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 tapering or gastroprotection.
Rationale for Perforated Duodenal Ulcer
Prolonged high-dose prednisolone (60 mg daily for 12 weeks) dramatically increases the risk of gastrointestinal perforation, and sudden death in a bathtub is consistent with rapid cardiovascular collapse from peritonitis and septic shock—the typical presentation of perforated peptic ulcer 1.
Key Supporting Evidence
FDA labeling explicitly warns that steroids should be used with caution in patients with active or latent peptic ulcer, and that signs of peritoneal irritation following gastrointestinal perforation may be minimal or absent in patients receiving corticosteroids 2.
Corticosteroids were associated with a 4.2-fold increased mortality from peptic ulcer complications (95% CI 0.9-25.6), with most deaths in steroid users due to serious sepsis 3.
The British Association of Dermatologists guidelines document that mortality during the first year is significantly higher in patients treated with high doses of systemic corticosteroids (prednisolone equivalent >40 mg daily) 4.
This patient's dose (60 mg) and duration (12 weeks without taper) far exceeded standard protocols, violating fundamental corticosteroid management principles 1.
Why Other Options Are Less Likely
Hypertensive Cerebral Hemorrhage (Option B)
- While corticosteroids can cause hypertension (occurring in only 4% of treated patients 5), this is not the most common cause of sudden death in this clinical scenario.
- The bathtub setting and prolonged high-dose steroid exposure point more strongly toward gastrointestinal catastrophe.
Acute Cerebral Vasculitis (Option C)
- Although SLE can cause cerebral vasculitis, the clinical scenario of prolonged steroid use and sudden death is more consistent with steroid-related complications rather than lupus activity.
- High-dose steroids would typically suppress active lupus vasculitis, not precipitate it 6.
Intestinal Ischemia with Perforation (Option D)
- While possible in SLE patients, this is less common than peptic ulcer perforation in the context of prolonged high-dose corticosteroid therapy.
- The specific risk profile points to peptic ulcer disease as the primary concern 2, 3.
Critical Clinical Pitfalls
Corticosteroids mask inflammatory symptoms and blunt the febrile response, meaning this patient may have had minimal warning signs before catastrophic perforation 1.
Major Management Errors in This Case
No gastroprotection: Patients on prolonged high-dose corticosteroids require proton pump inhibitor prophylaxis to prevent ulcer formation and perforation 1.
No tapering protocol: The patient continued 60 mg daily for 12 weeks without tapering, when guidelines recommend gradual reduction over 8 weeks, initially by one-third to one-quarter down to 15 mg daily, then by 2.5 mg decrements 4.
Abrupt cessation risk: Methylprednisolone should be weaned slowly (6-14 days) and not stopped rapidly or abruptly, as deterioration may occur 4.
Lack of monitoring: Regular monitoring for gastrointestinal symptoms is necessary, as infection surveillance is particularly important since corticosteroids blunt the febrile response 4, 1.
Clinical Presentation Details
Sudden death in a bathtub suggests rapid cardiovascular collapse from peritonitis and septic shock, which is the typical presentation of perforated peptic ulcer 1. The FDA label specifically notes that signs of peritoneal irritation following gastrointestinal perforation in patients receiving corticosteroids may be minimal or absent 2, explaining why this patient may not have sought medical attention before the catastrophic event.