Purple Discoloration Research Articles

Bilateral nevus of Ota with palatal involvement, unilateral nevus of Ito, and a port-wine stain: A rare presentation

Nevus of Ota and nevus of Ito are dermal melanocytoses, usually presenting themselves as a bluish-black or grayish-brown, patchy, diffuse, or mottled pigmentation of the skin. They share a common pathogenic mechanism involving failure in the migration of melanocytes from the dermis to the epidermis and differ only in the sites of their distribution on the body. Nevus of Ota, often unilateral, may rarely be bilateral or may involve the oral mucosa. Even rarer is its association with nevus of Ito and other extracutaneous features. A port-wine stain is a form of congenital capillary malformation presenting itself as a pinkish-red to purple discoloration, most commonly of the unilateral head and neck area. Only 25% of cases occur on other sites of the body. The presence of a port-wine stain in conjunction with two different dermal nevi has been an exceedingly rarely reported entity. Herein, we report a 26-year-old male who presented himself with a bilateral nevus of Ota with oral mucosal involvement and associated with nevus of Ito and a port-wine stain.

First Report of Powdery Mildew Caused by Podosphaera xanthii on Salvia farinacea in Korea.

Salvia farinacea Benth. (Lamiaceae) is an herbaceous perennial plant, native to Mexico and southern parts of the United States. This plant is cultivated worldwide for its ornamental value. In November 2019, hundreds of S. farinacea 'Blue Bedder" grown in a flower garden in Jeju (33°30'57"N 126°32'50"E), Korea have been found to be infected with a powdery mildew fungus. The disease severity was estimated to be 100%. Likewise in October 2020, a similar situation with this plant was also observed in a flower garden in Seoul (37°35'19"N 127°01'07"E), Korea. Leaves, stems and inflorescence of plants were covered by white, thin mycelial felt, bearing an abundance of conidiophores and conidia. Eventually, infected plants lose their ornamental value. Two voucher specimens have been deposited in the Korea University Herbarium (KUS-F31478 and F32164). Fresh materials were examined. Hyphal appressoria were nipple-shaped, but rarely found. Conidiophores (n = 30) were straight, 95 to 160 × 10 to 12 μm and produced 2 to 7 immature conidia in chains with a crenate outline. Foot-cells were cylindric and 36 to 60 μm long. Conidia (n = 30) were ellipsoid-ovoid to barrel-shaped, 32 to 38 × 18 to 24 μm, and contained conspicuous fibrosin bodies. Dark brown chasmothecia were found partly embedded in the mycelial felt on leaves, mostly hypophyllous, spherical, and 82 to 100 µm diameter, with a single ascus in each. Appendages were few, mycelioid, 1- to 4-septate, brown near the base when mature, but paler above. Asci were broadly ellipsoid to subglobose, 56 to 68 × 50 to 62 μm, sessile and 8-spored. Ascospores were colorless, oval to subglobose, and 14 to 18 × 12 to 15 µm. These characteristics were consistent with those of Podosphaera xanthii (Castagne) U. Braun & Shishkoff (Braun and Cook 2012). For further confirmation, genomic DNA was extracted from chasmothecia from KUS-F31478 and F32164. PCR amplification was performed using the primer pair ITS1F/PM6 for internal transcribed spacer (ITS) and PM3/TW14 for the large subunit (LSU) of the rDNA (Takamatsu and Kano 2001). Obtained sequences were deposited to the GenBank under the accession numbers MZ359847 and MZ359859 for ITS, MZ359858 and MZ359861 for LSU. For ITS regions 99.80-100% similarity was found with sequences MT131256 (Salvia farinacea), MT131254 (Mazus pumilus) and MT131252 (Erigeron bellioides) of P. xanthii, whereas it was 99.90% with sequences of this fungus on Echinacea purpurea (MT826247 and MT826245) for 28S rDNA gene. Pathogenicity tests were carried out by touching an infected leaf onto healthy leaves of disease-free 30 days old potted 'Blue Bedder' using replication of five plants, with five non-inoculated plants used as controls. The typical signs of powdery mildew started to develop on the inoculated leaves in 7 to 10 days, and microscopic examination revealed the morphological identity with the fungus observed from the field. All non-inoculated control plants remained symptomless. Hitherto Golovinomyces powdery mildews on Salvia spp. were reported globally (Farr and Rossman 2021). However, Podosphaera elsholtziae on Salvia sp. and P. xanthii on S. farinacea were reported from China and Taiwan (Zheng and Yu 1987, Yeh et al. 2021). To our knowledge, this is the first report of P. xanthii on S. farinacea in Korea. The occurrence of Podosphaera powdery mildew on S. farinacea could pose a serious threat to the beauty of this plant, causing premature senescence of young leaves and gray to purplish discoloration of the leaves.

