Perforated Duodenal Ulcer (Answer: A)
The most likely cause of death is a perforated duodenal ulcer resulting from prolonged high-dose corticosteroid therapy without appropriate tapering or gastroprotection.
Rationale for Perforated Peptic Ulcer as the Primary Cause
The clinical scenario strongly points to gastrointestinal perforation based on several critical factors:
Excessive steroid exposure: The patient received prednisolone 60 mg daily for 12 consecutive weeks (double the prescribed 6-week course) without any tapering, representing a profoundly dangerous prolonged exposure to high-dose corticosteroids 1, 2.
Direct mortality data: 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), with up to 77% of deaths in corticosteroid-treated patients being corticosteroid-related, and gastrointestinal complications being prominent 1.
FDA labeling warnings: The prednisolone FDA label specifically warns that prolonged use can produce peptic ulcer as a recognized complication of chronic overdosage 3.
Violation of fundamental management principles: 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. The patient's continuation of 60 mg daily for an additional 6 weeks without tapering violates these core principles 2.
Clinical Presentation Supporting This Diagnosis
Sudden death in bathtub: This presentation suggests rapid cardiovascular collapse from peritonitis and septic shock, which is the typical presentation of perforated peptic ulcer 2.
Masked symptoms: Perforated ulcers can present with minimal warning in patients on corticosteroids because steroids mask inflammatory symptoms and blunt the febrile response, allowing catastrophic complications to develop silently 2.
Increased gastrointestinal risk: Concomitant use of corticosteroids increases the risk of gastrointestinal side effects, and the FDA label specifically warns about this complication 3.
Why Other Options Are Less Likely
Hypertensive Cerebral Hemorrhage (Option B)
- While hypertension is a recognized steroid complication 4, the dose and duration in this case make gastrointestinal perforation far more probable as the immediate cause of death 1.
Acute Cerebral Vasculitis (Option C)
- This would represent active SLE disease, but the patient was on high-dose steroids which should suppress lupus activity 5.
- Early deaths in SLE patients on steroids are related to infections or disease activity, while this patient's death occurred after 12 weeks of therapy 6.
Intestinal Ischemia with Perforation (Option D)
- While lupus enteritis can occur 7, the overwhelming evidence points to steroid-induced peptic ulcer disease rather than lupus-related intestinal ischemia in a patient on such high-dose immunosuppression 1, 2.
Critical Clinical Pitfalls That Led to This Outcome
Absence of gastroprotection: Patients on prolonged high-dose corticosteroids require proton pump inhibitor prophylaxis to prevent ulcer formation and perforation 2.
Failure to taper: Methylprednisolone should be weaned slowly (6-14 days) and corticosteroids should be gradually reduced over 8 weeks, initially by one-third to one-quarter down to 15 mg daily, then by 2.5 mg decrements 2.
Excessive duration: The American Society of Hematology strongly recommends against prolonged courses (>6 weeks) of prednisone due to increased risk of side effects 8.
Lack of monitoring: Regular monitoring for gastrointestinal symptoms is necessary, as infection surveillance is particularly important since corticosteroids blunt the febrile response 2.