King George III's urine and indigo blue

Purple urine bag syndrome: An unusual manifestation of urinary tract infection, our experience at a tertiary care center

Background

Purple urine bag syndrome (PUBS) is an unusual condition in which a purple discoloration of urine and bag occurs in people with urinary catheters. People with purple urine usually do not complain of any symptoms. The purple discoloration of the urine bag is often the only finding, frequently noted by caregivers.

Materials and methods

This prospective observational study was conducted at our tertiary care institute from June 2018 to May 2020. A total of 46 patients with PUBS were included in this study. The objective of our study was to record the prevalence of each predisposing factor and to correlate the pathological mechanism through which the PUBS is manifested.

Results

The mean age of PUBS patients was 67.4years and 67.4% were males. Most patients of PUBS (60.9%) had a urethral catheter, while there was percutaneous nephrostomy in 26.1% patients and 13% patients had a percutaneous suprapubic cystostomy catheter. Among the patients, 69.65% were bedridden or in an institutionalized situation, 73.9% were suffering from chronic constipation, 21.7% were associated with dementia, and 47.8% were cerebrovascular accidents with hemiparesis patients. In addition, 93.5% of patients presented with alkaline urine and 3 patients with acidic urine. The most common bacteria isolated in urine culture were E coli and Pseudomonas.

Conclusions

Urinary catheter associated urinary tract infection and PUBS is most commonly documented in females, but our study showed that it is more common in males. The appearance of a purple bag does not depend on the material and type of the catheter or the catheterization method. In addition, no correlation was found between the microorganisms isolated from the environment and patients' urine.

Purple urinary bag syndrome: Our experience

Background

Purple urinary bag syndrome (PUBS) is a visually striking and rare manifestation of urinary tract infection characterised by purple discolouration of the catheter and the urobag, which are seen primarily in patients who are on long-term indwelling catheter. This rare syndrome results due to the breakdown of indole, a by-product of dietary tryptophan metabolism, to coloured pigments indigo and indirubin by urinary bacteria, which reacts with the catheter and the bag to impart a purple colour.

Methods

This was a prospective observational study, wherein all cases of PUBS diagnosed between March 2012 and February 2020 were analysed and followed up.

Results

A total of five patients were presented with PUBS. Among them, four were women, and four were chronically constipated. All of them were elderly and debilitated with either being bed bound or having restricted mobility. Three of them had associated chronic kidney disease. All of them were treated successfully with change of catheters and antibiotics.

Conclusion

This rare but alarming condition occurs in elderly patients who are on long-term indwelling catheters. The diagnosis is visually apparent, and the treatment may be just a simple change of catheter with oral antibiotics. The awareness may help in correct diagnosis and treatment.

What is happening in that urinary catheter bag?

An 86-year-old nursing home woman with an indwelling urinary catheter presented to our emergency department for abdominal pain, nausea, hyporexia after nine days of stubborn constipation despite the use of laxatives, on a background of IV stage Chronic Kidney Disease (CKD), type 2 diabetes, hypothyroidism, and bed rest syndrome with chronic pain treated with fentanyl transdermal patch. Blood tests showed a worsening of renal function (creatinine 5.7 mg/dL, nv 0.6-1; azotemia 177 mg/dL, nv 10-50), and increased C reactive protein value (5 mg/dL, nv < 0.5). Glucose and serum electrolytes were normal. Abdomen X-ray was unremarkable, and PoCUS excluded hydronephrosis and bladder globe. The urine drainage bag was purple with smelly urine.

Purple urine bag syndrome: A case report

INTRODUCTION

Purple Urine Bag Syndrome (PUBS) is purple discoloration of urine and is common in bedridden patients with long-term urinary catheter. Although typically benign, the purple discoloration is alarming to both the patients and their attendants.

CASE REPORT

This case report presents an uncommon case of PUBS in a 74-year-old lady with hypertension, type II diabetes and ischemic stroke from last 2 years. She has neurogenic bladder and has been catheterized from last 2 years. Her last catheter was changed 15 days back. She presented to the emergency room with complaints of change in color of urine with low grade fever from last 1 week. on clinical examination there was one bed sore on lumbar region that was grade 1 with pus oozing from base of ulcer.

CLINICAL DISCUSSION

PUBS is generally associated with alkaline urine and in patients who was chronically catheterized as was observed in this patient, although it has also been reported in acidic urine.

