A Tale of Two Urines J .A. Schneider, DO Medical Direct or, - - PowerPoint PPT Presentation

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

• bt ain t he f ollowing

hist ory...

• 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

Case # 1 - Polly Dipsia (cont inued)

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.

• 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

• f t he pink urine over several

weeks.

To make a long st ory short …

(cont inued)

Condit ions Simulat ing Hemat uria

• Dark Yellow-Orange
• Dehydrat ion
• Bilirubin pigment
• Urobilin pigment
• Carot ene pigment
• Pyridium
• Red Urine
• Porphyria
• Foods
• Beets (anthocyanin)
• Blackberries
• Food/ vegetable dyes
• Red Urine
• Drugs
• Phenothyazine
• Phenytoin
• Phenophthalein
• Red Diapers
• Urates
• Red Diaper syndrome
• Swallowed maternal

blood

• Uterine bleeding

Expanded List of Foods/ Drugs Associat ed wit h Pink-Red Urine Color

• Aminopyrine
• Ant hocyanin
• Azo dyes
• Beet s
• Blackberries
• Chloroquine
• Def eroxamine mesylat e
• I buprof en
• Met hyldopa
• Nit of urat oin
• Phenazopyridine
• Phenopht alein
• Pyridium
• Red f ood color
• Rif ampin
• Rhodamine B
• Sulf asalazine

4 Urat es

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
• f 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

• n 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-
• pt 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…

• ne

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