Case Report

Purple urine bag syndrome in a dead-on-arrival patient: case report and articles reviews

Purple urine bag syndrome (PUBS) is a very Rare condition, which usually happens to elderly women with urinary tract infection. Other etiologies include debilitated status, long-term catheterization, chronic constipation, and alkaline urine. Generally speaking, PUBS has a benign process and resolves after proper antibiotic administration or a catheter change. We present a 61-year-old woman who was dead on arrival in the emergency department. After cardiopulmonary resuscitation, she regained vital signs and was admitted to the intensive care unit. Purple urine was found after catheterization and was sustained for 16 hours. To our knowledge, this is the first case of PUBS occurring in a dead-on-arrival patient, and this syndrome does not appear to be confined to patients in the chronic care ward. A 61-year-old woman presented to our emergency department (ED) dead on arrival. According to her family’s statement, the patient worked in the market selling vegeta- bles. She was healthy before except for some joint pain. She took an over-the-counter painkiller shortly before collapsing to the ground. Brought to our ED by emergency medical service, she was intubated with a No. 7.5 endotracheal tube and fixed in the mark of 21 cm. Cardiac massage and advanced cardiac life support were immediately started. After a total of 2 A of epinephrine and 1 A of atropine, the patient regained pulse 5 minutes after arrival to our ED. Vital signs were as follows: body temperature, 36.58C; pulse rate, 151 beats/min; and blood pressure, 154/72 mm Hg. Blood tests showed white blood count (WBC) of 14900/mL, neutrophil of 54%, lymphocyte of 42%, monocyte of 4%,

hemoglobin of 12.5 g/dL, and platelet of 206000/lL.

Biochemistry data were as follows: glucose, 228 mg/dL; glutamic-oxaloacetic transaminase, 32 U/L; creatine kinase,

196 U/L; potassium, 5.9 mEq/L; sodium, 140 mEq/L; creatine kinase-MB, 17.1 U/L; blood urea nitrogen, 18 mg/dL; and creatinine, 0.9 mg/dL. After urinary catheter insertion, the purple urine was found (Fig. 1). Urine analysis showed a pH of 7.5 and a urine WBC of 0 per high-power field. Electrocardiogram after recovery of spontaneous circulation showed normal sinus rhythm. After admission to the intensive care unit, the purple urine disappeared while Urine pH was 5.5 and urine WBC was still 0 per high-power

field. Urine culture revealed no growth 3 days after admission. Sustained hypotension with aspiration pneumo- nia soon set in, and her family decided to sign the do-not- resuscitate order. She died 13 days after admission.

Purple urine bag syndrome (PUBS) is a rarely seen condition, and it is first described in 1978 [1,2]. Dealler et al

[3] provided the etiology of PUBS in 1988. They found that tryptophan is metabolized by intestinal bacteria, and then indoxyl sulfate is excreted into the urine and is digested into indoxyl by sulfatase/phosphatase produced by some bacteria such as Providencia stuartii, Providencia rettgeri, Klebsi- ella pneumoniae, Proteus mirabilis, Escherichia coli, Morganella morganii, Pseudomonas aeruginosa, Entero- coccus spp, etc. Indoxyl turns into indigo and indirubin in alkaline urine [3-6]. Indigo is blue and indirubin is red. As they mix together, the color becomes purple.

Known factors associated with PUBS include elderly women [2-7], debilitation [2], long-term urinary catheteri- zation [2,5], and alkaline urine [2,4,7-9]. Chronic constipa- tion is commonly associated with bacterial overgrowth in the colon in which tryptophan has been converted to indole [2,4-6,8]. The literature suggests PUBS per se appears to be a benign process without major consequences [2,5].

Fig. 1 The Purplish discoloration of urine in the urine bag was noted.

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In our case, there was no evidence of bacteria in the urine. This contradicts the previous hypothesis of higher bacterial count in urine as the most important of all facilitating factors in PUBS [7]. Purple urine bag syndrome has not previously been observed in Acute care facilities and has been associated with hospital infection transmitted by staff [6].

The clinical course of PUBS is benign, and almost all are asymptomatic [2,5]. Ihama et al [10] reported a case of PUBS with mortality due to other life-threatening cause (carcino- matosis). In our case, the patient was initially a case of dead on arrival. After successful resuscitation, she was admitted to the intensive care unit with recovery of spontaneous circulation. Finally she died of Aspiration pneumonia with septic shock 13 days later. Purple urine bag syndrome was not the leading cause of mortality in our case.

Yu-Jang Su MD Department of Emergency Medicine Mackay Memorial Medical Center Taipei 104, Taiwan, ROC

Mackay Medicine Nursing and Management College Taipei 112, Taiwan, ROC

E-mail address: [email protected]

Yen-Chun Lai MD Department of Anesthesiology Mackay Memorial Medical Center Taipei 104, Taiwan, ROC

Wen-Han Chang MD, PhD Department of Emergency Medicine Mackay Memorial Medical Center Taipei 104, Taiwan, ROC

doi:10.1016/j.ajem.2007.02.015

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