Seafood-associated rhabdomyolysis, known as Haff disease, is a rare but serious syndrome characterized by the rapid breakdown of skeletal muscle following the consumption of certain cooked fish or crustaceans. First identified in 1924 near the Baltic Sea coast (Königsberg Haff), the condition has since been documented in Europe, the United States, China, Brazil, and Japan. The disease is defined by three diagnostic criteria: consumption of cooked seafood within 24 hours of symptom onset, a creatine kinase (CK) level at least five times the upper limit of normal, and a CK-MB fraction (cardiac enzyme) below 5% .
Seafood Vectors and Global Patterns
Haff disease outbreaks are linked to specific aquatic species. In the United States, buffalo fish (Ictiobus cyprinellus) is the most common vector, while freshwater pomfret is frequently implicated in China. Crayfish (Procambarus clarkii) has caused cases in both countries, as well as in Brazil and Hong Kong. Marine species like Atlantic salmon (Salmo salar) and “olho-de-boi” (Seriola spp.) have also triggered outbreaks . The disease is not limited to wild-caught seafood; commercially sold fish from grocery stores have been associated with cases .
Clinical Presentation and Diagnosis
Symptoms typically begin 6 – 21 hours after ingestion, with a median onset of 8 hours. Patients experience severe muscle pain, stiffness, and tenderness, often accompanied by dark “tea-colored” urine due to myoglobinuria (myoglobin in urine). Systemic symptoms may include nausea, vomiting, chest pain, dyspnea, and diaphoresis. Laboratory findings show markedly elevated CK (often >5,000 U/L), myoglobinuria, and sometimes leukocytosis. Crucially, neurological symptoms, such as numbness or paralysis, are absent, distinguishing Haff disease from neurotoxic seafood poisonings .
Pathogenesis and Management
The causative toxin remains unidentified but is heat-stable, resisting cooking temperatures. It is suspected to be a myotoxin originating from algae or other environmental sources, possibly related to palytoxin but lacking neurotoxic effects. Treatment focuses on preventing acute kidney injury through aggressive intravenous hydration. Urine alkalization with sodium bicarbonate may be used, though evidence for its efficacy is limited. Most patients recover fully with supportive care, but complications like compartment syndrome, disseminated intravascular coagulation, or renal failure can occur, particularly in vulnerable populations such as transplant recipients .
Prevention and Public Health
Public health advisories recommend purchasing seafood from regulated suppliers, avoiding overconsumption (especially of crayfish heads/organs), and seeking immediate medical care if symptoms arise after ingestion. Traceback investigations and market recalls, according to leading nationwide food poisoning law firm Ron Simon & Associates, are critical during outbreaks to prevent additional cases.
