Available online on 15.09.2023 at http://jddtonline.info

Journal of Drug Delivery and Therapeutics

Open Access to Pharmaceutical and Medical Research

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Open Access   Full Text Article                                                                                                                                            Short Communication

Purple bag unmasking disguised Urinary tract infection

Sanjeev Sharma¹, Digvijay Singh Tanwar², Manjeet Kumar³* 

¹ Postgraduate MS Scholar (AMO), Department of Shalya Tantra, Rajiv Gandhi Government Post-Graduate Ayurvedic College Paprola, Kangra HP

² Senior Resident, Department of Urology, IGMC Shimla

³ Assistant Professor, Dept. of Urology, IGMC Shimla HP, India

Case summary 

A seventy-year lady with a medical history of diabetes mellitus presented with acute urinary retention in urology emergency. She was catheterized in emergency department and evaluated. Her retention volume was 700 ml. Blood investigations were Haemoglobin 11.5 gm/dl, TLC 9500/mm3, urea 20 mg/dl, creatinine 0.6 mg/dl, glycosylated haemoglobin 8.1 gm%. Urine culture showed growth of Klebsiella pneumoniae and started on levofloxacin. She was advised to come at 2 weeks for foleys catheter removal. She came at 2 weeks for follow up and foleys catheter removal. On examination, purple-coloured discolouration of urine and urobag was seen. (Figure 1)

Figure 1: Urobag showing purple discolouration.

Discussion

Purple urine bag syndrome is a rarely reported condition of decolouration of urine. This is reported in elderly females with diabetes mellitus having urinary tract infections. Discolouration of urine is due to the production of indigo (blue) and indirubin pigments as a result of bacterial growth. These pigments are produced from tryptophan. (Figure 2)

                                                                                             Tryptophan  

                                                                        Deamination

                                                                                            Indole

                                                          Hepatic conjugation

                                                                             Indoxyl sulphate

                  Bacteria (sulphatases and phosphatases)

                                                                                              Indoxyl

                  Bacteria (sulphatases and phosphatases)

                                                                             Indigo and Indirubin pigments

                                  Reaction with polyvinyl chloride

                                                                          Discolouration of urine in urobag

                                           Figure 2: Production of purple urinary colour from tryptophan

The bacteria associated with the production of purple bag syndrome are Klebsiella pneumoniae, Providencia stuartii, Proteus mirabilis, Providencia rettgeri, e coli, pseudomonas, morganella morganii, Citrobacter spp. And streptococci (group B). These bacteria produce enzymes such as sulphatases and phosphatases which convert indoxyl sulphate to indoxyl. Indoxyl is oxidized in the urinary tract to pigments indigo and indirubin pigments. Which on coming in contact with polyvinyl chloride tract of urobag results in the formation of purple discolouration. ^1,2

Discoloration of urine is a clinical sign in various diseases which helps in differentiating diseases. Discolouration of urine occurs in hematuria, bladder tumors, renal cell carcinoma, drugs, and dyes intakes, etc. Purple urine discoloration is rarely reported in the literature and is generally associated with urinary tract infections.³

In this report, a 70-year-old woman with a past medical history of Diabetes mellitus on oral hypoglycaemic, occasional constipation was evaluated in a urology emergency. She presented with chronic urinary retention. She was catheterized and the retention volume was 700 ml. she was advised with investigations and advised to come after 7 days. She had confusion and right hemiplegia in every neurological examination and required urinary catheterization due to immobilization. Purple coloration was observed in urine on the twelve days after catheterization. hospital day. She had asymptomatic however worried because of urine colour. The catheter was changed, and urine culture was repeated. Supportive management such as alpha-blockers tamsulosin, adequate fluids, catheter care, laxatives for constipation, medicine consultation for diabetes was taken. Urine colour changed to normal, and constipation improved. Her foleys catheter was removed after 2 weeks. She voided well with minimal residual volume. At follow-up at 3 months, she was asymptomatic with no urinary complaints. 

Funding source: None 

Competing interests/Conflicts of interest:   None

REFERENCES

1. Khan F, Chaudhry MA, Qureshi N, et al. purple urine bag syndrome: an alarming hue? A brief review of the literature. Int J Nephrol 2011; 2011:1-3. https://doi.org/10.4061/2011/419213 PMid:21977321 PMCid:PMC3184437

2. Kumar R, Devi K, Kataria D, et al. (July 11, 2021) Purple Urine Bag Syndrome: An Unusual Presentation of Urinary Tract Infection. Cureus 13(7): e16319. doi:10.7759/cureus.16319 https://doi.org/10.7759/cureus.16319

3. Mohamad Z, Chong VH. "Purple urine bag: think of urinary tract infection," The American Journal of Emergency Medicine, 2013; 31(1):265.e5-265.e6. https://doi.org/10.1016/j.ajem.2012.04.010 PMid:22795993