Most Likely Cause of Death in SLE Patient on Prolonged High-Dose Prednisolone
The most likely cause of death is perforated duodenal ulcer (Option A), as prolonged high-dose corticosteroid therapy is a well-established major etiologic factor for peptic ulcer perforation, which carries mortality rates up to 30% and can present with sudden catastrophic deterioration.
Rationale for Perforated Duodenal Ulcer
Corticosteroids as Primary Risk Factor
- Steroids are explicitly identified as a main etiologic factor for gastroduodenal ulcer perforations, alongside NSAIDs, smoking, H. pylori, and high-salt diet 1
- The patient received prednisolone 60 mg daily for 12 weeks continuously without tapering—this represents prolonged exposure to high-dose corticosteroids, dramatically increasing perforation risk 1
- Peptic ulcer disease associated with corticosteroid use affects acid secretion in the gastric mucosa, leading to ulceration 1
Clinical Presentation Fits Perforation
- Perforated peptic ulcers can present with sudden catastrophic deterioration, consistent with being found dead unexpectedly 1
- Mortality rates for peptic ulcer disease remain substantial: 3.7% die within 30 days and 11.8% within 1 year of hospitalization 2
- Historical mortality rates for gastroduodenal ulcer perforations reach up to 30% 1
- Perforated duodenal ulcers carry significantly impaired short-term survival, with hazard ratio of 2.06 at 6 months 2
Why Other Options Are Less Likely
Hypertensive Cerebral Hemorrhage (Option B)
While corticosteroids can cause hypertension, this would typically present with warning symptoms (severe headache, neurological deficits) rather than sudden death in a bathtub without prior indication 1
Acute Cerebral Vasculitis (Option C)
- CNS vasculitis in SLE typically presents with progressive mental status changes, encephalopathy, and coma rather than sudden death 3
- This complication would more likely occur during active lupus flares, not as a complication of steroid therapy itself 3
- The clinical course described (sudden death) does not fit the typical presentation of CNS vasculitis 3
Intestinal Ischemia with Perforation (Option D)
- While mesenteric vasculitis can occur in SLE and carries high mortality (approximately 70%), it is relatively uncommon compared to steroid-induced peptic ulcer disease 4, 5
- Intestinal ischemia typically presents with severe abdominal pain, distention, and progressive deterioration before death—not sudden unexpected death 6
- Mesenteric vasculitis is more associated with active SLE disease rather than as a complication of steroid therapy 4, 5
- The natural history involves progressive symptoms (abdominal pain, bloody diarrhea) before catastrophic perforation 6, 7
Critical Clinical Pitfalls
Steroid-Related GI Complications
- GI symptoms in SLE patients on steroids may be mild or absent until catastrophic perforation occurs 1, 5
- Approximately 50% of SLE patients experience GI symptoms, but these are usually mild unless vasculitis or perforation develops 5
- Stress ulcers with perforation may occur with minimal warning signs, especially in patients on high-dose corticosteroids 1
Mortality Considerations
- Perforated duodenal ulcer mortality of 17.1% has been reported, with deaths primarily from gram-negative septicemia and shock 8
- The combination of SLE (immunocompromised state) plus prolonged high-dose steroids (further immunosuppression and direct ulcerogenic effect) creates particularly high risk 1, 8
In summary, the 12-week exposure to prednisolone 60 mg daily without tapering represents the most direct and established risk factor for peptic ulcer perforation in this clinical scenario, making Option A the most likely cause of death 1, 2.