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Intravenous voriconazole therapy was unsuccessful.ocal irrigation of amphotericin has been reported touccessfully treat funguria6; therefore, a solution of lipo-omal amphotericin B in normal saline solution waselivered through the nephrostomy tube. To avoid furtherydrostatic damage behind the fluid infusion, an intracra-ial pressure monitor was connected to the nephrostomyube. Intrapelvic pressure was measured at the onset ofocal irrigation and hourly. Nephrostomy delivery of themphotericin B solution was titrated to 40 mL/h withressures �20 cm H2O. During the first day of irrigation,rine began to flow through the indwelling bladder cath-ter. After 6 days of treatment, a nephrostogram showedrisk contrast flow through the collecting system (FigB). Re-examination of urine showed it was sterile, anderum creatinine level normalized.

Kellie Calderon, MDRajiv Vij, MD

Azzour Hazzan, MDNorth Shore-Long Island Jewish Health System

Great Neck, New York

cknowledgementsWe thank Drs Madhu Bhaskaran, Lee Richstone, and

avid Herschwerk from the Departments of Nephrology,rology, and Infectious Disease at North Shore Long Island

ewish Health System, respectively.The corresponding author, Dr Vij, may be contacted at

ajvij@hotmail.comSupport: None.Financial Disclosure: The authors declare that they have

o relevant financial interests.

eferences1. Vuruskan H, Ersoy A, Girgin NK, et al. An unusual cause

f ureteral obstruction in a renal transplant recipient: uretericspergilloma. Transplant Proc. 2005;37(5):2115-2117.

2. Guleria S, Amlesh S, Dinda A, et al. Ureteric aspergil-oma as the cause of ureteric obstruction in a renal transplantecipient. Nephrol Dial Transplant. 1998;13(3):792-793.

3. Irby PB, Stoller ML, McAninch JW. Fungal bezoars ofhe upper urinary tract. J Urol. 1990;143(3):447-451.

4. Bell DA, Rose SC, Starr NK, Jaffe RB, Miller FJ Jr.ercutaneous nephrostomy for nonoperative management ofungal urinary tract infections. J Vasc Interv Radiol. 1993;(2):311-315.

5. Karlin G, Rich M, Lee W, Smith AD. Endourologicalanagement of upper tract fungal infection. J Endourol. 1987;1(1):

9-54.6. Orlando MD, Won JL. Percutaneous nephrostomy in the

anagement of renal candidiasis. Arch Surg. 1989;124(6):739-40.

2010 by the National Kidney Foundation, Inc.oi:10.1053/j.ajkd.2010.08.008

reen Urine Following Exposure to Flupirtineo the Editor:

A 37-year-old man with a history of analgesic and sedativebuse presented to our hospital with impaired consciousness.ecause spontaneous voiding was impossible, urine was ob-

ained for drug screening using a bladder catheter. His urinehowed a strong green discoloration (Fig 1). A routine urinaryrug screening test was positive for benzodiazepines, but nega-ive for methadone, ecstasy, amphetamines, methamphet-mines, barbiturates, cannabis, cocaine, or opiates. Laboratoryest results (including serum creatinine level of 0.9 mg/dL [80mol/L]) and urine sediment were unremarkable. The patient

eported recent daily use of several tablets of flupirtine, aentrally acting nonopioid analgesic available in Europe (butot approved for use in the United States). Very high free serumevels of flupirtine (ie, 22.4 �g/mL; therapeutic range, 0.5-1.5g/mL) were measured using high-performance liquid chroma-

ography. High levels of nordazepam (1.53 �g/mL; therapeuticange, 0.2-0.8 �g/mL) and diazepam (0.97 �g/mL; therapeuticange, 0.12-0.40 �g/mL) also were observed. Some drugs,ncluding benzodiazepines, can displace flupirtine from itsrotein-bound state, leading to a highly increased flupirtine levelnd green urine. Fluorescence excitation spectrometry of the pa-ient’s urine confirmed a peak at approximately 371 nm, character-stic of the phenol-group–containing flupirtine.1-3 After flupirtineas excreted, urine color returned to normal and the patient wasischarged from the hospital the following day. He was advised toeek medical care for drug abuse. This case suggests that flupirtine

Figure 1. Comparison of urine samples from (left) theatient and (right) an unaffected control.

Box 1. Causes of Green Discoloration of Urine

DrugsAmitriptylineCimetidineFlupirtineFlutamideIndomethacinMethylene blueMetoclopramideMitoxantronePropofol

MiscellaneousIngestion of Asparagus officinalis (a spring vegetable)Meconium aspiration syndrome in newborns

Urinary tract infection with Pseudomonas species

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hould be added to the list of potential causes of green discolora-ion of urine, which are summarized in Box 1.4-9

Alexandra Maier, MD1

Ying Liu1,2

Alexandra Scholze, MD1,2

Timm H. Westhoff, MD1

Martin Tepel, MD1,2

1Charite Berlin, Campus Benjamin FranklinBerlin, Germany

2Odense University HospitalUniversity of Southern Denmark Institute for

Molecular MedicineOdense, Denmark

cknowledgementsThe corresponding author, Martin Tepel, may be con-

acted at mtepel@health.sdu.dk.Support: None.Financial Disclosure: The authors declare that they have

o relevant financial interests.

eferences1. Hlavica P, Niebch G. Pharmacokinetics and biotrans-

ormation of the analgesic flupirtine in humans. Arzneimittel-

orschung. 1985;35(1):67-74. d

2. Wang H, Wang X, Li X, Zhang C. Theoreticaltudies on fluorescence of phenol and 1-naphthol in bothcid and alkali solutions. J Mol Struct (Theochem). 2006;(1-3):107-110.

3. Chen X, Zhong D, Xu H, Schug B, Blume H. Simulta-eous determination of flupirtine and its major active metabo-ite in human plasma by liquid chromatography-tandemass spectrometry. J Chromatogr B Biomed Sci Appl. 2001;

55(1-2):195-202.4. Leclercq P, Loly C, Delanaye P, Garweg C, Lamber-

ont B. Green urine. Lancet. 2009;373(9673):1462.5. Tan CK, Lai CC, Cheng KC. Propofol-related green

rine. Kidney Int. 2008;74(7):978.6. Hufschmidt A, Kirsch A. A girl with headache,

onfusion and green urine. J Neurol. 2009;256(7):1169-170.

7. Stratta P, Barbe MC. Images in clinical medicine.reen urine. N Engl J Med. 2008;358(11):e12.8. Pak F. Green urine: an association with metoclopra-

ide. Nephrol Dial Transplant. 2004;19(10):2677.9. Friedrichsdorf S, Prosnitz EH. Fallbericht und durch-

icht der literatur. Urologe. 2003;42(1):80-81.

2010 by the National Kidney Foundation, Inc.

oi:10.1053/j.ajkd.2010.08.012