Polymicrobial Sepsis in an Immunocompetent Host due to Self Injection of Urine

Sir,

Auto urine therapy (AUT) is practiced worldwide either as prophylaxis or as a therapy in complementary and alternative medicine[1] for many diseases. Though many cases of AUT are known, urine-induced sepsis is not reported yet to our knowledge. Herein, a case of near fatal polymicrobial sepsis with acute respiratory distress syndrome due to self injection of urine is reported for its rarity and to create awareness among physicians working in emergency care.

A 38-year-old livestock inspector was brought to the emergency room (ER) in an unconscious state following two episodes of a witnessed new-onset generalized tonic-clonic seizure (GTCS) within a period of 30 minutes. There was a history of fever associated with chills and rigors since 12 hours. The patient had no previous history of seizures, head injuries, or any other illnesses and was not on any regular medications or illicit drugs. Family history was not contributory.

On admission, he was unconscious with a Glasgow coma scale (GCS) of 8/15 and the pupils were 4 mm dilated and sluggishly reacting to light. There were no meningeal signs or rashes. He was febrile (104 F) and had frothy blood stained secretion in the oropharynx. He was tachycardic (pulse 128/minute) with supine BP 90/60 mmHg, SaO₂ 80%, and FiO₂ 0.9. He had shallow respiration (rate 11/minute) with bilateral coarse rales extending up to apices of both lungs. The rest of the clinical examination was unremarkable.

Arterial blood gas (ABG) revealed wide anion gap with metabolic acidosis and hypoxia. The total WBC was 36.0×10³ /mm³with 41% band forms and neutrophils 25.4×10³ /mm³. Hemoglobin, packed cell volume (PCV), platelet count, electrolytes, liver function test, coagulation profile, capillary blood sugar and CSF were normal. His HIV status and peripheral smear for malaria were negative. Blood and urine were negative for toxicology or for any drugs. His ultrasound abdomen, CT brain, and ECG were unremarkable. The chest X-ray showed extensive bilateral alveolointerstitial infiltrate compatible with acute respiratory distress syndrome (ARDS). He was started on anticonvulsants and intravenous broad-spectrum antibiotics in Intensive care unit (ICU). Inotropic support was started to maintain blood pressure. He was stabilized in the following 48 hours. His blood cultures grew K.pneumoniae, E. coli, and Proteus, which were sensitive to imipenem. Antibiotics were changed as per culture and sensitivity pattern. The sepsis started subsiding gradually and patient got discharged on day 12.

On day 11, he confessed that he collected his urine in a container and self injected about 10 ml of his urine intravenously to maximize his vitality and potency, as he had developed nausea and vomiting twice after drinking his urine orally. This might have led to polymicrobial sepsis, toxic encephalopathy, and septic shock with multi organ dysfunction. Psychological assessment did not reveal any abnormalities.

Drinking one's own urine in the morning (“amaroli”) is a traditional practice in yoga as well as “Siddha medicine” a branch of complementary and alternative medicine taught officially at some Indian medical universities.[2] It recommends drinking one's own urine for prophylactic and therapeutic purposes. Oral urea and methylglyoxal, both derivatives of urine have anticancer properties.[3,4]

Although urine therapy might have its own benefits, its practitioners and followers should exhibit caution. Also, when a clinician is confronted with challenges of polymicrobial infection, in an immunocompetent individual, history of an unconventional cause either deliberate (Munchausen's) or as unconventional methods needs to be elicited.