POS-010 PURPLE URINE BAG SYNDROME IN HEMODIALYSIS PATIENTS: REPORT OF TWO CASES

Purple urine bag syndrome (PUBS) is a rare but common case in female patients with risk factors for constipation, alkaline urine, use of urinary catheter, urinary tract infection (UTI) and end stage kidney disease. This condition is idiopathic but is thought to be due to changes in indoxyl sulfate in which bacteria containing the enzyme sulphatase/phosphatase convert indoxyl to indirubin (red) and indigo (blue) which mix to form a purple discoloration in the urine. We report two cases of PUBS in hemodialysis patients.

EP.TU.192Phlegmasia cerulea dolens associated with lung abscess

Abstract Introduction Phelgmasia cerulea dolens (PCD) is a rare limb and life-threatening condition caused by extensive of deep veins thrombosis of the extremities and it is classically associated with extensive oedema, severe pain and skin mottling which may lead to compartment syndrome, venous gangrene, and death. Case presentation We present a rare case of phlegmasia cerulea dolens associated with lung abscess. A 40-year-old male with background history of right femoral vein thrombosis, cardiomyopathy with ejection fraction of only 10% presented with three days history of progressive swelling, pain and purple discoloration of right leg to the accident and emergency department at a district general hospital. He was treated with therapeutic low molecular weight heparin. He was found to have lung abscess 2 weeks after admission for which he was treated with broad spectrum intra venous antibiotics. In view of his poor ejection fraction, he was treated without any surgical intervention for PCD. Patient succumbed after 3 months of presentation. PCD is a rare vascular emergency condition if not recognized early and treated aggressively may lead to high morbidity and mortality. Conclusion Phlegmasia cerulea dolens is an acute limb and life-threatening condition. Early diagnosis and aggressive intervention with thrombolysis and thrombectomy is necessary to prevent morbidity and mortality.

S2088 Acute Esophageal Necrosis: Patient with a History of Liver Cancer on Capecitabine

Introduction: Acute esophageal necrosis (AEN) is a life-threatening medical condition. It is characterized endoscopically by extensive black mucosal discoloration of the esophagus (1). To date, the etiology of the AEN is unknown, but it was suggested that vasculopathy or hemodynamic instability is the main contributor. Although esophageal necrosis seems a rare condition, gastric mucosal necrosis is even more rarely seen given the rich network of collaterals supplying this part of the gastrointestinal tract (2,3). Case Description/Methods: A 75-year-old female with intrahepatic cholangiocarcinoma on Capecitabine presented to the emergency room with dysphagia, odynophagia, and palpitation. Vital signs were remarkable for a heart rate (HR) of 151 bpm irregularly irregular, respiratory rate 23/min, blood pressure (BP)145/81mmHg. She had white blood count (WBC) 10,800/L, hemoglobin (Hgb) 16.7 g/dL, hematocrit 51%, platelet count 182,000/uL, albumin 2.9 g/d, prothrombin time 21.9 sec, INR 1.99, partial thromboplastin time 67.7 sec, and normal liver function test. Patient had sudden onset of maroon output from orogastric tube, and bright red blood per rectum with acute drop in BP to 90/38 mmHg, Hgb level 9.2 g/dL, lactic acid 13.3 mmol/L, WBC 27,3500/uL. Alanine aminotransferase and total bilirubin were 3100 unit/L, and 3.4 mg/dL, respectively. Patient was started on amiodarone, vasopressors, broad spectrum antibiotics, protonix and octreotide drips for hypovolemic shock due to acute gastrointestinal blood loss complicated with sepsis. Patient was intubation on mechanical ventilation for airway protection. Urgent esophagogastroduodenoscopy showed black necrotic esophagus (Fig.1a & b). The gastric mucosa was oozing and congested with a purplish discoloration (Fig. 1c). No endoscopic treatment was applied, and patient was continued on protonix drip. Discussion: We here discuss previously unseen association of esophageal and gastric necrosis in a patient on Capecitabine. To date, no clinical cases discussed Capecitabine-associated AEN. Although the mechanism of Capecitabine-induced ischemia is not fully understood, mesenteric vasoconstriction and thrombosis seem to cause ischemia (4,5). Also, the mucosal injury from chemotherapy causing massive release of proinflammatory markers contributing to tissue necrosis (6). The outcome of our patient illustrates that it is essential to keep high level of suspicion in AEN predisposing factors, and that the association of Capecitabine and AEN also needs to be looked at further.Figure 1.: Endoscopy image showing esophageal stricture.

