Outbreak of Haff Disease caused by consumption of crayfish (Procambarus clarkii), Nanjing, Jiangsu Province, China

The Accumulation of Toxic Elements (Pb, Hg, Cd, As, and Cu) in Red Swamp Crayfish (Procambarus clarkii) in Qianjiang and the Associated Risks to Human Health

Due to rapidly expanding crayfish consumption worldwide, the food safety of red swamp crayfish (Procambarus clarkii) is of great concern. China is the largest consumer and producer of crayfish globally. As of yet, it is unknown whether the main crayfish production cities in China are within safe levels of toxic heavy metals and metalloids. For 16 consecutive years, Qianjiang city ranked first in China in processing export volumes of red swamp crayfish. This study presents a comprehensive analysis of the enrichment levels and associated health risks of the species in Qianjiang. In our research, samples of four crayfish tissues, including the head, hepatopancreas, gills, and muscles, were collected from 38 sampling sites distributed in Qianjiang to evaluate the concentration levels of five heavy metals (Pb, Hg, Cd, As, and Cu). The concentration levels of all five metals in muscle did not surpass the national standard. Furthermore, eight significant correlations have been found. For further in-depth assess risk of crayfish in Qianjiang, estimated daily intake (EDI), target hazard quotient (THQ), carcinogenic risk (CR), and estimated maximum allowable consumption rates (CR_mm) were evaluated in the abdomen muscle and hepatopancreas. The THQ values for each metal were found to be less than 1, while the CR values were below 10^-6. Additionally, the CR_mm for adults was determined to be 17.2 meals per month. These findings, based on the analysis of five metallic elements included in this study, suggest that the consumption of crayfish abdomen muscle in Qianjiang does not pose any significant health risks. However, it is noteworthy that certain regions exhibit elevated levels of arsenic in the hepatopancreas, surpassing the national standard, thereby rendering them unsuitable for excessive consumption. In general, the findings can be used to provide guidance for safe dietary practices in China.

Trace elements in red swamp crayfish (Procambarus clarkii) in China: Spatiotemporal variation and human health implications

The enrichment and health risk assessment of trace elements in crayfish on a national scale are significant for food safety due to the rapidly expanding crayfish consumption in China. In the present study, 4709 samples were extracted from databases to explore the spatiotemporal variation characteristics of trace elements in crayfish. Due to the variance in the background value of trace elements, the level of trace elements varies by region. Additionally, levels of As and Cr in crayfish increased with the promotion of intensive rice-crayfish coculture in China. Health risk assessment results revealed that trace elements may cause non-carcinogenic risk for crayfish consumption for adults and children from the mid-lower reaches of the Yangtze River, and the main risk was from As and Hg. The cancer risk values of As for children and adults in Zhejiang, Anhui, Heilongjiang, Hubei, Hunan, Jiangsu, Jiangxi and Shandong provinces were above the allowable value. There is concern about the non-carcinogenic and carcinogenic risk of consuming crayfish containing trace elements in some areas in China. Therefore, the results can serve as a critical reference for policy purposes in China. In addition, it is recommended that further research and assessment on crayfish consumption are required.

Development and Validation of an Ultra-Performance Liquid Chromatography-Tandem Mass Spectrometry Method to Determine Maduramicin in Crayfish (Procambarus clarkii) and Evaluate Food Safety

Maduramicin (MAD) is widely introduced into aquatic environments and results in the contamination of fish products. Worryingly, the consumption of MAD-contaminated crayfish (Procambarus clarkii) may induce symptoms of Haff disease. In this study, to monitor this potential contamination and to understand the residue and elimination characteristics of MAD in edible tissues of crayfish, a sensitive and efficient ultra-performance liquid chromatography-tandem mass spectrometry method was developed, validated, and applied. After extraction with acetonitrile and purification by solid-phase extraction column, multiple-reaction monitoring mass spectrometry with positive ionization mode was used to determine MAD's residues. The limits of detection and of quantification were 6 μg·kg^-1 and 20 μg·kg^-1, respectively. The fortified recoveries ranged from 74.2% to 110.4%, with relative standard deviation of 1.2% to 10.1%. Furthermore, MAD was completely eliminated after 3 and 5 days from abdominal muscle and hepatopancreas tissues of crayfish, respectively. The maximum residue limits (MRLs) of MAD respectively was 200 μg·kg^-1 in muscle and 600 μg·kg^-1 in the hepatopancreas, and its withdrawal time in both edible tissues was 25.8 °C·d. Collectively, the results of this study indicate the proposed method is an efficient tool to evaluate the public health risk associated with crayfish consumption.