CONCLUSION

PUBS is a rare manifestation of urinary tract infection with an alarming appearance and can be a source of anxiety for patients and their families. Being asymptomatic and comparatively benign, purple discoloration is simply an indicator of underlying bacteriuria and is of no prognostic value.

Purple urine bag syndrome: An unusual but important manifestation of urinary tract infection. Case report and literature review

Purple urine bag syndrome is a rare albeit alarming purple discolouration of the urine typically seen in elderly ladies with constipation, urinary tract infection and concurrent urinary catheterisation. In this concise review, we report the pathophysiology of this condition and the case of one patient who developed this interesting phenomenon.

Purple Urine Bag Syndrome: A Scary but Easily Manageable Condition in a Patient with Prolonged indwelling Urinary Catheter

“Purple urine bag syndrome” (PUBS) is a rare but distressing presentation of urinary tract infection (UTI) among moribund patients on indwelling urinary catheter. A 56-year-old woman with carcinoma of the left breast and metastasis in vertebrae and liver was bed ridden. She was on Foley's catheter for 9 months, with the last catheter changed 3 weeks back. A 75-year-old woman presented with non-Hodgkin's lymphoma for 2 years and moderately differentiated squamous cell carcinoma of the right parotid region (8 months). She experienced fall and fracture of femur, bed ridden, and on Foley's catheter for 7 years. She had facial wound with maggots for 3 days. Both the women developed purple-colored urine with no other symptoms of UTI. No investigations were carried out and they were empirically treated with nitrofurantoin, catheter change reassurance, and increased fluid intake. Urine color was normal by a week. PUBS can be managed easily at home with simple antibiotics, adequate hydration, and family/patient counseling in palliative care settings.

Purple Urine Bag Syndrome: A Rare Spot Diagnosis

Purple urine bag syndrome (PUBS) is a complication of urinary tract infections (UTIs) where catheter bags and tubing turn purple. It is alarming for patients, families, and clinicians; however, it is in itself a benign phenomenon. PUBS is the result of UTIs with specific bacteria that produce sulphatases and phosphatases which lead tryptophan metabolism to produce indigo (blue) and indirubin (red) pigments, a mixture of which becomes purple. Risk factors include female gender, immobility, constipation, chronic catheterisation, and renal disease. Management involves reassurance, antibiotics, and regular changing of catheters, although there are debates regarding how aggressively to treat and no official guidelines. Prognosis is good, but PUBS is associated with high morbidity and mortality due to the backgrounds of patients. Here, we review the literature available on PUBS, present a summary of case studies from the last five years, and propose the Oxford Urine Chart as a tool to aid such diagnoses.

[Purple urine bag syndrome in a patient with bilateral nephrostomy]

This article presents a case of purple urine bag syndrome (PUBS) with purple discoloration of urine in a patient with bilateral nephrostomy and acute renal failure. The discoloration of the urine is a product of bacterial metabolism. In principle, PUBS is benign and not of relevance for prognosis. However, it must be taken seriously as an indication for urinary tract infection and treated accordingly. Important for treatment is adequate urologic hygiene and care of urinary catheters for prevention of bacterial contamination as well as avoiding obstipation.

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.

King George III and porphyria: a clinical re-examination of the historical evidence

The diagnosis that George III suffered from acute porphyria has gained widespread acceptance,but re-examination of the evidence suggests it is unlikely that he had porphyria.The porphyria diagnosis was advanced by Ida Macalpine and Richard Hunter, whose clinical symptomatology and historical methodology were flawed.They highlighted selected symptoms, while ignoring, dismissing or suppressing counter-evidence.Their claims about peripheral neuropathy, cataracts, vocal hoarseness and abdominal pains are re-evaluated; and it is also demonstrated that evidence of discoloured urine is exceedingly weak. Macalpine and Hunter believed that mental illnesses were primarily caused by physical diseases, and their diagnosis of George III formed part of a wider agenda to promote controversial views about past, contemporary and future methods in psychiatry.

