A teen boy’s urine looked like strong tea. What was wrong with him? | Medical Mystery
Fever, aches, and nausea point to many possibilities, but darkened urine indicates a more serious issue.
A 15-year-old boy went to the emergency department because he had felt terrible since he woke up that morning. His whole body was sore, especially his arms and legs, and he felt weak. What worried him even more was that his urine was dark brown--the color of strong tea.
The triage nurse in the ED checked the teen’s vital signs and he had a fever. She asked for a urine sample, and sure enough, it looked like tea. Blood and urine tests were sent to the lab for evaluation.
In the meantime, the ED doctor started to investigate. Hearing that the patient had fever, body aches, weakness, and nausea, she wondered if he had a viral illness like the flu or COVID. Although he did not have respiratory symptoms, it had been a bad year for the flu and the teen had not had his annual flu shot. Both flu and COVID rapid tests came back negative, making these diagnoses unlikely.
The doctor asked about his urine. Urine can change colors from medications, but he was not on any. Foods, like beets, can turn urine dark red, but he made it clear he wasn’t eating any beets. She inquired about his water consumption, and the teen admitted that he drank very little plain water, preferring energy, protein, and sports drinks. Due to nausea, he hadn’t had anything to drink since waking up.
The teen’s mother told the doctor she was worried that her son’s recent diet and behavior changes were causing his illness. Her son had repeatedly complained that he didn’t think he had enough muscles, frequently checked his abs in the mirror, and started weighing himself daily. He admitted that he felt embarrassed by his body because he thought he was too skinny. He hated changing for gym class because he worried that everyone was looking at his body and judging him.
About six months earlier, he started a high protein diet recommended by an influencer on social media. The influencer he found online bulked up with exercise and diet changes. He ate mostly eggs, chicken, and lean meats, and added protein powder to milk. He stopped eating fruits and vegetables and generally limited carbohydrates.
He also started going to the gym for two to four hours every day and taking a protein supplement he ordered online. The doctor asked what was in it, and the teen said he didn’t know, but it got high ratings online from satisfied customers who claimed it made them more muscular. The teen added that he might be sore because he had done a particularly high-intensity interval workout and weightlifting the day before.
On top of all this, the doctor also uncovered that the teen had stopped hanging out with his friends, and his grades were declining.
Solution
The doctor received an urgent call from the laboratory. The patient’s potassium and phosphate were extremely high which can cause dangerous heart rhythms. An EKG (electrical tracing of the patient’s heart rhythm) was ordered immediately; luckily it was normal but he was placed on a continuous cardiorespiratory monitor in case that changed.
More alerts from his blood tests: his creatinine and blood urea nitrogen were high, and his creatine kinase was so high that the lab could not compute the exact value. All this suggested that he had kidney damage. His urine result was positive for blood on the test strip, but when examined under the microscope, there were no red blood cells.
Diagnosis: rhabdomyolysis.
Rhabdomyolysis is a condition that causes muscles to break down, so that toxic components of the muscle fibers enter the circulatory system, potentially leading to kidney damage. Symptoms include swollen, weak, and tender muscles; nausea; and brown, red, or tea-colored urine. Loss of consciousness can also occur.
The most common cause of rhabdomyolysis is a traumatic muscle injury, particularly a crush injury, but it can also be caused by excessive physical exertion and severe dehydration. Symptoms usually develop one to three days after a muscle injury.
The teen was admitted to the hospital and with intravenous fluids his kidney function improved. He was told to stop the mystery supplement as it was not regulated by the FDA and could have anything in it.
The teen’s underlying diagnosis is Muscle Dysmorphic Disorder (MDD). MDD has been called “reverse anorexia,” as instead of trying to get smaller, people with MDD perform repetitive behaviors to fix their perceived smallness. Like anorexia, this preoccupation can be so intense that peer relationships and school performance suffer. Treatment goals are to normalize eating and exercise patterns, and address obsessions and thoughts. Cognitive behavioral therapy has been shown to help by teaching patients to challenge the thoughts that lead to these feelings, and learning how to change the way they see their bodies.
Our advice to parents:
Be on the lookout for red flags in your teenagers like decreased interaction with peers and decline in school performance.
Monitor teenagers for severe diet and exercise changes, and for any supplements they may consume.
Listen carefully to teens’ body image comments and address them with their primary care provider.
Samantha Starkey is a pediatric resident and Rima Himelstein is an adolescent medicine specialist at Nemours Children’s Hospital, Delaware.