Haff Disease
Haff disease, identified in Europe in 1924, is unexplained rhabdomyolysis in a person who ate fish in the 24 hours before onset of illness. We describe a series of six U.S. patients from 1997 and report new epidemiologic and etiologic aspects. Although Haff disease is traditionally an epidemic foodborne illness, these six cases occurred in two clusters and as one sporadic case.

In the summer and fall of 1924, physicians near the Königsberger Haff shores along the Baltic coast recognized an outbreak of an illness characterized by sudden, severe muscular rigidity. No neurologic abnormalities, fever, splenomegaly, or hepatomegaly were observed. Patients often had coffee-colored urine. The clinical spectrum of disease varied, few patients died, and most survivors recovered quickly. In the following 9 years, similar outbreaks, affecting an estimated 1,000 persons, occurred seasonally in the summer and fall along the coast of the "haff" (a shallow lagoon). Recent ingestion of fish, usually cooked, was common among those who became ill; species of fish included burbot, eel, and pike. Seabirds and cats reportedly died after eating fish in the wild. Because of the absence of fever and the fact that fish had been cooked, known infectious causes were eliminated. Several toxic etiologies were proposed but could not be confirmed. Among these was arsenic poisoning, which is still cited in modern medical dictionaries as the cause of Haff disease. From 1934 until 1984, other outbreaks resembling Haff disease were described in Sweden and the Soviet Union. The first two cases reported in the United States occurred in Texas in June 1984; through 1996, only four more cases were reported: two from Los Angeles, California, in 1985, and two from San Francisco, California, in April 1986 (M. Tormey, pers. comm.). All patients had eaten buffalo fish before onset of illness. Tests of the remains of one of the fish meals suggested a neutral lipid as a causative agent. Reports of six cases of Haff disease from California and Missouri during a 5-month period (March-August) in 1997 prompted an investigation with the objectives of describing the epidemiology and clinical characteristics of the 1997 U.S. cases of Haff disease, tracing back implicated fish, and elucidating the cause of Haff disease.