Lab Evidence Confirms Outbreak of Haff Disease

Haff disease is a syndrome of unexplained rhabdomyolysis following consumption of certain types of fish, and it is caused by an unidentified toxin. Rhabdomyolysis is a clinical syndrome caused by injury to skeletal muscle that results in release of muscle cell contents into the circulation.

Cases of Haff disease were first described in 1924, in the Baltic region of Prussia and Sweden and involved the consumption of different cooked freshwater fish, such as burbot, pike and freshwater eel. In the USA, the first cases of Haff disease were reported in Texas in 1984, and six additional cases of Haff disease were reported in patients from California and Missouri, who had eaten buffalo fish.

A team of Brazilian scientists led by those at the Faculdade de Tecnologia e Ciencias Medical School (Salvador, Brazil) have presented data on an 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, and four were isolated cases. The investigators reported that all but one of the patient consumed cooked fish; 11 within 24 hours 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 April 5, 2017.

The scientists performed serial measurements of muscle enzymes, such as creatine phosphokinase (CPK), aspartate aminotransferase (AST), alanine aminotransferase (ALT) and lactate dehydrogenase (LDH) in all patients. In addition, troponin I levels and creatine kinase-MB (CK-MB) fractions were measured in three and two cases, respectively. They screened 10 patients for chikungunya and Zika virus RNA. Sequencing was performed by a sequencing facility using the ABI-Prism 3500 genetic analyzer.

The team found that CPK levels at presentation ranged from 743 to 105,755 U/L, which was extremely elevated, and decreased rapidly on subsequent days in parallel with the improvement of symptoms. Troponin I levels were less than 0.034 ng/mL in all patients with measurements. CK-MB fraction ranged from 1.9% to 6.3%. Reverse transcription polymerase chain reaction (RT-PCR) for chikungunya and Zika viruses, as well as nested RT-PCR for parechovirus, yielded negative results for all patients in all types of samples. The RT-PCR for enterovirus generated non-specific products in four samples. However, upon analysis of the sequenced fragments no virus could be identified.

The authors concluded that it is important for travel medicine physicians to be alert in case of patients returning from Salvador, Brazil, with myalgia and symptoms of rhabdomyolysis to consider Haff disease as a possible differential diagnosis. Care should also be taken when treating these patients so as to avoid non-steroidal anti-inflammatory agents because of possible concurrent renal toxicity. The study was published on June 15, 2017, in the journal Eurosurveillance.

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Faculdade de Tecnologia e Ciencias Medical School