Outbreak of Haff Disease along the Yangtze River, Anhui Province, China, 2016

We investigated a large outbreak of Haff disease that occurred along the Yangtze River in Anhui Province, China, in 2016. Of the 672 cases identified during the outbreak, 83.3% (560/672) occurred in Wuhu and Ma’anshan. Patients experienced myalgia (100%) and muscle weakness (54.7%). The mean value of myoglobin was 330 + 121.2 ng/mL and of serum creatine kinase 5,439.2 + 4,765.1 U/L. Eating crayfish was the only common exposure among all cases; 96.8% (240/248) of implicated crayfish were caught on the shores of the Yangtze River or its connected ditches. Mean incubation period was 6.2 + 3.8 hours. This case–control study demonstrated that eating the liver of crayfish and eating a large quantity of crayfish were associated with an increased risk for Haff disease. The seasonal increases in crayfish population along the Yangtze River might explain the seasonal outbreaks of Haff disease.

Ionophore Toxin Maduramicin Produces Haff Disease-Like Rhabdomyolysis in a Mouse Model

Maduramicin is a toxic ionophore antibiotic that is isolated from Streptomyces, frequently occurring in an aquatic environment. To understand the potential role of maduramicin in crayfish consumption related Haff disease, a mouse model was established in this study. Two exposure routes of maduramicin in the abdominal muscle and the hepatopancreas tissue homogenates of crayfish were given intragastrically to mice in different doses for seven days. Action changes, clinical symptoms, feed consumption, body weight, blood biochemistry, and histopathology examination of mice were observed and analyzed. In the natural exposure group, relatively low concentration of maduramicin in crayfish muscle and hepatopancreas had no obvious effects on mental state, body weight, blood biochemical indexes, or histologic appearance. However, in the artificial exposure group, with increasing concentrations, maduramicin in crayfish muscle and hepatopancreas homogenates both induced mental sluggishness and weight loss of mice. Blood biochemical examination showed that 3.5 mg·kg-1 and 7 mg·kg-1 maduramicin in crayfish tissue homogenates significantly increased levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), blood urea nitrogen (BUN), lactate dehydrogenase (LDH), and creatine kinase (CK). Additionally, histopathological examination showed that multiple organs were damaged by maduramicin, including degeneration of liver cells, shedding of renal epithelial cells, and disturbance and partial lysis of myocardial and skeletal muscle filaments in the mice. In summary, maduramicin may not cause Haff disease through contamination of the aquatic environment under normal conditions. Maduramicin can be used as a potential toxin tool to establish a rhabdomyolysis disease animal model for drug development.

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.

A cluster of patients with rhabdomyolysis after eating crayfish

Crayfish or Procambarus clarkii is a freshwater crustacean with worldwide distribution. Tons of crayfish are consumed each year. In this report, four adult patients with rhabdomyolysis after consuming crayfish were described. All of them presented to the emergency department with myalgia. The diagnosis of rhabdomyolysis was supported by an elevated creatine kinase level. All recovered with supportive treatment. The clinical picture of these 4 patients was compatible with Haff disease. Haff disease is a syndrome in which rhabdomyolysis develops subsequent to consumption of certain cooked seafood. Crayfish is a common culprit. Diagnosis depends on obtaining a diet history and creatine kinase level. Most patients recover uneventfully with supportive treatment for rhabdomyolysis.

The Emergence and Epidemiology of Haff Disease in China

Haff disease is a rare syndrome of unexplained myalgia and rhabdomyolysis occurring within 24 h of consumption of certain types of cooked freshwater fish or crustacean. It is caused by a yet unidentified heat-stable toxin. In the present review of published case studies and official press releases, the main objective is to report the emergence and epidemiology of Haff disease in China. Haff disease first occurred in Beijing in 2000 and in Lianzhou and Liannan, Guangdong Province in 2009. Subsequent outbreaks mostly occurred in the Jiangsu Province—Nanjing, Yangzhou, Huai’an, and Yancheng. Isolated outbreaks occurred in other cities since 2010—Shijiazhuang, Yueyang, Shanghai, Wuhu, Baoding, Shenzhen, and Hong Kong (imported cases from Shenzhen). Outbreaks occurred predominately in the summer. Crayfish accounted for almost all the outbreaks. Two large outbreaks occurred in Lianzhou and Liannan in 2009 (n = 54) after eating pomfrets and in Nanjing in 2010 (n = 42) after eating crayfish. Other reports or outbreaks involved only 1–9 subjects (median 2 subjects). Variability in individual susceptibility and attack rates were noted, with many subjects remaining asymptomatic despite sharing the same seafood meal as the index cases. Adults were predominately involved. Symptoms occurred within 3–20 h of seafood ingestion, including myalgia, weakness, and, less frequently, nausea, vomiting, abdominal pain, and diarrhea. Myalgia and muscle weakness should normally subside within 2–3 days. Serum creatine phosphokinase became normal within 5–6 days. Abnormal renal function was uncommon. Serious complications (renal failure, multi-organ failure, and prolonged myopathy) and death were rare. In any subjects with unexplained myalgia and rhabdomyolysis, seafood consumption should be included in the history. All suspected cases of Haff disease, including milder presentations, should be reported to public health authorities.