1
|
Vilela M, Fernandes D, Salazar T, Duarte A. Hulk-Like Urine: A Case of Green Urine Caused by Flupirtine Intoxication. Cureus 2020; 12:e12333. [PMID: 33520530 PMCID: PMC7839280 DOI: 10.7759/cureus.12333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2020] [Indexed: 12/01/2022] Open
Abstract
Acute intoxications are common causes of admission to the Emergency Department (ED). Flupirtine is a non-opioid analgesic, originally used for acute and chronic pain. Because of several reports of severe liver toxicity, its use was limited to acute pain in 2013 by the European Medicines Agency. Although withdrawn from the European market in March 2018, there are still flupirtine tablets in many households, and most people are unaware of the hazards they might be facing. A 58-year-old man was admitted to the ED after a suicide attempt with 1 g of flupirtine. He was lethargic and confused but presented no focal neurological deficits or other symptoms, and the rest of his clinical examination was unremarkable. His cerebral CAT and blood chemistry showed no alterations. The only remarkable feature was that he had green urine. After a careful literature search, a similar case was found caused by flupirtine intoxication. After 24 hours of vigilance in the ED, he improved his neurological status and his urine lost part of its greenish color. He was then transferred to the Psychiatric Department, where he presented a complete remission of the clinical alterations. A follow-up check-up showed no permanent deficits.
Collapse
Affiliation(s)
- Maria Vilela
- Internal Medicine, Centro Hospitalar do Médio Ave, Vila Nova de Famalicão, PRT
| | - Diana Fernandes
- Internal Medicine, Centro Hospitalar Do Médio Ave, Vila Nova de Famalicão, PRT
| | - Tatiana Salazar
- Internal Medicine, Centro Hospitalar Do Médio Ave, Vila Nova de Famalicão, PRT
| | - Augusto Duarte
- Internal Medicine, Centro Hospitalar do Médio Ave, Vila Nova de Famalicão, PRT
| |
Collapse
|
2
|
Angarita SAK, Duarte S, Russell TA, Ruchala P, Elliott IA, Whitelegge JP, Zarrinpar A. Quantitative Measure of Intestinal Permeability Using Blue Food Coloring. J Surg Res 2019; 233:20-25. [PMID: 30502249 PMCID: PMC6561122 DOI: 10.1016/j.jss.2018.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 05/23/2018] [Accepted: 07/02/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Loss of intestinal barrier integrity plays a fundamental role in the pathogenesis of various gastrointestinal diseases and is implicated in the onset of sepsis and multiple organ failure. An array of methods to assess different aspects of intestinal barrier function suffers from lack of sensitivity, prolonged periods of specimen collection, or high expense. We have developed a technique to measure the concentration of the food dye FD&C Blue #1 from blood and sought to assess its utility in measuring intestinal barrier function in humans. MATERIALS AND METHODS Four healthy volunteers and 10 critically ill subjects in the intensive care unit were recruited in accordance with an institutional review board approved protocol. Subjects were given 0.5 mg/kg Blue #1 enterally as an aqueous solution of diluted food coloring. Five blood specimens were drawn per subject: 0 h (before dose), 1, 2, 4, and 8 h. After plasma isolation, organic extracts were analyzed by high-performance liquid chromatography/mass spectrometry detecting the presence of unmodified dye. RESULTS We found no baseline detectable absorption in healthy volunteers. After including the subjects in the intensive care unit, we compared dye absorption in the six subjects who met criteria for septic shock with the eight who did not. Septic patients demonstrated significantly greater absorption of Blue #1 after 2 h. CONCLUSIONS We have developed a novel, easy-to-use method to measure intestinal barrier integrity using a food grade dye detectable by mass spectrometry analysis of patient blood following oral administration.
