Purple urine bag syndrome in a hemodialysis patient

Analysis of purple urine bag syndrome by low vacuum scanning electron microscopy

Purple urine bag syndrome (PUBS) is seen in the prolonged indwelling bladder catheters, and the mechanism of its onset was investigated using low vacuum scanning electron microscopy (LVSEM), which enables us to study the 3D structure of urinary sediments and urine bag walls. The urinary sediment and urine bags of 2 cases of PUBS were observed by LVSEM. The urine was brown turbid urine with a pH of 8.5, and magnesium phosphate stones and granules were observed in the urinary sediment together with Gram-positive and Gram-negative bacilli. Bacteria that moved by Brownian motion were observed with a dark-field microscope. LVSEM showed granular crystals around the bacilli, cocci, or mycelium that adhered to the walls of the bag. Granular crystals were dissolved in chloroform and presumed to be a mixture of the bacterial metabolites indigo blue and indirubin red. LVSEM also detected unusual tubular and honeycomb-like graphene in the urinary sediments, which were derived from the inner layer of the silicon elastomer-coated rubber catheter. LVSEM revealed purple crystals produced by bacteria or fungi attached to the urine bag that caused PUBS.

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.

Risk factors of mortality in patients with purple urine bag syndrome

Aim: Purple urine bag syndrome (PUBS) is rarely seen in clinical practice. Several studies have reported that PUBS is relatively benign in its clinical course, but this study aimed to identify risk factors for mortality related to PUBS. Materials and methods: In a PubMed search from October 1980 to August 2016, using the search term "Purple urine bag syndrome (PUBS)", 106 articles (n = 174 cases) were identified. This study excluded 58 cases. Among them, 14 cases did not include information on patient sex and four cases did not include information on patient age. Thirty-seven cases did not report the white blood cell (WBC) count, shock, fever, or etiology. Three cases did not report patient survival. This study considered 116 PUBS cases. Chi-square tests were used to compare the survival and mortality groups. Results: In relative risk analysis, uremia (17.8), shock (14.4), diabetes (4.8), leukocytosis (1.1), and female sex (1.1) were significant risk factors for mortality after PUBS. However, it is possible that PUBS cases are under-reported worldwide. Conclusions: PUBS is a warning sign of a urinary tract infection, and it often follows a relatively benign clinical course. This study found that female sex, leukocytosis, shock at presentation, comorbidity with diabetes, and uremia are risk factors for mortality associated with PUBS.

Risk factors of mortality in patients with purple urine bag syndrome

Aim: Purple urine bag syndrome (PUBS) is rarely seen in clinical practice. Several studies have reported that PUBS is relatively benign in its clinical course, but this study aimed to identify risk factors for mortality related to PUBS. Materials and methods: In a PubMed search from October 1980 to August 2016, using the search term "Purple urine bag syndrome (PUBS)", 106 articles (n = 174 cases) were identified. This study excluded 58 cases. Among them, 14 cases did not include information on patient sex and four cases did not include information on patient age. Thirty-seven cases did not report the white blood cell (WBC) count, shock, fever, or etiology. Three cases did not report patient survival. This study considered 116 PUBS cases. Chi-square tests were used to compare the survival and mortality groups. Results: In relative risk analysis, uremia (17.8), shock (14.4), diabetes (4.8), leukocytosis (1.1), and female sex (1.1) were significant risk factors for mortality after PUBS. However, it is possible that PUBS cases are under-reported worldwide. Conclusions: PUBS is a warning sign of a urinary tract infection, and it often follows a relatively benign clinical course. This study found that female sex, leukocytosis, shock at presentation, comorbidity with diabetes, and uremia are risk factors for mortality associated with PUBS.

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.

[Purple urine-bag syndrome: A case report]

Purple urine-bag syndrome is a rare condition that occurs in patients with indwelling urinary catheters carried over a long period and frequently associated with a urinary tract infection. It is characterized by the appearance of a violet coloration of the probe and/or the urine collection bag. We report the first case in West Africa that occurred in a 47-year-old woman in uremic encephalopathy and carrier of a urinary catheter, which presented a violet color of the tubing and urine-bag associated with a urinary tract infection. The outcome was favorable under antibiotic therapy. Many patients benefit from the installation of urinary catheters for various reasons and the occurrence of this syndrome should lead the medical team to systematically seek an underlying urinary tract infection to avoid if possible paraclinical assessments generally costly to our patients without medical coverage in our developing countries.