First Report of Curly Top of Coriandrum sativum Caused by Beet curly top virus in the Columbia Basin of Washington State.

Two fields of coriander (Coriandrum sativum L.) seed crops of proprietary cultivars were observed in the Columbia Basin of Washington in July 2020 with 40 and 90% incidence of plants showing stunting and leaf and stem discoloration, sometimes with mild leaf curl. Foliar discoloration ranged from yellow to red and purple. Sweep-netting along the field edges collected one beet leafhopper (Circulifer tenellus Baker; BLH), the known vector of Beet curly top virus (BCTV), Beet leafhopper transmitted virescence agent (BLTVA) phytoplasma, and Spiroplasma citri, all of which affect Solanaceae and Apiaceae crops in Washington (Crosslin et al. 2006; Johnson and Martin 1998; Lee et al. 2006). Nucleic acids extracted from leaves and petioles of 12 coriander plants (8 from Field 1 and 4 from Field 2) using the Dellaporta method, and from the BLH using the CTAB method (Crosslin et al. 2006) were subjected to PCR assays to detect the BLH-transmitted pathogens which cause yellow and purple discoloration in potato (Solanum tuberosum L.) and carrot (Daucus carota subsp. sativus (Hoffm.) Arc.) in this region. BLTVA was targeted using a species-specific nested PCR assay with primers P1 and P7, followed by primers FU5 and BLTVA-int (Crosslin et al. 2006); S. citri was targeted using primers P89-F and P89-R (Yokomi et al. 2008); and BCTV was targeted using curtovirus primers BCTV2-F and BCTV2-R (Strausbaugh et al. 2008). BLTVA and S. citri were not detected in the plants, but curtovirus was detected in 10 of the 12 plants. All three pathogens were detected from the single BLH. A 519 bp region of the curtovirus capsid protein gene was amplified from seven plants (5 from Field 1 and 2 from Field 2) and the BLH, and cloned into TOP10 Escherichia coli cells using the pCR-2.1 TOPO vector (Invitrogen, Carlsbad, CA). Three clones were sequenced from each sample. For each of six plant samples and the BLH, the three clones were identical and consensus sequences were generated (GenBank Accessions MW234419 to MW234425). For the seventh plant, two clones were identical in sequence (MW234426) and the third contained 12 single nucleotide polymorphisms (MW234427). All sequences were subjected to an NCBI BLASTn analysis and showed 98.3 to 99.8% identity with BCTV sequences. Additional PCR assays with primers BMCTV-C1 2213F and BMCTV-C1 2609R (Strausbaugh et al. 2008), targeting the C1 gene of the Worland strain of BCTV, detected BCTV-Worland-like strains in all plants and the BLH, confirming that BCTV was present and indicating that the strain-specific primer pair was more sensitive than the universal curtovirus primers. Yield losses in the two fields were approximately 60%, with reduced seed size but not seed quality. BCTV infections in coriander crops have been observed in the Columbia Basin in 2002, 2005, 2008, and 2013, with yield losses ranging from 10 to 100% per field, though official reports were not made following the diagnoses (Crosslin, du Toit, and Frost, unpublished data). BCTV has caused millions of dollars of losses in the U.S. in crops such as sugar beet (Beta vulgaris subsp. vulgaris L.), tomato (S. lycopersicum L.), and pepper (S. annuum L.) (Johnson and Martin 1998). This is the first publication of BCTV affecting seed production of the specialty crop C. sativum. The observation of 90% incidence of symptoms in one field suggests that resistant cultivars and/or insect pest management practices are needed to prevent significant impacts of BCTV on coriander seed production in this semi-arid region.

Klebsiella Pneumoniae Necrotizing Fascitis of The Lower Extremity in A 7-Month-Old Male: A Case Report and Literature Review