Collapse
Affiliation(s)
- Stephanie A K Angarita
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Sergio Duarte
- Dumont-UCLA Transplant Center, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Tara A Russell
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Piotr Ruchala
- Semel Institue for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Irmina A Elliott
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Julian P Whitelegge
- Semel Institue for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Ali Zarrinpar
- Dumont-UCLA Transplant Center, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California.
| |
Collapse
|
3
|
Lee DE, Chung K, Cho JY, Lee JJ, Park HR, Song P. Propofol-Induced Green Urine in a Patient with Refractory Status Epilepticus. J Epilepsy Res 2018; 8:97-99. [PMID: 30809505 PMCID: PMC6374538 DOI: 10.14581/jer.18017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 12/15/2018] [Accepted: 12/21/2018] [Indexed: 11/30/2022] Open
Abstract
Propofol is commonly used for induction and maintenance of anesthesia, and sedation in the intensive care unit. In addition, it is also used as an anesthetic coma treatment for refractory status epilepticus. We present the case of a 52-year-old man, who developed green urine following propofol coma therapy for status epilepticus. The urine color recovered following discontinuation of propofol infusion. The green discoloration of urine is a rare and benign condition, which occurs when clearance of propofol exceeds the hepatic and extrahepatic elimination.
Collapse
Affiliation(s)
- Da Eun Lee
- Department of Nursing, Ilsan Paik Hospital, Inje University, Goyang, Korea.,Department of Neurology, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Kyuyoon Chung
- Department of Neurology, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Joong-Yang Cho
- Department of Neurology, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Jae Jung Lee
- Department of Neurology, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Hea Ree Park
- Department of Neurology, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Pamela Song
- Department of Neurology, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| |
Collapse
|
4
|
Metabolic Profiles of Propofol and Fospropofol: Clinical and Forensic Interpretative Aspects. BIOMED RESEARCH INTERNATIONAL 2018; 2018:6852857. [PMID: 29992157 PMCID: PMC5994321 DOI: 10.1155/2018/6852857] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 03/27/2018] [Accepted: 04/15/2018] [Indexed: 02/08/2023]
Abstract
Propofol is an intravenous short-acting anesthetic widely used to induce and maintain general anesthesia and to provide procedural sedation. The potential for propofol dependency and abuse has been recognized, and several cases of accidental overdose and suicide have emerged, mostly among the health professionals. Different studies have demonstrated an unpredictable interindividual variability of propofol pharmacokinetics and pharmacodynamics with forensic and clinical adverse relevant outcomes (e.g., pronounced respiratory and cardiac depression), namely, due to polymorphisms in the UDP-glucuronosyltransferase and cytochrome P450 isoforms and drugs administered concurrently. In this work the pharmacokinetics of propofol and fospropofol with particular focus on metabolic pathways is fully reviewed. It is concluded that knowing the metabolism of propofol may lead to the development of new clues to help further toxicological and clinical interpretations and to reduce serious adverse reactions such as respiratory failure, metabolic acidosis, rhabdomyolysis, cardiac bradyarrhythmias, hypotension and myocardial failure, anaphylaxis, hypertriglyceridemia, renal failure, hepatomegaly, hepatic steatosis, acute pancreatitis, abuse, and death. Particularly, further studies aiming to characterize polymorphic enzymes involved in the metabolic pathway, the development of additional routine forensic toxicological analysis, and the relatively new field of ‘‘omics” technology, namely, metabolomics, can offer more in explaining the unpredictable interindividual variability.
Collapse
|
5
|
Kolouri S, Daneshfard B, Jaladat AM, Tafazoli V. Green Urine in Traditional Persian Medicine: Differential Diagnosis and Clinical Relevance. J Evid Based Complementary Altern Med 2017; 22:232-236. [PMID: 27103627 PMCID: PMC5871183 DOI: 10.1177/2156587216641828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 02/11/2016] [Accepted: 03/05/2016] [Indexed: 11/16/2022] Open
Abstract
The color of urine is an important factor in urine examination, which can help physicians differentiate various diseases. Today, it is known that certain dyes, drug intoxications, and diseases can induce green urine discoloration. In the view of traditional Persian medicine, which is based on humoral medicine, green urine discoloration is generally referred to the dominance of coldness in the body. In fact, it is considered to be a result of a special kind of humoral imbalance and fluid depletion or retention in the human body. Persian scholars believed that green urine could be an indicator of intoxication or a predictor of an imminent spasm or convulsion in pediatric patients. Further investigations could result in finding new diagnostic scales of urine color based on the teachings of traditional Persian medicine.
