Bluish patches on the ears and axillae with dark urine: ochronosis and alkaptonuria

The Effects of Diet, Dietary Supplements, Drugs and Exercise on Physical, Diagnostic Values of Urine Characteristics

Background/Objectives: This review summarizes the current knowledge about factors that affect the physical characteristics of urine. It highlights proper urine sample collection and displays factors like diet, hydration status, and medications that can alter urine color, odor, clarity, specific gravity and pH. Results: Urinalysis is a minimally invasive examination of a patient's health, especially concerning nephrological and endocrinological abnormalities, as well as dietary habits and stimulants used. Certain deviations in appearance, composition or frequency/pain during urination may indicate an ongoing disease process in the body. Based on laboratory results, further medical treatment is determined. The reason for a change in the color of the urine, for its clouding or intense odor may be a disease, as well as the consumption of food, medication, intensive physical exercise or inadequate hydration of the body. Well-standardized procedures for collecting, transporting, preparing and analyzing samples should become the basis for an effective diagnostic strategy in urinalysis. It is worth noting that pharmacists in pharmaceutical care are often the first people to whom a patient turns for health advice and for the interpretation of simple laboratory tests. Acquiring the ability to interpret the results of laboratory tests and the principles of proper sampling for laboratory tests is indispensable in the process of possible counseling and providing reliable answers to patients' questions. Conclusions: Although urinalysis is not recommended as a routine screening tool for the general population, it can prove to be a valuable source of patient health data in some cases as the data will be useful to physicians and pharmacists to more effectively diagnose and better care for patients.

ENT manifestations of alkaptonuria: report on a case series

BACKGROUND

Alkaptonuria is an inborn error of metabolism. It is a multisystem disease with characteristic ENT manifestations. This paper reports, for the first time, the ENT findings in a cohort of alkaptonuria patients.

METHOD

Patients attending the National Centre for Alkaptonuria (Royal Liverpool and Broadgreen University Hospitals NHS Trust) underwent a full ENT assessment.

RESULTS

Eighteen of the 20 patients (90 per cent) had an ENT sign or symptom. These included discolouration of the pinna, cerumen, nasal septum and pharynx.

CONCLUSION

Discolouration of cerumen may occur before 30 years of age and may therefore be an important early clinical sign. Further audiological assessment of patients is needed to clarify if an association exists between alkaptonuria and hearing loss. Alkaptonuria is a condition that could present to the otolaryngologist. Successful early diagnosis and referral to a specialist centre is essential so that patients can be offered disease-modifying therapy.

Black urine due to urobilinogen in a patient with alcoholic pellagra

OBJECTIVES

Systemic exposure to drugs, chemicals and foods can cause abnormally colored urine. Food exposures are typically benign, but urine discoloration due to chemicals or drugs may indicate a potentially dangerous condition. Discolored urine can also be caused by medical problems. This brief report reviews the laboratory findings leading to lactic acidosis and elevated urine urobilinogen in an alcoholic patient with pellagra.

DESIGN AND METHODS

A 66-year-old male, found unconscious in his hotel room, was brought to the emergency department (ED). Upon arrival he had hypothermia, a diffuse rash and altered mental status. During ED evaluation, a urinary catheter was placed and demonstrated black urine. Medical history noted chronic alcoholism, malnutrition, and poor self-care.

RESULTS

Evaluation in the hospital suggested that his rash and neurologic changes were a result of malnutrition and vitamin deficiency. A thorough biochemical workup demonstrated that elevated urobilinogen was likely causing the patient's black urine. Serum niacin concentration was undetectable. His dermatitis improved with multivitamins, thiamine, and niacin as well as topical steroids. His mental status returned to baseline and he was discharged to a skilled nursing facility following a brief hospital stay.

CONCLUSIONS

The patient's abnormal laboratory results were explained by his alcoholism and poor nutrition. Furthermore, urine color returned to normal with decreased concentration of urobilinogen, after vitamin supplementation and supportive medical care.

Endogenous ochronosis: case report and a systematic review of the literature

BACKGROUND

Endogenous ochronosis (EO) is a rare autosomal recessive disorder due to accumulation of oxidized and polymerized forms of homogentisic acid (HGA) in connective tissues, giving them a deep dark blue pigmentation.

AIM

Through a new Tunisian case of EO and a review of the literature, we aimed to define the epidemioclinical features of EO, its diagnostic criteria, and evolution.

METHODS

Three hundred and forty patients were enrolled through 54 articles and four abstracts.

CASE REPORT

A 35-year-old woman, born in consanguineous parents, presented with blue-grey patches of fingernails, first interdigital spaces, and ears with brown conjunctival pigmentation. Urine specimen turned dark on standing overnight. The diagnosis of EO was confirmed by urinary high levels of HGA. Investigations revealed radiologic signs of ochronotic arthropathy.

REVIEW OF THE LITERATURE

EO is ubiquitary. Its prevalence was estimated at almost 6.5 cases/year. The mean age at diagnosis was 55.9 years (M/F: 1.85). Onset symptoms mainly consisted in cutaneous signs. Ochronotic arthropathy was the most frequently reported manifestation. Treatment was mainly symptomatic.

DISCUSSION

EO is often revealed in adulthood mainly after the fourth decade. Urinary darkening is the first sign of the disease but is rarely reported as an onset sign. Skin signs are the alerting features. Ochronotic arthropathy is insidious but may be debilitating. No specific medical treatment of EO is available.

CONCLUSION

Cutaneous manifestations are the hallmarks of OE. As vital organ involvement has been reported, close monitoring and continuous surveillance is warranted.

Endogenous ochronosis

Endogenous ochronosis or alkaptonuria is a rare, autosomal recessive disease of tyrosine metabolism that is caused by a deficiency of the enzyme homogentisic acid oxidase. The disease results in the accumulation and deposition of homogentisic acid in the cartilage, eyelids, forehead, cheeks, axillae, genital region, buccal mucosa, larynx, tympanic membranes, and tendons. The disease generally presents in adults with arthritis and skin abnormalities; occasionally, involvement of other organs may be seen. A 49-year-old man was referred to our clinic with verrucous lesions on his hands. On physical examination, caviar-like ochronotic papules were found around his eyes and the helix cartilage of his ears, and on the dorsa of both hands. There were brown macules on the sclera (Osler's sign). The patient had arthritis and nephrolithiasis, and a sample of his urine darkened upon standing. Histopathological examination showed deposition of ochronotic pigment. High-dose ascorbic acid was given, and the patient showed improvement on follow-up examination 6 months later.

[Ochronosis or black cartilage disease]

We report two cases of ochronosis. This rare disease (1/1,000,000) transmitted by recessive autosomic inheritance results from an enzyme disorder. Clinically, the disease begins by black deposits in connective tissue followed by a group of symptoms, particularly involving the joints, and then destructive joint disease affecting the larger joints. Diagnosis is often established late. Early detection is important, preoperatively if possible, in order to avoid the serious complication of infectious endocarditis. These patients require adapted multidisciplinary care associating social support and symptomatic treatment. Drug therapy is currently under study and appears to provide effective symptom relief.