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Practice

Green urine

Dongmei Sun and Shih-Han Susan Huang
CMAJ February 26, 2018 190 (8) E224; DOI: https://doi.org/10.1503/cmaj.171498
Dongmei Sun
Department of Medicine (Sun, Huang), Schulich School of Medicine and Dentistry; The Lilibeth Caberto Kidney Clinical Research Unit (Huang); Department of Medical Biophysics (Huang), Western University, London, Ont.
MD MSc
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  • For correspondence: [email protected]
Shih-Han Susan Huang
Department of Medicine (Sun, Huang), Schulich School of Medicine and Dentistry; The Lilibeth Caberto Kidney Clinical Research Unit (Huang); Department of Medical Biophysics (Huang), Western University, London, Ont.
MD PhD
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An 85-year-old woman was brought to the emergency department after she was found on the floor of her bedroom with generalized weakness and confusion. Her medical history was noteworthy for coronary artery disease, type 2 diabetes and atrial fibrillation. She was taking diltiazem, sitagliptin, pantoprazole, atorvastatin, bisoprolol and hydroxyzine.

At the emergency department, the patient was febrile (body temperature 38.3°C), hypotensive (blood pressure 88/70 mmHg) and tachycardiac (heart rate 120 beats/min). We found a diffuse abdominal tenderness on palpation. A urinary catheter was inserted and it drained green-colured urine (Figure 1). The patient had a white blood cell count of 42.3 (normal range 4.0–11.0) × 109/L, with neutrophils at 35.1 (normal range 2.0–7.5) × 109/L and a serum creatinine level of 100 (normal range 62–102) μmol/L. Results from urinalysis showed a pH of 6.5 (normal range 5.0–8.5) with trace ketones, but no blood or leukocytes were found. Computed tomography of the abdomen showed a distended gallbladder with mild wall thickening that was suggestive of cholecystitis.

Figure 1:
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Figure 1:

Catheter drainage showing green urine in an 85-year-old woman who was admitted to hospital with generalized weakness and confusion.

We started treatment with broad spectrum antibiotics, and, after 24 hours, the patient had improved substantially and was no longer confused. On further history, she reported that she had undergone a colonoscopy with snare polypectomy in a different hospital the day before her admission. During the procedure, the physician had used submucosal saline injections containing methylene blue to elevated the polyp, which led to urine discolouration.

Green-coloured urine has been reported with medications such as propofol, metoclopramide, methylene blue, Clorets breath fresheners and traditional Chinese medicines.1–3 Purple urine caused by formation of pigments from dietary trypotophan by gram-negative bacteria has been reported.4 Black urine, which stains the collection containers, can be seen with elevated urobilinogen.5

Although urine colour can be a clue to diagnosis of diseases such as porphyria, a thorough history can often provide a diagnosis without invasive investigations. Abnormal urine colour can be distracting to the health care providers. In this case, it was not the cause of sepsis in this patient.

Clinical images are chosen because they are particularly intriguing, classic or dramatic. Submissions of clear, appropriately labelled high-resolution images must be accompanied by a figure caption. A brief explanation (300 words maximum) of the educational importance of the images with minimal references is required. The patient’s written consent for publication must be obtained before submission.

Footnotes

  • Competing interests: None declared.

  • This article has been peer reviewed.

  • The authors have obtained patient consent.

References

  1. ↵
    1. Aycock RD,
    2. Kass DA
    . Abnormal urine color. South Med J 2012;105:43–7.
    OpenUrlCrossRefPubMed
    1. Elkoundi A,
    2. Bensghir M,
    3. Balkhi H,
    4. et al
    . Green urine in the operating room: the “Cloret Sign.” QJM 2017 Nov. 14. [Epub ahead of print]. doi: 10.1093/qjmed/hcx219.
    OpenUrlCrossRef
  2. ↵
    1. Lam CW,
    2. Wong SY
    . A case of green urine due to a traditional Chinese medicine containing methylene blue. N Z Med J 2010;123:71–6.
    OpenUrlPubMed
  3. ↵
    1. Lee J
    . Images in clinical medicine. Purple urine. N Engl J Med 2007;357:e14.
    OpenUrlCrossRefPubMed
  4. ↵
    1. Chindarkar NS,
    2. Rentmeester LL,
    3. Ly BT,
    4. et al
    . Black urine due to urobilinogen in a patient with alcoholic pellagra. Clin Biochem 2014;47:1132–5.
    OpenUrl
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Canadian Medical Association Journal: 190 (8)
CMAJ
Vol. 190, Issue 8
26 Feb 2018
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Green urine
Dongmei Sun, Shih-Han Susan Huang
CMAJ Feb 2018, 190 (8) E224; DOI: 10.1503/cmaj.171498

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Green urine
Dongmei Sun, Shih-Han Susan Huang
CMAJ Feb 2018, 190 (8) E224; DOI: 10.1503/cmaj.171498
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