Can insulin injection kill

Hypoglycemia is clinically defined as blood glucose levels low enough to cause symptoms and signs. However, if irreversible damage to brain has occurred, the third criterion would be unlikely to be fulfilled. Hypoglycemia can have varied presentation. Its clinical diagnosis is mainly based on symptomatology. These have been divided as neurogenic and neuroglyopenic. The neuroglyopenic symptoms range from subtle behavioral abnormalities to loss of consciousness and seizures.

Hypoglycemia can also present with hypotension and bradycardia as it was in this patient. Hypoglycemia in a non-diabetic can be due to either exogenous or endogenous hyperinsulinemia, in addition to drugs, tumors, critical illness, and hormone deficiencies. Exogenous insulin administration as a mode of suicide may be more common in medical and paramedical personnel. Hence, suicidal intent was strongly suspected.

It is also more common in patients with psychiatric disorder and in relatives of diabetics. All types of insulin have been used for suicidal intention, including the short- and long-acting insulins. Short-acting insulins can also produce delayed effects. This is explained on the basis of depot effect. Significant reduction in local blood flow results by compression of tissue at injection site, when large quantity of insulin is injected.

Delayed effects can also be seen in the presence of renal or hepatic dysfunction. In diabetics, lipoatrophy at the injection site or circulating antibodies against insulin can produce delayed effects. CSF analysis in hypoglycemia shows low glucose levels. CSF glucose reflects plasma glucose from a few hours earlier. But this can be misleading sometimes, especially in septic encephalomeningitis. High doses of insulin can lead to dyselectrolytemia. There can be intracellular shift of potassium and phosphorous, leading to hypokalemia and hypophosphatemia.

Our patient had hypophosphatemia at initial evaluation which spontaneously corrected. Acute pulmonary edema can complicate insulin overdose due to sympathetic activation[ 10 ] and hepatic steatosis has also been reported with suicidal insulin toxicity. Management of hypoglycemia is with dextrose.

Most patients require dextrose infusions for prolonged period. The average requirement of glucose till full recovery can be anywhere between and g and the duration of treatment might vary from 12 to 62 hours. If there are no contraindications, Ryle's tube feeding with a mixed meal should be initiated. Dextrose infusion can itself be a cause for excessive insulin secretion especially in non-diabetics and lead to recurrent hypoglycemia. Excision of subcutaneous fat at the injection site has been shown to drastically reduce the dextrose infusion rates.

We have successfully diagnosed and treated a young patient, who presented with coma and hypoglycemia due to exogenously administered insulin with probable suicidal intent. Source of Support: Nil,. Conflict of Interest: None declared. National Center for Biotechnology Information , U. Indian J Endocrinol Metab. Abhay Gundgurthi , Sandeep Kharb , M. Dutta , R. The typical physiological effect of its action is hypoglycemia reduction in blood glucose. The result of a casual or intentional overdose of insulin is a hypoglycemic coma and in extreme cases even death of the user.

Today it is used not only in medicine in the treatment of diabetic patients but also in competitive sport as a common doping agent for body building [ 2 , 3 ] and for different criminal purposes [ 4 , 5 , 6 , 7 , 8 ]. The first documented case of murder by insulin is dated to the year Kenneth Barlow case [ 9 ].

Vincent Marks in his review has analyzed case histories of 66 people alleged or proven to have been poisoned by insulin murders, manslaughters, attempted murders, Munchausen-by-proxy cases [ 7 ]. Of course, some insulin overdoses are accidental and associated with incorrect dosage of the drug by the patient [ 10 , 11 ].

Most of these cases are not clinically serious. It seems, however, that the risk of intentional suicidal insulin overdose in patients with diabetes of both types 1 and 2 is underestimated.

It is known that the risk of depression and attempted suicide is higher in patients with chronic diseases, including diabetes, so physicians who treat diabetic patients should evaluate co-occurring depression and substance abuse, both of which are major risk factors of suicide [ 13 , 14 ]. The aim of the author is to present the current state of basic knowledge about the nonmedical use of insulin, with particular emphasis on the possibility of postmortem diagnosis.

The study also highlighted the little known, rare clinical problem of insulin abuse for recreational purposes. In order to illustrate the abovementioned problems, I present two typical cases from routine medicolegal practice of the Department of Forensic Medicine and Forensic Toxicology in Katowice, School of Medicine in Katowice, Medical University of Silesia, Poland [ 15 , 16 ].

A year-old nondiabetic man was found dead lying on the bed in his flat. Near the body, an ampoule and almost empty syringe were found and taken for further analysis. Two days earlier, the man had called his wife and said that he is going to commit suicide. The forensic autopsy did not reveal the cause of death. The initial stage of putrefaction, blood fluidity, acute blood stagnation hyperemia in the internal organs, and two supravital point wounds on the right thigh, which might have been injection sites, were found.

