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Xanthine Calculus: a Case Report
XANTHINE CALCULUS: A CA:SJS REPORT ARTHUR J. BUTT, CAPT., M.C.
AND
HENRY D. HOLLIMAN, JR., CAPT., M.C.
From the 148th General Hospital, A.P.O. No. 960, San Francisco, Calif.
The rarity of xanthine stones in the urinary tract of man is attested by the paucity of case reports in the literature. In 1937 Kretschmer exhaustively reviewed the subject and tabulated the data on 16 cases reported up to that time. Since then there have been 2 additional cases reported, one by Ratner and Strasberg, the other by Hyman and Leiter. The following case report brings the total up to 19. CASE REPORT
H. A. H., a 28-year old soldier, was admitted to the 148th General Hospital on November 8, 1942, complaining of severe pain in the left lower quadrant of 3 hours' duration. For 2 weeks he had experienced vague digestive disturbances and had had difficulty in emptying his bladder. The patient had been on tropical duty for 4 months and was employed during this time in the x-ray section of the hospital. Other previous personal history and family history are irrelevant. Physical examination on November 8, 1942 revealed slight tenderness, but no rigidity, in response to deep palpation in the left lower quadrant. No abnormal masses were felt. There was marked redundancy of the foreskin. The prostate was normal to palpation. Temperature, pulse and respirations were normal. The blood pressure was 150/100 mm. of Hg. Laboratory procedures revealed the following findings: Hemoglobin 70 per cent (Tallqvist); red blood cells 4,580,000 per cu. mm.; white blood cells 22,050 per cu. mm.; Schilling count 27 per cent immature polymorphonuclears. Urinalysis revealed a clear, acid, straw-colored urine with specific gravity of 1.019. Occasional white blood cells were seen on microscopic examination. The prostatic secretion contained 1-3 white blood cells per high power field. The Kahn test was negative. In view of the above physical and laboratory :findings, a retrograde pyelogram was deemed advisable. On November 12, 1942, cystoscopic examination was performed. Some difficulty was encountered in passing a No. 24 cystoscope through the posterior urethra. It was necessary to pass metal sounds before the cystoscope could be passed. Ureteral catheters were passed to the right and left renal pelves, but with a moderate amount of difficulty. The retrograde pyelogram revealed a marked constriction at the left ureterovesical junction, with a moderate hydroureteronephrosis above the constriction. A film t::tken 5 minutes after removal of ureteral catheters showed very poor drainage oni the left side. Urine cultures produced colonies of Staphylococcus albus and :/3\li~terium aerogenes. The pH of the urine from the left kidney was 4.7; that of the right 5.3,. Following the intravenous injection of phthalein no dye appeared from the left ureter. SD
90
ARTHUR J. BUTT AND HENRY D. HOLLIMAN
One week later (November 19) an attempt was made to dilate the left ureter, but neither catheter nor bougie would pass more than 1.0 cm. beyond the ureterovesical junction. In washing the bladder, a small stone 0.2 cm. in diameter, surrounded by mucous threads and exudate, was removed through the cystoscope. Since this stone was not observed at the previous examination, it was concluded that the stone had entered the bladder from the ureter at some time between the two examinations. Chemical analysis of the stone was performed by one of us (A. J.B.) according to the procedure outlined by Hammersten and modified by Heller. Table I summarizes the analysis. Following the second cystoscopic examination the patient's symptoms completely disappeared. The urine and blood findings returned to normal. A third cystoscopic examination was performed on December 16, 1942. The obstruction noted previously in the left ureter had disappeared and a No. 6 ureteral bougie was TABLE 1 PROCEDURE
OBSERVATIONS
SIGNIFICANCE
1. Ignition
a,. Does burn
Organic material. (Exeludes phosphates, carbonates and oxalates) ---- --- ---- -~-- ------------ -- --- -- --- ----------------~-- -- --~ --- --- --- ---- - ----------- ----- ----------- -------b. Burns without flame Excludes cystine, urostealith and fibrin 2. Add 1 gtt. 10% KOH and 7 gtts. of uric acid reagent
No blue color
Excludes urates and uric acid
3. Dissolve in HN0 3 • Evaporate to dryness. Add NaOH Heat
No effervescence. Yellow residue. Orange color. Red color
XANTHINE
readily passed. On December 18, the patient was discharged without symptoms and was returned to duty. DISCUSSION
A comprehensive discussion of xanthine stones can be found in Kretschmer's excellent review. These calculi are found most frequently in the bladder, are usually single, occur more frequently in males than in females, and more frequently in young subjects. Approximately two-thirds of these stones are composed of "pure" xanthine and the rest are of the mixed type. Any calculus containing from 90-95 per cent of one salt is considered as a "pure" stone. Large stones are usually of the mixed type. Xanthine calculi may be yellow, yellowish brown or reddish brown, and if rubbed with a cloth they assume a polished, waxy or resinous luster. Early reports suggested that xanthine stones were not demonstrable by x-ray. In three of the more recent cases, positive x-ray findings were reported.