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.

A Case of Purple Urine Bag Syndrome in a Spastic Partial Quadriplegic Male

Purple bag urine syndrome (PUBS) is a benign and unique phenomenon of the urine turning a deep violet color within the urinary catheter tubing and bag. This phenomenon is commonly encountered in patients indicated with long-term catheter placement or, in certain conditions like chronic constipation, alkaline urine, limited ambulation, and, in terms of gender distribution, the female sex, predominates. PUBS gets its name from a unique phenomenon that takes places inside the gut where tryptophan (an amino acid) is metabolized, producing blue and red hues which together emanate a deep violet color. Here, the case of a middle-aged male patient with a suprapubic catheter in situ, following trauma causing spastic partial quadriplegia, is being presented with PUBS due to UTI secondary to Proteus vulgaris. The risk factors, in this case, include chronic constipation and recurrent urinary tract infections (UTIs).​

Catheter associated urinary tract infection: what is it, what causes it and how can we prevent it?

Catheter associated urinary tract infection (CAUTI) is one of the most frequently encountered health care associated infections today. Indwelling urinary catheters frequently become colonised with micro-organisms but the majority of cases will be asymptomatic. Differentiation between such colonisation and CAUTI is important for patient management, but unfortunately is not straightforward. This article discusses the diagnosis, causative microbiology and pathogenesis of CAUTI, and briefly considers complications of catheterisation and how these might be prevented.

Purple urine bag syndrome: a community-based study and literature review

AIM

Purple urine bag syndrome (PUBS) is considered as an uncommon phenomenon. This cohort study aimed to figure out the causative factors and the potential risks of PUBS.

METHODS

We recruited 84 patients with long-term urinary catheterization from seven nursing institutions and home care centre, then compared the differences of demographic, clinical, urine test and bacteriological data between the patients with and without PUBS.

RESULTS

The 2-month period prevalence of PUBS in chronic catheterized patients was 16.7%. PUBS-affecting patients had significantly higher proportion of female gender (P = 0.034), self oral intake (P = 0.036) and eating self-prepared food (P = 0.007). Otherwise, no statistical associations were found. Five different bacterial species were isolated from the urine of PUBS-affecting patients. No sequelae were found after forward follow-up for 6 months. We further discuss the associations between certain factors and PUBS according to literature review and the results of our study.

CONCLUSION

PUBS is not as rare as we thought before. The causative factors of PUBS have not been clearly characterized. It may be the combination of several factors that cause the PUBS. Female gender and food content were found to be associated factors of PUBS in our study. Asymptomatic PUBS is unnecessary to be treated by antibiotics.

An association of purple urine bag syndrome with intussusception

We report a case of an elderly lady with a long-term suprapubic catheter who developed purple discoloration of urine around the same time as she developed intussusception. Purple urine bag syndrome is a benign condition known to be associated with intestinal stasis. However, this association with intussusception should be kept in mind before the patient is reassured.

Mass spectrometry analysis of urine and catheter of a patient with purple urinary bag syndrome

INTRODUCTION

Purple urinary bag syndrome (PUBS) is considered to be a benign condition observed in the urinary catheter and bag in some catheterized patients with urinary tract infections. This syndrome is usually reported to occur in alkaline urine.

CASE REPORT

We report of a catheterized patient with PUBS and slightly acidic urine (pH 6-6.5). A novel analysis method was developed using high pressure liquid chromatography and mass spectrometry (HPLC/MS) to detect compounds that are thought to be associated with PUBS. Urine, urinary sediment, and the plastic collection system were assayed and quantitated using these methods. The potential toxicity of one of these compounds, indoxyl sulfate, is discussed.

CONCLUSIONS

The presence of PUBS in a catheterized patient with slightly acidic urine is reported. A novel method for the analysis of chemical components of PUBS and the first direct confirmation of the presence of indigo in the urine sediment and collecting system are described.