Indigogenic substrates for detection and localization of enzymes

Indoxyl esters and glycosides are useful chromogenic substrates for detecting enzyme activities in histochemistry, biochemistry and bacteriology. The chemical reactions exploited in the laboratory are similar to those that generate indigoid dyes from indoxyl-beta-d-glucoside and isatans (in certain plants), indoxyl sulfate (in urine), and 6-bromo-2-S-methylindoxyl sulfate (in certain molluscs). Pairs of indoxyl molecules released from these precursors react rapidly with oxygen to yield insoluble blue indigo (or purple 6,6'-dibromoindigo) and smaller amounts of other indigoid dyes. Our understanding of indigogenic substrates was developed from studies of the hydrolysis of variously substituted indoxyl acetates for use in enzyme histochemistry. The smallest dye particles, with least diffusion from the sites of hydrolysis, are obtained from 5-bromo-, 5-bromo-6-chloro- and 5-bromo-4-chloroindoxyl acetates, especially the last of these three. Oxidation of the diffusible indoxyls to insoluble indigoid dyes must occur rapidly. This is achieved with atmospheric oxygen and an equimolar mixture of K(3)Fe(CN)(6) and K(4)Fe(CN)(6), which has a catalytic function. H(2)O(2) is a by-product of the oxidation of indoxyl by oxygen. In the absence of a catalyst, the indoxyl diffuses and is oxidized by H(2)O(2) (catalyzed by peroxidase-like proteins) in sites different from those of the esterase activity. The concentration of K(3)Fe(CN)(6)/K(4)Fe(CN)(6) in a histochemical medium should be as low as possible because this mixture inhibits some enzymes and also promotes parallel formation from the indoxyl of soluble yellow oxidation products. The identities and positions of halogen substituents in the indoxyl moiety of a substrate determine the color and the physical properties of the resulting indigoid dye. The principles of indigogenic histochemistry learned from the study of esterases are applicable to methods for localization of other enzymes, because all indoxyl substrates release the same type of chromogenic product. Substrates are commercially available for a wide range of carboxylic esterases, phosphatases, phosphodiesterases, aryl sulfatase and several glycosidases. Indigogenic methods for carboxylic esterases have low substrate specificity and are used in conjunction with specific inhibitors of different enzymes of the group. Indigogenic methods for acid and alkaline phosphatases, phosphodiesterases and aryl sulfatase generally have been unsatisfactory; other histochemical techniques are preferred for these enzymes. Indigogenic methods are widely used, however, for glycosidases. The technique for beta-galactosidase activity, using 5-bromo-4-chloroindoxyl-beta-galactoside (X-gal) is applied to microbial cultures, cell cultures and tissues that contain the reporter gene lac-z derived from E. coli. This bacterial enzyme has a higher pH optimum than the lysosomal beta-galactosidase of animal cells. In plants, the preferred reporter gene is gus, which encodes beta-glucuronidase activity and is also demonstrable by indigogenic histochemistry. Indoxyl substrates also are used to localize enzyme activities in non-indigogenic techniques. In indoxyl-azo methods, the released indoxyl couples with a diazonium salt to form an azo dye. In indoxyl-tetrazolium methods, the oxidizing agent is a tetrazolium salt, which is reduced by the indoxyl to an insoluble coloured formazan. Indoxyl-tetrazolium methods operate only at high pH; the method for alkaline phosphatase is used extensively to detect this enzyme as a label in immunohistochemistry and in Western blots. The insolubility of indigoid dyes in water limits the use of indigogenic substrates in biochemical assays for enzymes, but the intermediate indoxyl and leucoindigo compounds are strongly fluorescent, and this property is exploited in a variety of sensitive assays for hydrolases. The most commonly used substrates for this purpose are glycosides and carboxylic and phosphate esters of N-methylindoxyl. Indigogenic enzyme substrates are among many chromogenic reagents used to facilitate the identification of cultured bacteria. An indoxyl substrate must be transported into the organisms by a permease to detect intracellular enzymes, as in the blue/white test for recognizing E. coli colonies that do or do not express the lac-z gene. Secreted enzymes are detected by substrate-impregnated disks or strips applied to the surfaces of cultures. Such devices often include several reagents, including indigogenic substrates for esterases, glycosidases and DNAse.

Purple urine bag syndrome with acidic urine

Purple discoloration of a urinary catheter bag is very rare. This phenomenon is known as the purple urine bag syndrome. It is associated with urinary tract infections occurring in catheterized patients, generally elderly females with significant co-morbidities and constipation. The urine is usually alkaline. We present a unique case of this rare and interesting phenomenon occurring in acidic urine and discuss the pathophysiology.

