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Case Report: Purple Urine Bag Syndrome
The Journal of Emergency Medicine, Vol. 44, No. 4, pp. e335–e336, 2013 Copyright Ó 2013 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2012.11.030
Visual Diagnosis in Emergency Medicine
CASE REPORT: PURPLE URINE BAG SYNDROME Michelle L. Duff, MS4, MSA Des Moines University, Des Moines, Iowa Reprint Address: Michelle L. Duff, MS4, MSA, Des Moines University, 55 Hosptal Drive, Athens, OH 45701
DISCUSSION Purple urine bag syndrome (PUBS) is a rare condition reported in 1978, which presents as discoloration of the urine bag (1). This condition is seen in patients with long-term indwelling catheters, chronic constipation, and in the female population. Prevalence of PUBS has been reported to be as high as 9.8% in institutionalized patients with long-term indwelling urinary catheter use (2). The most common bacteria seen in urinary tract infections associated with PUBS are Providencia stuartii
CASE REPORT A 57-year-old woman presented to the Emergency Department (ED) with a 3-day history of diffuse abdominal pain. She denied fever, vomiting, diarrhea, and dysuria. Her past medical history was positive for transverse myelitis requiring chronic catheterization, and a history of multiple urinary tract infections. Her past surgical history was positive for two cesarean sections, as well as colostomy bag placement to eliminate bowel problems associated with her transverse myelitis. On physical examination, she had diffuse abdominal tenderness with increased focal tenderness in the suprapubic region. The patient’s Foley catheter bag was noted to have a deep purple hue (Figure 1). The current catheter and bag had been in place for 3 weeks. Vital signs were within normal limits except for a sinus tachycardia. After placement of a new Foley catheter, urine analysis and culture were ordered. The urine specimen was dark orange and cloudy. Urinalysis revealed a pH of 7.5, a moderate amount of blood, large amounts of leukocyte esterase, 5–10 packed red blood cells (RBC) and many bacteria. Her culture grew Gram-negative rods of Klebsiella pneumonia sensitive to fluoroquinolones. Upon removal of the catheter, the patient’s pain resolved. She was treated with ciprofloxacin empirically, as well as a new Foley catheter.
Figure 1. Patient’s urine bag showing a purple discoloration of the urine.
RECEIVED: 3 April 2012; FINAL SUBMISSION RECEIVED: 16 August 2012; ACCEPTED: 3 November 2012 e335
e336
and Providencia rettgeri, Proteus mirabilis, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Proteus vulgaris (3,4). The discoloration of the urine in PUBS occurs from the breakdown of tryptophan into indole by gut bacteria. Indole is absorbed and enters the portal circulation into the liver. Indole is converted to indoxyl sulfate, which is then converted to indoxyl by urinary bacteria via sulfatase and phosphatase enzymes. Indoxyl is converted by alkaline urine into indirubin (red) and indigo (blue) and mixed together; the red and blue hues create a purple discoloration to the urine. Indicans interact with the plastic material of the catheter bag and tubing and produce a purple coating layer (1,5). However, if the urine is transferred into other sterile containers, no color change occurs. Patients with chronic constipation are more apt to have PUBS due to the increased transit time of tryptophan in the gut. The result is an increase in levels of indoxyl sulfate in
M. L. Duff
the urine, and due to the presence of alkaline urine, it turns a purple color (5). In conclusion, PUBS is a benign condition seen most commonly in female patients, those with chronic indwelling catheters and chronic constipation. PUBS has a dramatic appearance, but can simply be treated with catheter replacement and antibiotics. REFERENCES 1. Barlow GB, Dickson JAS. Purple urine bags [letter]. Lancet 1978;1: 220–1. 2. Dealler SF, Belfield PW, Bedford M, Whitley AJ, Mulley GP. Purple urine bags. J Urol 1989;142:769–77. 3. Dealler SF, Haekey PM, Millar MR. Enzymatic degradation of urinary indoxyl sulfate by Providencia stuartii and Klebsiella pneumoniae causes the purple urine bag syndrome. J Clin Microbiol 1988;26: 2152–6. 4. Vallego-Munzur F, Mireles-Cabodevila E, Varon J. Purple urine bag syndrome. Am J Emerg Med 2005;23:521–4. 5. Stott A, Khan M, Roberts C, Galpin IJ. Purple urine bag syndrome. Ann Clin Biochem 1987;24:185–8.