Introduction: Klebsiella pneumoniae necrotizing fasciitis is an uncommon soft tissue infection characterized by rapidly progressing necrosis involving the skin, subcutaneous tissue, and fascia. This condition may result in gross morbidity and mortality if not treated in its early stages. In fact, the mortality rate of this condition is high, ranging from 25 to 35%. We present a case of 7-month-old male with K. pneumoniae necrotizing fasciitis of the lower extremity. Materials and Methods: A 7-month-old male presented with large areas over both left and right inferior side of the lower limbs to the emergency department of Dr. Soetomo Academic Medical Center Hospital, Surabaya, Indonesia. Physical examination revealed elevated heart rate of 136 times per minute and increased body temperature of 38oC. The large areas on both lower limbs were darkened, sloughed off, and very tender to palpation. A small area over the right hand was erythematous and sloughed off. Laboratory evaluation demonstrated decreased hemoglobin of 6.2 g/dL and elevated leukocyte of 28,850 g/dL. Blood cultures demonstrated that K. pneumoniae was present. Discussion: NF is usually hard to diagnose during the initial period. The findings of NF can overlap with other soft tissue infections including cellulitis, abscess or even compartment syndrome. However, pain out of proportion to the degree of skin involvement and signs of systemic shock should alert the clinical to the possibility of NF. The clinical manifestations of NF start around a week after the initiating event, with induration and edema, followed by 24 to 48 hours later by erythema or purple discoloration and increasing local fever In the next 48 to 72 hours, the skin turns smooth, bright, and serous, or hemorrhagic blisters develop. If unproperly treated, necrosis develops, and by the fifth or sixth day, the lesion turns black with a necrotic crust. Conclusions: K. pneumoniae necrotizing fasciitis is a rare but lifethreatening disease. A high index of suspicion is required for early diagnosis and treatment of this condition

38. Painless Labia Hair Tourniquet Presenting as a Recurrent Vulvar Mass

<h3>Background</h3> Hair tourniquets are a rare phenomenon effecting potentially any appendage. Male genitalia and digits are the most common locations with female genitalia classified as an "other" site, occurring in less than 6% of reported reviews. The most recent review of female genital hair tourniquets identified 34 patients from 32 reports or series. Pain was reported as a presenting symptom in 30 cases, while the remaining four cases did not comment on pain. We present a case of an asymptomatic labial hair tourniquet presenting as a vulvar mass. <h3>Case</h3> The patient is a 5-year 7-month female born at 24 weeks gestation with intraventricular hemorrhage and subsequent cerebral palsy (CP) and lower extremity contractures. The patient was referred by her PCP for possible biopsy due to a recurrent vulvar mass that waxed and waned in size and purple discoloration over two months. The patient was scheduled for exam under anesthesia and noted to have an edematous left labia minora (Fig 1) with tightly wound hair and cotton threads at the base leaving an erosion with an indentation flap in its mid portion (Fig 2). The fibers were released, a ‘V" excision was created removing the mid portion (Fig3), and the inferior and superior areas of the labia were approximated restoring symmetry. (Figs 4) The patient's postoperative course was uncomplicated and at 20 months post procedure her parents report normal anatomy without new incidents of labia edema. <h3>Comments</h3> This case report demonstrates a presentation of chronic painless swelling due to a labia hair tourniquet, which has not yet been described in the literature. Absence of pain may have led to a delay in referral for definitive diagnosis and treatment. It is possible that sensory disruptions in the lower extremities from CP contributed to the lack pain perception by the patient.

A Case of Thrombotic Vasculopathy in the Setting of High-Dose Hydroxyurea Use

This case study describes the presentation of a 76-year-old male with a past medical history that included atrial fibrillation, essential hypertension, coronary artery disease status post cardiac stent placement, heart failure, hyperlipidemia, thyroid cancer (with thyroid resection resulting in hypothyroidism), prostate cancer status post brachytherapy (in remission), and a history of JAK2-positive myeloproliferative disease. He presented with painful areas of hyperpigmentation appearing as purple discoloration to his neck, lower abdominal skinfold, and bilateral groin areas that progressed to painful ulcerations a few weeks after a myocardial infarction. Due to the patient’s multiple medical conditions and uncommon presentation of wounds, a multidisciplinary team was involved in his care. Differential diagnosis included antiphospholipid syndrome, symmetrical drug-related intertriginous and flexural exanthema, warfarin-induced necrosis, cutaneous thrombotic vasculopathy, myeloproliferative disorder, and high-dose hydroxyurea therapy. It was determined by the authors that the high-dose hydroxyurea therapy was the cause of the wounds. Because of the patient’s initial health status, treatment of the wounds included use of collagenase and sodium hypochlorite solution to reduce the risk of infection and attempt to promote autolytic debridement until surgical wound debridement could be done. The patient required multiple hospital stays, but ultimately his health status improved and the wounds resolved with the assistance of the combined efforts of the multidisciplinary team to diagnose and treat this complex patient and his uncommon wound presentation.