Histopathological findings in the main internal organs were the following: brain, hyperemia with numerous petechiae, and edema; heart, adipositas, medium grade of atherosclerosis of the coronary arteries, and local fragmentation of muscle fibers; and lungs, hyperemia with local hemorrhages into alveoli and edema.

The standard toxicological analysis disclosed no evidence of drug abuse or alcohol, so due to the suspicion of suicide by insulin injection, a directed analysis with immunoradiometric assay IRMA Kit Immunotech , routinely used for the in vitro determination of insulin in human serum and plasma, was conducted. It revealed a high insulin concentration level— All these results information from the prosecutor about the crime scene, results of medicolegal autopsy, results of histopathological and toxicological studies clinched the thesis of insulin overdose.

Such situation in forensic medicine is called homicide-suicide or dyadic death. In the apartment a farewell letter and empty packages after insulin, NovoMix 30 Penfill a mixture of fast and long-acting insulin analogue , were revealed Figure 2. External medicolegal examination and forensic autopsies carried out at the Department of Forensic Medicine and Forensic Toxicology of the Medical University of Silesia in Katowice did not explain the cause of death.

However, potential injection sites on the thighs and the shoulder of woman were revealed Figure 3. Different biological materials for additional tests—biochemical, chemical-toxicological, and histopathological and for forensic genetics—were taken. Due to the inability to quickly determine insulin level in body fluids and the site of injection using the reference chromatographic methods [ 17 , 18 , 19 , 20 ], the determination of this hormone was ordered to two clinical diagnostic laboratories by chemiluminometric and immunoradiometric methods.

Incomplete, difficult-to-interpret results were obtained. In addition, a successful attempt of immunohistochemical IHC detection of insulin in samples taken from the injection sites was made Figure 4 [ 21 , 22 ]. The results of the tests carried out in the abovementioned clinical laboratories confirmed our previous experience with the low usefulness of insulin determinations in the autopsy hemolyzed blood specimens article in press.

Empty packages after insulin, NovoMix 30 Penfill a mixture of fast and long-acting insulin analogue , revealed in the apartment of victim. Needles can be analyzed by forensic geneticists for the presence of DNA mixture of the victim and murderer in the case of homicide-suicide death. Numerous supravital point wounds and surrounding bruises on the thighs—potential insulin injection sites. Positive immunohistochemical IHC detection of insulin in the subcutaneous tissue around needle tracts between adipocytes right and control section from distant area of the skin with no reaction left.

A classic postmortem macroscopic examination of the corpses forensic autopsy usually does not explain the cause and mechanism of death [ 23 , 24 ]. Typically a feature of acute cardiorespiratory failure and nonspecific lesions related to the age of victim e. For this reason, additional laboratory tests are necessary in each case. In addition to routinely collected sections from internal organs and body fluids blood and urine , it is worth to take at least the sample of vitreous humor VH and the samples from potential injection sites for both histopathological and directed toxicological analyses.

Its low amounts can indirectly confirm insulin overdose, as it was presented in the first case [ 15 ]. Another useful option is to perform IHC staining for the presence of insulin at the injection site. It is not necessary to buy special antibodies. These routinely used in clinical histopathology can be successfully used for this purpose, as we demonstrated in the second case [ 16 ].

In routine forensic practice, usually antemortem blood samples of the victim, who sometimes is hospitalized before the death, are unavailable for forensic toxicologists, so they can analyze only postmortem biological material taken during autopsy and nonbiological specimens revealed at the crime scene, like syringes, ampoules, vials, or remnants of the infusion solution and tubings [ 24 , 25 , 26 ].

The suicide note left behind states that they could not cope with the severe financial loss and that no one should be held responsible for their death. The deceased were identified as Mahesh Vijay Kulkarni 42 from Patwardhan Baugh area in Erandawane and Milind Panditrao Pujari 44 , who stayed near Deenanath Mangeshkar hospital , also in Erandawane Kulkarni and Pujari together were running a business in commodities for over two decades. They had left for Chiplun, around km from here, on Thursday and checked in a hotel around 8pm.

Sachin Ingole , assistant inspector of the Chiplun police station, told TOI over phone that around The hotel staff rushed to the room and repeatedly rang the door bell, but no one responded. The staff later managed to open the door with the help of a spare key. They were shocked to see both of them lying unconscious on their respective beds.

The hotel manager immediately alerted the police and the duo was rushed to a nearby private hospital. The doctors declared Pujari dead on arrival at the hospital, while Kulkarni, who was in an unconscious state, was immediately taken to another hospital. He died while undergoing treatment at the hospital around 6am on Saturday.

Four insulin syringes of 3 ml each and the suicide note were recovered from the room. Ingole said the note was written and signed by the deceased in Marathi said that they had committed suicide because they had suffered a severe financial loss in the commodity business.