Collapse
Affiliation(s)
- Sepideh Kolouri
- Research Center for Traditional Medicine and History of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
- Essence of Parsiyan Wisdom Institute, Phytopharmaceutical and Traditional Medicine Incubator, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Babak Daneshfard
- Research Center for Traditional Medicine and History of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
- Essence of Parsiyan Wisdom Institute, Phytopharmaceutical and Traditional Medicine Incubator, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amir-Mohammad Jaladat
- Essence of Parsiyan Wisdom Institute, Phytopharmaceutical and Traditional Medicine Incubator, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Traditional Persian Medicine, School of Traditional Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Vahid Tafazoli
- Essence of Parsiyan Wisdom Institute, Phytopharmaceutical and Traditional Medicine Incubator, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Traditional Persian Medicine, School of Traditional Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| |
Collapse
|
6
|
Marvin S, Gustafson S, Thibeault S. Detecting Aspiration and Penetration Using FEES With and Without Food Dye. Dysphagia 2016; 31:498-504. [DOI: 10.1007/s00455-016-9703-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 03/07/2016] [Indexed: 10/22/2022]
|
7
|
Regensburger M, Huttner HB, Doerfler A, Schwab S, Staykov D. Propofol-related urine discoloration in a patient with fatal atypical intracerebral hemorrhage treated with hypothermia. SPRINGERPLUS 2014; 3:551. [PMID: 25332856 PMCID: PMC4192142 DOI: 10.1186/2193-1801-3-551] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 09/16/2014] [Indexed: 11/10/2022]
Abstract
Introduction Mild therapeutic hypothermia is an increasingly recognised treatment option to reduce perihemorrhagic edema in severe intracerebral hemorrhage. Case description We report the case of a 77-year old woman with atypical intracerebral hemorrhage that was treated with mild hypothermia in addition to osmotic therapy. The patient’s urine subsequently showed a green discoloration. Urine discoloration was completely reversible upon discontinuation of propofol. Discussion and evaluation Propofol-related urine discoloration may have been provoked by hypothermia. Due to the benign nature of this side effect, propofol should be stopped and gastrointestinal function should be supported. Conclusion More studies are needed to show a causal role of hypothermia and related decreased enzymatic function.
Collapse
Affiliation(s)
- Martin Regensburger
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054 Erlangen, Germany ; Division of Molecular Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054 Erlangen, Germany
| | - Hagen B Huttner
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054 Erlangen, Germany
| | - Arnd Doerfler
- Department of Neuroradiology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054 Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054 Erlangen, Germany
| | - Dimitre Staykov
- Department of Neurology, University of Erlangen-Nuremberg, Schwabachanlage 6, 91054 Erlangen, Germany
| |
Collapse
|
8
|
Viswanathan S. Urine bag as a modern day matula. ISRN NEPHROLOGY 2013; 2013:215690. [PMID: 24959539 PMCID: PMC4045424 DOI: 10.5402/2013/215690] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 05/08/2013] [Indexed: 11/23/2022]
Abstract
Since time immemorial uroscopic analysis has been a staple of diagnostic medicine. It received prominence during the middle ages with the introduction of the matula. Urinary discoloration is generally due to changes in urochrome concentration associated with the presence of other endogenous or exogenous pigments. Observation of urine colors has received less attention due to the advances made in urinalysis. A gamut of urine colors can be seen in urine bags of hospitalized patients that may give clue to presence of infections, medications, poisons, and hemolysis. Although worrisome to the patient, urine discoloration is mostly benign and resolves with removal of the offending agent. Twelve urine bags with discolored urine (and their predisposing causes) have been shown as examples. Urine colors (blue-green, yellow, orange, pink, red, brown, black, white, and purple) and their etiologies have been reviewed following a literature search in these databases: Pubmed, EBSCO, Science Direct, Proquest, Google Scholar, Springer, and Ovid.
