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Bahia and Ceara states, Brazil: At least 69 cases of undiagnosed illness, 2 deaths - symptoms of muscle pain and black urine - probable Haff disease

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  • Bahia and Ceara states, Brazil: At least 69 cases of undiagnosed illness, 2 deaths - symptoms of muscle pain and black urine - probable Haff disease

    Two ProMED Portuguese posts - machine translations:

    UNIDENTIFIED DISEASE - BRAZIL (03) (BAHIA), MYOPATHY, OUTBREAK
    ************************************************** **************
    A message / A message / from ProMED-PORT
    Http://www.promedmail.org
    ProMED-mail and a program from / is a program of the
    International Society for Infectious Diseases
    Http://www.isid.org

    Date: Friday, December 16, 2016

    [1]
    Source: G1 [15/12/2016] [edited]
    Http://g1.globo.com/bahia/noticia/20...ina-preta.html

    Mysterious virus in Salvador causes muscle pain and leaves black urine
    -------------------------------------------------- --------------------------------------
    Extreme muscle pain and black urine. These are the main symptoms of a disease that has already taken at least 9 people to the hospitals of Salvador in the last days and that, in more serious cases, can lead to renal failure. Dr. Gubbio Soares, a researcher at the virology laboratory at the Federal University of Bahia (UFBA) and a doctor of virology, says that the disease is caused by a virus that has not yet been identified.

    "We already know that it is a virus that causes the disease, but we have not yet determined which type" [is it already known that the etiology is viral? What evidence has already been identified? - Mod RNA], says Dr. Gubbio, who adds already have collected samples of patients, to try to identify the virus. "We need about 10 to 15 days to get this ID."

    The specialist believes that the transmission is via oral, through the respiratory apparatus [confused ... - Mod RNA]. He points out that another symptom of the disease is the increase in the body's enzyme CPK, which acts on regulating the metabolism of contractile tissues, such as the skeletal and cardiac muscles. "He had a patient with a CPK index of 100,000 units per liter of blood, while the normal one was 200 units per liter," Dr. Gubbio said. "Because of the risk of kidney failure, patients should be hospitalized until their urine returns to normal," he says.

    The G.C. student, 24, was one of the people who had the disease in Salvador. She says her boyfriend, T.P. The same symptoms, in the same period as her. "Last Friday (9) [December / 2016], I felt a very strong pain in the whole body." It started at the neck, radiating, and took the whole body.I took a muscle relaxant and it did not work, then I took a second tablet And I felt a slight improvement.When I woke up on Saturday morning (10) [December / 2016], I was still in pain and went to the hospital, "says G., who reports that the pain was unbearable. "When you think about moving, it hurts every muscle you use to make the move you want. It's a pain I do not want for my worst enemy," says the student.

    According to G., she was admitted to the hospital on Saturday until last Wednesday (December 14, 2016) when she was discharged. The infectious doctor Antônio Bandeira says that the treatment is done with hydration and analgesic. "The patient should not under any circumstances take anti-inflammatory, because it can worsen renal function," he warns. The improvement time, on average, lasts three days.

    The doctor says that the capital of Bahia lives an outbreak of the disease. "This is an outbreak," said Dr. Antônio Bandeira. "It is an outbreak.

    According to him, of the 9 confirmed patients, three had black urine and, of these, one patient had progressed to renal failure. "Despite the condition, the insufficiency was temporary and it improved," says the doctor.

    Through a note, the Directorate of Epidemiological Surveillance (Divep) of the State Department of Health (Sesab) reported that it has already been notified about the disease [which disease? It has been notified about outbreak - Mod. RNA] and that it is investigating the cases.

    -
    Communicated by: ProMED-PORT http://www.promedmail.org

    [2]
    Source: Correio da Bahia [16/12/2016] [edited]
    Http://www.correio24horas.com.br/det...46625c45995287

    Sesab issues alert to health units after outbreak of mysterious disease in Bahia
    -------------------------------------------------- -------------------------------------------------- ------
    The State Health Department (Sesab) has issued an alert for health units in Bahia, on Friday (December 16, 2016), due to a mysterious illness that affected at least 11 people, some of them after visiting North Coast. The document was protocolated by the strategic information centers in health surveillance in Bahia and Salvador (CIEVS-BA and CIEVS Salvador). Sesab's communications adviser informed CORREIO that the alert is not directed at the population.

    According to the publication, the cases are suspected of a possible variant of epidemic myalgia. On December 14 [2016] 9 suspected cases were reported by a hospital unit in Salvador to people from 3 different families.

    The patients were treated and admitted to a health unit in the capital on December 2 and 10 [2016], presenting a clinical picture characterized by sudden onset of severe pain in the cervical region, trapezius, followed by intense muscular pains in the arms, back, Thighs and calves.

    According to Sesab, the disease showed a rapid spread among the relatives, which suggests that transmission occurs through contact or droplets [or exposure to a toxic agent, for example, occurred simultaneously - RNA Mod.]. The clinical picture presented is compatible with a variant of Epidemic Myalgia Syndrome - usually caused by an Echovirus.

    Epidemic myalgia is also known as Bornholm's disease. Muscle pain is caused by a viral infection and affects the upper abdomen and lower thorax. The pain is characterized as spasmodic and develops suddenly, worsening with each movement and deep breathing, causing shortness of breath for the affected individual (in the outbreak in question, the cases did not present respiratory compromise). In many cases, the disease also causes abdominal pain, fever, headache, sore throat and muscle. Transmission occurs through fecal-oral or, less commonly, person-to-person, through droplets or contaminated objects.

    Experts investigate whether the consumption of the bull's eye fish, also known as Arabaiana, is related to the disease. According to the infectious physician Antonio Bandeira, the 11 patients who are receiving medical follow-up reported that they consumed fish meat before or during the onset of symptoms. The fish was bought fresh and prepared at home [this makes the hypothesis of intoxication more likely - mod. RNA].

    "A family of four, which consumes a lot of fish, said that in the days before the onset of symptoms, they did not eat. But we have at least five people who fed on fish in Guarajuba, which is a couple of boyfriends, the aunt , A woman who bought the food and also her maid, "said the doctor.

    According to him, the couple's aunt even confused the symptoms with a virus. "These five people who had the symptoms ate bull's eye, also known as the Arabavian, and so this is a hypothesis, the other is that we are looking for a virus that may be causing this," he said.

    There is still no certainty as to the causes of the disease, but the advice is that when patients are aware of symptoms, they hydrate enough, avoid taking anti-inflammatories and seek a doctor. "The risk is that the person has dark urine, does not hydrate properly and end up having kidney failure, and that can happen," the doctor said.

    The identification of the toxin or virus that is causing the mysterious disease will depend on the clinical analysis of the patients already registered. "Of course, if we remove the viral causes, and if more cases appear, they can lead to believing that there is such a situation," the doctor said about the relationship with the fish.