Purple Urinary Bag Syndrome (PUBS) in Benign Prostate Hyperplasia (BPH) with long-term indwelling urinary catheter use: a case report and literature review

Background: PUBS is one of the clinical manifestations of urinary tract infection. This condition often leads patients, patients’ families, and medical workers to worrisome. Metabolism of tryptophan and infection of sulfatase and phosphatase - producing bacteria is the most acceptable pathogenesis explaining PUBS. Many risk factors are underlying this condition, including long-term use of indwelling urinary catheters, constipation, dementia, chronic kidney disease, and bedridden patients. This case study aims to evaluate the recent treatment of supporting factors in treating the underlying urinary infection.Case Presentation: We presented a case report of a 67year-old man with Benign Prostate Hyperplasia (BPH) and long-term use of indwelling urinary catheter who complained of purple discoloration of urine a day prior to Transurethral Resection of the Prostate (TURP) surgery. The patient complained of no fever and pain while urinating and having no history of the same complaint and other diseases. In addition, the patient has diagnosed with BPH and Urinary Tract Infection. The administration of Cefazolin 2 grams dosage was given before the TURP procedure, and the following procedure continued.Conclusion: PUBS is a rare clinical course alarming the urinary tract infection. Appropriate treatment by Cefazolin 2 grams dosage following by TURP shows a favorable outcome in this case study.

Characterization of Fusarium species causing dry root rot disease of citrus trees in Morocco

Citrus have been grown as a commercial fruit crop in Morocco for a decade. The area dedicated to growing and producing citrus has increased from 2006 to 2018 throughout the country. The rapid decline of citrus trees has been observed in many locations. Therefore, this study aimed to identify and characterize fungal pathogens associated with dry root rot (DRR) disease of citrus from diseased trees and soil collected from different citrus-growing plantations. Isolation and morphological identification of pathogens were performed using PDA-SC medium. Thirty-four Fusarium isolates were recovered from symptomatic plants. These isolates were identified based on morphological traits and the sequence of the internal transcribed spacer (ITS) region. Four Fusarium species were identified. Fusarium solani (Martius) was most frequently identified (70.60%), followed by F. oxysporum (17.65%), F. equiseti (8.82%) and F. brachygibbosum (2.94%). The two latter species have recently been associated with DRR in Morocco. Two separate pathogenicity trials were conducted to test the effect of the pathogens on young citrus seedlings. Results indicated that, with the exception of F. equiesti, Fusarium isolates were aggressive pathogens of citrange-Troyer and sour orange seedlings 2 months postinoculation. Citrus trees displayed key symptoms of DRR such as root rot, discolored and necrotic roots, purple wood discoloration, plant yellowing and general weakness. Further, all four species were able to induce lesions when they were used to inoculate citrus branches. This is the first detailed report of Fusarium species associated with DRR in Morocco.

HIT THE HEART: A CASE OF ARTERIAL AND VENOUS THROMBOEMBOLI

SESSION TITLE: Medical Student/Resident Pulmonary Vascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Critically ill patients present with a conundrum of different signs and symptoms in need of a unifying diagnosis. This case was interesting given the presence of both arterial and venous thromboemboli in the setting of recent cardiac surgery. CASE PRESENTATION: 62-year-old male with a history of ischemic cardiomyopathy status post coronary artery bypass graft and bio-prosthetic aortic valve replacement (POD 16) presented with complaints of palpitations and lightheadedness for 2 days. His vitals were notable for tachycardia with EKG confirming atrial flutter with a heart rate in the 160s. His exam was notable for a purplish discoloration of his left great toe concerning for limb ischemia. He was admitted to the ICU where his labs showed acute kidney injury and a troponin of 93 ng/l, peaking at 116 ng/l. Due to high clinical suspicion of embolic phenomenon and risk of limb ischemia in the setting of atrial flutter and he was started on empiric anticoagulation with heparin. Arterial Doppler confirmed embolic phenomenon. Vascular surgery was consulted and they recommended medical management. During his first night, his mental status acutely worsened. Code Stroke was called. His CT head and CTA head and neck were negative for evidence for acute bleeding or clot in the cerebral vasculature. His mental status improved back to baseline quickly. On closer review of the CTA neck, a large right sided PE was visualized, and his labs showed a precipitous drop in his platelet count, due to which there was a concern for heparin-induced thrombocytopenia (HIT). His anticoagulation was changed from Heparin to Argatroban. Heparin/PF4 Ab confirmed HIT. DISCUSSION: HIT is a life-threatening complication after exposure to heparin that occurs regardless of the dose or route of administration. Type I is a mild transient drop in platelet counts that occurs within the first 2 days of heparin exposure and is typically not associated with thrombosis. Type II on the other hand is a clinically significant syndrome due to an immune-mediated process resulting in an auto-antibody directed against endogenous platelet factor 4 complex with heparin (HIT antibodies), which in turn can result in rampant thrombosis. It is associated with both arterial and venous thrombosis. Thrombosis occurs in up to 50 percent of individuals with HIT who are not treated with a non-heparin anticoagulant, with venous more common than arterial thrombi. The reported frequencies range from 20 to 50 percent for venous thrombosis and 3 to 10 percent for arterial thrombosis. This case was interesting in the fact that the patient developed both arterial and venous thromboembolic phenomenon that was managed conservatively. CONCLUSIONS: Arterial and venous thromboembolism are a common finding in HIT, although can be easily masked by other possible diagnoses. Diagnostic vigilance is essential for the prompt initiation of treatment. Reference #1: Fathi M. Heparin-induced thrombocytopenia (HIT): Identification and treatment pathways. Glob Cardiol Sci Pract. 2018;2018(2):15. Published 2018 Jun 30. doi:10.21542/gcsp.2018.15 Reference #2: Warkentin TE. Heparin-induced thrombocytopenia-associated thrombosis: from arterial to venous to venous limb gangrene. J Thromb Haemost. 2018;16(11):2128-2132. doi:10.1111/jth.14264 DISCLOSURES: No relevant relationships by Imama Ahmad, source=Web Response no disclosure on file for Thomas Carr; No relevant relationships by Sneha Lakshman, source=Web Response No relevant relationships by Usama Talib, source=Web Response

