Purple urine bag syndrome in a patient with ileal conduit: a case report

Purple urine bag syndrome (PUBS) is a rare but visually striking manifestation of urinary tract infection (UTI), most commonly seen in patients with long-term urinary drainage systems. We present a case of PUBS in a 73-year-old man with an ileal conduit urostomy created after treatment for prostate cancer. He presented with purple discoloration of his urostomy bag and was found to be afebrile but tachycardic (heart rate 101 beats/min), with neutrophilic predominance (WBC 11,000/µL, 90.9% neutrophils), reactive thrombocytosis (platelets 737 × 10³/µL), and an acute rise in serum creatinine to 2.0 mg/dL (BUN 36 mg/dL) from a fluctuating baseline of 1.2–1.7 mg/dL. Admission lactate was normal (1.6 mmol/L) and procalcitonin was 0.85 ng/mL; blood cultures were negative at five days. Urinalysis showed alkaline urine (pH 8), pyuria, and hematuria. The acute 2-point rise in the renal component of the Sequential Organ Failure Assessment (SOFA) score in the setting of a documented urinary source fulfilled Sepsis-3 criteria for sepsis (without shock). Urine culture grew Klebsiella pneumoniae and Providencia rettgeri, both susceptible to ciprofloxacin. Treatment with empiric intravenous cefepime, transition to oral ciprofloxacin, and urostomy appliance replacement led to resolution of tachycardia, downtrending creatinine (2.0 → 1.5 → 1.3 mg/dL), and complete resolution of the discoloration within 72 h. PUBS in patients with an ileal conduit is rare; this case illustrates that it can be the presenting sign of early, paucisymptomatic sepsis and should prompt evaluation for systemic infection.