An association of purple urine bag syndrome with intussusception

Violet discoloration of urine: A case report and a literature review

BACKGROUND

Purple Urine Bag Syndrome (PUBS) is an uncommon event that can be described as purple discoloration of urine due to a series of chemical reactions induced by Urinary Tract Infections (UTIs). PUBS has been reported in the past but still remains unrecognized by healthcare givers leading to misdiagnosis and inappropriate management. We report our case alongside a literature review of previously published cases.

CASE PRESENTATION

We present the first case report of Purple Urine Bag Syndrome in Jordan of a catheterized 80-year-old wheel-chaired female with a history of type 2 Diabetes Mellitus (DM), stage 5 Chronic Kidney Disease (CDK), Hypertension, and ischemic stroke. Her condition was initially misdiagnosed for hematuria but later on was correctly diagnosed with PUBS. She was treated with a course of appropriate antibiotic and by changing her urinary catheter and bag. The patient returned for a follow up visit and her problem resolved with the color of her urine in the urine bag returning back to normal.

CLINICAL DISCUSSION

PUBS is an uncommon event that occurs in association with UTIs. Such cases are mostly seen in elderly catheterized patients with other risk factors.

CONCLUSION

Purple Urine Bag Syndrome can be managed by changing urinary catheter, and by the administration of appropriate antibiotics. Such event can be easily misdiagnosed thus leading to unnecessary and consuming measures. Creating a better awareness of this condition among physicians and healthcare givers is essential for better patient outcomes.

Purple Urine Bag Syndrome: More Than Eyes Can See

BACKGROUND/AIMS

Purple urine bag syndrome (PUBS) is an uncommon clinical entity characterized by purple urine discoloration in the setting of urinary tract infections. Pa-thophysiology of PUBS has been correlated to aberrant metabolism of tryptophan. Multiple predisposing factors have been recognized, namely: female gender, advanced age, constipation, institutionalization, long-term catheter-ization, dementia and chronic kidney disease. Herein, we present a comprehensive review of all PUBS cases reported in PubMed, focusing on the predisposing factors and the microorganisms related to PUBS.

METHODS

We performed a search in PubMed database for articles referring to PUBS, published in English, French, Spanish and German from January 1978 until November 2017. The literature recruitment strategy was based on several keywords and Medical Subject Heading combination such as "purple urine bag syndrome" or PUBS or "urine discoloration". The finally selected articles were categorized into case reports/series (88 articles including 112 patients) and studies (10 articles including 134 patients). Demographical data as well as predisposing factors were recorded and further analyzed.

RESULTS

According to our findings, mean age of PUBS patients was 78.9 ± 12.3 years, 70.7% were female while 90.1% were suffering from constipation, 76.1% were in a bedridden situation, 45.1% were experiencing long-term catheterization, 42.8% had been diagnosed with dementia, 14.3% had recurrent urinary tract infections and 14.1% were chronic kidney disease patients. 91.3% of patients presenting with PUBS alkaline urine were observed while the most common microbe in urine cultures was E. coli.

CONCLUSIONS

PUBS is considered benign process in the majority of catheterized patients. Clinicians should be aware of the syndrome that may indicate serious comorbidities.

Trends in the epidemiology of purple urine bag syndrome: A systematic review

Purple urine bag syndrome (PUBS) is rarely observed in clinical practice. The present study aimed to identify the epidemiological trends in PUBS in recent decades. A search of PubMed articles published between 1980 October and 2016 August was conducted, in which 106 articles (174 cases) described PUBS. Of these cases, 58 cases were excluded: 14 cases without mention of gender, 4 cases without description of age, 37 cases without mention of white blood cell (WBC) count, shock status, fever status or description of etiology, and 3 cases without information on mortality. The remaining 116 PUBS cases were collected and analyzed in the present study. The articles were divided into three groups by publication year: 1991 to 2000, 2001 to 2010 and 2011 to 2016. The χ² test was used for statistical analysis, with P<0.05 (two-tailed) defined as the threshold for significance. Of the total enrolled cases, there were 47 men (40.5%) and 69 women (59.5%), with a mean age ± standard deviation of 75.6±12.8 years. Of these, 98 cases (84.5%) were elderly (≥65 years old). A total of 93.1% of cases had a urine pH >7 while 6.9% of cases had acidic urine (pH <7). Furthermore, although WBC count elevated progressively, the mortality rate of patients with PUBS decreased over subsequent decades. This necessitates the advancement of antibiotics and application of early goal-directed therapy. Additionally, the overall mortality rate of PUBS (1980-2016) was 6.8%, which decreased to 4.3% in the last 5 years (2011-2016). In conclusion, although PUBS has previously been considered a benign process in the majority of indwelling catheterized patients, emphasis is required on early examination and aggressive antibiotic administration.