Purple Urine Bag Syndrome: Uncommon Clinical Entity Associated with Common Infection, Case Report

Purple urine bag syndrome (PUBS) is a rare medical syndrome where purple discoloration of urine occurs predominantly in chronically constipated bedridden elderly women, chronically catheterized and associated with urinary tract infections (UTIs). The etiology is related to UTIs with specific bacteria that produce sulphatase and phosphatase enzymes which lead tryptophan metabolism to produce two pigments: Indigo (blue) and indirubin (red), mixtures of which become purple in color. Several risk factors are associated with PUBS; including female gender, increased dietary tryptophan, alkaline urine, constipation, catheterization, high urinary bacterial load, renal failure and use of polyvinyl chloride plastic catheters. Herein, I present this rare benign interesting condition on a 78 years old lady with purple discoloration of her urine bag due to urinary tract infection caused by Escherichia coli that was successfully treated by culture guided antibiotic (Ciprofloxacin). The purple urine disappeared after antibiotic therapy and change of the urine catheter and bag.

Purple Urine Bag Syndrome in a Critically Ill Patient: Case Report

Purple urine bag syndrome (PUBS) is a rare manifestation characterized by purple discoloration of the urine drainage system. It may appear as a disconcerting finding for patients and healthcare workers not aware of this condition. It’s mostly seen in patients with long-term urine catheterization and a coexisting urinary tract infection (UTI); however, this is not always the case. We describe the case of a 43-year-old patient with cervical cancer and end-stage renal disease who presented to the emergency room with fever and urinary retention which required catheterization. Three hours later, purple urine was noted in the bag. She was diagnosed with bacteremia and a urinary tract infection which were treated with intravenous antibiotics, eventually presenting an unfavorable clinical evolution. Although usually considered benign, it does not always run a harmless course. It’s important to assess this finding on a patient-specific basis to uncover a possible underlying UTI, considering that some may not be able to adequately communicate symptoms, as is the case of the critically ill or patients with communication difficulties. This report contributes to raising awareness and a better comprehension of this unusual entity.

A Case Report: An Unusual Presentation of Purple Urinary Bag Syndrome

Background: The Purple Urinary Bag Syndrome (PUBS) is an uncommon and under-reported syndrome. It results from the purple discoloration of urine by tryptophan-oxidizing bacteria in a favorable alkaline milieu and usually affects patients with indwelling catheters. Other risk factors include female gender, chronic constipation, tryptophan-rich diet, and cognitive impairment. Although asymptomatic in the majority of cases, PUBS may be the sole and earliest sign of an aggressive urinary tract infection, especially in elderly patients where the presentation may be atypical and associated with resistant organisms, such as Pseudomonas aeruginosa and Vancomycin-resistant Enterococci (VRE). Proper treatment consists of catheter replacement and antibiotic therapy, which is indicated only in the setting of symptomatic infections. Case Presentation: We report an unusual presentation of PUBS in a 79-year-old male patient with no classical risk factors. The patient had a supra-pubic catheter for urinary retention secondary to urethral strictures. Every month, by the time of catheter exchange, the patient developed an asymptomatic purple discoloration of the urinary bag, which was not investigated until he presented at our facility. Urine analysis revealed acidic urine. Appropriate antibiotic therapy was initiated after the development of urinary symptoms, and the catheter was replaced. No recurrent urine discoloration occurred. Conclusion: This case represents the rare occurrence of PUBS in the setting of a suprapubic catheter in a male patient. It also highlights that even in atypical presentations, antibiotic therapy should be tailored to the clinical status of the patient and not the mere presence of bacteriuria. Raising awareness about this “esoteric” syndrome is essential for early diagnosis and proper management.

