabetic ketoacidosis (DKA), hypertriglyceridemia (HTG), and acute pancreatitis (AP), termed the "enigmatic triad," presents diagnostic uncertainty because each condition may precipitate the others. The forensic and pathological significance of associated gastrointestinal findings, including Wischnewsky spots (WS) and black esophagus (BE), remains insufficiently described. We aimed to describe the forensic, biochemical, and histopathological findings in an autopsy case of a possible enigmatic triad with BE and WS and to explore the likely sequence of events leading to death. We conducted a forensic autopsy on a man in his 50 s with hypertension and bipolar disorder. Gross examination, histopathology, toxicology, and biochemical analyses (ketone bodies, glucose, HbA1c, triglycerides, and inflammatory markers) were conducted. BE and WS were identified in the upper gastrointestinal tract. Renal histology revealed basal subnuclear vacuolization and Armanni-Ebstein lesions, and focal neutrophilic infiltration was observed in the pancreas. Markedly elevated ketone bodies, HbA1c, glucose indicated severe DKA, with hypertriglycemia and pancreatic involvement. A lethal concentration of olanzapine was detected, while alcohol was absent. Our findings suggest that DKA likely preceded HTG and AP and may have been exacerbated by olanzapine-associated hyperglycemia. This case highlights the forensic relevance of recognizing metabolic and gastrointestinal markers of the enigmatic triad. As a single-case report, causal relationships cannot be confirmed; further clinicopathological studies are needed to clarify mechanisms and drug-related risks.