Abstract
Purple urine bag syndrome (PUBS) is seen in the prolonged indwelling bladder catheters, and the mechanism of its onset was investigated using low vacuum scanning electron microscopy (LVSEM), which enables us to study the 3D structure of urinary sediments and urine bag walls. The urinary sediment and urine bags of 2 cases of PUBS were observed by LVSEM. The urine was brown turbid urine with a pH of 8.5, and magnesium phosphate stones and granules were observed in the urinary sediment together with Gram-positive and Gram-negative bacilli. Bacteria that moved by Brownian motion were observed with a dark-field microscope. LVSEM showed granular crystals around the bacilli, cocci, or mycelium that adhered to the walls of the bag. Granular crystals were dissolved in chloroform and presumed to be a mixture of the bacterial metabolites indigo blue and indirubin red. LVSEM also detected unusual tubular and honeycomb-like graphene in the urinary sediments, which were derived from the inner layer of the silicon elastomer-coated rubber catheter. LVSEM revealed purple crystals produced by bacteria or fungi attached to the urine bag that caused PUBS.
Highlights
Purple urine bag syndrome (PUBS) is rarely observed in the patients with long-term balloon catheter placement [1, 2]
We tried to elucidate the mechanism of PUBS using low vacuum scanning electron microscopy (LVSEM)
Approximately 1 month after wearing the bladder balloon catheter, urinary tract infections were confirmed by an increase in urinary leukocytes, multiple bacteria, or fungi, but no antibiotics were given
Summary
Purple urine bag syndrome (PUBS) is rarely observed in the patients with long-term balloon catheter placement [1, 2]. Some bacteria, such as Klebsiella, are thought to breakdown indoxyl sulfate to produce blue indigo and red indirubin pigments [3]. It is not completely understood why it is only found in some patients and why the urine itself does not turn purple [4]. The crystals produced from indoxyl sulfate by cultured bacteria were not perfectly the same but similar to purple and blue crystals on the lucid polypropylene surface of the urine bag (Fig. 5c)
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