Haff Disease After Eating Salmon:

Surveillance for rhabdomyolysis after the consumption of crayfish in Wuhan, China, 2016-2022

Objectives

To analyze the epidemiological characteristics and etiology of crayfish-related rhabdomyolysis.

Methods

Cases of crayfish-related rhabdomyolysis in Wuhan were monitored, and professional training of city's surveillance personnel was conducted. Unified questionnaires were used to collect data.

Results

The first case of crayfish-related rhabdomyolysis occurred on July 12, 2016. Subsequently, 423 patients were reported over the next 7 years, with muscle pain, weakness, and chest distress as main symptoms. In total, 64.54% (273/423) of patients were females, and young adults (aged 20-49 years) account for 86.22% (363/423) of patients. The primary clinical presentations were muscle pain, muscle weakness, and chest discomfort. The median incubation time was 6 h. And the number of cases may be related to water levels in Yangzi river. Laboratory tests revealed elevated creatine kinase and myoglobin levels. In total, 95.16% (236/248) of patients had consumed crayfish tail shrimp and 91.53% (227/248) had consumed crayfish liver and pancreas (Female crayfish also contain ovaries). Only 25.00% (62/248) of patients had a history of alcohol consumption. On average, 227 patients consumed 15 (3-50) crayfish, of whom 84.14% (191/227) consumed more than 10 crayfish. All patients had a favorable prognosis.

Conclusion

Crayfish-related rhabdomyolysis is a kind of a case or cluster of patients present with severe myalgia or weakness of unknown etiology and mechanism disease in Wuhan, China, 2016-2022. Excessive consumption of crayfish may be a risk factor for the disease. The relationship between the specific parts of crayfish consumed and the onset of the disease is unclear, suggesting further research is needed to identify the relevant risk factors for the 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.

Haff Disease in Salvador, Brazil, 2016-2021: Attack rate and detection of toxin in fish samples collected during outbreaks and disease surveillance

Background

From late 2016 to early 2021, cases of Haff disease, a rare cause of rhabdomyolysis, possibly due to poisoning by palytoxin-like compounds in seafood, were detected in Salvador, Brazil. Surveillance was established to detect additional cases aiming at describing the clinical characteristics of the cases, identifying associated factors, estimating disease attack rate, and investigating the presence of biotoxins and trace metals in selected fish specimens obtained from cases.

Method

Between December/2016-January/2021, surveillance investigated Haff disease suspected cases, and obtained clinical and fish samples to test.

Findings

Of 65 cases investigated during the 2016-2017 outbreak, 43 (66%) had high creatine phosphokinase (CPK) levels. Among those with laboratory-confirmed rhabdomyolysis, 38 (88%) were hospitalized, 11 (26%) required intensive care, and three (7%) dialysis. Ingestion of marine fish 24h before disease onset was reported by 74% of the cases with elevated CPK and by 41% of those without CPK measurement (P=0·02). Attack rate for individuals who ate fish related to the outbreak was 55%. Following this outbreak, surveillance identified 12 suspected cases between 2017-2019, and a second outbreak in 2020-2021, with 16 laboratory-confirmed rhabdomyolysis patients (five required intensive care; one died). No traces of ciguatoxins and metals were detected in fish specimens obtained in 2016, found to be Seriola rivoliana. Some fish samples from 2020 were screened for palytoxin (PlTX)-like compounds and contained detectable levels of molecule fragments characteristics of isobaric PlTX, ovatoxin-a (OVTX-a), OVTX-b and OVTX-d.

Interpretation

These findings support the hypothesis that compounds related to PlTX accumulated in marine fish may be the toxic agent causing the disease. Haff disease is a life-threatening condition, requiring clinical suspicion for patients with sudden-onset myalgia following fish ingestion. Suspected cases should be reported to health authorities for investigation.

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.

Elevated Liver Enzymes as a Manifestation of Haff Disease

BACKGROUND

Haff disease is a rare syndrome of rhabdomyolysis thought to be caused by a heat-stable toxin associated with the consumption of seafood from fresh or brackish water.