    According to Bandeira, the analysis in fish is more difficult, since it can be a toxin or chemical, which is more difficult to discover than a bacterium or virus, for example. "So it's important that the Sanitary Surveillance and government agencies seek to investigate, because we can not do this," he concluded.

    -
    Communicated by: ProMED-PORT http://www.promedmail.org

    [As we have always pointed out: information about person-time-place is essential for investigating any outbreak and formulating hypotheses.

    What is the age group of the patients? Is there a link between the 3 families?

    Information on the clinical picture suggests that the only two manifestations are myalgia (with rhabdomyolysis) and darkened urine (possibly myoglobinuria). There was, in fact, no fever, headache, rash, respiratory symptoms,


    ------------------------------------------------------------------------------------

    Published Date: 2016-12-17 05:44:53
    Subject: PRO / PORT> Unidentified disease - Brazil (04) (BA), outbreak, myopathy, update, epidemiological report
    Archive Number: 20161217.4704477
    DISEASE NON-IDENTIFIED - BRAZIL (04) (BAHIA), SURGERY, MYOPATHY, UPDATE, EPIDEMIOLOGICAL REPORT
    ************************************************** ************************************************** (I.e.
    A message / A message / from ProMED-PORT
    Http://www.promedmail.org
    ProMED-mail and a program from / is a program of the
    International Society for Infectious Diseases
    Http://www.isid.org

    Date: Saturday, December 17, 2016
    Source: Directorate of Epidemiological Surveillance, Health Secretariat of the State of Bahia [16/12/2016] [edited]

    Epidemiological Alert
    ----------------------------
    The Centers for Strategic Information in Health Surveillance in Bahia and Salvador (CIEVS-BA and CIEVS Salvador) warn health units in Salvador about the occurrence of suspected cases of a possible variant of epidemic myalgia.

    On December 14 [2016], 9 suspected cases of epidemic myalgia in people from 3 different families were reported by a hospital unit in Salvador: family 1 (N = 4); Family 2 (N = 3) and family 3 (N = 2). The cases were attended to and hospitalized at a health unit located in Salvador, on December 2 and 10 [2016], presenting a clinical picture characterized by sudden onset of severe pain in the cervical region, trapezius region, followed by intense muscle pain in the Arms, back, thighs and calves. All the patients presented significant elevations of the muscular enzymes, without fever, arthralgia or headache.

    The disease had a rapid spread [hours, days? - Mod. RNA] among the relatives, which suggests that the transmission occurs through contact or droplets [or exposure to the same inoculum, toxin - Mod. RNA]. Since the clinical picture presented is compatible with a variant of Epidemic Myalgia Syndrome - usually caused by an Echovirus, the CIEVS-BA and the CIEVS / Salvador issue the present epidemiological alert with recommendations for conducts and guidelines for hospital and emergency health teams Of the capital, in order to elucidate the event, verify the occurrence of other cases, investigate in a timely manner and adopt appropriate measures.

    1. About the disease: Epidemic myalgia is also known as Bornholm's disease. Muscle pain is caused by a viral infection and affects the upper abdomen and lower thorax. The pain is characterized as spasmodic and develops suddenly, worsening with each movement and deep breathing, causing shortness of breath for the affected individual (in the outbreak in question the cases did not present respiratory compromise). It sometimes causes abdominal pain, fever, headache, sore throat and muscle aches. Transmission occurs through fecal-oral or, less commonly, person-to-person, through droplets or contaminated objects.

    2. Notification: - Notification by email (contacts below) of cases with the following signs and symptoms: severe pain in the cervical and trapezius regions, sudden onset, followed by intense muscle pains in the arms and / or back, and / Or thighs, and / or calves, with no apparent cause. - Carry out an active search for compatible cases in the medical records of patients treated as of November 1, 2016. If compatible cases are identified in this period, broaden the search to the previous month.

    3. From the Laboratory: - Collect samples of serum and feces for laboratory examination for arbovirus and enterovirus, respectively. - Forward the samples to the State LACEN, to the care of Francisco Barroso, accompanied by the individual notification form of SINAN, duly identified: "suspicion of epidemic myalgia" - The sample must be kept refrigerated until the moment of sending it to the laboratory, which Should not exceed 24 hours.

    4. Treatment: The disease has no specific treatment. In the occurrence of suspected cases, it is recommended to test for creatine phosphokinase (CPK) or OGT to observe the increase of muscle enzymes. Observe the color of urine (dark) as a warning sign and the development of rhabdomyolysis, because in this case, the patient should be rapidly hydrated for 48 or 72 hours, and the use of anti-inflammatories and acetylsalicylic acid (ASA) .

    5. Prevention: - Guidance to the population on the modes of transmission. - Care of the hygiene of the objects and washing of the hands. -Individual with suspected infection should not circulate in public and closed environments.

    6. Contacts for additional information - Coordination of Research and Strategic Information on Health Surveillance (Cievs / BA) - Tel: (71) 3116-0018 / 37 (8 a.m. to 6 p.m.); 9994-1088 (on call) notifica.cievsbahia@gmail.com - Strategic Information Center Health Surveillance (CIEVS / SSA) Tel: (71) 3202-1721 / 1722; (71) 99982-0841 (on duty)

    Communicated by: ProMED-PORT http://www.promedmail.org

    [The Epidemiological Report presented here refers to the epidemiological event of the post [PRO / PORT> Unidentified disease - Brazil (03) (BA), myopathy, outbreak Archive Number: 20161216.4704355, http://www.promedmail.org/post/ 4704355]. As pointed out in previous comment [access http://www.promedmail.org/post/4704355] information is still scarce ... Faced with (in) available information, it is still difficult and potentially premature to point out the etiology of the disease. .. Or would the Health Department already have results of tests that suggest viral infection?

    Several answers have not yet been presented: is there a link between families? What is the age profile of the cases? Has there been a food survey? What is the distribution of the cases according to the date of onset of symptoms? There was a report of fish consumption preceding the onset of symptoms: how long before the onset of symptoms? The 3 families consumed? What is the attack rate? Was there collection of samples for analysis? ...

    Depending on the possible exposure to a common source and / or the temporal distribution of the onset of symptoms of the cases, the hypothesis of infectious etiology may be less likely, especially considering that incubation periods may vary widely and that infrequently All individuals from a viral disease outbreak will start symptoms on the same day after a common exposure (ie they will exhibit exactly the same incubation period).

    Well, for now, without more robust clinical and epidemiological information, there are only hypotheses to be investigated, which should include viruses and toxins ... Bacterial or parasitic infection, possible but less (very) probable.

    - Mod RNA

    This entry was posted in Uncategorized Leave a Reply Click here to cancel reply. Name (required) Mail (will not be published) (required)
    As we have always pointed out: information about person-time-place is essential for investigating any outbreak and formulating hypotheses.

