Article

Purple urine bag syndrome, not always a benign process

Purple urine bag syndrome, not always a “>diffuse bone pain for 3 hours before arriving at the emergency department. On admission, he was free of chest pain, and blood pressure was 136/70 mm Hg, pulse rate was 66 beats per minute, and body temperature was

36.2?C. A routine 12-lead electrocardiography was obtained, and it revealed ST-segment elevation of leads II, III, and aVF with reciprocal ST-segment depression of leads I and aVL. The laboratory findings demonstrated a raised leukocyte count of 16 800/uL and positive cardiac troponin-I. Under the impression of acute Inferior wall myocardial infarction, emergent coronary angiography with primary percutaneous coronary angioplasty to the infarct-related right coronary artery was carried out. As soon as the forward flow of right coronary artery was restored, the symptom of severe bone pain was resolved. To our knowledge, patients with unrecognized acute myocar- dial infarction usually presenting with aTypical symptoms instead of chest pain have poor prognosis and outcomes [4]. Risk factors including elderly persons, female sex, type 2 diabetes, and inferior wall myocardial infarction have been reported with a higher incidence of atypical manifestations during myocardial infarction. Although severe bone pain due to an increase of endogenous G-CSF response after acute coronary syndromes has rarely been emphasized before, the preliminary data in our hospital revealed about 6% of patients diagnosed as acute myocardial infarction presenting concomitant bone pain with or without angina pectoris on admission. Herein, we stress that the presence of unexplainable bone pain in a patient with high risk of cardiovascular event should be considered as an atypical early presentation of acute myocardial infarction.

Gen-Min Lin MD Department of Internal Medicine Tri-Service General Hospital National Defense Medical Center Neihu 114, Taipei, Taiwan Department of Internal Medicine

Hualien Armed Forces General Hospital

Hualien, Taiwan E-mail address: [email protected]

Chih-Lu Han PhD Department of Internal Medicine Tri-Service General Hospital National Defense Medical Center Neihu 114, Taipei, Taiwan

doi:10.1016/j.ajem.2009.01.017

References

  1. Leone AM, Rutella S, Bonanno G, et al. Endogenous G-CSF and CD34+ cell mobilization after acute myocardial infarction. Int J Cardiol 2006;111:202-8.
  2. Han CL, Campbell GR, Campbell JH. Circulating bone marrow cells can contribute to neointimal formation. J Vasc Res 2001;38:113-9.
  3. Ogata S, Ito K, Kadoike K, et al. The incidence of bone pain with granulocyte colony stimulating factor (G-CSF) administration and the effect of hydroxyzine. ASCO Annual Meeting Proceedings. J Clin Oncol 2005;23(Suppl 1):8242.
  4. Canto JG, Shlipak MG, Rogers WJ, et al. Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain. JAMA 2000;283:3223-9.

Purple urine bag syndrome, not always a benign process

To the Editor,

The subject of the case report presented by Su et al [1] is quite interesting as authors described a patient that was sent to the emergency department in critical condition upon arrival, and purple urine bag syndrome (PUBS) was also found at that time. Finally, the patient died of Aspiration pneumonia and septic shock in the intensive care unit. The case report described the first case of PUBS that occurred involving a patient in critical condition. The authors claimed that PUBS was not the leading cause of mortality in this case. We realize that urinary tract infection is an important factor contributing the development of PUBS [2]. Fourier’s gang- rene is a Urologic emergency with high mortality [3]. One of the major sources of Fourier’s gangrene is urinary tract infection. We came across 2 patients who had PUBS and pyuria. Both of them progressed to Fourier’s gangrene days later. This is the first report of PUBS-associated Fourier’s gangrene.

Case 1

A 50-year-old patient had respiratory failure and required ventilator dependence for 5 months. In addition, he had diabetes mellitus, a previous cerebral vascular accident, and congestive heart failure. He also had urinary catheterization for 3 months. He had purple urine bag syndrome since May 20, 2008, and his urine data yielded alkaline urine (pH 8.5) and a urine white blood cell count of 15 to 20 per high-power field (HPF). Blood examination revealed WBC of 10 200/uL, hemoglobin of 8.9 g/dL, and platelet of 141 000/uL. His urine culture grew Escherichia coli and Acinetobacter baumanii. We did not prescribe any antibiotics for him because he was asymptomatic with the exception of purple urine. However, he had abrupt hypotension and hypothermia 1 week later. A detailed physical examination disclosed his edematous necrotic scrotum with a foul odor. Fourier’s gangrene was impressed. Meropenen was imme- diately administered, and repeated extensive debridement was performed. The pus culture yielded Morganella

morganii and Klebsiella pneumoniae. After careful manage- ment, his condition improved and the necrotic perineal and Genital area healed gradually. Unfortunately, sudden-onset cerebral hemorrhage occurred 1 month later and the patient died on July 14, 2008.