CASE REPORT

We present the case of a patient with Haff disease who presented to the emergency department with nausea/vomiting, diarrhea, and myalgias after a seafood buffet. Initially, he was treated with i.v. fluids and antiemetics for presumed gastroenteritis, but his symptoms did not improve. He was found to have elevated aspartate aminotransferase and alanine aminotransferase, normal point-of-care ultrasound, urinalysis with large blood and no red blood cells, and an elevated creatine phosphokinase (CPK). He was admitted to the hospital to receive ongoing fluid resuscitation for rhabdomyolysis presumed to be from fish. Liver enzymes and CPK downtrended, and patient was discharged on hospital day 3. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Undiagnosed Haff disease has important clinical implications, including multi-organ failure and death. Always maintain a high level of suspicion for Haff disease in patients with symptoms suggestive of gastroenteritis, but complicated by minor liver function test elevations and dipstick positivity for heme, without significant numbers of red blood cells per high-power field, in the setting of recent seafood ingestion.

[Chemical burns caused by crust anemone]

We present a case of a toxic reaction in both eyes caused by secretions from an encrusting anemone of the genus Protopalythoa. The patient presented with chemosis and follicular reaction of the conjunctiva and whitish spots on the limbus. Under local treatment with steroids and antibiotic eyedrops, remission was achieved within a few days. Palytoxin, a poisonous component of Protopalythoa secretions, leads to inhibition of the sodium-potassium-ATPase, to destabilization of the membrane potential and to cell death. Ocular exposure can lead to severe anatomical and functional impairments with systemic symptoms.

A Retrospective Analysis of Crayfish-Related Rhabdomyolysis (Haff Disease)

OBJECTIVE

To investigate the epidemiologic and etiologic factors, clinical features, therapeutic regimen, and prognosis of crayfish-related rhabdomyolysis (Haff disease).

METHODS

Retrospectively analyzed the clinical data of 29 patients with crayfish-related rhabdomyolysis (Haff disease) from July to August 2016, summarized the clinical characteristics, and evaluated the prognosis.

RESULTS

Clinical data of a total of 29 cases of Haff disease were retrospectively analyzed. The disease onset occurred after consumption of cooked crayfish with the incubation period ranging from 1 h to 48 h. There were no gender differences and significantly elevated CK in the duration with peak value of 41575.0U/L; the median value was 2445.0U/L (range: from 1187.0 U/L to 4722.0 U/L) and there was coincident elevated CK-MB. There was also no hepatorenal damage and transient urinalysis was abnormal. The most common presenting symptoms were myalgia (100%), weakness and numbness (51.7%), chest tightness and chest pain (41.4%), back pain (41.4%), and extremities pain (37.9%). All the patients recovered and no patients died.

CONCLUSIONS

Crayfish-related rhabdomyolysis (Haff disease) is a kind of a case or cluster of patients present with severe myalgia or weakness of unknown etiology and mechanism disease; however, the clinical signs and symptoms are relatively mild with favorable outcome.

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.

Two Cases of Rhabdomyolysis (Haff Disease) After Eating Carp Fish

Unexplained rhabdomyolysis after eating fish is a rare condition caused by an unidentified toxin. Most of the incidences in the United States have been linked to consuming buffalo fish or crawfish. We present 2 cases of Haff disease in which the patients consumed grass carp as opposed to the usual suspects of buffalo fish or crawfish.

Haff disease complicated by multiple organ failure after crayfish consumption: a case study

Haff disease is a syndrome consisting of unexplained rhabdomyolysis. Patients suffering from Haff disease report having eaten fish within 24 hours before the onset of illness. Most patients survive and recover quickly. The present study is the first report of Haff disease complicated by multiple organ failure after crayfish consumption. A 66-year-old Chinese man ate cooked crayfish on the night of June 23, 2013. He arrived at our hospital 2 days later and was admitted to the intensive care unit. After admission, the patient was diagnosed with Haff disease complicated by multiple organ failure. Despite supportive and symptomatic treatments, the condition of the patient deteriorated, and he died due to his illness. Haff disease is a rare clinical syndrome that is sometimes misdiagnosed. Early diagnosis and proper treatment are essential to prevent progression to multiple organ failure.