XANTHINE CALCULUS
91
Xanthine is found in the urine of normal individuals in amounts of less than 50 mgm. per 24 hrs. It may occur in larger quantities as a product of deranged nuclein metabolism. Xanthine is one of the end products of the metabolism of nucleic acid, the chief ingredient of nuclei, and is closely related to uric acid. Xanthine and uric acid are formed not only by the endogenous metabolism of body protein, but by metabolism of protein from exogenous sources, viz. from glandular meats, and also from the alkaloids of tea and coffee. The therapy of patients with xanthine calculus should include abstinence from liver, brain, sweetbreads, roe, mushrooms, coffee, tea, cocoa, chocolate and asparagus. SUMMARY
A xanthine calculus, the nineteenth to be recorded in the literature, is reported. It was removed from the bladder of a 28-year old white male and was associated with a constriction at the left ureterovesical junction, and a dilatation of the left ureter and left renal pelvis. REFERENCES BRAY, W. E.: Synopsis of Clinical Laboratory Methods, 2nd ed, 1938. p. 344. HYMAN, A. AND LEITER, H. E.: J. Mt. Sinai Hosp., 8: 84, 1941. JoLY, J. S.: Stone and Calculous Disease of the Urinary Organs. 1940. p. 434. KRETSCHMER, H. L.: J. Urol., 38: 183, 1937. RATMER, M. AND STRASBERG, A.: Canad. M.A. J., 40: 350, 1939.
AND
HENRY D. HOLLIMAN, JR., CAPT., M.C.
From the 148th General Hospital, A.P.O. No. 960, San Francisco, Calif.
The rarity of xanthine stones in the urinary tract of man is attested by the paucity of case reports in the literature. In 1937 Kretschmer exhaustively reviewed the subject and tabulated the data on 16 cases reported up to that time. Since then there have been 2 additional cases reported, one by Ratner and Strasberg, the other by Hyman and Leiter. The following case report brings the total up to 19. CASE REPORT
H. A. H., a 28-year old soldier, was admitted to the 148th General Hospital on November 8, 1942, complaining of severe pain in the left lower quadrant of 3 hours' duration. For 2 weeks he had experienced vague digestive disturbances and had had difficulty in emptying his bladder. The patient had been on tropical duty for 4 months and was employed during this time in the x-ray section of the hospital. Other previous personal history and family history are irrelevant. Physical examination on November 8, 1942 revealed slight tenderness, but no rigidity, in response to deep palpation in the left lower quadrant. No abnormal masses were felt. There was marked redundancy of the foreskin. The prostate was normal to palpation. Temperature, pulse and respirations were normal. The blood pressure was 150/100 mm. of Hg. Laboratory procedures revealed the following findings: Hemoglobin 70 per cent (Tallqvist); red blood cells 4,580,000 per cu. mm.; white blood cells 22,050 per cu. mm.; Schilling count 27 per cent immature polymorphonuclears. Urinalysis revealed a clear, acid, straw-colored urine with specific gravity of 1.019. Occasional white blood cells were seen on microscopic examination. The prostatic secretion contained 1-3 white blood cells per high power field. The Kahn test was negative. In view of the above physical and laboratory :findings, a retrograde pyelogram was deemed advisable. On November 12, 1942, cystoscopic examination was performed. Some difficulty was encountered in passing a No. 24 cystoscope through the posterior urethra. It was necessary to pass metal sounds before the cystoscope could be passed. Ureteral catheters were passed to the right and left renal pelves, but with a moderate amount of difficulty. The retrograde pyelogram revealed a marked constriction at the left ureterovesical junction, with a moderate hydroureteronephrosis above the constriction. A film t::tken 5 minutes after removal of ureteral catheters showed very poor drainage oni the left side. Urine cultures produced colonies of Staphylococcus albus and :/3\li~terium aerogenes. The pH of the urine from the left kidney was 4.7; that of the right 5.3,. Following the intravenous injection of phthalein no dye appeared from the left ureter. SD
