Where are the lemons?

aka Unusual Urine 001

You are wandering past the bedside of a 42 year old male with a cerebral abscess…and you notice the colour of his urine

What is unusual about the appearance of the urine?

Unusual Answer

The urine is orange!


What are the possible causes?

Unusual Answer

The causes of orange urine include:

Medications:

  • Idarubicin – an anthracycline used for hematological malignancies
  • Ferrioxamine – an iron chelator that classically causes ‘vin rose’ urine – tends to be orange to reddish-brown
  • Oxamniquine – antischistosomal quinoline selective for S. mansoni
  • Phenazopyridine – an azo dye used for analgesia in urinary tract infections – it can cause false-positive urine dipstick results for bilirubin and urobilinogen – can have nasty side-effects
  • Rifampicin – see below
  • Sulfasalazine – 5-aminosalicylate with a local effect on the bowel wall used in inflammatory bowel disease
  • Warfarin – urine may be pink or orange

Foods, supplements, and vitamins:

  • Carotenes – e.g. vitamin A, orange juice, pumpkin, and carrots
  • B-complex vitamins
  • Food dyes – what goes in must come out…
  • Senna
  • Rhubarb
  • Beets and blackberries — urine tends to be red-coloured

Disorders that cause hypercarotenemia:

  • Diabetes mellitus
  • Dietary excess of carotenoids
  • Hyperlipidemia
  • Hypothyroidism
  • Porphyria

Note: Urine may also appear ‘orange-ish’ as a result of dehydration or jaundice (hyperbilirubinemia).

Hypercarotenemia is associated with yellowish skin without scleral icterus (in contrast to jaundice). It can also cause orange discolouration of cerebrospinal fluid (CSF).


…but what happened in this case?

Unusual Answer

This patient had a cerebral abscess and was being being treated with rifampicin. The orange colour is benign. Other body secretions such as sweat and tears – as well as CSF – may also be discoloured.

Rifampicin is an RNA polymerase inhibitor that is active against most Mycobacteria, most Gram-positive bacteria and some Gram-negative bacteria, eg N. meningitidis, H. influenzae. It is generally reserved for MRSA, mycobacterial infections and prophylaxis of meningitis and epiglottitis. Resistance to rifampicin can occur rapidly if it is used as the sole agent for antibotic therapy.

Adverse effects of rifampicin include gastrointestinal disturbance and elevated liver enzymes. Rarely it may result in Clostridium difficile-associated disease, allergy or hepatitis.

Rifampicin decreases the concentration and reduces the activity of many other drugs. This occurs because rifampicin induces hepatic and intestinal CYP enzymes as well as transporter proteins (e.g. P-glycoprotein). Induction of enzymes and transporter proteins is maximal at about 1 week of therapy and lasts for about 2 weeks after discontinuation.


References

CLINICAL CASES

Unusual Urine

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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