Does the post‑mortem toxicology report include cortisol, ACTH, sodium, potassium, and glucose values indicating adrenal crisis or primary adrenal insufficiency in this woman?

Post-Mortem Toxicology and Adrenal Crisis Diagnosis

Standard post-mortem toxicology reports do not routinely include cortisol, ACTH, sodium, potassium, or glucose measurements, and even when obtained, these values are extremely difficult to interpret after death due to rapid post-mortem degradation and redistribution of hormones and electrolytes. 1, 2

Why Post-Mortem Biochemistry Cannot Reliably Diagnose Adrenal Crisis

Hormone Instability After Death

• Cortisol degrades rapidly post-mortem, making serum or plasma cortisol measurements unreliable for diagnosing adrenal insufficiency at autopsy—the hormone breaks down within hours of death, and values do not reflect ante-mortem physiological status 1, 3

• ACTH is even more unstable than cortisol, degrading within minutes to hours after death, rendering post-mortem ACTH levels essentially uninterpretable for diagnostic purposes 1, 4

Electrolyte Redistribution

• Sodium and potassium undergo massive post-mortem redistribution as cellular membranes lose integrity, causing potassium to leak from cells into serum and creating artifactually elevated potassium levels that do not reflect ante-mortem hyperkalemia 2, 3

• Hyponatremia cannot be reliably diagnosed post-mortem because fluid shifts, hemolysis, and tissue autolysis alter sodium concentrations unpredictably 2, 5

Glucose Metabolism

• Post-mortem glucose levels drop rapidly due to ongoing glycolysis in tissues and blood cells even after death, making hypoglycemia impossible to diagnose retrospectively from autopsy samples 2, 6

What Autopsy Findings Can Support Adrenal Crisis

Histopathological Evidence

• Bilateral adrenal atrophy or absence of identifiable adrenal cortical tissue on microscopy strongly suggests chronic primary adrenal insufficiency (Addison disease) as the underlying condition that predisposed to adrenal crisis 3

• Patchy chronic inflammation of the adrenal glands is consistent with autoimmune adrenalitis, the most common cause (~85%) of primary adrenal insufficiency in Western populations 1, 3

• Adrenal hemorrhage, tuberculosis, fungal infection, or metastatic tumor identified on gross examination or histology can establish the etiology of primary adrenal insufficiency 1, 6

Clinical Context from Medical Records

• Documented history of Addison disease or chronic steroid therapy in the decedent's medical records provides critical context that death may have resulted from adrenal crisis 3

• Ante-mortem laboratory values showing hyponatremia (present in 90% of adrenal insufficiency cases), hyperkalemia (50% of cases), hypoglycemia, or elevated creatinine from emergency department or hospital records obtained before death support the diagnosis 1, 2, 6

• Morning cortisol <250 nmol/L (<9 μg/dL) with elevated ACTH documented in medical records before death is diagnostic of primary adrenal insufficiency 1, 6

Precipitating Factors

• Evidence of gastrointestinal illness (vomiting/diarrhea), infection (pneumonia identified at autopsy), trauma, or surgical procedures documented in the clinical history or found at autopsy identifies common triggers for adrenal crisis 2, 3

• Acute pneumonia identified histologically at autopsy can serve as the precipitating infection that triggered adrenal crisis in a patient with underlying adrenal insufficiency 3

Critical Diagnostic Limitations

• The absence of hyperkalemia on ante-mortem labs does not exclude adrenal insufficiency, as hyperkalemia occurs in only ~50% of cases—relying on electrolyte abnormalities alone will miss many cases 1, 2

• Normal or even elevated cortisol levels measured shortly before death do not exclude relative adrenal insufficiency in physiologically stressed patients, as the stress response may be inadequate despite "normal" absolute values 2

• Forensic pathologists must rely on a combination of medical history, ante-mortem laboratory data, autopsy findings (especially adrenal histology), and clinical context rather than post-mortem biochemistry to support a diagnosis of death due to adrenal crisis 3, 5

Practical Approach for Forensic Investigation

• Request complete medical records including any documented history of adrenal insufficiency, steroid use, autoimmune conditions, or ante-mortem cortisol/ACTH/electrolyte measurements 3, 5

• Perform meticulous gross and microscopic examination of both adrenal glands, documenting size, weight, cortical thickness, and any inflammation, hemorrhage, necrosis, or infiltration 3

• Identify precipitating factors such as infection (pneumonia, sepsis), gastrointestinal illness, trauma, or medication non-compliance documented in the clinical history or found at autopsy 2, 3

• Recognize that exhaustive biochemical analyses are mandatory to support the diagnosis further, but interpret post-mortem values with extreme caution given the limitations described above 3