A female patient with systemic lupus erythematosus who received prednisolone 60 mg daily for 12 weeks without tapering was found dead in her bathtub; what is the most likely cause of death?

Most Likely Cause of Death: Perforated Duodenal Ulcer

The most likely cause of death in this patient is perforated duodenal ulcer (Option A), resulting from prolonged high-dose corticosteroid therapy without appropriate gastroprotection or tapering. 1, 2

Rationale for Perforated Duodenal Ulcer

Critical Medication Error and Risk Factors

• This patient received prednisolone 60 mg daily for 12 consecutive weeks without tapering, which grossly violates fundamental corticosteroid management principles 1
• Continuation of high-dose corticosteroids beyond 6 weeks without a tapering plan is contraindicated because prolonged exposure heightens the risk of gastrointestinal perforation and related mortality 2
• The American Society of Hematology strongly recommends against prolonged courses (>6 weeks) of prednisone due to increased risk of side effects 1
• Patients receiving more than 20 mg of prednisolone daily for longer than six weeks have a markedly increased risk of short-term surgical complications, including an approximately five-fold rise in infectious complications 2

Clinical Presentation Consistent with Perforation

• Sudden death in a bathtub suggests rapid cardiovascular collapse from peritonitis and septic shock, which is the typical presentation of perforated peptic ulcer 1
• Perforated ulcers can present with minimal warning in patients on corticosteroids because steroids mask inflammatory symptoms and blunt the febrile response 1, 2
• The FDA label for prednisolone specifically warns that prolonged use can produce peptic ulcer as a complication 3

Absence of Gastroprotection

• Initiation of high-dose corticosteroid therapy (≥ 20 mg prednisolone daily) for courses exceeding three to four weeks should be accompanied by proton-pump inhibitor prophylaxis to reduce the incidence of ulcer formation and perforation 2
• Patients on prolonged high-dose corticosteroids require proton pump inhibitor prophylaxis to prevent ulcer formation and perforation 1
• There is no indication this patient received appropriate gastroprotection

Why Other Options Are Less Likely

Hypertensive Cerebral Hemorrhage (Option B)

• While hypertension is a recognized comorbidity in systemic autoimmune diseases and corticosteroid therapy can exacerbate blood pressure levels 2, cardiovascular complications typically account for late mortalities in SLE patients, not acute deaths during active high-dose steroid therapy 4
• The clinical scenario of sudden death in a bathtub is more consistent with acute peritonitis and septic shock rather than cerebral hemorrhage 1

Acute Cerebral Vasculitis (Option C)

• Early deaths in SLE patients are primarily related to infections or lupus activity, while cardiovascular complications account for late mortalities 4, 5
• There is no evidence suggesting active lupus flare in this scenario; the patient was on treatment
• Cerebral vasculitis would be an unusual presentation for sudden death in this context

Intestinal Ischemia with Perforation (Option D)

• While intestinal complications can occur with corticosteroids, the most common gastrointestinal perforation site with steroid use is the duodenum, not the intestines 1, 2
• The concomitant use of corticosteroids increases the risk of gastrointestinal side effects, with peptic ulcer disease and perforation being the primary concern 1

Critical Clinical Pitfalls to Avoid

• Never continue high-dose steroids (>20 mg prednisolone) beyond 6 weeks without implementing a tapering schedule 1, 2
• Always prescribe proton-pump inhibitor prophylaxis when steroids are used for >3-4 weeks at doses ≥20 mg daily 2
• Avoid concomitant NSAID use with steroids, or provide additional gastroprotection if NSAID therapy is unavoidable 2
• Regular monitoring for gastrointestinal symptoms is necessary, as corticosteroids blunt the febrile response and mask warning signs 1
• The British Association of Dermatologists recommends gradual reduction of corticosteroids over 8 weeks, initially by one-third to one-quarter down to 15 mg daily, then by 2.5 mg decrements 1

Mortality Context in SLE Patients

• Infections account for 25-50% of overall mortality in SLE patients, with early deaths primarily related to infections or lupus activity 4
• In one study of SLE patients receiving pulse methylprednisolone, 38.5% died, with early deaths (within first two weeks) mainly due to disease activity while later deaths were mainly due to infection 5
• However, this patient's death at 12 weeks falls into the timeframe where gastrointestinal perforation from prolonged steroid use becomes the dominant risk 1, 2