Collapse
Affiliation(s)
- Stalin Viswanathan
- Department of General Medicine, Indira Gandhi Medical College, Kathirkamam, Pondicherry 605009, India
| |
Collapse
|
9
|
|
10
|
|
11
|
Hufschmidt A, Krisch A, Peschen I. A girl with headache, confusion and green urine. J Neurol 2009; 256:1169-70. [PMID: 19252777 DOI: 10.1007/s00415-009-5061-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2008] [Revised: 01/15/2009] [Accepted: 01/17/2009] [Indexed: 11/29/2022]
Abstract
The case of a 17-year-old girl with a history of headache, blurred vision, confusion, ataxia and syncope is presented. On admission, she had already recovered except for a slurring of speech. Her urine was found to be green. Screening for illegal drugs was negative, but gas chromatography with subsequent mass spectroscopy (GC-MS) revealed an extremely high concentration of flupirtine.
Collapse
|
12
|
Abstract
The development of discolored urine may have many possible causes. Here we present the case of a 76-year-old woman who was admitted after ingesting the inorganic herbicides, mefenacet and imazosulfuron. Her urine color changed to green almost immediately. Since the patient had no specific medication or medical history we considered that the most likely cause of the change in urine color was the ingestion of the herbicides. Spectrophotometric analysis of the urine was conducted and a peak was observed in the green area of the wavelength spectrum. These findings show that mefenacet and imazosulfuron should be considered in the differential diagnosis of green discolored urine.
Collapse
Affiliation(s)
- Yun-Suk Shim
- Division of Nephrology, Department of Internal Medicine, SoonChunHyang University Cheonan Hospital, Cheonan, Korea
| | - Hyo-Wook Gil
- Division of Nephrology, Department of Internal Medicine, SoonChunHyang University Cheonan Hospital, Cheonan, Korea
| | - Jong-Oh Yang
- Division of Nephrology, Department of Internal Medicine, SoonChunHyang University Cheonan Hospital, Cheonan, Korea
| | - Eun-Young Lee
- Division of Nephrology, Department of Internal Medicine, SoonChunHyang University Cheonan Hospital, Cheonan, Korea
| | - Soo-Hyun Kim
- Proteome Analysis Team, Korea Basic Science Institute, Daejeon, Korea
| | - Sae-Yong Hong
- Division of Nephrology, Department of Internal Medicine, SoonChunHyang University Cheonan Hospital, Cheonan, Korea
| |
Collapse
|
13
|
Use of Colored Dyes in Enteral Formulas. TOP CLIN NUTR 2006. [DOI: 10.1097/00008486-200607000-00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
14
|
|
15
|
Abstract
Visual inspection of a patient's urine has long been used by physicians, with colour recognised as having important clinical implications. In this review the authors will revisit this ancient pastime with relevance to contemporary medical practice.
Collapse
Affiliation(s)
- C L Foot
- The Critical Care Research Group, The Prince Charles Hospital, Queensland, Australia.
| | | |
Collapse
|
16
|
Lucarelli MR, Shirk MB, Julian MW, Crouser ED. Toxicity of Food Drug and Cosmetic Blue No. 1 dye in critically ill patients. Chest 2004; 125:793-5. [PMID: 14769768 DOI: 10.1378/chest.125.2.793] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Food Drug and Cosmetic Blue No. 1 dye (FD&C Blue No. 1) is commonly added to enteral nutrition formulations in order to facilitate the detection of gastric aspirate in tracheal secretions of critically ill patients. However, reports of systemic blue dye absorption and associated adverse outcomes are emerging. We report two cases of abnormal systemic absorption of FD&C Blue No. 1 in critically ill patients who subsequently died of refractory shock and metabolic acidosis. Risk factors and mechanisms of FD&C Blue No. 1 toxicity are discussed, and alternate approaches to gastric aspiration detection in critically ill patients are considered.
Collapse
Affiliation(s)
- Maria R Lucarelli
- Division of Pulmonary and Critical Care Medicine, Department of Pharmacy, The Dorothy M. Davis Heart & Lung Research Institute, The Ohio State University Medical Center, 473 West Twelfth Avenue, Columbus, OH 43210-1252, USA
| | | | | | | |
Collapse
|
17
|
|