Haff disease associated with the ingestion of the freshwater fish Mylossoma duriventre (pacu-manteiga)

Haff disease associated rhabdomyolysis is correlated with the ingestion of certain freshwater fish and shellfish and is caused by an unidentified toxin. We report the case of a patient who experienced rhabdomyolysis approximately 2 hours after ingestion of the freshwater fish Mylossoma duriventre (pacu-manteiga) approximately 3 years after an outbreak had been reported in Manaus, Brazilian Amazon.

Haff disease: rhabdomyolysis after eating buffalo fish

Haff disease, rhabdomyolysis after ingesting certain types of fish, was first reported in 1924 in Europe. There have been a limited number of cases reported in the United States. We present the case of a patient who presents with symptoms of rhabdomyolysis after eating cooked buffalo fish purchased at a suburban grocery market.

A past Haff disease outbreak associated with eating freshwater pomfret in South China

Background

Haff disease is unexplained rhabdomyolysis caused by consumption of fishery products in the previous 24 h. It was first identified in Europe in 1924 but the condition is extremely rare in China. Here we describe a past outbreak of acute food borne muscle poisoning that occurred in Guangdong Province (South China) in 2009.

Methods

The first full outbreak of Haff disease reported in Jiangsu Province (East China) in 2010, indicated that the incidence of the disease may be increasing in China. We, therefore first retrospectively reviewed epidemiologic, trace-back, environmental studies, and laboratory analyses, including oral toxicity testing to ascertain risk and chemical analysis to identify toxin(s), from the 2009 Guangdong outbreak. Then we compared data from the 2009 outbreak with data from all other Haff disease outbreaks that were available.

Results

Clinical symptoms and laboratory findings indicated that the 2009 Guangdong outbreak disease was consistent with rhabdomyolysis. Epidemiologic, trace-back, environmental studies and laboratory analyses implied that the disease was caused by freshwater Pomfrets consumed prior to the onset of symptoms. We also identified common factors between the 2009 Guangdong outbreak and previous Haff disease outbreaks reported around the world, while as with other similar outbreaks, the exact etiological factor(s) of the disease remains unknown.

Conclusions

The 2009 Guangdong outbreak of ‘muscle poisoning’ was retrospectively identified as an outbreak of Haff disease. This comprised the highest number of cases reported in China thus far. Food borne diseases emerging in this unusual form and the irregular pattern of outbreaks present an ongoing public health risk, highlighting the need for improved surveillance and diagnostic methodology.

Haff disease after eating crayfish in east China

Haff disease, first identified in Europe, is unexplained rhabdomyolysis in a person who ingested fish within the 24 hours before onset of illness. Cases of Haff disease after the consumption of fresh water fish have never been reported in China but have been frequently reported from the Baltic region. We first describe five cases of muscle weakness and rhabdomyolysis that occurred after eating crayfish in China and discuss the different epidemiologic and etiologic aspects of this disease.

Rapid isolation of single-chain antibodies by phage display technology directed against one of the most potent marine toxins: Palytoxin

Several recombinant antibodies against one of the most potent marine toxins, Palytoxin (PlTX), were obtained using two naive human semi-synthetic phage display libraries (Tomlinson I and J) as an effective method for generating specific anti-toxin single-chain variable fragment (scFv) antibodies. After four rounds of panning and selection on free palytoxin adsorbed immunotubes, individual clones were isolated, sequenced and characterized by Enzyme-Linked Immunosorbent Assay (ELISA). Four phage-antibody clones specifically recognized the toxin. A competitive ELISA assay was optimized with one of these phage antibodies giving a very reproducible standard curve with a linear regression (R(2)=0.9945), showing a working range of 0.0005-500ngmL(-1). Several spiked shellfish samples were analysed by competitive ELISA to determine the accuracy of the assay, with a mean recovery rate of 90%. This study demonstrates that phage display libraries provide a valuable system for the easy and rapid generation of specific antibody fragments directed against difficult antigenic targets, such as free small molecules. Large-scale, low-cost production of anti-palytoxin scFv antibodies in Escherichia coli (E. coli) is an exciting prospect for the development of rapid and simple detection methods. Our results suggest that anti-palytoxin phage antibodies could be a valuable tool with competitive ELISA to detect palytoxin in natural shellfish samples.