    What is the age group of the patients? Is there a link between the 3 families?

    Information on the clinical picture suggests that the only two manifestations are myalgia (with rhabdomyolysis) and darkened urine (possibly myoglobinuria). There was, in fact, no fever, headache, rash, respiratory symptoms, gastrointestinal manifestations, lymphadenopathy ...?

    Did the onset of symptoms occur on the same day? How many hours of difference between fish intake and the onset of symptoms? Have there been other laboratory changes? Were the fish consumed purchased in the same place? Was there any use of drugs or other substances?

    What samples were taken from patients, fish and other possible foods? Was there environmental sampling, including water?

    Additional information would be welcome.

  • #2
    I wonder if this is the same outbreak as the following short English language ProMED post - same location, similar symptoms:


    Published Date: 2016-12-18 00:12:19
    Subject: PRO/EDR> Haff disease - Brazil: susp, RFI
    Archive Number: 20161218.4706067
    HAFF DISEASE - BRAZIL: SUSPECTED, RFI
    *************************************
    A ProMED-mail post
    http://www.promedmail.org
    ProMED-mail is a program of the
    International Society for Infectious Diseases
    http://www.isid.org

    Date: Fri 16 Dec 2016
    From: Tatiana Otero [edited]



    I am the infectologist from Brazil. I live in Salvador de Bahia.

    In July [2016] I saw a family with rhabdomyolysis related to fish ingestion. I thought about Haff disease.

    This week a [news] release, a warning, talking about similar symptoms, and I think we have an outbreak.

    --
    Tatiana Otero


    [Haff disease, rhabdomyolysis after ingesting certain types of fish, was 1st reported in 1924 in Europe. There have been a limited number of cases reported in the United States, and more farther south to Brazil and throughout Brazil. Symptoms of rhabdomyolysis can occur after eating cooked buffalo fish purchased at a suburban grocery market, or fresh from markets or the ocean. This suggests the substance responsible for rhabdomyolysis is not changed, denatured, or altered by the heat of cooking. A toxicological agent has not been identified. If there is an outbreak of this disease in Brazil we would appreciate an authoritative comment regarding the situation. - Mod.TG

    Last edited by sharon sanders; December 18, 2016, 12:22 PM. Reason: format

    Comment


    • #3
      Published Date: 2016-12-18 21:42:37
      Subject: PRO/AH/EDR> Haff disease - Brazil (02)
      Archive Number: 20161218.4707549
      HAFF DISEASE - BRAZIL (02)
      **************************
      A ProMED-mail post
      http://www.promedmail.org
      ProMED-mail is a program of the
      International Society for Infectious Diseases
      http://www.isid.org

      Date: 18 Dec 2016
      Source: Member, EpiCore Global Surveillance Project


      According to the Government of Bahia [Directorate of Epidemiological Surveillance, Health Secretariat of the State of Bahia 16 Dec 2016], up to now, 12 people have had symptoms such as myelitis and urine with black coloration. [The black coloration of the urine is often due to the breakdown of the muscles and release of myoglobin associated with rhabdomyolysis.- Mod.TG]

      The infectologist responsible for monitoring the cases suspects that these patients may come from toxic contamination of fish from the Amazon region. [Although toxins have been suspected, there has never been a toxin linked to this situation. There has been some thought that it may be an interaction of fish with some host genetic factor but that has not been proven either. - Mod.TG]

      According to Professor Gúbio Soares, from the Federal University of Bahia (Ufba), the samples have already been collected, but the report that should indicate what the cause of the disease will only be completed in 15 days.

      Experts investigate whether the consumption of the Ox Eye fish, also known as Arabaiana, is related to the disease. According to Antônio Bandeira, the 11 patients who are receiving medical follow-up reported that they consumed fish meat before or during the onset of symptoms. The fish was bought fresh and prepared at home. [It has been noted previously that cooking the fish does not diminish the reaction. If it is a toxin, it is heat stable. - Mod.TG]

      "A family of 4, which consumes a lot of fish, said in the days before the onset of symptoms, they did not eat [fish?]. But we have at least 5 people who fed on fish in Guarajuba, which is a couple of boyfriends, the aunt, a woman who bought the food and also her maid, "said the doctor.

      According to the expert, the couple's aunt even confused the symptoms with a virus. "These 5 people who have had the symptoms have eaten the Bull's Eye, which is also known as the Arabaiana, and so this is a hypothesis, the other is that we are looking for a virus that may be causing this,

      There is still no certainty as to the causes of the disease, but the advice is that when patients notice the symptoms, they hydrate enough, avoid taking anti-inflammatories, and seek a doctor. The risk is that the person has dark urine, does not hydrate properly and end up having kidney failure, and that can happen.

      The identification of the toxin or virus that is causing the mysterious disease will depend on the clinical analysis of the patients already registered.

      According to Bandeira, the analysis in fish is more difficult, since it can be a toxin or chemical, which is more difficult to discover than a bacterium or virus, for example.
      --
      Communicated by:
      ProMED-mail

      [A toxin has never been found or linked, but only suspected in this condition. There has been some thought it is a genetic interaction in some people. This has never been proven either. There are a number of different fish that this syndrome has been linked to.]

      Comment


      • #4
        Published Date: 2016-12-20 18:28:09
        Subject: PRO/AH/EDR> Haff disease - Brazil (03), clarification, more cases
        Archive Number: 20161220.4710424
        HAFF DISEASE - BRAZIL (03), CLARIFICATION, MORE CASES
        ************************************************** ***
        A ProMED-mail post
        http://www.promedmail.org
        ProMED-mail is a program of the
        International Society for Infectious Diseases
        http://www.isid.org

        [1]
        Date: Mon 19 Dec 2016
        From: Rodrigo Angerami [edited]


        [Re: ProMED-mail Haff disease - Brazil (02) 20161218.4707549]
        -------------------------------------------------------------
        "...According to the Government of Bahia [Directorate of Epidemiological Surveillance, Health Secretariat of the State of Bahia 16 Dec 2016], up to now, 12 people have had symptoms such as myelitis and urine with black coloration. [The black coloration of the urine is often due to the breakdown of the muscles and release of myoglobin associated with rhabdomyolysis. - Mod.TG]"

        However, the main clinical picture of this epidemiological event is myositis not myelitis.

        --
        Rodrigo Angerami
        Seção de Epidemiologia Hospitalar
        Hospital de Clínicas, UNICAMP
        Departamento de Vigilância em Saúde de Campinas
        ProMED-PORT Moderator
        http://www.promedmail.org/pt

        [Rodrigo is correct.

        Myelitis involves the infection or the inflammation of the white matter or gray matter of the spinal cord, which is a part of the central nervous system that acts as a bridge between the brain and the rest of the body.

