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 Table of Contents  
ORIGINAL ARTICLES
Year : 2021  |  Volume : 12  |  Issue : 2  |  Page : 201-207

Spectrum of diabetic lesions: An autopsy study


Department of Pathology, Lokmanya Tilak Municipal Medical College and Hospital, Sion, Mumbai, Maharashtra, India

Date of Submission30-Jul-2020
Date of Decision13-Oct-2020
Date of Acceptance20-Oct-2020
Date of Web Publication31-Mar-2021

Correspondence Address:
Dr. Urmi Chakravarty-Vartak
Department of Pathology, Lokmanya Tilak Municipal Medical College and Hospital, Sion, Mumbai, Maharashtra.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jod.jod_71_20

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  Abstract 

Background: The aim of our study was to study the gross morphological changes, histopathology, prevalence, and characteristics of pathological lesions in various organs in patients of diabetes mellitus; to determine the contribution of diabetes to mortality; and to study complications of diabetes mellitus in the cases studied. Materials and Methods: Ours was a descriptive cross-sectional study of a five-year duration carried out at a tertiary care hospital. A complete medical autopsy was done of all the cases; all organs were examined grossly and microscopically, and their details were recorded. Results: A total of 137 patients with diabetes were studied at autopsy. Overall, 32.8% of the patients with diabetes were in the age group of 61–70 years, with a female:male ratio of 1.2:1. The highest frequency of deaths was due to diseases of the cardiovascular system (39%), whereas both septicemia and diseases of the respiratory system followed as a close second (37%). Overall, 10.94% patients died due to diseases of the central nervous system. Conclusion: The global burden of diabetes mellitus is increasing worldwide, and it is necessary to have an improved understanding of its etiology, pathogenesis, and pathophysiology to focus therapeutic and research efforts appropriately to reduce its effects on lives and economies.

Keywords: Autopsy study, cardiovascular disease, diabetes


How to cite this article:
Vartak S, Neelakantan A, Chakravarty-Vartak U, Mutha K. Spectrum of diabetic lesions: An autopsy study. J Diabetol 2021;12:201-7

How to cite this URL:
Vartak S, Neelakantan A, Chakravarty-Vartak U, Mutha K. Spectrum of diabetic lesions: An autopsy study. J Diabetol [serial online] 2021 [cited 2021 Apr 20];12:201-7. Available from: https://www.journalofdiabetology.org/text.asp?2021/12/2/201/312671




  Introduction Top


Diabetes mellitus is a syndrome characterized by chronic hyperglycemia and relative insulin deficiency, resistance, or both, accompanied by greater or lesser impairment in the metabolism of carbohydrates, lipids, and proteins.[1] It affects more than 463 million people worldwide as of 2019 and is estimated to affect 578 million by the year 2030.[2] Diabetes is usually an irreversible illness, and even though patients tend to have a reasonably normal lifestyle, they may have late complications resulting in reduced life expectancy and major health costs. These include macrovascular disease, leading to coronary artery disease, stroke, vascular disease, and microvascular damage causing diabetic retinopathy, diabetic neuropathy, and diabetic nephropathy.[3]

Diabetes has become a growing epidemic in the Asia-Pacific region. Diabetes is a disease rapidly increasing throughout the world today and is often called the modern epidemic. Diabetes may be caused due to decreased production of insulin or decreased ability to utilize insulin. It is a chronic illness that will lead to high risk factors, if not treated immediately. There are several different reasons for the development of diabetes. Common causes include obesity, family history, age, ethnicity etc. This disease occurs in several forms but Diabetes Mellitus Type 1 [Insulin-dependent diabetes mellitus or IDDM], Diabetes Mellitus Type 2 [Non-Insulin-dependent diabetes mellitus or NIDDM], and gestational diabetes are commonly encountered in practice.[4] At present, the number of patients with confirmed diabetes in India is approximately 77 million as per the International Diabetes Federation.[5] As of 2019, 463 million adults have diabetes mellitus, and this number is estimated to increase to 700 million.[5] The greatest number of people with diabetes are between the ages of 40 to 59.[6] Diabetes is the leading cause of adult-onset blindness and kidney failure worldwide and is responsible for approximately 6% of total global mortality, accounting for 3.8 million deaths in 2007.[6] Diabetes affects people in both urban and rural areas. The most disturbing trend is shift in age of onset of diabetes at younger age. Lifestyle changes have led to decreased physical activity, increased consumption of fat, sugar, and calories, and higher stress levels affecting insulin sensitivity and obesity. The primary reason for studying the dead is to save the living by correlating the events that have transpired during life with the state of the body after death and to come to a conclusion as to the cause and the effect. Hence, autopsy is an important tool not only to detect the cause of death but also to elicit whether such death is preventable. The aims of this study are to determine at autopsy the prevalence and characteristics of pathological lesions in patients with diabetes and to determine the contribution of diabetes to the mortality.


