Peer Reviewed

Photo Quiz

What Explains This Man’s Apparent Urine Discoloration?

Eiyu Matsumoto, MB, and Jennifer R. Carlson, PA-C

Volume 57 - Issue 12 - December 2017

Authors:
Eiyu Matsumoto, MB, and Jennifer R. Carlson, PA-C

Citation:
Matsumoto E, Carlson JR. What explains this man’s apparent urine discoloration? Consultant. 2017;57(12):711.

 

An 82-year-old man residing in a skilled nursing facility presented to the emergency department with a 1-week history of discolored urine in his collection bag. He had a history of benign prostatic hyperplasia requiring long-term urinary catheter placement, as well as congestive heart failure and hypertension. He also reported having new-onset dysuria. He denied having fever, chills, back pain, nausea, or vomiting. At presentation, he was afebrile with stable vital signs.

His urine appeared to have a purplish discoloration while in the catheter and bag (Figure 1), but the color of the urine changed after being removed from the bag and being placed in a specimen cup (Figure 2). Urinalysis results were positive for both nitrites and leukocyte esterase.

Purple urine bag syndrome

Purple urine bag syndrome

 

 

Answer on next page

Answer: Purple Urine Bag Syndrome

purple urine bag syndrome

purple urine bag syndrome

 

Based on his presentation, the patient received a clinical diagnosis of purple urine bag syndrome (PUBS).

Discussion

PUBS, first described in 1978,1 is a phenomenon associated with bacterial urinary tract infection in persons with indwelling urinary catheters. Although PUBS has been reported as being relatively rare, its prevalence has been estimated to be from 8.3% to as high as 16.7% in patients with long-term urinary catheters.2-4 Risk factors for PUBS include older age, female gender, chronic constipation, dementia, and a high bacterial load in the urine.2-8 Cases have been reported in association with hemodialysis for end-stage renal disease and with nephrostomy.9-11 The bacterial pathogens most often associated with PUBS are Escherichia coli, Klebsiella pneumoniae, Providencia species, Proteus species, Pseudomonas species, Morganella species, and Enterococcus species.1-7,9-12

The pathogenesis of PUBS begins with the metabolism of tryptophan by gastrointestinal tract bacteria, which eventually leads to the formation of the pigments indigo and indirubin in the urine.3 The combination of indigo, which is blue, and indirubin, which is red, causes the purple discoloration. It is important to note that this discoloration results from an interaction between urine and the urine bag and/or plastic tubing, and that the bag or tubing is purple, not the urine itself.

The prognostic implication of this condition has been controversial. Earlier, PUBS had been thought to be benign.3 However, a number of reported cases have required therapeutic intervention.5,6,8,12,13 Thus, PUBS is not always benign, and some patients need treatment of catheter-associated urinary tract infection or urosepsis. To date, there is no consensus on the management of PUBS.

Outcome of the Case

The patient’s long-term urinary catheter was exchanged. He was started on nitrofurantoin, 100 mg twice a day for 10 days. Urine cultures grew K pneumoniae, Enterococcus species, and methicillin-susceptible Staphylococcus aureus. His dysuria resolved shortly after starting nitrofurantoin therapy. He was lost to follow-up, so it is unknown whether his PUBS has resolved. 

Eiyu Matsumoto, MB, is a clinical assistant professor in the Department of Internal Medicine, Division of Infectious Diseases, at the University of Iowa Carver College of Medicine in Iowa City, Iowa.

Jennifer R. Carlson, PA-C, is a physician assistant at the Iowa City Veterans Affairs Health Care System in Iowa City, Iowa.

REFERENCES:

  1. Barlow GB, Dickson JAS. Purple urine bags. Lancet. 1978;311(8057):220-221.
  2. Su F-H, Chung S-Y, Chen M-H, et al. Case analysis of purple urine-bag syndrome at a long-term care service in a community hospital. Chang Gung Med J. 2005;28(9):636-642.
  3. Hadano Y, Shimizu T, Takada S, Inoue T, Sorano S. An update on purple urine bag syndrome. Int J Gen Med. 2012;5:707-710.
  4. Shiao C-C, Weng C-Y, Chuang J-C, Huang M-S, Chen Z-Y. Purple urine bag syndrome: a community-based study and literature review. Nephrology (Carlton). 2008;13(7):554-559.
  5. Khan F, Chaudhry MA, Qureshi N, Cowley B. Purple urine bag syndrome: an alarming hue? A brief review of the literature. Int J Nephrol. 2011;2011:419213. doi:10.4061/2011/419213
  6. Tasi Y-M, Huang M-S, Yang C-J, Yeh S-M, Liu C-C. Purple urine bag syndrome, not always a benign process. Am J Emerg Med. 2009;27(7):895-897.
  7. Mantani N, Kogure T, Ochiai H, et al. A case-control study of purple urine bag syndrome in geriatric wards. J Infect Chemother. 2003;9(1):53-57.
  8. Lau CL, Ong KL. An elderly with purple urine. Hong Kong J Emerg Med. 2009;16(3):159-160.
  9. Ting I-W, Wang R, Wu V-C, Hsueh P-R, Hung K-Y. Purple urine bag syndrome in a hemodialysis patient. Kidney Int. 2007;71(9):956.
  10. Ferrara F, D’Angelo G, Costantino G. Monolateral purple urine bag syndrome in bilateral nephrostomy. Postgrad Med J. 2010;86(1020):627.
  11. Hirzallah MI, D’Souza DL. Purple urine bag syndrome in a patient with a nephrostomy tube. N Z Med J. 2010;123(1312):68-70.
  12. Pillai BP, Chong VH, Yong AML. Purple urine bag syndrome. Singapore Med J. 2009;50(5):e193-e194.
  13. Bhattarai M, Bin Mukhtar H, Davis TW, Silodia A, Nepal H. Purple urine bag syndrome may not be benign: a case report and brief review of the literature. Case Rep Infect Dis. 2013;2013:863853. doi:10.1155/2013/863853