Sir Henry Halford, president of the Royal College of Physicians, with a note on his involvement in the exhumation of King Charles I

Henry Halford (formerly Vaughan) (1766-1844) was president of the Royal College of Physicians for an unprecedented 24 years. A successful physician, he had to resign his post at the Middlesex Hospital because of his growing private practice. He was physician to four reigning monarchs and had many famous patients including Geogiana Duchess of Devonshire in whom he correctly diagnosed a liver abscess when other physicians had failed. He was also involved in the exhumation of King Charles I, and the fourth cervical vertebra, through which the King had been executed, came into his possession.

Sir William Osler's Perceptions of Urolithiasis and the Case of the Indigo Calculus

BACKGROUND

Sir William Osler published his textbook, The Principles and Practice of Medicine, in 1892. It became the definitive treatise on a wide variety of diseases. The section on nephrolithiasis clearly presents the etiology, pathology, symptoms, diagnosis, and treatments. What remains a mystery is the mention, under rare forms of human stones, of a type called "indigo."

MATERIALS AND METHODS

A search of Index Medicus starting from 1909 backward to its inception in 1879 was performed for key words "indigo," "calculus," "renal" or "bladder stones" and "indicanuria." Twelve textbooks of urology published before 1940 were scrutinized for references to indigo calculi.

RESULTS

Only two references to indigo were found, both related to its use for treating constipation (1887 and 1891). Of the 12 textbooks, only 4 make passing reference to "indigo stones." They all mention that such calculi are very rare, but direct references to cases are lacking. One textbook references a study of blue stones from Egyptian mummies.

CONCLUSION

It is unlikely that Osler's reference to an indigo calculus was taken lightly during his writing of The Principles and Practice of Medicine. The case of the indigo calculus is fascinating and perhaps enlightening if only for the source of Osler's intrigue.

Purple urine bag syndrome

The purple urine bag syndrome (PUBS) is a rare condition associated with chronic urinary catheterization. It is characterized by the purple discoloration of the urine, collecting bag, and tubing. A number of factors are involved, but not always present, in its development including female sex, urinary tract infection, constipation, indicanuria, and alkaline urine. Despite multiple theories that involve the complex tryptophan metabolism to the tubing dye, the cause remains elusive. The syndrome resolves usually after treatment of urinary tract infection or changing of the collecting bag. We present a case of a patient with purple urine bag syndrome and a pertinent literature review.

Russia's imperial blood: was Rasputin not the healer of legend?

The only son of Russia's last Tsar, a great-grandson of Queen Victoria, continues to be used as the favorite example of the X-linked inheritance of hemophilia, in spite of the fact that this popular historical diathesis has never been confirmed by any form of modern medical laboratory testing. Certain to be controversial, a new study of the symptoms that were witnessed by those who were closest to the teenaged Russian heir now raises the possibility that his blood disorder might well have been something other than hemophilia. The key to discovering Tsarevich Alexei's true diagnosis is found in those now legendary allegations that the infamous "Mad Monk", Grigory Rasputin, had possessed a power of healing that was somehow responsible for the young boy's mysterious history of spontaneous recoveries. If we are to accept the popular diagnosis of history and call it a clotting factor deficiency, then the boy's now famous sudden recoveries will remain a complete mystery. The so-called "Mad Monk" Rasputin, as a direct result of the revolutionary propaganda of the time, is then overblown into a larger-than-life legend. If, however, we are to change the diagnosis and call it a platelet disorder, then the air is let out of the legend, and Rasputin is revealed to have been nothing more than a very ordinary middle-aged Siberian hippie who did not possess any healing powers at all.

Purple urinary bag syndrome: a harmless but alarming problem

Patients who are not catheterized may notice a discolouration in their urine or faeces, either occasionally or continually. Such discolouration can usually be put down to waste materials caused by medication or food. However, a comment often made by nurses who see catheterized patients is, 'My patient's drainage bag has turned purple'. Patients with this condition can show no underlying urine infection. It is also noticeable that the longer the drainage bag is used, the deeper the colour purple becomes. Over a period of time this discolouration then impregnates their catheter. This condition also produces a strong odour, and as air temperature increases, so does the smell. This condition is known as purple urinary bag syndrome or PUBS.

Porphyria: the road not traveled

As our ability to evaluate patients with porphyria expands there have been some inconsistencies that are not easily explained. These inconsistencies are biochemical, enzymatic and genetic in nature. Recent work by others has led me to believe there is another way to look at the problem. I will propose how an evolutionary approach could reconcile these problems. In doing so it will imply that porphyria could potentially affect many more people than currently thought.