Fever, shivering ... and blue urine

(Section Editor: T.J. Rabelink)

Friedrich C. Prischl, Ingrid Hofinger and Reinhard Kramar

3rd Department of Medicine, Krankenhaus der Barmherzigen Schwestern, vom Hl.Kreuz, Wels, Austria

A 51-year-old male (GC, speaking Italian only) was admitted to our hospital in Austria because of shivering, fever and dysuria for approximately 2 days. Clinical evaluation revealed no abnormal findings at physical examination. Blood pressure was 150/80 mmHg, pulse was 80 per minute and body temperature was 39.6°C. The patient denied any irregularities regarding stool.

Routine laboratory tests showed an elevated white blood cell count of 17.9 G/l and a C-reactive protein of 153 mg/l. The patient was asked to provide urine for examination and a few minutes later he brought a beaker with blue urine (Figure 1Go). Dipstick urine analysis revealed leukocytes +++, nitrit +, protein +, and erythrocytes +. Microscopic examination showed numerous leucocytes (Figure 2Go). Renal sonography was normal.



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Fig. 1. Urine sample from patient GC after centrifugation at 2000 rev/min for 10 min. Pay attention to the arrow!

 


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Fig. 2. Urine sediment of patient GC (Papanicolaou stain, x400), with few uroepithelial cells and masses of (neutrophil and eosinophil) granulocytes.

 
Question

What is the diagnosis in this Italian tourist? Why is the urine blue? (Answer on next page).

Answers to quiz on the preceding page

Changes in colour of the urine are always impressive at least for the patients, and may be an important diagnostic sign. Most frequently, an altered colour is caused by gross haematuria with pink to red or black appearance [1]. Other changes include milky-white, pink-red-purple, red-brown-black, and blue-green [2]. Among others a blue-green urine may result from inherited metabolic disorders like the blue diaper syndrome [3], drug ingestion (e.g. amitriptyline, indometacin), or results from administration of indigo carmine or methylene blue. This latter substance is used for diagnostic purposes [4], in therapy of methemoglobinaemia [5], but also as a disinfectant due to its mild antiseptic action [6]. Methylene blue is excreted slowly, partly unchanged. Martindale lists 28 preparations containing methylene blue [6], of whom 14 are used topically for diverse eye disorders and six are given orally for urinary tract infections in a few countries of the world only (France, Germany, Italy, Spain, USA).

Our patient had no history of inherited disease. When confronted with the strange finding of a blue urine, the patient apologized not to have mentioned the medication he was taking. Because of dysuria he was prescribed Mictasol bleu® (Italian and French trademark; containing methylene blue 20 mg, malva purpurea 250 mg) thrice daily by his Italian doctor 2 weeks ago. Microscopic analysis of the urine was characteristic (Figure 2Go), and Escherichia coli could be grown in urine culture. A broad spectrum antibiotic was given and the patient left the clinic the next day. The diagnosis was urinary tract infection, and blue coloured urine due to ingestion of methylene blue.

There is a saying that `travelling educates', but travellers may do so too with doctors.

Notes

* The readers of our journal are encouraged to submit material for this section. Submissions should be directed to the Section Editor, Dr T. Rabelink, University Hospital, Department of Nephrology, PO Box 85500, Fo 3.226, 3508 GA Utrecht, The Netherlands.

References

  1. Fogazzi GB, Fenili D. Urinanalysis and microscopy. In: Davison AM, Cameron JS, Grünfeld JP, Kerr DNS, Ritz E, Winearls CG, eds. Oxford Textbook of Clinical Nephrology, 2nd Edition. Oxford University Press, Oxford, New York, Tokyo: 1998: 21–38
  2. Miller RB. Urine analysis. In: Massry SG, Glassock RJ, eds. Textbook of Nephrology, 2nd Edition. Williams & Wilkins, Baltimore, Hong Kong, London, Sydney: 1989: 1587–1609
  3. Drummond KN, Michael AF, Ulstrom RA, Good RA. The blue diaper syndrome: familial hypercalcemia with nephrocalcinosis and indicanuria. A new familial disease, with definition of the metabolic abnormality. Am J Med 1964; 37: 928–948[ISI][Medline]
  4. Kraus RP, Grof P, Arana GW, Workman RJ, Harvey KJ, Hux M. Methylene blue: a reliable and practical marker for validating compliance on the DST. J Clin Psychiatry 1987; 48: 224–229[ISI][Medline]
  5. Lukens JN. Methemoglobinemia and other disorders accompanied by cyanosis. In: Lee GR, Bithell TC, Foerster J, Athens JW, Lukens JN, eds. Wintrobe's Clinical Hematology, 9th Edition. Lea & Febiger, Philadelphia, London: 1993: 1262–1271
  6. Reynolds JEF. ed. Martindale The Extra Pharmacopoeia, 30th Edition. London: The Pharmaceutical Press 1993: 684–685 and 2195




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