Trends in the epidemiology of purple urine bag syndrome: A systematic review

Purple urine bag syndrome (PUBS) is rarely observed in clinical practice. The present study aimed to identify the epidemiological trends in PUBS in recent decades. A search of PubMed articles published between 1980 October and 2016 August was conducted, in which 106 articles (174 cases) described PUBS. Of these cases, 58 cases were excluded: 14 cases without mention of gender, 4 cases without description of age, 37 cases without mention of white blood cell (WBC) count, shock status, fever status or description of etiology, and 3 cases without information on mortality. The remaining 116 PUBS cases were collected and analyzed in the present study. The articles were divided into three groups by publication year: 1991 to 2000, 2001 to 2010 and 2011 to 2016. The χ² test was used for statistical analysis, with P<0.05 (two-tailed) defined as the threshold for significance. Of the total enrolled cases, there were 47 men (40.5%) and 69 women (59.5%), with a mean age ± standard deviation of 75.6±12.8 years. Of these, 98 cases (84.5%) were elderly (≥65 years old). A total of 93.1% of cases had a urine pH >7 while 6.9% of cases had acidic urine (pH <7). Furthermore, although WBC count elevated progressively, the mortality rate of patients with PUBS decreased over subsequent decades. This necessitates the advancement of antibiotics and application of early goal-directed therapy. Additionally, the overall mortality rate of PUBS (1980-2016) was 6.8%, which decreased to 4.3% in the last 5 years (2011-2016). In conclusion, although PUBS has previously been considered a benign process in the majority of indwelling catheterized patients, emphasis is required on early examination and aggressive antibiotic administration.

Two Cases of the Purple Urine Bag Syndrome

The purple urine bag syndrome, purple discoloration of urine, is an uncommon and alarming condition in patients requiring long-term urinary catheterization but the clinical course is usually benign. We report two cases of the syndrome with a literature review on its aetiology and management.

An Elderly with Purple Urine

Purple discolouration of urine is not commonly encountered in accident and emergency departments. We report a case of an elderly gentleman on long-term urinary catheter who presented with purple discolouration of urine. He was found to have urinary tract infection caused by the bacteria Proteus mirabilis. The urine became clear after urinary catheter change and antibiotic treatment. This is called the purple urine bag syndrome and emergency physicians should be aware of this uncommon condition and the associated potentially dangerous conditions in order to initiate appropriate management.

Purple Urine Bag Syndrome

Purple urine bag syndrome (PUBS) is a rare disorder seen in elderly persons, wherein the urinary bag and the tubing turn in to purple colour. It is usually seen in patients who are on urinary catheters for a long time. Purple coloured urine occurs due to the accumulation of indigo and indirubin, which are the end products of tryptophan metabolism due to the action of sulfatases and phosphatases formed by bacteria like Providencia, Citrobacter, Enterobacter, Klebsiella etc. We present this interesting phenomenon of purple urine in a young male who was on prolonged urinary catheterization. The urine culture was positive for Providencia and constipation was an added risk factor for the purple urine. The urinary catheter and tubing was changed along with a course of antibiotics which lead to the normalization of the urine colour.

Purple urine bag syndrome: A case report and review of literature

Purple urine bag syndrome (PUBS) is an infrequent condition, seen mostly in elderly female patients, characterized by an intense purple discoloration of contents of urine bag following long-term indwelling urinary catheterization. The purple discoloration is most often due to the presence of indigo and indirubin pigments which are metabolites of tryptophan. Urinary bacteria with indoxyl sulphatase activity metabolize indoxyl sulphate to produce indigo and indirubin, particularly in alkaline urine. We report an elderly woman with a urinary tract infection and constipation who presented with PUBS. The purple urine disappeared after antibiotic therapy and change of the urine bag. To the best of our knowledge, this is the first case of PUBS reported from this region.

Purple urine bag syndrome: an alarming hue? A brief review of the literature

Purple urine bag syndrome (PUBS) is a unique disease entity characterized by an alarming purple discoloration of the urine secondary to recurrent urinary tract infections with indigo- and indirubin-producing bacteria. It is usually associated with prolonged urinary catheterization and chronic debilitated states. We hereby present a concise review of this rare phenomenon with historic perspectives, epidemiology, emphasizing on current concepts of etiology, pathogenesis, relevant clinical associations, treatment modalities, prognosis, and future directions in PUBS. In addition, we highlight an interesting occurrence of this intriguing phenomenon in a 39-year-old gentleman at our institution.