A Tale of Two Urines
A healthy young girl with a pink specimen and a male teen whose urine is green. What's in your differential Dxs?
The Tale of Two Urines
Polly, 8-years-old,
is brought in acutely because she told her mother that her urine was “red.”
History/PE:
Polly has always been healthy; no urinary tract infections/disease in the past; no renal disease in either Polly or the family; no trauma, no menarche.
No new or unusual foods
introduced recently; Polly has not been given any medications in the last year or so.
Urine is collected
and is definitely reddish-pink.
But, the dipstick is negative for hematuria.
Microscopic examination
of the urine specimen is now required.
Urate crystals
are present in every field.
Likely diagnosis was urate-induced pink coloration
of the urine. More detailed history found that Polly's diet was very rich in purines-sardines, roasted nuts, fried foods.
Conditions that simulate hematuria
include dehydration, pigments, medications.
Red urine can be caused by numerous substances
including anthocyanin, azo dyes, beets, chloroquine, rifampin, rhodamie B, sulfasalazine, urates.
A 16-year-old male presents with green urine.
He was asymptomatic and otherwise entirely well; no history of gall bladder disease.
The urine's green hue
is unmistakable.
Detailed family history,
noncontributory; physical exam, totally normal.
On closer examination,
the young man's tongue also is green.
Green urine and green tongue
appear to be caused by ingestion of Clorets gum for the past several days.
FD&C blue #1
is the culprit ingredient.
Differential diagnosis of green urine:
Iodochlorhydroxyquin-induced, myelo-optic neuropathy, Pseudomonas bacteremia, bile pigment, amitriptyline HCl, methocarbamol, metoclopramide (not an exhaustive list).
Green urine also is caused by dyes:
indigo, carmine, phenol, methylene blue.
Over my years in working with residents, I have always impressed on them that we are all very much medical detectives. It is nice to use dermatology clues, but they are not always present.So, I always emphasize the holistic approach â we must look at urine and stool specimens, blood smears, microbiology plates⦠whatever we might have to  assist us as we try to solve “mystery cases.”In recent times, however, performing our own lab tests is not allowed. I, being “old school,” have always had a microscope available in the office which allows me to provide some quick answers/additional clues. It is also advantageous to have the lab close by and to hav friendly lab techs who will invite you to come have a look at what they are seeing. This, I suggest, is the true art of medicine and reinforces learning. I often tell residents that “I am a PGY-XX” and that I will always be a student.This year I announce that “I am a PGY- 43 11/12” as I ignore the eye rolling and the “under the breath” snickering.And that brings us to today’s two medical mysteries as I invite you and a virtual resident to reenact your version of Sherlock Holmes/Columbo.
References:
Resources/Additional reading (alphabetical order)
Gupta D, Gupta R. Green urine. ScientificWorldJOURNAL. 2011;11: 1101–1102. https://www.researchgate.net/publication/51175592_Green_Urine
Koratala A, Leghrouz M. Green urine. Clin Case Rep. 2017;8:549-550. doi: 10.1002/ccr3.891. eCollection 2017 Apr.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5378838/
La Manna A, Polito C, Marte A, et al. Hyperuricosuria in children: clinical presentation and natural history. Pediatrics. 2001; 107:
http://pediatrics.aappublications.org/content/107/1/86
Prakash S, Saini S, Mullick P, Pawar M. Green urine: A cause for concern? J Anaesthesiol Clin Pharmacol. 2017;33:128-130. doi: 10.4103/0970-9185.202190. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5374818/
Raymond JR, Yarger WE. Abnormal urine color: differential diagnosis. South Med J. 1988;81:837-41. https://www.ncbi.nlm.nih.gov/pubmed/?term=Abnormal+Urine+Color%2C+Raymond+JR%2C+Yarger+WE%2C+South+Med+J