  Subjects and Methods Top


Study setting

This was a descriptive cross-sectional study of five years carried out in the Department of Pathology at a tertiary care hospital with a capacity of 1700 indoor beds and an average of 10,000 patients visiting the OPD daily. All known cases of diabetes mentioned in the autopsy records were included in the study. Case histories were retrieved by going through indoor case papers.

Data collection and procedure

After selection of cases as per inclusion and exclusion criteria, a complete medical autopsy was done and a gross and microscopic examination of the organs was carried out.

History was recorded from autopsy records mentioned in the indoor paper under the following headings:

  • Age


  • Sex


  • Ward/Unit


  • Duration of stay in hospital


  • Complaints


  • Radiological findings, if any


  • Laboratory findings:

  • Complete Blood Count


  • Serum blood urea and serum creatinine levels


  • Blood sugar levels


  • Gross morphological details were recorded after the specimens were fixed in 10% formalin for 24 hours and were recorded as follows:

  • Appearance


  • Color, consistency


  • Cut surface


  • Microscopy details were also recorded and studied. For retrospective cases, the information was gathered by retrieving previous autopsy and case reports.

    Ethical clearance

  • Approved from institutional ethical committee.


  • Confidentiality was maintained in the records.



  •   Results Top


    Over the course of the five-year study, a total of 2146 autopsies were performed by our department, of which 137 were deaths in patients with diabetes and were included in this study. These deaths contributed to 6.3% of deaths in patients with diabetes. The results obtained were analyzed.

    The majority of the patients with diabetes were in the age group of 61 to 70 years (32.8%). The youngest death occurred at 21 years and the eldest at 96 years. There were no diabetics in the age group of 0 to 20 years [Table 1].
    Table 1: Age distribution

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    Of the 137 patients with diabetes, 76 patients (55.5%) were females and 61 patients (45.5%) were males, with a female: male ratio of 1.2:1 [Table 2].
    Table 2: Sex distribution (n = 137)

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    The highest frequency of deaths was due to diseases of the cardiovascular system (39) followed by septicemia and diseases of the respiratory system. A lower frequency of deaths in diabetics was due to malignancy: 11 patients died due to tuberculosis, and a few deaths showed multisystem involvement [Table 3].
    Table 3: Causes of death (n = 137)

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    Myocardial infarction was found in 22 cases [Figure 1]c and [Figure 1]d, and left ventricular hypertrophy [Figure 1] in 56 cases. The main cardiovascular causes leading to death in patients with diabetes were acute coronary insufficiency [Figure 1]b, acute myocardial infarction, dilated cardiomyopathy, and heart failure.
    Figure 1: (A) Heart—left ventricular hypertrophy. (B) Heart—blocked coronaries. (C) Healed myocardial infarction (H&E 100×). (D) Healed myocardial infarction (H&E 400×). (E) Aorta-atherosclerosis (gross). (F) Atherosclerosis (H&E 100×)

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    57 cases were observed to have the gross findings of atherosclerosis, and 31 cases showed atherosclerotic changes on microscopy [Figure 1e] and [1f]. Among the deaths due to diseases of the respiratory system, death due to pulmonary edema (48.9%) accounted for the maximum number [Table 4] and [Figure 2].
    Table 4: Lung pathology (n = 137)

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    Figure 2: (A) Fibrocaseous tuberculosis. (B) Fibrocaseous tuberculosis (H&E 100×)

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    Although microscopic lesions in the kidney were common in patients with diabetes, they were rarely severe enough to be considered the principal cause of death. Histologic spectrum showed tubules with cloudy change in 38 cases (27.7%), with diabetic nephropathy following in 22 cases (16.05%) [Table 5] and [Figure 3].
    Table 5: Histologic spectrum (kidney)

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    Figure 3: (A) Bilaterally swollen kidney, multiple cysts of varying sizes. (B) Glomeruli, of which 1 is unremarkable and 2 shows KW lesions (H&E 100×)

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    Out of 137 cases, 15 patients died due to diseases of the central nervous system, which constituted 10.9% of all deaths in diabetics. Microscopic findings of the brain revealed cerebral edema (63.5%) [Figure 4] as the most common finding, which may be attributed to the high incidence of cerebrovascular accidents in patients with diabetes [Table 6].
    Figure 4: Brain—mild cerebral edema (H&E 400×)

