A 78-year-old woman, weighing 40 kg and 1.65 m tall, with a history of gastrectomy for gastric ulcer with Billroth II reconstruction more than 30 years ago, which was subsequently converted to Roux-en-Y due to alkaline reflux. One year later, he began to suffer from subocclusive symptoms, requiring surgery for intestinal obstruction. Secondary malnutrition with severe hypoalbuminaemia, severe chronic anaemia, pressure ulcers in the sacral region and heels, urinary incontinence and immobility syndrome. He also had renal TB more than 20 years ago, with repeated pyelonephritis, which required surgery due to ureteral stenosis.
He was admitted for anaemia with a haemoglobin of 4.8 g/dl (VN: 12-18 g/dl) secondary to gastrointestinal bleeding. He presented severe protein-calorie malnutrition (BMI: 14.7 kg/m2), with albumin of 2.48 g/dl (VN: 3.30-5.20 g/dl). On admission she had a urinary catheter with urine in a purple collection bag. Three months earlier, she had been admitted for anasarca symptoms related to malnutrition due to malabsorptive syndrome, and at that time she was started on hypercaloric/hyperproteic nutritional supplements (Fortimel® 1 every 8 hours). Table I shows the improvement in the biochemical nutritional markers from this first admission and the start of the nutritional supplements until discharge from hospital.
During the first admission, the patient required bladder catheterisation for diuresis control, which was subsequently maintained to promote healing of the ulcers in the sacral region. Shortly before discharge, purple urine was observed in the bladder catheter bag, so fosfomycin was empirically administered in a long regimen due to suspicion of urinary tract infection. On admission, the persistence of the purple colour of the urine in the bladder catheter bag was observed despite antibiotic treatment. The patient describes having noticed this change in colour since previous discharge and that it persists when the catheter is changed, reappearing three or four days after each change. She did not present fever or leukocytosis at any time. The biochemical analysis of the urine shows an alkaline pH (8.5), which can also be observed in the analyses of previous months. In addition, the sediment shows magnesium ammonium phosphate crystals, 10-25 red blood cells per field, 10-25 leukocytes per field and abundant bacteriuria. The nitrite reaction was negative. Urine culture isolated Proteus vulgaris, resistant to fosfomycin. Treatment was started with ciprofloxacin (sensitive according to the antibiogram) and the bladder catheter was changed. After 48 hours the urine was normal in colour.