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Multi System Failure Case Study

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

Doença de Haff complicada por falência de múltiplos órgãos após ingestão de lagostim: estudo de caso

Gang Feng,1Qiancheng Luo,1Ping Zhuang,1Enwei Guo,1Yulan Yao,1 and Zhongyu Gao2,3

1Intensive Care Unit, Gongli Hospital, Second Military Medical University, Pudong New Area - Shanghai, China.

2Office of Teaching, Gongli Hospital, Second Military Medical University, Pudong New Area - Shanghai, China.

3Department of General Surgery, Gongli Hospital, Second Military Medical University, Pudong New Area - Shanghai, China.

Corresponding author: Zhongyu Gao, Gongli Hospital, Second Military Medical University, Pudong New Area, Nº 219, Miaopu Road, Gongli, Shanghai, 200135, China. E-mail: moc.liamtoh@oaguygnohz

Author information ►Article notes ►Copyright and License information ►

Received 2014 Jun 30; Accepted 2014 Aug 2.

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This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract

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.

Keywords: Rhabdomyolysis, Astacoidea, Eating, Case reports

Abstract

A doença de Haff é uma síndrome que consiste de rabdomiólise não explicada. Pacientes que apresentam a doença de Haff relatam ter ingerido pescado nas últimas 24 horas antes do início da doença. A maioria dos pacientes sobrevive apresentando breve recuperação. O presente artigo é o primeiro relato de doença de Haff complicada por falência de múltiplos órgãos após ingestão de lagostim. Um homem chinês de 66 anos de idade ingeriu lagostim cozido na noite de 23 de junho de 2013. Chegou ao hospital 2 dias mais tarde, sendo admitido à unidade de terapia intensiva. Após a admissão, o paciente recebeu o diagnóstico de doença de Haff complicada por falência de múltiplos órgãos. Apesar dos tratamentos de suporte e sintomático, a condição do paciente deteriorou, vindo o mesmo a falecer em consequência da doença. A doença de Haff é uma rara síndrome clínica que é, às vezes, mal diagnosticada. O diagnóstico precoce e o tratamento adequado são essenciais para prevenir a progressão para falência de múltiplos órgãos.

INTRODUCTION

Haff disease was first reported in the Baltic region in 1924 and is defined as unexplained rhabdomyolysis in a person who consumed fish within 24 hours before the onset of symptoms.(1) Since the first report, outbreaks of Haff disease have been reported in Sweden, the former Soviet Union, the United States, Brazil, and China.(2-5) Haff disease is a rare clinical syndrome. If patients receive prompt treatment, the prognosis is good. This paper reports a case of severe Haff disease complicated by multiple organ failure caused by eating crayfish.

CASE PRESENTATION

A 66-year-old man with a 20-year history of hypertension ate cooked crayfish from a local seafood market on the night of June 23, 2013. Twelve hours later, he began to feel back pain and was misdiagnosed with lumbar disc disease. The patient felt better after analgesic therapy at a local hospital. At 8:00 on the morning of June 25, 2013, the patient developed diffuse myalgia accompanied by weakness and rigidity of the limbs, oliguria, coffee-colored urine, and shortness of breath. He arrived at our hospital and was admitted to the intensive care unit (ICU). Physical examination upon admission revealed a body temperature of 37° C, pulse of 110 beat/min, respiratory rate of 30/min, blood pressure of 100/60mmHg, bilateral slight yellowing of the sclera, rapid and shallow respirations, and a few rales in the lungs bilaterally. The patient presented obvious full-body muscular tenderness, but no neurological abnormalities, splenomegaly, or hepatomegaly were observed. Laboratory tests revealed elevated white blood cell count at 20.10×109/L (Table 1). Urobilirubin and urobilinogen were negative. Electrocardiography revealed sinus tachycardia. Computed tomography (CT) revealed exudate in the right middle lung lobe, the lingula of the left lung, and the lower lobes bilaterally. Distension and fluid retention were observed in the esophagus and stomach, as well as reduced liver density. Low-density shadowing and exudation and swelling changes were present in muscle tissues (latissimus dorsi, subscapular muscle, bilateral psoas major, iliopsoas, gluteus maximus, and abdominal muscles), accompanied by unclear muscle borders (Figure 1).

Table 1

Test results at hospital admission

Figure 1

Computed tomography showing low-density shadows, exudation and swelling changes in muscle tissues (latissimus dorsi and subscapular muscle, bilateral psoas major muscles, iliopsoas, gluteus maximus, and abdominal muscles) accompanied by unclear muscle...

After admission, the patient was diagnosed with Haff disease complicated by multiple organ failure. Treatment included endotracheal intubation with artificial ventilation, infusions of dopamine and norepinephrine to increase blood pressure, methylprednisolone to inhibit the inflammatory response, omeprazole to prevent stress ulcers, sodium bicarbonate to alkalize the urine, and other supportive and symptomatic treatments. Despite treatment, the condition of the patient deteriorated and he died at 22:00 on the evening of June 25, 2013.

DISCUSSION

Haff disease is a syndrome consisting of unexplained rhabdomyolysis characterized by sudden, extreme muscular rigidity, diffuse myalgia, chest pain, shortness of breath, full-body numbness and weakness, and coffee-colored urine, as well as elevated serum creatine kinase, myoglobin, transaminases, and lactate dehydrogenase. Generally, neurological abnormalities, fever, splenomegaly, or hepatomegaly are not observed.(1-5) All patients suffering from Haff disease report a history of eating fish (pomfret, buffalo, or crayfish) within 24 hours before the onset of illness.(6,7) A few patients have died from Haff disease, but most survive and recover quickly.