        Haff disease involves myositis.
        Myositis refers to any condition causing inflammation in muscles. Weakness, swelling, and pain are the most common myositis symptoms. - Mod.TG]

        [A previously posted article incorrectly mentioned myelitis in place of myositis and/or rhabdomyolysis. Most case reports of Haff's disease mention dark urine and rhabdomyolysis as common symptoms. Presumably rhabdomyolysis is associated with an initial myositis although there are also reports that include "acute alimentary myositis" in the nomenclature (https://www.ncbi.nlm.nih.gov/pubmed/14847389), which may be a distinct syndrome from Haff disease. As a reminder, the 1st report posted on this outbreak here on ProMED (see Haff disease - Brazil: susp, RFI 20161218.4706067) raised the suspicion of Haff's disease describing the presenting symptoms as "a family with rhabdomyolysis related to fish ingestion" and in section [2] below there is a description of 7 additional cases involving "strong muscular pain and dark urine". - Mods.JH/MPP]

        ******
        [2]
        Date: Mon 19 Dec 2016
        Source: EpiCore Global Surveillance Project [edited]


        Another 7 cases of the unknown disease that causes strong muscular pain and dark urine were notified to the Municipal Health Department (SMS), in addition to the 11 already known since last week, totaling 18 cases. The balance was released on [Sat 17 Dec 2016], after data collection in hospitals and Emergency Care Units (UPAs). 16 of the cases were registered in Salvador, but cases were also reported in Valença, in Baixo Sul Baiano.

        Symptoms include sudden muscle pain with no apparent cause, and changes in the levels of CPK [creatine phosphokinase], the intracellular enzyme of contracting tissues, such as muscles.

        An investigation roadmap that will begin to be applied this [Mon 19 Dec 2016] is being prepared by SMS, Osvaldo Cruz Foundation, and by the infectious physician Antônio Bandeira, who treated part of the occurrences of the outbreak.

        One of the suspicions is that the symptoms are related to the consumption of the bull's eye fish -- part of the patients reported to have eaten the fish, also known as Arabaiana.

        After being reported that a family that showed signs of disease after they were fed with [bull's eye fish], in Guarajuba, on the north coast of the state, fishermen of the locality denounced that the sellers of the products pack the merchandise in water and formaldehyde. Cases have been reported, for the time being, as "acute myalgia with the outbreak to be clarified."

        This [Fri 16 Dec 2016], the State Health Department has issued an epidemiological alert that guides a treatment for a possible hypothesis that the episodes are from Bornholm Disease.

        --
        Communicated by:
        ProMED-mail


        [The situation seems to fit Haff disease but information on Bornholm disease is included as a possible differential. However, it should be noted that Bornholm disease is not associated with consumption of fish, while Haff disease is associated with it. Thus far, the affected people report having eaten fish.

        Bornholm disease is an uncommon viral infection of the intercostal muscles, which join the ribs together. The lining of the lungs is also sometimes affected. The condition is sometimes known as pleurodynia, or epidemic pleurodynia.

        Symptoms
        The main symptom of Bornholm disease is severe stabbing chest pain, which is often made worse by deep breathing, coughing, or sudden movements. The pain tends to come and go, with episodes lasting 15 to 30 minutes.

        Bornholm disease sometimes also causes abdominal pain, fever, headache, a sore throat, and muscle pain. These symptoms usually start suddenly and persist for several days before going away without the need for treatment. They may return, however.

        How the infection is spread
        Bornholm disease is caused by a group of viruses called enteroviruses, mainly the Coxsackie B virus.

        It spreads by the faecal-oral route, where traces of contaminated faeces reach the mouth. Less commonly, it can be spread through respiratory droplets in much the same way as the common cold.

        The viruses are found in faeces and the millions of tiny droplets that come out of the nose and mouth when someone with the condition coughs or sneezes.

        Hands, water, or food can become contaminated by the virus. Respiratory droplets can also hang suspended in the air before falling to contaminate surfaces. Anyone who touches these surfaces can spread the virus by touching something else.

        A person usually becomes infected by picking up the virus on their hands from contaminated objects, such as a toilet of unclean counter top, and then placing their hands in their mouth.

        Other ways the virus can be spread include drinking contaminated water and breathing in contaminated droplets from the air.

        This is why it's very important to wash your hands properly and avoid sharing utensils if you've been infected with the virus or if someone close to you has Bornholm disease

        Portions of this comment were extracted from http://www.nhs.uk/conditions/bornhol...roduction.aspx. - Mod.TG

        Comment


        • #5
          Published Date: 2016-12-21 01:56:25
          Subject: PRO / PORT> Unidentified disease - Brazil (05) (BA), outbreak, myopathy, update, increase in the number of suspected cases
          Archive Number: 20161221.4713256
          UNIDENTIFIED DISEASE - BRAZIL (05) (BAHIA), OUTBREAK, MIOPATHY, UPDATE, INCREASE IN THE NUMBER OF SUSPECTED CASES
          ************************************************** ************************************************** ******************
          A message / A message / from ProMED-PORT
          Http://www.promedmail.org
          ProMED-mail and a program from / is a program of the
          International Society for Infectious Diseases
          Http://www.isid.org

          Date: Tuesday, December 20, 2016
          Source: G1 [12/20/2016] [edited]
          Http://g1.globo.com/bahia/noticia/20...ina-preta.html

          Salvador has 22 [suspected - RNA] cases of mysterious disease that causes black urine
          -------------------------------------------------- -------------------------------------------------- ----------------
          The Municipal Health Department of Salvador (SMS) reported that up to Monday (19), 22 cases of the still-unidentified disease that causes severe muscle pain and black urine [ - Mod. RNA]. The data were released on Tuesday (20) [December / 2016] by the agency, which tracks the cases.

          The secretariat's latest bulletin on Monday [December 19, 2016] reported 19 reported cases of the disease. There is still no information from other cities in Bahia where there are case records. The State Health Department (Sesab) also took a stand on the case and issued an epidemiological alert so that health professionals pay attention and report cases of the disease. According to Sesab, all reported patients reside in the state of Bahia, 14 of whom reported fish consumption, while eight did not remember or did not consume fish (ie, it would be possible so much that some cases arise from different causes and are not related to The outbreak in question, as far as fish intake is unrelated to the outbreak - Mod. RNA].

          By means of a note, the State Department of Health informed that a process of investigation is in progress that brings together professionals of epidemiological surveillance, sanitary and environmental vigilance, as well as the technicians of the State Central Laboratory (Lacen).

          Sesab warns that the population should immediately seek a health facility if they present symptoms such as severe muscle pain, sudden onset, mainly affecting the cervical region (neck), shoulders, back, thighs or calves. All emergency and urgency units are designed to immediately notify suspected cases of acute myalgia, which makes it possible to speed up the investigation process.

