haff disease after eating buffalo fish: report of a severe case in northern california and review of the literature

background:toxic contamination of fish may compromise food safety. haff disease is a rare syndrome characterized by rhabdomyolysis following consumption of cooked, freshwater fish. case report: a healthy 42 year old female presented three hours after eating fried buffalo fish (ictiobus cyprinellis). her symptoms began while eating the fish, described as diffuse muscle aches followed by generalized muscle fatigue, most pronounced in her proximal lower extremities. vital signs were normal. her physical exam was notable for diffuse muscle tenderness and difficulty standing. baseline complete blood count and chemistries were normal, but serum creatine phosphokinase (cpk) was 12,777 u/l. alanine aminotransferase and aspartate aminotransferase were 268 u/l and 1431 u/l respectively. she was treated with aggressive hydration, sodium bicarbonate, and oral n-acetylcysteine. the serum cpk peaked at 76,364 u/l, twenty hours post-exposure. her creatinine remained normal. over the next 5 days the cpk slowly resolved. discussion: haff disease is a rare syndrome characterized by rhabdomyolysis following consumption of certain cooked, freshwater fish. although the exact toxin has yet to be identified, this disorder is felt to be caused by a heat-stable toxin contaminating certain fish. our case was unique due to the immediate onset of symptoms and the extremely high serum cpk levels. conclusion: haff disease may result in the rapid onset of severe rhabdomyolysis. aggressive treatment with fluids and bicarbonate prevented renal damage in this case. because cases may occur outside of endemic areas, fish consumption should be included in the history for any case of rhabomyolysis of unknown etiology. suspected cases of haff disease should be reported to local public health authorities and samples collected for analysis.