The present case is the first report of Haff disease complicated by multiple organ failure after crayfish consumption. The outcome of this case of severe Haff disease may be the consequence of an initial misdiagnosis and treatment delay. The patient was initially misdiagnosed with lumbar disc disease and received only analgesic therapy. Multiple organ failure developed because of the delayed treatment. Early diagnosis and proper treatment are essential to improving the prognosis for patients with Haff disease.

The etiology of Haff disease remains unclear. One possible cause is an unknown heat-stable biological toxin that accumulates in the implicated food, but the toxin has not yet been identified. This putative biological toxin causes rhabdomyolysis, renal dysfunction, and coagulation abnormalities, and it damages the liver, respiratory system, and gastrointestinal tract. Striated muscle damage leads to full-body myalgia, weakness, and muscle rigidity. Carbon dioxide retention and respiratory failure occur due to respiratory muscle weakness. When Haff disease is suspected, proper treatment should be initiated as soon as possible to prevent deterioration in the condition of the patient. A CT scan of our patient revealed low-density shadow, exudation, and swelling changes in the muscle tissues throughout the body. CT can be performed as a painless, noninvasive method of confirming a diagnosis of Haff disease.

CONCLUSION

This is the first report of Haff disease complicated by multiple organ failure after crayfish consumption. Early diagnosis and proper treatment are essential to prevent progression to multiple organ failure. Computed tomography can be used to confirm a diagnosis of Haff disease.

Footnotes

Conflicts of interest: None.

Responsible editor: Rui Moreno

REFERENCES

1. Buchholz U, Mouzin E, Dickey R, Moolenaar R, Sass N, Mascola L. Haff disease: from the Baltic Sea to the U.S. shore. Emerg Infect Dis. 2000;6(2):192–195.[PMC free article][PubMed]

2. Berlin R. Haff disease in Sweden. Acta Med Scand. 1948;129(6):560–572.[PubMed]

3. dos Santos MC, de Albuquerque BC, Pinto RC, Aguiar GP, Lescano AG, Santos JH, et al. Outbreak of Haff disease in the Brazilian Amazon. Rev Panam Salud Publica. 2009;26(5):469–470.[PMC free article][PubMed]

4. Zhang B, Yang G, Yu X, Mao H, Xing C, Liu J. Haff disease after eating crayfish in east China. Intern Med. 2012;51(5):487–489.[PubMed]

5. Tolesani Júnior O, Roderjan CN, do Carmo Neto E, Ponte MM, Seabra MC, Knibel MF. Haff disease associated with the ingestion of the freshwater fish Mylossoma duriventre (pacu-manteiga) Rev Bras Ter Intensiva. 2013;25(4):348–351.[PMC free article][PubMed]

6. Langley RL, Bobbitt WH., 3rd Haff disease after eating salmon. South Med J. 2007;2007(11):1147–1150.[PubMed]

7. Centers for Disease Control and Prevention (CDC) Tetrodotoxin poisoning associated with eating puffer fish transported from Japan-California, 1996. MMWR Morb Mortal Wkly Rep. 1996;45(19):389–391.[PubMed]

Articles from Revista Brasileira de Terapia Intensiva are provided here courtesy of Associação de Medicina Intensiva Brasileira

Author

Ali H Al-Khafaji, MD, MPH Professor of Critical Care Medicine, Director, Transplant Intensive Care Unit, Department of Critical Care Medicine, University of Pittsburgh School of Medicine

Ali H Al-Khafaji, MD, MPH is a member of the following medical societies: American College of Chest Physicians, American College of Gastroenterology, American College of Physicians, International Liver Transplantation Society

Disclosure: Nothing to disclose.

Coauthor(s)

Sat Sharma, MD, FRCPC Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba Faculty of Medicine; Site Director, Respiratory Medicine, St Boniface General Hospital, Canada

Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, World Medical Association

Disclosure: Nothing to disclose.

Gregg Eschun, MD Assistant Professor, Department of Internal Medicine, Sections of Respirology and Critical Care, St Boniface Hospital, University of Manitoba Faculty of Medicine, Canada

Gregg Eschun, MD is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society, Canadian Medical Association, College of Physicians and Surgeons of Manitoba

Disclosure: Nothing to disclose.

Chief Editor

Michael R Pinsky, MD, CM, Dr(HC), FCCP, MCCM Professor of Critical Care Medicine, Bioengineering, Cardiovascular Disease, Clinical and Translational Science and Anesthesiology, Vice-Chair of Academic Affairs, Department of Critical Care Medicine, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine

Michael R Pinsky, MD, CM, Dr(HC), FCCP, MCCM is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American Thoracic Society, European Society of Intensive Care Medicine, Society of Critical Care Medicine

Disclosure: Received income in an amount equal to or greater than $250 from: Masimo, Edwards Lifesciences, Cheetah Medical<br/>Received honoraria from LiDCO Ltd for consulting; Received intellectual property rights from iNTELOMED for board membership; Received honoraria from Edwards Lifesciences for consulting; Received honoraria from Masimo, Inc for board membership.

Acknowledgements

Cory Franklin, MD Professor, Department of Medicine, Rosalind Franklin University of Medicine and Science; Director, Division of Critical Care Medicine, Cook County Hospital

Cory Franklin, MD is a member of the following medical societies: New York Academy of Sciences and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Daniel R Ouellette, MD, FCCP Associate Professor of Medicine, Wayne State University School of Medicine; Consulting Staff, Pulmonary Disease and Critical Care Medicine Service, Henry Ford Health System

Daniel R Ouellette, MD, FCCP is a member of the following medical societies: American College of Chest Physicians and American Thoracic Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment