Journal of Family Medicine and Primary Care

: 2018  |  Volume : 7  |  Issue : 2  |  Page : 484--485

Purple urine bag as indicator of multidrug-resistant vulvar abscess: Lessons for primary caregivers

Ganesh Singh Dharmshaktu1, Tanuja Pangtey2,  
1 Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand, India
2 Department of Pathology, Government Medical College, Haldwani, Uttarakhand, India

Correspondence Address:
Ganesh Singh Dharmshaktu
C/O Dr. Y. P. S. Pangtey, Ganga Vihar, Malli Bamori, Haldwani - 263 139, Uttarakhand

How to cite this article:
Dharmshaktu GS, Pangtey T. Purple urine bag as indicator of multidrug-resistant vulvar abscess: Lessons for primary caregivers.J Family Med Prim Care 2018;7:484-485

How to cite this URL:
Dharmshaktu GS, Pangtey T. Purple urine bag as indicator of multidrug-resistant vulvar abscess: Lessons for primary caregivers. J Family Med Prim Care [serial online] 2018 [cited 2021 Apr 16 ];7:484-485
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Full Text

Dear Editor,

Purple discoloration of urine, urinary bag, or tubing has been an uncommon entity reported in the setting of prolonged indwelling catheterization. The condition is incidental finding in most circumstances with no significant problem apart from distress to patient and family members. Most of the cases are nursing home inhabitants, females, elderly, or those constipated with limited mobility and urinary tract infection.[1],[2] The alkaline nature of urine has been found in most cases; however, acidic urine may be exceptionally associated.[3] Mostly considered a benign condition, the occurrence of it still warrants a careful observation for subsequent morbidity.[1],[4] We hereby describe a case with initiation of purple discoloration of the urinary catheter that was later complicated into multidrug-resistant vulvar abscess resulting in prolonged stay and cost of treatment along with higher antibiotic consumption.

A 42-year-old female was admitted for fixations of her lower extremity fractures and was catheterized given nonambulatory status as she waited for surgery at primary care center. Purple discoloration of the urine bag and tubing was noted in the 9th day along with dark and concentrated appearing urine owing to reduced fluid intake by the patient [Figure 1]. The catheter was changed, and the tip along with urine sample was sent for culture and sensitivity. There, however, were no clinical features of regional pain, fever, or other “red flags” present. Two days later, she complained of mild fever and painful micturition and subsequent blood counts were indicating increased total leukocyte and neutrophil counts. Vulvar abscess was diagnosed clinically following due surgical and gynecological references. Left labia majora was swollen with purulent collection that was drained for culture and further evaluation by surgery team. Regular dressing was advised along with repeat swab sampling of affected area along with urinary routine and microscopy evaluation. Broad spectrum empiric antibiotics including coverage for Gram-negative infection were administered during the course of treatment. The urinary examination was unremarkable except alkaline urine while the swab culture showed MRSA infection with Escherichia coli and Proteus vulgaris coinfection. The infection was resistant to most broad-spectrum antibiotics including linezolid and sensitive only to imipenem and chloramphenicol. The treatment with imipenem intravenous for 6 days resulted in marked reduction of infection, and she was discharged on oral therapy for three more weeks. The follow-up saw no remote complication or recurrence of the condition.{Figure 1}

The pigments indigo and indirubin have been causative factor for purple or bluish discoloration of urinary bags through altered tryptophan metabolism.[5],[6] The gut bacteria process tryptophan into indoles which are later converted into indoxyl sulfate in liver. Indoxyl in urine is the precursor of aforementioned pigments responsible for the color purple as end result of combination of indigo (blue color) and indirubin (red color). Reports of grave complications as aftermath of this entity have been reported like infective gangrene of scrotal area.[7]Proteus mirabilis, Klebsiella pneumonii, Providencia sp., E. coli, and Enterobacter sp. have been common associated organisms.[2],[6],[8] Avoidance or limiting the use of indwelling catheters or proper care if used is mainstay of the treatment. Training of intermittent catheterization to the patient and attendants is another important step. The immunocompromised patients require more cautious assessment for complications. Associated urinary infection may require culture-specific antibiotics along with symptomatic care. Our case highlights the importance of knowledge of this uncommon condition associated with a common ward procedure with special reference to primary care settings where adherence to proper catheterization instructions and knowledge of complications and follow-up shall go long way avoid and counter sinister complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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1Yaqub S, Mohkum S, Mukhtar KN. Purple urine bag syndrome: A case report and review of literature. Indian J Nephrol 2013;23:140-2.
2Su FH, Chung SY, Chen MH, Sheng ML, Chen CH, Chen YJ, et al. Case analysis of purple urine-bag syndrome at a long-term care service in a community hospital. Chang Gung Med J 2005;28:636-42.
3Chung SD, Liao CH, Sun HD. Purple urine bag syndrome with acidic urine. Int J Infect Dis 2008;12:526-7.
4Hadano Y, Shimizu T, Takada S, Inoue T, Sorano S. An update on purple urine bag syndrome. Int J Gen Med 2012;5:707-10.
5Payne B, Grant A. Purple urine bags. Lancet 1978;1:502.
6Dealler SF, Hawkey PM, Millar MR. Enzymatic degradation of urinary indoxyl sulfate by Providencia stuartii and Klebsiella pneumoniae causes the purple urine bag syndrome. J Clin Microbiol 1988;26:2152-6.
7Tasi YM, Huang MS, Yang CJ, Yeh SM, Liu CC. Purple urine bag syndrome, not always a benign process. Am J Emerg Med 2009;27:895-7.
8Lin CH, Huang HT, Chien CC, Tzeng DS, Lung FW. Purple urine bag syndrome in nursing homes: Ten elderly case reports and a literature review. Clin Interv Aging 2008;3:729-34.