NICOLAU SYNDROME DUE TO INTRAMUSCULAR DICLOFENAC SODIUM INJECTION

Nicolau syndrome (NS) is a rare complication characterized by tissue necrosis that occurs after parenteral injection of drugs. The exact pathogenesis is uncertain, but there are several hypotheses, including direct damage to the end artery, acute vasospasm and cytotoxic effects of the drug. Severe pain in the immediate post injection period and purplish discoloration of the skin with reticulate pigmentary pattern is characteristic of this syndrome. Diagnosis is mainly clinical and there is no standard treatment for the disease. Herein, we present a rare case of NS due to Diclofenac Sodium (Voltaren®) injection in an 80-year-old female suffering from Lower Respiratory Tract Infection (LRTI) who was managed conservatively.&#x0D; Keywords: Nicolau Syndrome, Embolia cutis medicamentosa, Voltaren, Diclofenac sodium

A rare cause of ischemic colitis: A case series of idiopathic mesenteric phlebosclerotic colitis from two medical centers in Taiwan

AbstractIdiopathic mesenteric phlebosclerotic colitis (IMP) is a rare disease entity of intestinal ischemia that is predominant in Asian populations. We present the clinical features, diagnosis, treatment, and outcome of this disease via a case series. We collected data from medical records in two medical centers in Taiwan. From 2008 to 2017, 11 cases were diagnosed with IMP, and their clinical features were analyzed. Eleven cases were included in our case series. The average age of the patients was 59 (±6.77) years old, and there was a predominance of women. More than half of our patients had a history of herb consumption. Their symptoms varied from asymptomatic to lethal, such as mechanical ileus. The most common colonoscopic finding was the dark purple discoloration and decreased vascularity over the edematous mucosa. In our case series, nine patients showed no disease progression after conservative treatment alone. In contrast, two cases required surgical intervention due to mechanical ileus. The symptoms of IMP may vary extremely, and it may present as asymptomatic or lethal. The etiology of this rare disease remained unknown, and some offending materials such as herb were considered responsible for its genesis. Both the specific radiological and colonoscopic characteristics helped to confirm its diagnosis. IMP should be always considered for ischemic colitis in long‐term herb users.

Purple Urine Bag Syndrome: More Than Eyes Can See

Background/Aims: Purple urine bag syndrome (PUBS) is an uncommon clinical entity characterized by purple urine discoloration in the setting of urinary tract infections. Pa-thophysiology of PUBS has been correlated to aberrant metabolism of tryptophan. Multiple predisposing factors have been recognized, namely: female gender, advanced age, constipation, institutionalization, long-term catheter-ization, dementia and chronic kidney disease. Herein, we present a comprehensive review of all PUBS cases reported in PubMed, focusing on the predisposing factors and the microorganisms related to PUBS. Methods: We performed a search in PubMed database for articles referring to PUBS, published in English, French, Spanish and German from January 1978 until November 2017. The literature recruitment strategy was based on several keywords and Medical Subject Heading combination such as “purple urine bag syndrome” or PUBS or “urine discoloration”. The finally selected articles were categorized into case reports/series (88 articles including 112 patients) and studies (10 articles including 134 patients). Demographical data as well as predisposing factors were recorded and further analyzed. Results: According to our findings, mean age of PUBS patients was 78.9 ± 12.3 years, 70.7% were female while 90.1% were suffering from constipation, 76.1% were in a bedridden situation, 45.1% were experiencing long-term catheterization, 42.8% had been diagnosed with dementia, 14.3% had recurrent urinary tract infections and 14.1% were chronic kidney disease patients. 91.3% of patients presenting with PUBS alkaline urine were observed while the most common microbe in urine cultures was E. coli. Conclusions: PUBS is considered benign process in the majority of catheterized patients. Clinicians should be aware of the syndrome that may indicate serious comorbidities.

