Background: Voluntary starvation is a rare cause of death. Full understanding of how comorbidities interact is crucial for characterizing the pathological cascades of death. In the present case, we discuss and illustrate the intertwined relationship between prolonged starvation and diabetes mellitus (DM), with a focus on the psychological aspects and the complexity of food strikes as a method of suicide.
Case Presentation: A 49-year-old male voluntarily withheld food but consumed juices for almost two years. He was admitted to the hospital due to altered consciousness, blood acidosis, and died within 48 hours from the insulin treatment initiation. Postmortem vitreous analysis detected diabetic ketoacidosis (DKA) with glucose level of 325 mg/dl which surpassed the fatal level of > 234 mg/dl. Prolonged fasting was accompanied by insulin deficiency and insulin resistance which was not reversed by treatment at hospital. Conclusion: Lack of other pathological or toxicological findings suggests that the fatal DKA was the cause of death. Hence, starvation condition might have aggravated the diabetic state and the insulin resistance. The cardiac arrest was consistent with arrhythmia secondary to profound electrolytes disturbance associated with severe DKA non-responsive to insulin therapy with short duration from presentation to death.