Haff Time: fish-induced rhabdomyolysis

November 24, 2014, 3:06 pm

Buffalo fish

Buffalo fish (Ictiobus cyprinellus)


Haff Disease: Rhabdomyolysis After Eating Buffalo Fish. Herman LL, Bies C. West J Emerg Med 2014 Sept;15:664-6.


Haff Disease was first described in 1924 after an outbreak of acute muscle rigidity accompanied by dark  urine among patients living near the Königsberger Haff shores along the Baltic Coast.  Similar cases occurred in the following summers along the haff (a shallow lagoon.) Most victims gave a history of recently ingesting various fish — burbot, eel, pike, etc.

Cases of rhabdomyolysis after ingesting fish were not reported in the United States until 1984. Most were associated with eating freshwater buffalo fish. Haff disease is diagnosed when a patient develops rhabdomyolysis without another etiology within 24 hours of eating fish. The toxin causing the condition has not been identified, but appears to be heat-stable since cooking does not prevent illness. Common presenting signs and symptoms include back pain, chest pain, sweating, dyspnea, nausea and vomiting.

This case report, from Resurrection Hospital in Chicago, describes a 34-year-0ld woman who presented with chest pain, back pain and vomiting after consuming cooked buffalo fish. Evaluation revealed markedly elevated myoglobin and creatine kinase levels. Chest CT was unremarkable and troponin levels were normal.

The paper makes the following important points:

  • Because of the presentation, life-threatening conditions such as acute coronary syndrome and aortic dissection must be ruled-out.
  • The causative toxin may be similar to palytoxin, a potent vasoconstrictor found in several marine species.
  • In contrast to cases in Europe, U.S. outbreaks of Haff disease have been associated with ingestion of freshwater fish or shellfish (buffalo fish, crayfish.)
  • Many patients with Haff disease have a moderate leukocytosis
  • The key to treatment is supportive care focused on maintaining adequate urine output.
  • The benefit of alkalinizing the urine in rhabdomyolysis has not been proven.


Additional resources:

Illinois Department of Public Health February 2014 release on Haff disease

MMWR report on Haff disease




  1. milkshake Says:

    the causative toxin probably is not chemically related to palytoxin as the paper claims, because it is much greasier than palytoxin based on its extraction into hexane. Palytoxin is insoluble in hexanes, not even in ether or chloroform

  2. Leon Says:


    Thanks for the information!