          The virology laboratory of the Federal University of Bahia (UFBA), coordinated by Professor Gúbio Soares, has already analyzed samples of urine, feces and blood from four patients who presented the symptoms [and what results? - Mod RNA], as strong pains that start in the neck and back, and that in 24 hours spread to arms and legs. The suspicion raised by the research is that the disease is caused by the enterovirus type "b" or the human parechovirus. Both cause myalgia, which is muscle pain. According to the researcher, the biggest suspicion is that parechovirus is responsible for the outbreak, since the pain caused by it is stronger. In the last 10 years, in France and Japan, contaminations of at least 60 people who have experienced pain caused by parechovirus have been recorded.

          The form of transmission may be by air or by the feces of contaminated persons, which are scattered at sea. Some of the patients were in Guarajuba, on the North Coast of Bahia, before presenting the symptoms. Contamination from fish ingestion was not ruled out. "If in Guarajuba the sewage is being thrown into the sea, this sea will probably be contaminated. All this opens up a range of research and an opportunity to study," he explained.

          The Institute of Environment and Water Resources (Inema) reported that although they are responsible for assessing the quality of water in the North Coast, the subject is the responsibility of the State Department of Health (Sesab), who said that the case is being investigated. Embasa said that the sewage of the region is properly treated and destined for the Pojuca River, which flows into the sea, between the beaches of Guarajuba and Praia do Forte.

          The infectologist Antônio Bandeira had already pointed out that the disease can be caused by a virus or a toxin present in saltwater fish, on account of reports of patients who presented symptoms. In one of the most serious cases in Bahia, the disease eventually caused renal failure.


          Communicated by: ProMED-PORT http://www.promedmail.org

          [The above news refers to a (possible) outbreak of myopathy detected in the state of Bahia and reported in the posts [PRO / PORT> Unidentified disease - Brazil (03) (BA), myopathy, outbreak Archive Number: 20161216.4704355 http: (04) (BA), Outbreak, Myopathy, Update, Epidemiological Report Archive Number: 20161217.4704477 http://www.promedmail.org / Post / 4704477].

          As observed in the previous comments, the clinical, laboratory and epidemiological information disclosed are still scarce ... Given the little that is available, it is still difficult, and potentially premature, to point out the etiology of the disease.

          Initially, a technical report from the Bahia State Department of Health pointed out the possible association with viral infection (hypothesis still supported as seen in the present news) and, according to the same document, would be "a variant of Epidemic Myalgia Syndrome - usually caused by an Echovirus ... Bornholm disease. " In fact, Bornholm's disease is most often associated with the Coxsackie virus. However, no conclusive results were presented (or revealed).

          Another hypothesis that has been considered by several experts, and as we pointed out in the comments of previous posts, is the possible association of the outbreak with toxins related to fish intake (Haff's syndrome).

          However, for the time being, there are no conclusive results that definitively establish the etiology (and magnitude) of this (possible) outbreak of myopathy. As we have always emphasized: information about the person-time-place is essential to investigate any outbreak and enable the formulation of feasible hypotheses.

          Information on the clinical picture suggests that the only two manifestations are myalgia (with rhabdomyolysis) and dark urine (possibly myoglobinuria) and apparently no fever, headache, rash, respiratory symptoms, gastrointestinal manifestations and lymphadenopathy.

          There are several answers that have not been presented yet: is there any other link between initially affected families and not fish consumption? What is the age profile of the cases? What is the temporal distribution of cases according to the onset date of the symptoms? There was a report of fish consumption before the onset of symptoms: how long before the onset of symptoms? What is the attack rate among those who consumed the fish in question? Was there sampling of the fish for analysis? Do the new cases have any links between them and / or the first cases? When did the symptoms of the most recent cases start? Are cases with recent onset of symptoms or old but recently reported?

          Depending on the possible exposure to a common source and / or the temporal distribution of the onset of the symptoms of the cases, the hypothesis of infectious etiology may be less likely, especially considering that the incubation periods may vary widely and that rarely all individuals related to An outbreak of viral disease will show the first symptoms on the same day, even after a common exposure (ie, they will exhibit exactly the same incubation period). In this case, the intoxication / toxin hypothesis becomes even more consistent. Well, for the time being, without more robust clinical and epidemiological information, there are only hypotheses that should be investigated and that should include viruses, but especially toxins.

          Detail: the way in which the outbreak has spread in the media and the possible etiologies has generated great apprehension in the population and among health professionals. The surveillance system is sensitive. Other states, other than Bahia, have already issued warnings about the outbreak, which at the moment, we do not know what. If we consider the sensitive criterion of definition proposed, "severe pain in the cervical and trapezius regions, sudden onset, followed by intense muscular pains in the arms and / or back, and / or thighs, and / or calves, with no apparent cause" ( That is, the definition criterion is myalgia - an extremely frequent symptom, difficult to measure - regardless of whether myopathy is laboratory-proven by the elevation of muscle enzymes) it would not be unlikely that the outbreak would gain magnitude of epidemic, inflated by one without Number of cases of myalgia (which already occur / would occur normally), not necessarily myopathy, of the most varied etiologies, infectious or not.

          At that moment, the greatest challenge seems to be to find the right dosimetry between, on the one hand, guaranteeing the population access to clear and transparent information and guidelines and on the other hand to maintain prudence, caution and responsibility in a scenario with so many doubts, uncertainties, Hypotheses and speculations.

          As always, let's partner.



          Comment


          • #6
            Published Date: 2016-12-22 08:28:08
            Subject: PRO / PORT> Unidentified disease - Brazil (06) (BA), outbreak, myopathy, update, information received from EpiCore
            Archive Number: 20161222.4716699
            UNIDENTIFIED DISEASE - BRAZIL (06) (BAHIA), OUTBREAK, MYOPATHY, UPDATE, INFORMATION RECEIVED FROM EPICORE
            ************************************************** ************************************************** **************
            A message / A message / from ProMED-PORT
            Http://www.promedmail.org
            ProMED-mail and a program from / is a program of the
            International Society for Infectious Diseases
            Http://www.isid.org

            Date: Thursday, December 22, 2016

            [1]
            Source: Member, EpiCore Global Surveillance Project [21/12/2016] [edited]

            Below is information sent / shared by Dr. Tatiana Otero Melendez in response to some questions pointed out in the previous post [PRO / PORT> Unidentified disease - Brazil (05) (BA), outbreak, myopathy, Number: 20161221.4713256, http://www.promedmail.org/post/4713256]:

            1) ProMED-PORT Question: Is there any other link between patient families and non-fish consumption?
            Answer EpiCore: "Most consumed fish".

            2) Question ProMed-PORT: What is the age range of the cases?
            EpiCore: "There are families with children and adults affected. I [Dr. Melendez] saw a family with 5 members who were 4, 11, 30-40 years old."