http://dx.doi.org/10.1016/j.jemermed.2012.11.030
Visual Diagnosis in Emergency Medicine
CASE REPORT: PURPLE URINE BAG SYNDROME Michelle L. Duff, MS4, MSA Des Moines University, Des Moines, Iowa Reprint Address: Michelle L. Duff, MS4, MSA, Des Moines University, 55 Hosptal Drive, Athens, OH 45701
DISCUSSION Purple urine bag syndrome (PUBS) is a rare condition reported in 1978, which presents as discoloration of the urine bag (1). This condition is seen in patients with long-term indwelling catheters, chronic constipation, and in the female population. Prevalence of PUBS has been reported to be as high as 9.8% in institutionalized patients with long-term indwelling urinary catheter use (2). The most common bacteria seen in urinary tract infections associated with PUBS are Providencia stuartii
CASE REPORT A 57-year-old woman presented to the Emergency Department (ED) with a 3-day history of diffuse abdominal pain. She denied fever, vomiting, diarrhea, and dysuria. Her past medical history was positive for transverse myelitis requiring chronic catheterization, and a history of multiple urinary tract infections. Her past surgical history was positive for two cesarean sections, as well as colostomy bag placement to eliminate bowel problems associated with her transverse myelitis. On physical examination, she had diffuse abdominal tenderness with increased focal tenderness in the suprapubic region. The patient’s Foley catheter bag was noted to have a deep purple hue (Figure 1). The current catheter and bag had been in place for 3 weeks. Vital signs were within normal limits except for a sinus tachycardia. After placement of a new Foley catheter, urine analysis and culture were ordered. The urine specimen was dark orange and cloudy. Urinalysis revealed a pH of 7.5, a moderate amount of blood, large amounts of leukocyte esterase, 5–10 packed red blood cells (RBC) and many bacteria. Her culture grew Gram-negative rods of Klebsiella pneumonia sensitive to fluoroquinolones. Upon removal of the catheter, the patient’s pain resolved. She was treated with ciprofloxacin empirically, as well as a new Foley catheter.
Figure 1. Patient’s urine bag showing a purple discoloration of the urine.
RECEIVED: 3 April 2012; FINAL SUBMISSION RECEIVED: 16 August 2012; ACCEPTED: 3 November 2012 e335
e336
and Providencia rettgeri, Proteus mirabilis, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Proteus vulgaris (3,4). The discoloration of the urine in PUBS occurs from the breakdown of tryptophan into indole by gut bacteria. Indole is absorbed and enters the portal circulation into the liver. Indole is converted to indoxyl sulfate, which is then converted to indoxyl by urinary bacteria via sulfatase and phosphatase enzymes. Indoxyl is converted by alkaline urine into indirubin (red) and indigo (blue) and mixed together; the red and blue hues create a purple discoloration to the urine. Indicans interact with the plastic material of the catheter bag and tubing and produce a purple coating layer (1,5). However, if the urine is transferred into other sterile containers, no color change occurs. Patients with chronic constipation are more apt to have PUBS due to the increased transit time of tryptophan in the gut. The result is an increase in levels of indoxyl sulfate in
M. L. Duff
the urine, and due to the presence of alkaline urine, it turns a purple color (5). In conclusion, PUBS is a benign condition seen most commonly in female patients, those with chronic indwelling catheters and chronic constipation. PUBS has a dramatic appearance, but can simply be treated with catheter replacement and antibiotics. REFERENCES 1. Barlow GB, Dickson JAS. Purple urine bags [letter]. Lancet 1978;1: 220–1. 2. Dealler SF, Belfield PW, Bedford M, Whitley AJ, Mulley GP. Purple urine bags. J Urol 1989;142:769–77. 3. Dealler SF, Haekey PM, Millar MR. Enzymatic degradation of urinary indoxyl sulfate by Providencia stuartii and Klebsiella pneumoniae causes the purple urine bag syndrome. J Clin Microbiol 1988;26: 2152–6. 4. Vallego-Munzur F, Mireles-Cabodevila E, Varon J. Purple urine bag syndrome. Am J Emerg Med 2005;23:521–4. 5. Stott A, Khan M, Roberts C, Galpin IJ. Purple urine bag syndrome. Ann Clin Biochem 1987;24:185–8.