Purple Urine Bag Syndrome A Case Report by fdh56iuoui


									                                                                                                           Purple urine bag syndrome
                                                                                                  CASE REPORT

Purple Urine Bag Syndrome — A Case Report

                                         1                         2                       2                     2
Yun-Ke Chiou, Giou-Teng Yiang , Chih-Hsien Wang , Ching-Shing Liao , Bang-Gee Hsu

                                                          1              2
Department of Family Medicine, Emergency Medicine , Nephrology , Buddhist Tzu Chi General Hospital, Hualien, Taiwan

Purple urine bag syndrome (PUBS) is a condition in which the urinary catheter bag of some elderly patients develops an intense
purple coloration. The purple discolouration of urine and bag is most often reported to be due to the indirubin dissolved in the plastic
and indigo crystals in the urine, which coat the bag surface. Urinary indoxyl sulphate is derived from metabolised tryptophan in the
gut. Urinary bacteria with indoxyl sulphatase activity metabolise indoxyl sulphate to produce indigo and indirubin, particularly in
alkaline urine. Here, we report a 90-year-old woman with a Pseudomona aeruginosa, Klebsiella pneumonia, and Morganella moganii
mixed urinary tract infection with constipation who presented with purple urine bag syndrome. The purple urine disappeared after
antibiotic treatment and the following urinalysis was sterile. She was discharged in stable condition. (Tzu Chi Med J 2005; 17:

Key words: purple urine bag syndrome, urinary catheter, urinary tract infection

                                                                        day. She could sit for a while with a caregiver’s help.
                                                                        She had Foley catheterization for one year because of a
                                                                        neurogenic bladder. Turbid urine with purple sediment
     Purple urine bag syndrome (PUBS) was first de-                     was found in the urine bag one day before admission
scribed in 1978 [1]. In this condition, a urinary catheter-             (Fig. 1). Because of worries about the violet-colored
ized patient has a purple-colored urine bag following                   urine in the urine bag, she was taken to emergency de-
urinary catheterization. It is most often observed in                   partment for further management. In the emergency
chronically catheterized and constipated women [2,3].                   department, plain radiography of the abdomen showed
This phenomenon is known to occur with alkaline urine                   stool impaction. She did not have fever or a history of
as well as in urinary tract infections [4]. However, con-               drug administration before admission. Physical exami-
sidering the number of patients in the risk group, purple               nation revealed diffuse tenderness on palpation of the
urine bag syndrome happens infrequently [3]. We would                   abdomen. Other examinations did not indicate any other
like to present this interesting case of an elderly woman               noteworthy symptoms. The urinalysis showed alkaline
who had a purple colored urine bag.                                     urine with a pH of 8 and the urinary sediment contained
                                                                        5-10 white blood cells /high-power-field and was posi-
                                                                        tive for nitrates. Occult blood was also found. However
                     CASE REPORT                                        no red blood cells were found and urine myoglobulin
                                                                        was negative. She was admitted under the impression of
     A 90-year-old woman had a history of osteoporosis                  urinary tract infection and constipation. She was given
and multiple spinal fractures for 7 years. Her daily ac-                first generation cephalosporin 1 gm intravenous every 8
tivity was limited and she was bedridden most of the                    hours per day and gentamicin 80 mg intravenous injec-

Received: October 27, 2004, Revised: November 23, 2004, Accepted: December 9, 2004
Address reprint requests and correspondence to: Dr. Bang-Gee Hsu, Department of Nephrology, Buddhist Tzu Chi General
Hospital, 707, Section 3, Chung Yang Road, Hualien, Taiwan

Tzu Chi Med J 2005      17     No. 4                                                                                                OTV
Y. K. Chiou, G. T. Yiang, C. H. Wang, et al

                                                                                             Gut flora enzyme

                                                                                          Absorted into portal circulation
                                                                                          and converted in the liver
                                                                             Indoxyl sulfate
                                                                                          Urine: Indoxyl sulphatase