            3) Question ProMed-PORT: What is the time interval between fish consumption and the onset of symptoms?
            EpiCore responds: "It depends on the amount of fish consumed The day before, the mother, who consumed the most fish, had symptoms the next day, a few hours after [consumption, probably - RNA Mod.].

            4) Question ProMed-PORT: What was the attack rate among those who consumed fish?
            EpiCore Response: "All patients who consumed fish had symptoms."

            5) Question ProMED-PORT: Have samples of the fish (s) incriminated (s) / suspect (s) been carried out for laboratory tests?
            EpiCore Response: "So far no, since in most cases all fish has been used [consumed? Scorned? - RNA Modified?].

            6) ProMED-PORT Question: Is there any link between the most recently reported cases and the first suspected cases of the outbreak?
            EpiCore Response: "No. There are no other reported links."

            7) ProMED-PORT Question: Are the last reported cases a case of recent onset of symptoms or are they old but only recently reported?
            EpiCore: "I [Dra Melendez] made contact with surveillance, I have cases since July."
            [It would be important to know how many cases, their clinical characteristics, their epidemiological history - Mod RNA].

            8) ProMED-PORT Question: Have the most recently reported cases reported laboratory changes suggestive of myopathy?
            EpiCore Response: "Cases had fairly elevated levels of CPK [creatine phosphokinase enzyme - Mod. RNA] and pain, and some of them had renal failure."

            9) Question ProMed-PORT: It was mentioned that biological samples from 4 patients were analyzed. Is there any result?
            EpiCore Response: "There is no information."

            9) Question ProMed-PORT: How long will the symptoms and laboratory changes last?
            EpiCore Response: "Few Days".

            Epicore Information: the fish incriminated and potentially associated with the outbreak of myopathy are whiting and "bulls eye".

            -
            Posted by: Tatiana Otero Melendez, medical infectologist, member of the Member, EpiCore Global Surveillance Project

            Communicated by: ProMED-PORT http://www.promedmail.org

            -
            [2]
            Source: Member, EpiCore Global Surveillance Project [21/12/2016] [edited]

            The Municipal Health Department of Salvador (SMS) reported that up to Monday (19) [December / 2016], 22 cases of the as yet unidentified disease that causes intense muscular pain and black urine have been reported. The data were released on Tuesday (20) [December / 2016] by the agency, which tracks the cases.

            The secretariat's latest bulletin on Monday [December 19, 2016] reported 19 reported cases of the disease. There is still no information from other cities in Bahia where there are case records. The State Health Department (Sesab) also took a stand on the case and issued an epidemiological alert so that health professionals pay attention and report cases of the disease. According to Sesab, all reported patients reside in the state capital of Bahia, 14 reported the consumption of fish, while eight do not remember or did not consume.

            By means of a note, the State Department of Health informed that a process of investigation is in progress that brings together professionals of epidemiological surveillance, sanitary and environmental vigilance, as well as the technicians of the State Central Laboratory (Lacen).

            Sesab warns that the population should immediately seek a health facility if they present symptoms such as severe muscle pain, sudden onset, mainly affecting the cervical region (neck), shoulders, back, thighs or calves. All emergency and urgency units are designed to immediately notify suspected cases of acute myalgia, which makes it possible to speed up the investigation process.

            The virology laboratory of the Federal University of Bahia (UFBA), coordinated by Professor Gúbio Soares, has already analyzed urine, feces and blood samples from four patients who presented with symptoms, such as severe neck and back pain. 24 hours spread to arms and legs. The suspicion raised by the research is that the disease is caused by the enterovirus type "b" or the human parechovirus. Both cause myalgia, which is muscle pain. According to the researcher, the biggest suspicion is that parechovirus is responsible for the outbreak, since the pain caused by it is stronger. In the last 10 years, in France and Japan, contaminations of at least 60 people who have experienced pain caused by parechovirus have been recorded.

            The form of transmission may be by air or by the feces of contaminated persons, which are scattered at sea. Some of the patients were in Guarajuba, on the North Coast of Bahia, before presenting the symptoms. Contamination from fish ingestion was not ruled out. "If in Guarajuba the sewage is being thrown into the sea, this sea will probably be contaminated. All this opens up a range of research and an opportunity to study," he explained.

            The Institute of Environment and Water Resources (Inema) reported that although they are responsible for assessing the quality of water in the North Coast, the subject is the responsibility of the State Department of Health (Sesab), who said that the case is being investigated. Embasa said that the sewage of the region is properly treated and destined for the Pojuca River, which flows into the sea, between the beaches of Guarajuba and Praia do Forte.

            The infectologist Antônio Bandeira had already pointed out that the disease can be caused by a virus or a toxin present in salty fish, on account of reports of patients who presented symptoms. In one of the most serious cases in Bahia, the disease eventually caused renal failure.

            [The information above is the same as previously disclosed in the post [PRO / PORT> Unidentified disease - Brazil (05) (BA), outbreak, myopathy, update, increase in the number of suspected cases Archive Number: 20161221.4713256, http: // www .promedmail.org / post / 4713256 - Mod. RNA].

            -
            Posted by: Member, EpiCore Global Surveillance Project
            Communicated by: ProMED-PORT http://www.promedmail.org

            [For now, nothing conclusive yet.

            ProMED-PORT greatly appreciates the prompt response of the EpiCore Global Surveillance Project members and hopes that the partnership will become increasingly intense, frequent and profitable.

            Additional information is always welcome.

            See the comment from the previous post: [PRO / PORT> Unidentified disease - Brazil (05) (BA), outbreak, myopathy, update, increase in suspect cases Archive Number: 20161221.4713256, http://www.promedmail.org/ Post / 4713256].

            As always, we are following ...

            Comment


            • #7
              Wed, 12/21/2016 at 10:45 p.m.
              Up to 24 the number of cases of mysterious disease


              Prefeitures criticize the release of unproven information that attribute disease to fish consumption
              The number of patients with acute myalgia (muscle pain) without a specific cause was increased to 24, according to data from the Municipal Health Department of Salvador (SMS). As of Tuesday, 20, 22 cases had been registered.

              The two new patients are relatives of one of the people who already have the clinical picture being investigated by the secretary.


              The municipal body leads the investigative process of the cases, through the Center for Strategic Information on Health Surveillance (Cieves), an instance linked to the SMS.

              The three people in the same family reported to the doctors who presented the symptoms in the same period. In common, all patients report severe pain in the cervical region, intense muscle pain in the arms, back, thighs and calves, as well as turbid urine.

              According to the coordinator of Cieves, Cristiane Cardozo, two hypotheses are being investigated: Halff's disease and epidemic myalgia. The first one has a clinical picture similar to that presented by the patients. It is transmitted by a toxin present in fish and has as symptom myalgia and dark urine.

