ACUTE KIDNEY INJURY PRECIPITATED BY HAFF DISEASE IN A 28-YEAR-OLD NIGERIAN MALE “CASE REPORT”

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V. Ogala-Akogwu^1,2, P. Uduagbamen³, H. Galadanci², E. Anteyi²

1. Department of Medicine, State House Medical Centre, Abuja, Nigeria.
2. Department of Medicine, National Hospital, Abuja, Nigeria.
3. Department of Internal Medicine, Bowen University/Bowen University Teaching Hospital, Ogbomosho Nigeria.

Abstract

Haff disease is defined as unexplained rhabdomyolysis following ingestion of some sea fish and crayfish. First reported in 1926 from the Baltic region, its pathophysiologic mechanism is largely unknown, but toxins release have been implicated. Common features include generalized myalgia, brown/ dark urine, elevated serum creatine kinase and creatinine, kidney dysfunction can be severe enough to cause acute kidney injury (AKI). We present the case of a 28-year-old man who ate cooked freshwater fish and initially presented with diffuse myalgia, headache and brown-colored urine, and later fever and diarrhea. He had severely elevated serum creatine kinase and creatinine, and was managed as a case of Haff disease related AKI (HDRAKI) complicated by sepsis. He had haemodialysis and antibiotics, and recovered kidney function. A detailed history of recent diet and occupational exposure is essential in the diagnosis and management of HDR-AKI. Dialysis could be life-saving.

Keywords: Fresh water fish, Haff disease, Rhabdomyolysis, Acute kidney failure, Haemodialysis, Creatine kinase, Myalgia.

Introduction

Haff disease, defined as unexplained rhabdomyolysis following ingestion of some sea fish and crayfish.¹ It was first reported in the Baltic region in 1924, then from the former Soviet Union, and United States², among others. Organ enlargement is rare but early deaths have been reported in the few case fatalities.² Acute kidney injury (AKI) can complicate rhabdomyolysis of whatever cause.³ Pathophysiologic mechanisms for AKI include ischemic tubular necrosis, direct toxicity and tubular obstruction. ⁴ Renal replacement therapy (RRT) may be required for kidney function restoration.⁴ We present the first case of Haff disease in Nigeria and Africa and the first association with AKI, requiring RRT (haemodialysis).

Case profile: A 28-year-old digital analyst presented with a week history of generalized myalgia and diarrhea, 4 days of low grade fever, and 3 days of oliguria, and altered sensorium. He took a meal of cooked freshwater fish the night preceding the onsetn of symptoms. He had vomiting with six episodes that lasted for 2 days and this was followed by the passage of loose watery stool. He self-administered Metronidazole and Ibuprofen, and had at a peripheral facility, antimalarial and Ceftriaxone. He had no history of ingesting herbal remedies. His urine became darker, the volume progressively became smaller and he developed altered sensorium. He had no prior risk for kidney disease, and neither smoked nor took alcohol.

He was restless, confused, jaundiced, afebrile but pale. He had tachycardia, tachypnea, but blood pressure (BP) was 110/60 mmHg. He had vague abdominal tenderness but no organ enlargement.

We made an assessment of acute kidney injury (AKI) precipitated by sepsis, to rule out nephrotoxicities.

On further questioning, patient gave more detailed information concerning the ingested fish and the timing (within 24 hours incubation period). This raised the probability of Haff disease and, drugs induced toxic ephropathy).

Labs showed proteinuria ++, haematuria +++, no nitrites. Serum biochemistry (Table 1) at presentation showed severe renal and hepatic dysfunction. Blood and urine culture yielded no growth, Serology for Hepatitis B and C and HIV were negative.