Pink urine syndrome: a combination of insulin resistance and
21-year-old, Caucasian male with no previous medical history, was admitted to the intensive care unit with acute hypoxic/hypercapnic respiratory failure, acute kidney injury (AKI) and septic shock in the setting of heroin use. The patient has diagnosed with methicillin-susceptible Staphylococcus aureus pneumonia.

Due to worsening hypoxia and respiratory acidosis, he was intubated, using propofol for induction. The following morning his creatinine increased to 1.8mg/dl (from a baseline of 1.1mg/dl) and urine sediment (pellet) upon gross inspection was bright pink and light microscopy of the spun urine sediment demonstrated many amorphous crystals.

In order to identify the crystal type, the patient’s urine was acidified and alkalized and re-assessed under light microscopy. Upon acidification, polychromatic birefringence rhomboid uric acid crystallization became prominent, whereas when we alkalinized the urine, amorphous urate crystals were present.

The patient was given intravenous fluids and the serum creatinine returned to baseline within two days. He was extubated three days later and discharged shortly after on oral antibiotics.

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