Rhabdomyolysis after fish consumption: Haff's disease

Haff disease associated with consumption of buffalofish (Ictiobus spp.) in the United States, 2010-2020, with confirmation of the causative species

BACKGROUND

In the United States, buffalofish (Ictiobus spp.) are sporadically associated with sudden onset muscle pain and weakness due to rhabdomyolysis within 24 h of fish consumption (Haff disease). Previous genetic analyses of case-associated samples were unable to distinguish the three species of buffalofish that occur in the US, Ictiobus cyprinellus (bigmouth buffalo), Ictiobus bubalus (smallmouth buffalo), and Ictiobus niger (black buffalo).

METHODS

Ten events were investigated between 2010 and 2020 and demographic and clinical information was collected for 24 individuals. Meal remnants were collected from 5 of 10 events with additional associated samples (n = 24) collected from another five of 10 events. Low-coverage whole-genome sequencing (genome skimming) was used to identify meal remnants.

RESULTS

Patients (26-75 years of age) ranged from 1-4 per event, with 90% involving ≥2 individuals. Reported symptoms included muscle tenderness and weakness, nausea/vomiting, and brown/tea-colored urine. Median incubation period was 8 h. Ninety-six percent of cases were hospitalized with a median duration of four days. The most commonly reported laboratory finding was elevated creatine phosphokinase and liver transaminases. Treatment was supportive including intravenous fluids to prevent renal failure. Events occurred in California (1), Illinois (2), Louisiana (1), New York (1), Mississippi (1), Missouri (2), New Jersey (1), and Texas (1) with location of harvest, when known, being Illinois, Louisiana, Mississippi, Missouri, Texas, and Wisconsin. Meal remnants were identified as I. bubalus (n = 4) and I. niger (n = 1). Associated samples were identified as I. bubalus (n = 16), I. cyprinellus (n = 5), and I. niger (n = 3).

DISCUSSION

Time course, presentation of illness, and clinical findings were all consistent with previous domestic cases of buffalofish-associated Haff disease. In contrast to previous reports that I. cyprinellus is the causative species in US cases, data indicate that all three buffalofish species are harvested but I. bubalus is most often associated with illness.

Efficacy of Active Charcoal and Mannitol in Patients with Haff Disease Caused by the Consumption of Crayfish (Procambarus clarkii): A Retrospective Cohort Study

This study evaluates the clinical efficacy of activated charcoal combined with mannitol (ACM) for the treatment of Haff disease. This is a retrospective cohort study conducted at the Emergency Department of Affiliated Hospital of Integrated Traditional Chinese and Western Medicine. Consecutive patients who were hospitalized during a two-year time frame (from June 2016 to August 2017) and diagnosed with Haff disease were reviewed. Clinical symptoms, laboratory findings, pain/anxiety scores, and treatment-related adverse events were collected. Sixty-eight Haff disease patients after boiled crayfish consumption were enrolled in this study. Besides standard treatments for Haff disease, 22 patients had an oral administration of activated charcoal and mannitol within 12 hours of hospital admission (ACM group), while the other 46 patients did not receive such treatment (non-ACM group). Baseline characteristics including clinical symptoms, serum enzyme levels, and pain/anxiety scores were comparable between the two groups. Activated charcoal and mannitol treatment led to lower CK-MB and AST levels from 12 hours to 60 hours, lower ALT and LDH levels from 12 hours to 72 hours, and lower CK levels from 24 hours to 72 hours after hospitalization. Patients in the ACM group had significantly shortened duration of hospital stays (7.5 [6.0–8.0] days vs 8.0 [6.8–10.0] days, p = 0.032) and lower anxiety scores 24 hours after hospital admission (40.7 ± 4.9 vs 44.1 ± 6.3, p = 0.032) than in the non-ACM group. No patient experienced treatment-related adverse events. The overall prognosis of both groups is good. Among patients with Haff disease caused by boiled crayfish, activated charcoal combined with mannitol treatment resulted in shorter hospital stays, lower serum CK, CK-MB, AST, ALT, and LDH levels, and lower anxiety scores.

