British Journal of Medical Practitioners, December 2011, Volume 4, Number 4 Medicine in Pictures: Purple Urine Bag Syndrome

Capt Gary Chow , Katerina Achilleos and Col Hem Goshai

An 86-year-old lady was admitted from her residential home Differential diagnoses:
with acute on chronic confusion, new symptoms of expressive and receptive dysphasia, dysphagia, vacant episodes and urinary Discoloration of urine can be caused by trauma if blood stained, incontinence. She had a previous significant history of urinary tract infections, ingestion of dye (methylene blue), haemorrhagic stroke with residual right sided weakness, atrial fibrillation, hypertension, and moderate dementia. Following a CT head, this lady was started on acyclovir for encephalitis. She Explanation:
failed to respond to treatment, and developed constipation. With careful consideration of her poor prognosis and quality of life, this lady was placed on the End of Life Pathway. She was neuropsychological symptoms or photosensitivity, and urine catheterised for comfort. Nine days after initial insertion of the discoloration is likely to occur from initial onset of disease. urinary catheter, purple urine was noted in the catheter bag with yellow urine in the tubing leading to the bag. Urine Propofol is an anaesthetic agent, excreted in the urine as phenol dipstick showed Blood ++, Protein ++, Leuc +, Nit –ve, Glu - derivatives which can cause a green urine discolouration1. This ve, Ketone +, pH 8.0. Urine microscopy showed: WCC 454, medication is unlicensed for End of Life Pathway. Propofol RBC 279, epithelial cells 52, no casts. Urine culture revealed infusion syndrome is associated with prolonged high dose heavy mixed growth with multiple organisms. infusion, but is not always accompanied by urine discoloration. Blue diaper syndrome is an inherited metabolic disorder of tryptophan with presentation at infancy2-3. Correct answer
Purple urine bag syndrome (PUBS)
PUBS is an uncommon condition with purple discoloration of the urine catheter system. This phenomenon is due to the presence of indigo and indirubin in the collected urine. PUBS was first published in 19784. Some academics would argue that PUBS was reported even earlier historically as an observation in Sir Henry Halford's bulletin in 18115-6. Two recent literature reviews suggested the prevalence of PUBS is as high as 9.8% in institutionalized Question:
A triad of key factors are suggested as cause of PUBS: Answers:
1. High level of tryptophan in the gut due to diet intake or 3. Urinary tract infection (uti) with bacteria possessing British Journal of Medical Practitioners, December 2011, Volume 4, Number 4 REFERENCES
pneumoniae,morganella, citrobacter species, group b 1. Foot C, Fraser JF. Uroscopic Rainbow: Modern Matula Medicine. streptococci and enterococci8, 13. 2. Drummond K, Miachael A, Ulstrom R, et al. The Blue Diaper It is understood that bowel stasis causes accumulation of Syndrome: Familial Hypercalcemia with Nephrocalcinosis and tryptophan, which leads to an increase in urinary indoxyl Indicanuria; A new familial disease, with definition of the metabolic sulphate (UIS). In the presence of indoxyl phosphatase and abnormality. Am J Med. 1964 Dec;37:928-48. 3. Cochat P, Pichault V, Bacchetta J, et al. NephrolithiasisRelated to sulphatase enzyme activities, whilst collected in the catheter Inborn Metabolic Diseases. Pediatr Nephrol 2010;25(3):415–424. system, UIS is degraded to form a mixture of indigo and 4. Barlow G, Dickson J. Purple Urine Bags. Lancet 1978;1:220-221. dissolved indirubin in the plastic11, coating the catheter system 5. Arnold W. King George III's Urine and Indigo Blue. Lancet with a purple appearance. Intensity of discoloration is deeper the longer the urine is in contact with the catheter plastic7, 10-12. 6. Macalpine I, Hunter R. The "Insanity" of King George III: A Classic The urine does not appear purple prior to entering the catheter. 7. Su F, Chung S, Chen MH, et al. Case Analysis of Purple Urine-Bag Syndrome at a Long-Term Care Service in a Community Hospital. Recent literature7-8 also suggested female gender, alkaline urine, bed bound debilitated patient population, PVC material7 and 8. Khan F, Chaudhry M, Qureshi N, et al. PurpleUrine Bag Syndrome: institutionalization are further predisposing factors of PUBS. An Alarming Hue? A Brief Review of the Literature. Int J Nephrol. 2011;2011:419213. Management of PUBS requires catheter change and treatment 9. Dealler S, Belfield P, Bedford M, et al. Purple Urine Bags. J 10. Al-Sardar H, Haroon D, Purple urinary bag syndrome. Am J Med Good catheter hygiene and shorter duration of catheterisation 11. Dealler S, Hawkey P, Millar M. Enzymatic Degradation of Urinary Indoxyl Sulfate by Providencia Stuartii and Klebsiella Pneumoniae Causes the Purple Urine Bag Syndrome. J Clin Microbiol Competing Interests
12. Lin C, Huang H, Chien C, et al. Purple Urine Bag Syndrome in Author Details
Capt GARY CHOW, Medical Officer, 2 Medical Regiment, Glyn Hughs Bks,
Nursing Homes: Ten Elderly Case Reports and a Literature Review. Hohne. KATERINA ACHILLEOS, MBBS BSc(Hons) MRCP, CT2 Acute Medicine, Southend University Hospital, UK. Col HEM GOSHAI, MBE 13. Vallego-Manzur F, Mireles-Cabodevila E, Varon J. Purple Urine Bag MBCHB BSc, Garrison Clinical Director, Hohne Garrison. Syndrome. Am J Emerg Med 2005;23:521-524. CORRESSPONDENCE: Capt GARY CHOW, Medical Officer, 2 Medical Regiment, Glyn Hughs Brks, Hohne, BFPO 30. Email: [email protected]


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