2593 The Importance of Endoscopy in Diagnosis of Lupus Enteritis

INTRODUCTION: Lupus enteritis is defined as vasculitis or inflammation of the small bowel with supportive image and/or biopsy findings in patients with SLE. Symptoms such as abdominal pain (97% of cases) and vomiting (42%) are non-specific. These symptoms represent a wide differential, including vasculitis, medication reactions, and infection. This can cause diagnostic dilemmas in patients with multiple comorbidities. CASE DESCRIPTION/METHODS: A 28-year-old female with SLE, lupus nephritis, and ESRD after failed renal transplant presented with one day of abdominal pain and vomiting. Her medications included mycophenolate mofetil, prednisone, and hydroxychloroquine. Physical examination revealed periumbilical tenderness without rebound or guarding. CT abdomen showed small bowel wall thickening and hyperemia in the proximal jejunum with bowel dilatation and no transition point. Labs were remarkable for elevated CRP and decreased C3 complement. Given her symptoms and abdominal imaging, she underwent small bowel enteroscopy that showed severe inflammation in the proximal jejunum with purple discoloration (Figure 1). Initial jejunal biopsy was concerning for vasculitis. The patient was treated with methylprednisolone. Her symptoms improved within one day. A CTA abdomen two days later showed no vascular abnormalities with interval improvement of jejunal edema. Final pathology of the jejunal biopsy (Figures 2 and 3) showed mildly inflamed and injured small intestinal mucosa with fibrin thrombi in small vessels, lamina propria hemorrhage and patchy lymphangiectasia, consistent with lupus enteritis in this clinical setting. DISCUSSION: The clinical presentation of lupus enteritis is non-specific but often associated with abdominal pain and vomiting in SLE patients. The jejunum is involved in 80% of cases. The underlying cause is believed to be immune-complex deposition and complement activation that produce diffuse microvascular injury, thrombosis, and increased vascular permeability. This can result in intestinal necrosis and perforation. Timely diagnosis and treatment lead to excellent response within days. This patient achieved symptomatic improvement after one day of high-dose steroids. Due to her dialysis schedule, CT angiogram of her abdomen was delayed until after symptom resolution. The normal imaging reflected treatment response rather than lack of disease and led to initial non-diagnosis until final pathology resulted. Our case highlights the value of endoscopy in patients with a suspicion of lupus enteritis.

2732 Signet Ring Cell Carcinoma: A Rare Case Report Masquerading as Digital Infarction

INTRODUCTION: Signet Ring Cell Carcinoma (SRCC) is a mucin producing adenocarcinoma, commonly seen in the gastrointestinal tract, also rarely in the urinary bladder, pancreas, breast and gallbladder. Tumor embolism due to slowly evolving disseminated intravascular coagulation (DIC) can manifest as digital infarction and this report highlights its presentation in a case of SRCC. CASE DESCRIPTION/METHODS: An 82-year-old African American lady presented with 2 weeks of low back pain, hematuria and purplish discoloration of toes. Physical exam was significant for multiple gangrenous digits but palpable pulses. CT Abdomen and Pelvis revealed diffuse bony metastases and moderate bilateral hydronephrosis. Labs were significant for Hemoglobin of 6.6 gm/dl and Creatinine 1.8. Bone marrow biopsy was consistent with metastatic carcinoma of SRCC. Pathologic staining was positive for AE1/AE3, CK7, CK20, and CDX2, suggestive of gastric tract origin than urinary bladder. Further investigation for the location of the primary tumor was negative. Evaluation for peripheral arterial disease, vasculitis, thrombophilia, and endocarditis for digital infarction was negative. With elevated D-Dimer, prolonged PTT and normal fibrinogen suggestive of slowly evolving DIC, digital infarction from tumor embolism was diagnosed. Ureteral stent placement for hydronephrosis was attempted but was unsuccessful due to multiple clots in the bladder, likely owing to DIC and she further deteriorated to end stage renal disease. Goals of care were discussed with the patient and she was transitioned to hospice care. DISCUSSION: Slowly evolving DIC is seen in cancer (mostly adenocarcinoma), liver disease, aneurysm, hemangioma and rarely sepsis. It’s believed that the destruction and production of coagulation factors/platelets are balanced. Diagnostic labs indicate thrombocytopenia, normal to prolonged PT/PTT, normal to low fibrinogen level and elevated D-Dimer. Heparin is the treatment of choice when bleeding is not suspected. Unfortunately, heparin was contra-indicated in our patient who had hematuria. In conclusion, this case illustrates the aggressive presentation of SRCC, which can present as digital infarction. Identifying tumor embolism and slowly evolving DIC is important as it may indicate poor prognosis. This case is unique in its presentation and cancer should be ruled out in digital infarction when other common causes are not identified.