Clinical features of Haff disease and myositis after the consumption of boiled brackish water crayfish: a retrospective study of 96 cases at a single centre

The present study describes the difference in clinical features between the patients with Haff disease and crayfish-related myositis (CRM) after crayfish consumption. This was a single-centre, retrospective analysis at the Emergency Department of the Drum Tower Hospital of Nanjing University School of Medicine from July to August of 2016. The baseline information came from the Electronic Medical Record System at the institution. Totally 96 patients were included, of whom 52 patients were confirmed to have Haff disease and 44 patients were CRM. The illness predominately occurs in summer and most of them (55/96) are female. The primary clinical features are myalgia, muscle allodynia and back and body pain. Statistical differences in the baseline CK, CK-MB, myoglobin, and the WBC count exist between the Haff disease and CRM groups (P < 0.05). The serum levels of CK and CK-MB increase in the second (a median time 29.2 ± 7.4 h) or third day (a median time 54.8 ± 9.3 h) of disease course, and then rapidly decreased to normal levels, while the levels of myoglobin peak at the admission (a median time 7.7 ± 6.4 h) and became normal after admission. There were no fatalities or complications during this study. All 96 patients recovered in a week. Of them, 75 were followed-up within 1 month and none had recurrence. The Haff disease and CRM after boiled crayfish consumption reflect a different severity of muscle injury, and reveal similar clinical characteristics and most of the laboratory values. The overall prognosis of both is good.

Outbreak of Haff disease caused by consumption of crayfish (Procambarus clarkii) in nanjing, China

CONTEXT

This paper reports a detailed epidemiological investigation of a large Haff disease outbreak in Nanjing, China, including laboratory analysis of water, river sediment, and fish.

METHODS

Structured questionnaires were administered to all case-patients. An unmatched case-control study was conducted to identify the factors affecting the incidence of Haff disease. Thirteen samples of crayfish, together with four samples of water and four samples of sediment were collected and sent for laboratory analysis.

RESULTS

The disease onset of 494 patients occurred between 2 am on 30 June 2016 and 3 am on 29 August 2016. The median incubation time for onset of symptoms after crayfish ingestion was 7.1 hours (range: 1-20 hours). All patients presented with or developed local or diffuse myalgia. However, no kidney injury was observed. Serum creatinine kinase was elevated in all patients (mean: 4614 U/L, median: 2000 U/L, range: 81-55200 U/L). The average number of crayfish consumed by patients on the day of illness was 20 (2-80). The case-control study revealed that eating a large quantity of crayfish, drinking alcohol, and eating the crayfish head and/or intestines were associated with an increased risk of disease. Chemical analysis of crayfish, river water and sediment did not identify known or novel toxins including anticoccidiosis drugs, niclosamide, organophosphorus pesticides, and microcystins.

CONCLUSION

An outbreak of Haff Disease was associated with consumption of crayfish from the Yangtze River and its surrounding water system. Eating a large quantity of crayfish, eating the head and/or intestines, and consuming alcohol with the crayfish were associated with the development of Haff Disease.

Clinical and laboratory evidence of Haff disease - case series from an outbreak in Salvador, Brazil, December 2016 to April 2017

We describe a series of 15 Haff disease cases from an outbreak in Salvador, Brazil, starting early December 2016. Eleven cases were grouped in four family clusters of two to four individuals, four were isolated cases. All but one patient consumed cooked fish; 11 within 24h before symptoms onset. Cases consumed ‘Olho de Boi’ (Seriola spp.) and ’Badejo’ (Mycteroperca spp.). A total of 67 cases were detected, the last case was reported on 5 April 2017.

Diagnostic evaluation of rhabdomyolysis

Rhabdomyolysis is characterized by severe acute muscle injury resulting in muscle pain, weakness, and/or swelling with release of myofiber contents into the bloodstream. Symptoms develop over hours to days after an inciting factor and may be associated with dark pigmentation of the urine. Serum creatine kinase and urine myoglobin levels are markedly elevated. Clinical examination, history, laboratory studies, muscle biopsy, and genetic testing are useful tools for diagnosis of rhabdomyolysis, and they can help differentiate acquired from inherited causes of rhabdomyolysis. Acquired causes include substance abuse, medication or toxic exposures, electrolyte abnormalities, endocrine disturbances, and autoimmune myopathies. Inherited predisposition to rhabdomyolysis can occur with disorders of glycogen metabolism, fatty acid β-oxidation, and mitochondrial oxidative phosphorylation. Less common inherited causes of rhabdomyolysis include structural myopathies, channelopathies, and sickle-cell disease. This review focuses on the differentiation of acquired and inherited causes of rhabdomyolysis and proposes a practical diagnostic algorithm. Muscle Nerve 51: 793-810, 2015.