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    Table 6: Histologic spectrum (brain) (n = 137)

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    The majority of cases showed no findings in the liver. Hepatomegaly was found in 27 out of 137 cases (19.70%) [Table 7].
    Table 7: Liver pathology (n = 137)

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    On microscopy, steatosis was seen in 33.5% of the cases [Table 8] and [Figure 5].
    Table 8: Histologic spectrum (liver)

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    Figure 5: Liver—macrovesicular fatty change (H&E scanner view)

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    Acute pancreatitis was observed in one case, and interstitial fibrosis in the pancreas was seen in five cases. One case of pancreatic adenocarcinoma was analyzed from the autopsy data of diabetics. One case of bile duct carcinoma was reported.

    Overall, 85 cases showed Red pulp congestion in the spleen and one case showed splenic lymphoma.

    Septicemia was seen in the form of splenic abscess, pyelonephritis, cellulitis, pyonephrosis, bronchopneumonia, and gangrene. Diabetes and hypertension were together found in 37 cases. Gastrointestinal mucosa was congested in very few cases.


      Discussion Top


    The tide of diabetes is rising all over the globe, thereby becoming an increasingly powerful global threat. The World Health Organization projects that by the year 2025 more than 5% of the world population, that is, 300 million people will suffer from diabetes.[4]

    In the current study, 137 patients were studied and the results of the study are discussed under the headings as given in [Table 9]. A total of 2146 autopsies were performed in our institution in the duration studied, of which 137 autopsies were diabetic cases, which attributes to 6.3% of the total autopsies.
    Table 9: Prevalence of diabetes in autopsies performed

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    According to [Table 10], the contribution of diabetic deaths to the total autopsies performed in our study (6.3%) is comparable to that of Alex et al. (7.3%)[7] and Tu et al. (7.1%).[8]
    Table 10: Comparison of diabetic deaths with other studies

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    The male:female ratio affected in our study attributes to 1:1.2, of which 61 were males (44.5%) and 76 (55.4%) were females. Our study was comparable to that of Gibson et al.[9] and Alex et al.[7] The remaining two studies showed slight male preponderance [Table 11].
    Table 11: Gender distribution in various studies

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    Average age at autopsy in our study was 67.7 years, which was comparable to other studies. Joron et al.[10] compared average ages at three hospitals, which were comparable to the current study [Table 12].
    Table 12: Average age of autopsy in various studies

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    The principal causes of death in patients with diabetes on various autopsy studies are enlisted in [Table 13].
    Table 13: Main causes of death

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    In the current study, deaths due to cardiovascular diseases contribute to the majority cases, followed by infections and diseases of the respiratory system. This is comparable to the study by Warren and LeCompte.[11] However, Goto et al.[12] observed infections to be the major cause of death in patients with diabetes.

    The incidence of cirrhosis in diabetes is enlisted in [Table 14].
    Table 14: Incidence of cirrhosis

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    According to Frankel et al.,[13] most adult diabetics have little or no enlargement of the liver. According to Marble,[14] this condition in the diabetic is attributed to an excessive amount of fat and glycogen. According to Goodman,[15] enlargement is frequent in patients with diabetes (44.5%). The current study shows 19.7% cases of liver enlargement and 33.5% cases of steatosis. According to the table just cited, cirrhosis of the liver is found in 10.2% cases in our study.

    Joslin and Graham[16] has reported that cerebrovascular accident accounts for only 8% of all diabetic deaths, an incidence that is about the same order of magnitude as the 8.4% found by Webster in a large autopsy series (2400 cases).

    Deaths due to cerebrovascular events contributed to 6% of all deaths in the study by Laing et al.[17] and to 7% of deaths in the study by Deckerdt et al. (n = 307).[18] This is comparable to the current study, where cerebrovascular accident contributes to 10.9% of deaths.

    Although microscopic lesions in the kidney were common in patients with diabetes, they were rarely severe enough to be considered the principal cause of death. The frequency of occurrence of diabetic nephropathy was 13.9% according to Alebioso et al. (n = 138),[19] which is comparable to the current study with a frequency of occurrence of 16.05% (n = 137). The frequency of occurrence of diabetic nephropathy of all given studies was comparable to the current study [Table 15].
    Table 15: Frequency of diabetic nephropathy

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    Renal failure was found to be associated with diabetes in 2.9% in the study by Gibson et al.[9] and to 14.9% in the study by Goto et al.[12] In the current study, we observed renal involvement in the form of acute and chronic pyelonephritis, multiple renal abscesses, and pyonephrosis in about 7.8% of cases. Glomerulosclerosis is common in patients with diabetes, but it rarely causes death.

