No, It's Not a Manufactured Purple Foley Bag!

Introduction: Purple Urine Bag Syndrome (PUBS) is a rare condition where urinary catheter bags turn purple. It typically affects patients with chronic kidney disease, and chronically ill patients with long-term catheters, as these conditions are often linked to UTIs. Though benign, it may alarm those unfamiliar with the condition. We present a case of a 75-year-old male with multiple comorbidities who developed PUBS where we highlight the diagnostic and clinical implications. Case Description: A 75-year-old male with stage 3 CKD, neurogenic bladder, and recurrent UTIs presented with 10 days of dyspnea, fevers, anorexia. He met SIRS criteria for sepsis: WBC 20.4, 38.1°C, RR 23. He tested positive for COVID-19; imaging showed multifocal opacities. Urinalysis revealed leukocyte esterase, nitrites, bacteria, and alkaline urine. Blood and urine cultures grew gram-negative organisms. His Foley bag was noted to be purple, with discoloration beginning a week earlier after a catheter change. A new catheter was placed. Despite appropriate treatment, he developed septic shock and arrested within 24 hours. Discussion: PUBS is linked to conditions that increase risk for UTIs such as chronic catheterization and chronic kidney disease. Other factors include alkaline urine, constipation, and debilitation. Bacteria metabolize tryptophan to indole, which becomes indoxyl sulfate. In the bladder, bacterial enzymes convert indoxyl sulfate to indigo and indirubin, producing a purple color. Common organisms include E. coli, Proteus, Pseudomonas, Klebsiella, and Enterococci. While benign, it can indicate significant infection. Management includes catheter change and antibiotics. In patients with complex presentations, PUBS may be an early visual clue. This case underscores the need to recognize PUBS as a sign of serious infection. Early intervention is crucial to prevent deterioration.