Case 2

A 78-year-old man had uremia with regular hemodialysis, chronic obstructive pulmonary disease, and diabetes melli- tus. He also had received urinary catheterization for 2 months. He was sent to our hospital because of fever on December 18, 2008. He was noted as having purple urinary bag syndrome on the day of admission. The urinary analysis showed alkaline urine (pH 7.5) and WBC of 10 to 15/HPF. Blood examination revealed WBC of 12 500, hemoglobin level of 8.6 g/dL, and platelet of 538 000/uL. Five days later, he had abruptly diffuse genital necrosis with foul odor and Fourier’s gangrene was impressed. Emergent debridement was performed, and Empiric antibiotics with ceftazidime and metronidazole were prescribed immediately. His urine culture and wound culture both grew Proteus mirabilis. After repeated debridement, his condition went from bad to worse, with severe metabolic acidosis and respiratory failure occurring shortly afterward. His family refused intubation and signed the do-not-resuscitation order. He died on December 29, 2008.

Fournier’s gangrene is a urologic emergency and is characterized as infective necrotizing fascitis of the perineal, genital, or perianal region. The major sources of Fournier’s gangrene were dermatologic, colorectal, and urologic [3]. However, both urethral and perirectal infections ultimately reach the superficial perineal space and produce the same pattern of disease [4]. Purple urine bag syndrome often has a benign process, which resolves after proper antibiotic administration or just a catheter change, and we do not often pay attention to the condition. Purple urine bag syndrome generally occurs in elderly women who are bedridden, chronically catheterized, and constipated; they also have alkaline urine and higher bacterial counts in urinary analysis [5]. In other words, urinary tract infection is an important factor contributing the development of PUBS [2]. Regarding the possible mechanism, progression to Fourier’s gangrene is possible, such as in the case of these 2 patients (Fig. 1). Both of our patients had diabetes mellitus and those with such an immunocompromised status are also prone to the development of Fourier’s gangrene. PUBS is not always benign; in particular, we should pay more attention to patients who are immunocompromised with PUBS and closely monitor their genital or perineum region daily to ensure that no complications occur. Broad-spectrum anti- biotics are essential to control the multiplication and systemic spread of bacteria; prompt and aggressive debride- ment of necrotic tissues should be performed if Fourier’s gangrene occurs in such patients.

Fig. 1 Two patients had PUBS progressed to Fourier’s gangrene in Taiwan.

Ying-Ming Tasi* Ming-Shyan Huang MD, PhD Department of Internal Medicine Kaohsiung Medical university hospital Kaohsiung Medical University Kaohsiung 807, Taiwan

E-mail address: [email protected]

Chih-Jen Yang* Shih-Meng Yeh

Department of Internal Medicine Kaohsiung Medical University Hospital Kaohsiung Medical University Kaohsiung 807, Taiwan

Wen-Hsiung Hospital Kaohsiung 807, Taiwan

* Ying-Ming Tasi MD and Chih-Jen Yang MD contributed equally to the article and were the co-first authors in the final manuscript.

Chia-Chu Liu

Department of Urology Kaohsiung Medical University Hospital Kaohsiung Medical University Kaohsiung 807, Taiwan

doi:10.1016/j.ajem.2009.01.030

References

  1. Su YJ, Lai YC, Chang WH. Purple urine bag syndrome in a dead-on- arrival patient: case report and articles reviews. Am J Emerg Med 2007; 25(7):861-6.
  2. Coquard A, Martin E, Jego A, et al. Purple urine bags: a geriatric presentation of lower urinary tract infection. J Am Geriatr Soc 1999;47 (12):1481-2.
  3. Eke N. Fournier’s gangrene: a review of 1726 cases. Br J Surg 2000;87 (6):718-28.
  4. Edmondson RA, Banerjee AK, Rennie JA. Fournier’s gangrene: an aetiological hypothesis. Br J Urol 1992;69(5):543-4.
  5. Mantani N, Ochiai H, Imanishi N, et al. A case-control study of purple urine bag syndrome in geriatric wards. J Infect Chemother 2003;9(1): 53-7.

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