Ceremonial haemoglobinuria

A fit young infantry officer told me that he had passed deep red urine. It was only on one occasion—the Lord Mayor's Show, London, 1949. Confident that this was march haemoglobinuria I gave him some containers and asked for urine samples before, at about half time, and after his next hard march. This turned out to be quite soon and the urine samples he then brought in looked normal; none contained methaemoglobin.

We discussed the matter and he made the point that the difference between usual marches and the Lord Mayor's Show was the ceremonial aspect. There was a sense of apprehension about doing well in the public gaze, a feeling not associated with other often more strenuous and stressful events. An opportunity to test the idea that the nature of the occasion made the difference soon came. He was due to command a unit carrying out the changing of the guard at Buckingham Palace. After he had done so he brought in two urine samples, one before and one after. The first was normal, the second was deep red and had the spectrum of methaemoglobin. He was otherwise quite well and we decided to let the matter drop.

Some years later, coming across a note I had made about him, I wrote and traced him. He was still serving as an infantry officer and had been attached to the Parachute Regiment. He answered at some length to say that he had had red urine on only two more occasions. Both were during the Korean War. The first was as his unit, aboard ship, was drawing in to Pusan harbour in darkness, ship lights dimmed and he and his regiment keyed up with the expectation of what might lie ahead. The second was during the waiting period before a dawn attack. He went on to say that since then there had been many stressful episodes but no further red urine. He remained well.

I recently submitted the above account to the BMJ and was advised to get the patient's consent for publication. He is well and has had no further haemoglobinuria despite having “been under stress on many occasions in many theatres of operations in my career.” It is pleasing not only to hear that he is still well but also to have achieved a 48 year follow up.

So far as I (and Medline) know, haemoglobinuria apparently precipitated by a stressful event has not previously been recorded. This account surely emphasises that stress can mean different things to different people. At the first consultation we went carefully into the question of the physical stress of marching but forced marches involving much more effort than his ceremonial duties had never been followed by haemoglobinuria.

I might have written him up as a formal case report years ago if I had felt able to speculate usefully on an explanation to account for stress leading to haemoglobinuria. Unfortunately, I still cannot and have not found anyone who can. Any suggestions?