A Tale of Two Urines J .A. Schneider, DO Medical Direct or, Adolescent Medicine Mobile Healt h Out reach St . Vincent Hospit al - J acksonville, FL CAPT, MC, USN (Ret ) Asst . Prof essor, Division of Adolescent Medicine, Universit y of Florida (Ret )
Case # 1 - Polly Dipsia • 8-year-old Polly is brought in acut ely because she t old her mot her t hat her urine was red. • A t ot ally normal physical examinat ion is perf ormed as you obt ain t he f ollowing hist ory...
Case # 1 - Polly Dipsia (cont inued) • Hist ory: • “Perfect” health for Polly’s entire life • No urinary t ract inf ect ions disease / renal disease in eit her Polly nor in t he f amily… and has not been given pyridium • No t rauma • No bleeding nor vascular disorders • No menarche yet • No recent impet igo nor inf ect ions of any kind!
Case # 1 - Polly Dipsia (cont inued) • Hist ory: • No new f oods or unusual f oods including: • Beet s • Colored f ood drinks of any kind • Blackberries • Not been given any medicat ions of any kind in t he last year or so
On a closer view, t here is lit t le doubt that Polly’s urine is a pinkish-red color
Hey, wait a minut e… t he urine dip st ick indicat es t hat t here is no blood! Could it be that this isn’t hemat uria at all? Hmm… .
You t ake a walk down t o t he lab... • “Look at t his,” says t he lab t echnician when you ask what she sees on t he microscopic examinat ion
There are urat e cryst als in every f ield
To make a long st ory short ... • A very caref ul hist ory (see f ollowing chart s) lef t us wit h t he likely diagnosis of urat e induced pink colorat ion of t he urine. • Her diet was rich in purines… sardines, roast ed nut s, f ried f oods. • A pediat ric nephrology consult was obt ained because of concerns about possible uric acid calculi. Appropriat e st udies indicat ed no st ones. Biannual examinat ion over several years indicat ed normal renal and urinary t ract f unct ion.
To make a long st ory short … (cont inued) • Met abolic condit ions involving disorders of purine met abolism (including xant hinuria) were considered and st udies were perf ormed t hat ruled-out a met abolic et iology. • A change of diet and encouraging increased hydrat ion led t o resolut ion of t he pink urine over several weeks.
Condit ions Simulat ing Hemat uria • Dark Yellow-Orange • Red Urine • Dehydrat ion • Drugs • Bilirubin pigment • Phenothyazine • Urobilin pigment • Phenytoin • Carot ene pigment • Phenophthalein • Pyridium • Red Diapers � • Red Urine Urates • Red Diaper syndrome • Porphyria • Swallowed maternal • Foods blood • Beets (anthocyanin) • Uterine bleeding • Blackberries • Food/ vegetable dyes
Expanded List of Foods/ Drugs Associat ed wit h Pink-Red Urine Color • Aminopyrine • Nit of urat oin • Ant hocyanin • Phenazopyridine • Azo dyes • Phenopht alein • Beet s • Pyridium • Blackberries • Red f ood color • Chloroquine • Rif ampin • Def eroxamine mesylat e • Rhodamine B • I buprof en • Sulf asalazine 4 Urat es • Met hyldopa
Ref erence • Pediat rics Vol. 107 No. 1 J anuary 2001, pp. 86-90 Hyperuricosuria in Children: Clinical Present at ion and Nat ural Hist ory. Angela La Manna, Cesare Polit o, Ant onio Mart e, Ant onio I ovene, and RosarioDi Toro Conclusions . The lack of hemat uria is not predict ive of absence of urolit hiasis. Theref ore, it may be misleading t o j udge on t he ef f icacy of a given t herapy only based on disappearance of hemat uria. HU and hypercalciuria have t o be suspect ed in children wit h dysuria and t hose wit h recurrent abdominal/ f lank pain and f amilial hist ory of urolit hiasis, alt hough t hey have no hemat uria.
Pink Urine (Uric Acid Cryst als) f rom I ncreased Purines in Diet • Children can have t ransient hyperuricemia wit h increased renal clearance. St aplet on, B. Uric Acid Secret ion in Normal Children. J . of Ped. Vol. 92, 911 1982.
Red Diaper Syndrome This is t he diaper of a one-mont h-old who was an NI CU graduat e. She was colonized wit h Serat ia marcesans
Ben Dover Ben is a 16-year-old male wit h t he chief complaint , “My urine has been green t he past t wo days.” • Has been ent irely well and ot her t han green urine, asympt omat ic • Ben has no hist ory of gall bladder disease
A “normal” urine specimen on the lef t; Ben’s urine on the right… No question about it… it certainly is green!
Ben Dover • The f amily hist ory is noncont ribut ory • Physical exam: • ABSOLUTELY NORMAL! Except f or...
Yikes!!! His tongue is green!
How about t hat ! Green urine and a green t ongue How do you f igure t hat ? Are you ready f or t he answer?
Answer: Chloret s I nduced Green Urine • Has been eat ing at least a six-pack of Chloret s daily f or t he last t wo days • Ben has a new girlf riend and he want ed his breat h t o smell nice and f resh!
Dif f erent ial Diagnosis: Green Urine • I odochlorhydroxyquine induced myelo- opt ic neuropat hy • Pseudomonas bact eremia • Bile pigment • Amit ript yline HCL • Met hocarbimol Also...
Dif f erent ial Diagnosis: Green Urine (cont inued) • Dyes: indigo, carmine, phenol, met hylene blue And last but not least ... NChloret s
Ref erences • Let t er t o t he Edit or in J AMA : Vol.247 # 1 Pg. 29 J an 1, 1982. And...
A wonderf ul ref erence… one t hat everyone should have in t heir f iles... • Raymond J R, Yarger WE: Abnormal Urine Color: Dif f erent ial Diagnosis. Sout hern Medical J ournal. 1988, 81:137
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