Most Likely Cause of Death: Perforated Duodenal Ulcer
The most likely cause of death in this patient is a perforated duodenal ulcer (Option A), resulting from prolonged high-dose corticosteroid therapy without appropriate gastroprotection. The clinical scenario of 12 weeks of prednisolone 60 mg daily (far exceeding the recommended 3-month threshold for "prolonged use") combined with sudden death in a bathtub strongly suggests acute gastrointestinal perforation with peritonitis and shock.
Why Perforated Duodenal Ulcer is Most Likely
Corticosteroid-Related GI Complications
Prolonged high-dose corticosteroid use significantly increases the risk of gastrointestinal bleeding and perforation 1. The patient received 60 mg prednisolone daily for 12 weeks—well beyond the 3-month threshold that defines "prolonged steroid use" associated with serious complications 1.
Corticosteroids do not increase gastroduodenal bleeding risk at standard doses in controlled trials, but this patient's dose and duration far exceed standard protocols 1. The 2019 British Society of Gastroenterology guidelines explicitly warn that prolonged steroid use (>3 months continuous therapy) carries increased infection risk, osteoporosis, and cardiovascular disease—all contributing to mortality 1.
The mechanism involves direct mucosal injury, reduced prostaglandin synthesis, and impaired healing of existing ulcers, making perforation more likely with extended high-dose therapy.
Clinical Presentation Fits Acute Perforation
Sudden death in a bathtub suggests rapid cardiovascular collapse from peritonitis and septic shock, which is the typical presentation of perforated peptic ulcer. The patient likely experienced acute abdominal pain, became hypotensive, and collapsed.
Perforated ulcers can present with minimal warning in patients on corticosteroids because steroids mask inflammatory symptoms and blunt the febrile response 1. This makes the diagnosis particularly treacherous—patients may have minimal abdominal pain until catastrophic perforation occurs.
Why Other Options Are Less Likely
Hypertensive Cerebral Hemorrhage (Option B)
While corticosteroids can cause hypertension, there is no evidence in the provided guidelines that prednisolone at this dose directly causes cerebral hemorrhage as a primary complication 1.
SLE patients do have increased cardiovascular risk from chronic inflammation 1, but this is a long-term complication, not an acute cause of sudden death after 12 weeks of therapy.
Acute Cerebral Vasculitis (Option C)
Cerebral vasculitis would represent uncontrolled SLE disease activity, which is unlikely given the high-dose immunosuppression 2, 3. The patient was receiving 60 mg prednisolone daily—a dose that should control active lupus manifestations.
Early deaths in SLE patients on corticosteroids are primarily due to infections, not disease activity 3. The evidence shows that disease activity causes early mortality (within 2 weeks), while later deaths are infection-related 3.
Intestinal Ischemia with Perforation (Option D)
While SLE can cause mesenteric vasculitis, this is far less common than corticosteroid-induced peptic ulcer disease in the context of prolonged high-dose steroid therapy.
The evidence does not support intestinal ischemia as a primary complication of corticosteroid therapy in SLE patients 1.
Supporting Evidence for Infection Risk (Alternative Consideration)
Why Infection is Also a Strong Possibility
Infection is a major cause of mortality in SLE patients on corticosteroids 1. The 2017 AGA guidelines emphasize that infections account for 24% of all deaths in severe conditions requiring corticosteroids 1.
Prolonged prednisolone use (>3 months) is associated with increased mortality in IBD patients, with infection being a primary driver 1. A recent study showed that prednisolone use was an independent risk factor for mortality 1.
The risk of serious infection increases significantly with doses of 5.0-7.5 mg prednisolone or higher 4. This patient was on 60 mg daily—far exceeding this threshold.
Most infections occur within the first month after high-dose corticosteroid therapy 5, but the risk persists throughout treatment. Bacterial infections represent 90% of infectious episodes, with respiratory infections being particularly common during or after corticosteroid treatment 1.
However, Perforation Remains Most Likely
Despite the high infection risk, the clinical scenario of sudden death in a bathtub more strongly suggests acute perforation with peritonitis rather than infection, which typically presents with fever, progressive deterioration, and respiratory or urinary symptoms 1.
Critical Clinical Pitfalls
Failure to Taper Appropriately
The patient continued 60 mg daily for 12 weeks without tapering—this violates fundamental corticosteroid management principles 1. Methylprednisolone should be weaned slowly (6-14 days) and not stopped rapidly or abruptly 1.
Steroid dependency is defined as inability to wean below 10 mg prednisolone within 3 months of starting 1. This patient never attempted to taper, suggesting inadequate monitoring.
Lack of Gastroprotection
- Patients on prolonged high-dose corticosteroids require proton pump inhibitor prophylaxis, though this is not explicitly stated in the provided guidelines. The absence of gastroprotection likely contributed to ulcer formation and perforation.
Inadequate Monitoring
The 2024 KDIGO guidelines emphasize that infections, cardiovascular complications, and CKD are major causes of death in SLE patients 1. Early deaths are related to infections or lupus activity, while cardiovascular complications account for late mortalities 1.
This patient should have had regular monitoring for infection, cardiovascular risk factors, and gastrointestinal symptoms 1. The sudden death suggests these complications were not adequately screened.
Conclusion
Perforated duodenal ulcer (Option A) is the most likely cause of death, given the prolonged high-dose corticosteroid therapy, sudden presentation, and typical clinical scenario of acute perforation leading to peritonitis and shock. While infection remains a strong alternative consideration given the evidence, the acute presentation in a bathtub more strongly suggests catastrophic gastrointestinal perforation.