What is the most likely cause of death in a patient with Systemic Lupus Erythematosus (SLE) taking prednisolone (corticosteroid) 60 mg daily for 12 weeks?

Perforated Duodenal Ulcer (Answer: A)

The most likely cause of death in this patient is a perforated duodenal ulcer, which represents a catastrophic complication of prolonged high-dose corticosteroid therapy without appropriate gastroprotection.

Clinical Reasoning for Perforated Peptic Ulcer

Prolonged high-dose corticosteroid use (60 mg prednisolone daily for 12 weeks) dramatically increases the risk of gastrointestinal perforation and bleeding, particularly when continued beyond standard protocols without tapering. 1 This patient's dose and duration far exceeded safe management principles, as corticosteroids should be weaned slowly over 6-14 days rather than maintained at high doses for extended periods 1.

Presentation Consistent with Perforation

• Sudden death in a bathtub strongly suggests rapid cardiovascular collapse from peritonitis and septic shock, which is the typical presentation of perforated peptic ulcer 1.
• Corticosteroids mask inflammatory symptoms and blunt the febrile response, meaning perforated ulcers can present with minimal warning in patients on these medications 1.
• The patient may have had no preceding symptoms due to the anti-inflammatory effects of prednisolone masking the typical pain and peritoneal signs 1.

Critical Management Failures

• This patient violated fundamental corticosteroid management principles by continuing 60 mg daily for 12 weeks without tapering, which substantially increased mortality risk 1.
• Patients on prolonged high-dose corticosteroids require proton pump inhibitor prophylaxis to prevent ulcer formation and perforation, which was presumably not provided 1.
• The FDA drug label explicitly warns that corticosteroids can cause gastrointestinal complications, though it emphasizes infection risk more prominently 2.

Why Other Options Are Less Likely

Hypertensive Cerebral Hemorrhage (Option B)

While corticosteroids can cause hypertension and salt/water retention 2, this typically develops more gradually and would not explain sudden death in a bathtub without preceding neurological symptoms. Cerebral hemorrhage would more likely present with witnessed neurological deterioration rather than sudden collapse.

Acute Cerebral Vasculitis (Option C)

• In SLE patients, early deaths are primarily related to infections or disease activity, while cardiovascular complications account for late mortalities 3.
• Cerebral vasculitis from active lupus would be unlikely given the patient was on high-dose immunosuppression (60 mg prednisolone daily) 3.
• This dose should have adequately suppressed lupus activity, making acute vasculitis an improbable cause 4, 5.

Intestinal Ischemia with Perforation (Option D)

While possible, intestinal ischemia is far less common than peptic ulcer disease in corticosteroid-treated patients. The mechanism and epidemiology strongly favor duodenal ulcer perforation over mesenteric ischemia in this clinical context 1.

Supporting Evidence on Corticosteroid Complications

Infection Risk Context

• Infection accounts for 24-25% of all deaths in SLE patients requiring corticosteroids, making it a major mortality driver 1, 3.
• However, infections typically present with fever, sepsis, or organ-specific symptoms rather than sudden death 3, 5.
• Even doses of 5.0-7.5 mg prednisolone significantly increase infection risk (adjusted HR 6.80), so 60 mg daily represents extreme risk 5.

Mortality Patterns in Perforated Peptic Ulcer

• Long-term mortality after surgery for perforated peptic ulcer is high, with 19.2% dying within 90 days and 46.6% dying during extended follow-up 6.
• The most frequent cause of death following perforation is sepsis and multiorgan failure (25% of long-term deaths), consistent with peritonitis from perforation 6.
• Risk factors for mortality include older age, comorbidity burden, and severe postoperative complications 6.

Critical Clinical Pitfalls

• Never continue high-dose corticosteroids (>7.5 mg prednisolone equivalent) for extended periods without gastroprotection 1, 5.
• Regular monitoring for gastrointestinal symptoms is essential, though corticosteroids mask these warning signs 1.
• The combination of immunosuppression and gastrointestinal perforation creates a lethal scenario with rapid progression to septic shock 1, 6.