Purple Urine Bag Syndrome in a Male Patient with Chronic Hemodialysis.

A 78-year-old male patient who had an indwelling urinary catheter because of benign hyperplasia of the prostate and who had been receiving hemodialysis twice a week due to endstage renal disease was admitted to our hospital complaining of three days of purple urine color (Figure 1). His medications included beta blocker, anti-aggregant, erythropoietin, piracetam and calcitriol therapies. A urine analysis was performed; the results were as follows: pH: 8.0, density: 1012, leukocyte esterase: (++), leukocyte: 11/HPF (high power field), erythrocyte: 4/HPF and nitrite: negative. The diagnosis of purple urine bag syndrome (PUBS) was made. Treatment with ceftriaxone 2 g/day intravenously (IV) was started immediately on an empirical basis, and the catheter was replaced. Extendedspectrum beta-lactamase-positive Escherichia coli was isolated in urine culture, and the antibiotherapy was changed to imipenem/cilastatin 250 mg IV twice daily. On the fifth day of treatment, the patient’s urine color returned to normal, and a urine sample was negative for leukocyte esterase. Discoloration of urine is important in clinical diagnosis and treatment. PUBS stands for purple discoloration of the urine occurring in patients with long-term urinary catheterization. The interesting point of this syndrome is that the urine itself is unchanged in color but the only change in color is within the bag itself. Reported risk factors of PUBS include chronic urinary catheterization, old age, female gender, dehydration, bedridden, constipation, advanced chronic kidney disease, alkaline or acidic urine, and PVC catheters and bags (1-3). Briefly, pathogenesis is related to sulfatase and/or phosphatase enzyme carrying bacteria (such as Klebsiella, E. Coli, Morganella, Pseudomonas, Enterobacter, Proteus) (1) that leads to metabolize indican into indigo (blue pigment) and indirubin (red pigment) in the urine which results purple discoloration of urine in the plastic of the urine bag (4). Copyright 2016 © Trakya University Faculty of Medicine Balkan Med J 2016;33:717-8 Clinical Image | 717