              Already in epidemic myalgia, the pains are caused by a viral infection. However, there are no conclusive results yet.

              Exams

              Cristiane Cardozo said that answers are still awaited from laboratory tests made from samples of feces and blood from the first people who presented symptoms.

              "Next week we can have some answers about laboratory tests. In the meantime, we will be collecting samples from patients who represent these new cases, to be analyzed, "said Cristiane.

              Among the 24 cases, all of Salvador, there are nine people from three different families, as well as one couple and 13 others who presented the symptoms and who have no family relationship with each other. Of the 22 first cases, only 14 reported having consumed fish, while eight do not remember whether they did or did not consume.


              "We have to put all the pieces together to come up with a common denominator. What will help are epidemiological investigations, which include a series of questions that identify symptoms and habits, "said the coordinator of Cieves.

              According to Cristiane, there is no clear evidence on whether there is a relationship between the disease and consumption of fish or seafood. However, SMS has already received calls from people who live in São Paulo and want to spend the summer in the north coast of Bahia, but they have doubts if this is convenient, which shows that the news cause concern. "We need to be careful about the information being disseminated," he said.

              TARDE looked for restaurants in Salvador that specialize in seafood to know if the disclosure of the cases has reduced the flow of customers. "Some ask about it, but no one left to eat," said one female employee who declined to be identified.

              By means of a note, the Secretary of Culture and Tourism of Mata de São João reported that the dissemination of news without a study that proves the real reason for this disease may harm the region of the north coast, but that so far there was no impact In tourism.

              The municipality of Camaçari says that the municipality's Tourism Department monitors the occurrences - some of the patients were in Guarajuba on the north coast before presenting the symptoms - but also that there was no reduction in the flow of tourists.

              Alert

              On the 16th, Sesab and SMS jointly issued an epidemiological alert on the outbreak of acute myalgia to be clarified. The alert was directed to the health units of the state, advising the professionals to verify the occurrence of cases that could be framed in this way and on how to proceed.

              The process of investigation of the cases brings together professionals from the Epidemiological Surveillance, Sanitary and Environmental Surveillance, as well as technicians from the Central State Laboratory (Lacen). According to Sesab, the population should immediately seek a health unit if they present the symptoms reported.Wed, 12/21/2016 at 10:45 p.m.
              Up to 24 the number of cases of mysterious disease

              Anderson Sotero

              Tags health mysterious myalgia acute savior

              A +
              TO-
              Prefeitures criticize the release of unproven information that attribute disease to fish consumption - Photo: Adilton Venegeroles l Ag. A TARDE
              Prefeitures criticize disclosure of unproven information that attribute disease to fish consumption
              Adilton Venegeroles l Ag. A TARDE

              The number of patients with acute myalgia (muscle pain) without a specific cause was increased to 24, according to data from the Municipal Health Department of Salvador (SMS). As of Tuesday, 20, 22 cases had been registered.

              The two new patients are relatives of one of the people who already have the clinical picture being investigated by the secretary.

              The municipal body leads the investigative process of the cases, through the Center for Strategic Information on Health Surveillance (Cieves), an instance linked to the SMS.

              The three people in the same family reported to the doctors who presented the symptoms in the same period. In common, all patients report severe pain in the cervical region, intense muscle pain in the arms, back, thighs and calves, as well as turbid urine.

              According to the coordinator of Cieves, Cristiane Cardozo, two hypotheses are being investigated: Halff's disease and epidemic myalgia. The first one has a clinical picture similar to that presented by the patients. It is transmitted by a toxin present in fish and has as symptom myalgia and dark urine.

              Already in epidemic myalgia, the pains are caused by a viral infection. However, there are no conclusive results yet.

              Exams

              Cristiane Cardozo said that answers are still awaited from laboratory tests made from samples of feces and blood from the first people who presented symptoms.

              "Next week we can have some answers about laboratory tests. In the meantime, we will be collecting samples from patients who represent these new cases, to be analyzed, "said Cristiane.

              Among the 24 cases, all of Salvador, there are nine people from three different families, as well as one couple and 13 others who presented the symptoms and who have no family relationship with each other. Of the 22 first cases, only 14 reported having consumed fish, while eight do not remember whether they did or did not consume.

              "We have to put all the pieces together to come up with a common denominator. What will help are epidemiological investigations, which include a series of questions that identify symptoms and habits, "said the coordinator of Cieves.

              According to Cristiane, there is no clear evidence on whether there is a relationship between the disease and consumption of fish or seafood. However, SMS has already received calls from people who live in São Paulo and want to spend the summer in the north coast of Bahia, but they have doubts if this is convenient, which shows that the news cause concern. "We need to be careful about the information being disseminated," he said.

              TARDE looked for restaurants in Salvador that specialize in seafood to know if the disclosure of the cases has reduced the flow of customers. "Some ask about it, but no one left to eat," said one female employee who declined to be identified.

              By means of a note, the Secretary of Culture and Tourism of Mata de São João reported that the dissemination of news without a study that proves the real reason for this disease may harm the region of the north coast, but that so far there was no impact In tourism.

              The municipality of Camaçari says that the municipality's Tourism Department monitors the occurrences - some of the patients were in Guarajuba on the north coast before presenting the symptoms - but also that there was no reduction in the flow of tourists.

              Alert

              On the 16th, Sesab and SMS jointly issued an epidemiological alert on the outbreak of acute myalgia to be clarified. The alert was directed to the health units of the state, advising the professionals to verify the occurrence of cases that could be framed in this way and on how to proceed.

              The process of investigation of the cases brings together professionals from the Epidemiological Surveillance, Sanitary and Environmental Surveillance, as well as technicians from the Central State Laboratory (Lacen). According to Sesab, the population should immediately seek a health unit if they present the symptoms reported.http://atarde.uol.com.br/bahia/notic...nca-misteriosa
              CSI:WORLD http://swineflumagazine.blogspot.com/

              treyfish2004@yahoo.com

              Comment


              • #8
                Municipal Health Department confirms two more cases of 'mysterious disease'

                According to the agency, there are now 24 patients suspected of having Acute Myalgia in Bahia
                From the Newsroom (redacao@correio24horas.com.br)
                12/21/2016 15:26:00 Updated 12/21/2016 16:00:28

                The Municipal Health Department (SMS) of Salvador confirmed, on Wednesday (21), two more suspected cases of Acute Myeliasis. According to the agency, there are now 24 patients with the so-called 'mysterious disease' in the state. Also according to the folder, the cases were notified by the Center for Strategic Information Health Surveillance (CIEVS / SSA).

                The SMS also said that investigations are being carried out to find out where the patients were treated and whether they ate fish meat. Since the consumption of certain fish has been suspected of causing the disease.