90
ARTHUR J. BUTT AND HENRY D. HOLLIMAN
One week later (November 19) an attempt was made to dilate the left ureter, but neither catheter nor bougie would pass more than 1.0 cm. beyond the ureterovesical junction. In washing the bladder, a small stone 0.2 cm. in diameter, surrounded by mucous threads and exudate, was removed through the cystoscope. Since this stone was not observed at the previous examination, it was concluded that the stone had entered the bladder from the ureter at some time between the two examinations. Chemical analysis of the stone was performed by one of us (A. J.B.) according to the procedure outlined by Hammersten and modified by Heller. Table I summarizes the analysis. Following the second cystoscopic examination the patient's symptoms completely disappeared. The urine and blood findings returned to normal. A third cystoscopic examination was performed on December 16, 1942. The obstruction noted previously in the left ureter had disappeared and a No. 6 ureteral bougie was TABLE 1 PROCEDURE
OBSERVATIONS
SIGNIFICANCE
1. Ignition
a,. Does burn
Organic material. (Exeludes phosphates, carbonates and oxalates) ---- --- ---- -~-- ------------ -- --- -- --- ----------------~-- -- --~ --- --- --- ---- - ----------- ----- ----------- -------b. Burns without flame Excludes cystine, urostealith and fibrin 2. Add 1 gtt. 10% KOH and 7 gtts. of uric acid reagent
No blue color
Excludes urates and uric acid
3. Dissolve in HN0 3 • Evaporate to dryness. Add NaOH Heat
No effervescence. Yellow residue. Orange color. Red color
XANTHINE
readily passed. On December 18, the patient was discharged without symptoms and was returned to duty. DISCUSSION
A comprehensive discussion of xanthine stones can be found in Kretschmer's excellent review. These calculi are found most frequently in the bladder, are usually single, occur more frequently in males than in females, and more frequently in young subjects. Approximately two-thirds of these stones are composed of "pure" xanthine and the rest are of the mixed type. Any calculus containing from 90-95 per cent of one salt is considered as a "pure" stone. Large stones are usually of the mixed type. Xanthine calculi may be yellow, yellowish brown or reddish brown, and if rubbed with a cloth they assume a polished, waxy or resinous luster. Early reports suggested that xanthine stones were not demonstrable by x-ray. In three of the more recent cases, positive x-ray findings were reported.
XANTHINE CALCULUS
91
Xanthine is found in the urine of normal individuals in amounts of less than 50 mgm. per 24 hrs. It may occur in larger quantities as a product of deranged nuclein metabolism. Xanthine is one of the end products of the metabolism of nucleic acid, the chief ingredient of nuclei, and is closely related to uric acid. Xanthine and uric acid are formed not only by the endogenous metabolism of body protein, but by metabolism of protein from exogenous sources, viz. from glandular meats, and also from the alkaloids of tea and coffee. The therapy of patients with xanthine calculus should include abstinence from liver, brain, sweetbreads, roe, mushrooms, coffee, tea, cocoa, chocolate and asparagus. SUMMARY
A xanthine calculus, the nineteenth to be recorded in the literature, is reported. It was removed from the bladder of a 28-year old white male and was associated with a constriction at the left ureterovesical junction, and a dilatation of the left ureter and left renal pelvis. REFERENCES BRAY, W. E.: Synopsis of Clinical Laboratory Methods, 2nd ed, 1938. p. 344. HYMAN, A. AND LEITER, H. E.: J. Mt. Sinai Hosp., 8: 84, 1941. JoLY, J. S.: Stone and Calculous Disease of the Urinary Organs. 1940. p. 434. KRETSCHMER, H. L.: J. Urol., 38: 183, 1937. RATMER, M. AND STRASBERG, A.: Canad. M.A. J., 40: 350, 1939.