What is the most likely cause of death in a female patient with systemic lupus erythematosus (SLE) who was on prednisolone (corticosteroid) 60 mg daily for 12 weeks without tapering and was found dead?

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 tapering or gastroprotection. 1, 2

Rationale for Perforated Peptic Ulcer

High-Dose Steroid Exposure

• This patient received prednisolone 60 mg daily for 12 consecutive weeks without tapering, representing a significantly prolonged exposure to high-dose corticosteroids 1, 3
• Guidelines consistently recommend tapering corticosteroids within 4-12 weeks to minimize toxicity, with doses above 7.5 mg/day associated with substantially increased risks of irreversible organ damage 1, 3, 4
• The FDA drug label explicitly warns that concomitant use of corticosteroids increases the risk of gastrointestinal side effects, including peptic ulcer 2

Mechanism of GI Perforation

• Corticosteroids decrease mucosal defense mechanisms and increase gastric acid secretion 2
• Peptic ulcer perforation can occur suddenly and catastrophically, particularly in the bathtub setting where the patient may have been relaxing when acute peritonitis developed 1
• The British Association of Dermatologists guidelines specifically note that very high-dose steroids can cause death from complications including infection and cardiac events, with gastrointestinal perforation being a recognized severe adverse effect 1

Mortality Data Supporting This Diagnosis

• Studies demonstrate that mortality during the first year is significantly higher in patients treated with high doses of systemic corticosteroids (prednisolone equivalent >40 mg daily) 1
• The pemphigus vulgaris guidelines report that up to 77% of deaths in corticosteroid-treated patients were corticosteroid-related, with gastrointestinal complications being prominent 1
• Prolonged use of high-dose prednisolone can produce peptic ulcer as a documented adverse effect 2

Why Other Options Are Less Likely

Hypertensive Cerebral Hemorrhage (Option B)

• While corticosteroids can cause hypertension, this typically develops more gradually and would be less likely to cause sudden death in a bathtub without preceding symptoms 2
• No mention of pre-existing severe hypertension or neurological symptoms

Acute Cerebral Vasculitis (Option C)

• This would represent active SLE disease, but the patient was on high-dose immunosuppression for 12 weeks, which should have controlled active vasculitis 1, 5
• CNS vasculitis typically presents with progressive neurological symptoms rather than sudden death 1

Intestinal Ischemia with Perforation (Option D)

• While possible with SLE vasculitis, this is much rarer than peptic ulcer disease in the context of prolonged high-dose corticosteroid use 2
• Mesenteric vasculitis would typically require active, uncontrolled SLE, which is unlikely given the high steroid dose 1

Critical Clinical Pitfalls

Failure to Taper Appropriately

• The patient continued 60 mg daily for an additional 6 weeks beyond the initial 6-week course without tapering, violating fundamental steroid management principles 1, 3, 4
• Guidelines recommend tapering to ≤7.5 mg/day by 4-6 months, with rapid initial reduction after disease control is achieved 1, 3

Lack of Gastroprotection

• Patients on high-dose corticosteroids require proton pump inhibitor prophylaxis to prevent peptic ulcer disease 2
• The combination of prolonged high-dose steroids without gastroprotection creates extremely high risk for GI complications 1

Inadequate Monitoring

• No mention of clinical follow-up during the extended high-dose period 1, 3
• Patients on doses >40 mg daily require close monitoring for complications including GI bleeding, infection, and metabolic derangements 1, 2