    Atherosclerosis was found in 41.6% cases in our study. Gibson et al.[9] also observed an increase in the incidence of atherosclerosis. This is attributed to the changes in the dietary and lifestyle practices, for example, decreased physical activity and consumption of energy-dense food. Vascular changes due to diabetes and hypertension are very minor according to various studies. Vascular changes characteristic of hypertension are hyalinization of the afferent arteriole immediately before it enters the glomerulus, whereas hyalinisation of both afferent and efferent arterioles is pathognomonic of diabetic nephropathy.

    Diseases in the cardiovascular system caused the majority of deaths in diabetics. The causes were coronary artery disease, acute myocardial infarction, heart failure, dilated cardiomyopathy (one case), and acute coronary insufficiency. Joron et al.[10] also found diseases related to the circulatory system as the major cause. Also, according to Dokken et al.,[20] the presence of diabetes was associated with left ventricular enlargement in both sexes. Currently, myocardial hypertrophy is seen in 56 cases.

    Pulmonary thromboembolism accounted for 10% deaths in the studies by Gibson et al.[9]; however, this was not a major contributor in our study. We did not find a single case of pulmonary thromboembolism in our study. We were unable to locate any causal association between diabetes and pulmonary thromboembolism.

    Blumenthal et al.[21] reported signs of chronic inflammatory infiltrate in the pancreas in 11.2% of cases. Olsen[22] reported 19% cases with pancreatic atrophy and also histologic evidence of the same. Different pancreatic diseases are known to induce diabetes mellitus, for example, pancreatitis, pancreatic carcinoma, and cystic fibrosis. However, these diseases are believed to contribute to the burden of diabetes, being less than 1% cases. The current study showed one case of acute pancreatitis, five cases of pancreatic fibrosis, and one case of pancreatic adenocarcinoma.

    The frequency of deaths secondary to neoplasms was lower in our study. It accounted for 2.9% deaths, which was comparable to the study by Gibson et al.,[9] which accounted for 5.5% deaths. Also, the frequency of neoplasms was low in the study by Joron et al.[10]

    Gastrointestinal deaths accounted for 5% and 2.3% of deaths in the studies by Gibson et al.[9],[25] and deMarco. However, in our study, they did not contribute to the principal cause of death though congested mucosa and gastrointestinal bleed were found in a few cases.

    In the nineteenth century, tuberculosis was the scourge of patients with diabetes. A diabetic was virtually doomed to die of tuberculosis if not of diabetic ketoacidosis. But now the death rate has substantially decreased as compared with the nineteenth century. In our study, 11 cases of diabetes had tuberculosis, which contributes to 8% of deaths.


      Conclusion Top


    Autopsies of patients with diabetes constituted 6.3% of the total medical autopsies.

    The maximum number of deaths occurred in the age group of 61 to 70 years. The youngest death occurred at 21 years and the eldest at 96 years. The male:female ratio attributed to 1:1.2.

    Deaths in diabetics due to diseases of the cardiovascular system (39 cases) comprised the majority, followed by deaths due to infections (37 cases) and diseases of the respiratory system (37 cases).

    The global burden of diabetes mellitus is increasing worldwide. To reduce it and its effects on lives and economies, it is necessary to have an improved understanding of the etiology, pathogenesis, and pathophysiology of the disease.

    A coordinated multidisciplinary approach is needed, which involves scientists, public health practitioners, educators, clinicians, and pathologists with support from government and nongovernment organizations to reduce the incidence of diabetes significantly.

    Ethical approval

  • Approved from institutional ethical committee.


  • Confidentiality was maintained in the records.


  • Financial support and sponsorship

    Nil.

    Conflicts of interest

    There are no conflicts of interest.



     
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    White P, Graham CA Joslin’s diabetes mellitus. Philadelphia, PA: Lea & Febiger; 1971. p. 581.  Back to cited text no. 16
        
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    Laing SP, Swerdlow AJ, Slater SD, Burden AC, Morris A, Waugh NR, et al. Mortality from heart disease in a cohort of 23,000 patients with insulin-treated diabetes. Diabetologia 2003;46:760-5.  Back to cited text no. 17
        
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        Figures

      [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
     
     
        Tables

      [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14], [Table 15]



     

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