                                                              Oxygen,                                 Low Oxygen, alkali
                                                                    Indigo                       Indirubin
Fig. 1.   Purple urine bag.                                  Fig. 2. The formation of indigo and indirubin from trytophan.

tions daily for her urinary tract infection. A glycerol      observed in chronically catheterized and constipated
enema was given for her constipation. Her urine bag          people [2,3]. Several bacterial species have been reported
was changed after admission but the purple urine was         in association with PUBS including Providencia stuartii,
still present for another two days. The purple urine dis-    Providencia rettgeri, Klebsiella pneumoniae, Proteus
appeared after the third day of the hospitalization. Urine   species, Escherichia coli, Enterococcus species,
cultures yielded evident Pseudomona aeruginosa, Kleb-        Morganella morganii, and Pseudomonas aeruginosa [2-
siella pneumonia, and Morganella moganii and all bac-        5]. In our case, the patient had chronic constipation and
terial growth was greater than 105 /mL. The antibiotic       the urine culture yielded Pseudomona aeruginosa, Kleb-
therapy was changed to oral levofloxacin according to        siella pneumonia, and Morganella moganii. The consti-
antibiotic sensitivity tests of the urine cultures. The      pation induced tryptophan to convert into indole. Indole
purple urine disappeared and the following urinalysis        was absorbed into the portal circulation and converted
was sterile. She was discharged in stable condition.         in the liver. The urine bacteria digested indoxyl sulphate
                                                             into indoxyl. In alkaline urine, the indoxyl turned into
                                                             indigo and indirubin, which then mixed into a purple
                      DISCUSSION                             color.
                                                                  Most patients who present with PUBS are asymp-
     Most authors believe that purple urine is a mixture     tomatic. Aggressive management with antibiotics is not
of indigo and indirubin which are derived from the me-       advised. Improvement in the care of urinary catheters
tabolites of tryptophan. Tryptophan is metabolized           prevents both PUBS and catheter associated urinary tract
in the gastrointestinal tract by gut bacteria and it pro-    infection [2].
duces indole that is absorbed into portal circulation. In-        In conclusion, we described an elderly woman with
dole is converted into indoxyl sulphate in the liver. Most   constipation and a Foley catheter associated urinary tract
indoxyl sulphate is excreted into the urine and digested     infection who presented with purple sediment in the urine
into indoxyl by indoxyl sulphatase produced by some          bag.
bacteria. Indoxyl turns into indigo (blue color) and in-
dirubin (red color) in alkaline urine, and these colors
then mix to form a purple color (Fig. 2) [3,5]. However,
there were some patients who presented with a purple
urine bag without indicanuria and the violet pigment may      1. Barlow GB, Dickson JAS: Purple urine bags. Lancet
be either a steroidal or bile acid conjugate [5].                1978; i:220-221.
     Chronic constipation is commonly associated with         2. Dealler SF, Hawkey PM, Millar MR: Enzymatic degra-
                                                                 dation of urinary indoxyl sulfate by Providencia stuartii
bacterial overgrowth in the colon which increases the            and Klebsiella pneumoniae causes the purple urine bag
conversion of tryptophan into indole. Catheter associ-           syndrome. J Clin Microbiol 1988; 26:2152-2156.
ated urinary tract infection increases the conversion of      3. Lin HH, Li SJ, Su KB, Wu LS: Purple urine bag
indoxyl sulphate into indoxyl. So, PUBS is most often            syndrome: A Case Report and Review of the Literature.
                                                                 J Intern Med Taiwan 2002; 13:209-212.

OUM                                                                                   Tzu Chi Med J 2005        17    No. 4
                                                                                             Purple urine bag syndrome

 4. Ollapallil J, Irukulla S, Gunawardena I: Purple urine bag   5. Jones RA, Deacon HJ, Allen SC: Two cases and a short
    syndrome. ANZ J Surg 2002; 72:309-310.                         discussion of purple urine bag syndrome. CME Geriatr
                                                                   Med 2003; 5:84-87.

Tzu Chi Med J 2005     17    No. 4                                                                                 OUN

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