                According to the Coordinator of Health Surveillance of the Municipality, Dr. Isabel Guimarães, of the 24 suspected cases, samples from 11 patients have already been collected and are being investigated. The results, however, are still inconclusive. "We are waiting for the results. One of the suspicions is viruses, but there is nothing confirmed yet," said Isabel.

                Intense pain
                The mysterious disease causes strong muscular pains and leaves the urine black. According to the infectious physician Antônio Bandeira, one of the patients reached kidney failure. Muscle pain is caused by a viral infection and affects the upper abdomen and lower thorax.

                The pain is characterized as spasmodic and develops suddenly, worsening with each movement and deep breathing, causing shortness of breath for the affected individual (in the outbreak in question the cases did not present respiratory compromise). It sometimes causes abdominal pain, fever, headache, sore throat and muscle aches. Transmission occurs through fecal-oral or, less commonly, person-to-person, through droplets or contaminated objects.http://www.correio24horas.com.br/det...8c9520cdc37941
                CSI:WORLD http://swineflumagazine.blogspot.com/

                treyfish2004@yahoo.com

                Comment


                • #9
                  Published Date: 2016-12-22 23:54:30
                  Subject: PRO/AH/EDR> Haff disease (04): susp
                  Archive Number: 20161222.4715885
                  HAFF DISEASE (04): SUSPECTED
                  ****************************
                  A ProMED-mail post
                  http://www.promedmail.org
                  ProMED-mail is a program of the
                  International Society for Infectious Diseases
                  http://www.isid.org

                  Date: 19 Dec 2016
                  From: EpiCore Surveillance Project

                  [1]
                  From: Tatiana Otero, [edited]

                  There are already 22 patients with similar symptoms. Most of them were exposed to fish. They reported that they ate fish one day and a day afterwards started having pain in their muscles. A few patients did not remember whether they had eaten fish.

                  There was a media release with a warning and a request to report all suspected cases.

                  The Surveillance Department of the Ministry of Health have some samples from patients, and they are still working on it.

                  --
                  Responding Member: Tatiana Otero Melendez, infectologist (Infectious Disease Specialist), Brazil.

                  [Dr. Otero Melendez submitted the 1st report of these cases (see Haff disease - Brazil: susp, RFI 20161218.4706067). - Mod.MPP]

                  ******
                  [2]
                  [Mod.RNA of the ProMED-PORT network sent a series of questions to EpiCore Surveillance Project members in Brazil. Dr. Otero Melendez sent the responses below]:

                  Q1 - Are there any other links between initially affected families who have not consumed fish?
                  - Most of them had eaten fish.

                  Q2 - What is the age profile of the cases?
                  - There are families where both children and adults are affected. I saw a family of 5 people with adults ranging in age from 30 to 40 years old and children between 4 and 11 years of age.

                  Q3 - What is the time distribution of cases according to the onset date of the symptoms?
                  - It depends on how much of this they ate. The mother, having eaten more of the fish, had symptoms the next day, a few hours after [ingestion of the fish?].

                  Q4 - There was a report of fish consumption before the onset of symptoms: how long before the onset of symptoms?
                  - It was related to the consumption of the fish; one day before.

                  Q5 - When did the symptoms of the most recent cases start?
                  - Approximately 18 to 24 hours after fish ingestion.

                  Q6 - What is the attack rate among those who consumed the fish in question?
                  - All of the patients that ate the fish had symptoms.

                  Q7 - Was there sampling of the fish for analysis?
                  - Not yet, because in most of the cases, all of the fish had been consumed.

                  Q8 - Do the new cases have any links between them and/or the 1st cases?
                  - No. There is no relationship between them.

                  Q9 - Are these new cases, or are they older cases that have only recently been reported?
                  - I have talked to the surveillance unit since I had seen the cases in July [2016].

                  Q10 - Do the newer cases present with pain and laboratory abnormalities that suggest a myopathy?
                  - Yes, they presented with very high CPKs, pain, and, in some cases, renal failure.

                  Q11 - How long were symptoms present, and were they reflected in the lab changes?
                  - The symptoms were present for a few days. As I said, CPK was elevated, but the leucograms were normal.

                  There are 2 kind of fish reported to be involved thus far: Badejo and olho de Boi.

                  Responding Member: Tatiana Otero Melendez, infectologist [Infectious Disease Specialist]

                  --
                  Tatiana Otero Melendez, infectologist
                  Bahia, Brazil


                  [The Infectious Disease specialist is responding to questions based on the cases she has personally seen. From information provided in prior posts, it appears as though there is a leaning towards a viral etiology in some quarters. That being said, the clinical information and descriptive epidemiology provided by Dr. Otero Melendez strongly suggests this may well be an outbreak of Haff disease.

                  Haff disease was 1st reported in 1939 in the German medical literature (Zu Jeddeloh B. Haffkrankheit [Haff disease]. Erg Inn Med 1939;57: 138-82), where it was described as "a syndrome of unexplained rhabdomyolysis following consumption of certain types of fish; it is caused by an unidentified toxin. (Rhabdomyolysis is a clinical syndrome caused by injury to skeletal muscle that results in release of muscle cell contents into the circulation)," (from Haff Disease Associated with Eating Buffalo Fish -- United States, 1997, CDC. MMWR. 25 Dec 1998 / 47(50);1091-3 https://www.cdc.gov/mmWR/preview/mmwrhtml/00056038.htm).

                  In the MMWR article, there is a report of 6 cases of Haff disease identified (4 in California and 2 in Missouri) among persons who ate buffalo fish (_Ictiobus cyprinellus_), a bottom-feeding species found mostly in the Mississippi River or its tributaries. Checking on the 2 types of fish mentioned by Dr. Otero Melendez as having been consumed by the patients prior to onset of symptoms, the Badejo is in the _Serranidae_ family of fish, including grouper and sea bass. (http://goo.gl/ZPzYYM. Fish of the _serranidae_ family include some that are bottom feeders (http://www.fishbase.org/summary/Fami...ary.php?ID=289). The other fish I (Mod.MPP) believe is amberjack (in the tuna family). I found a picture of the fish at http://www.bahia-guesthouse.com/Fish...-Imbassai.html, and it resembles amberjack.

                  The enigma remains as to whether the clinical picture described in the previous posts is more consistent with a viral disease leading to Bornholm disease or more consistent with Haff disease. - Mods.TG/MPP

                  Comment


                  • #10
                    http://redenews360.com.br/2017/01/ce...a-diz-governo/

                    Ceará has three suspected cases of 'black urine disease', says government

                    Posted on January 14, 2017 - 680 views

                    The Secretary of Health of the State of Ceará reported on Thursday (12) that he suspected three cases of "black urine disease." Notifications occurred until January 10.
                    According to the technical note, the cases are properly under investigation by the state secretariat staff and also by the municipal secretary of Fortaleza. Samples were collected from the patients for laboratory diagnosis, which are still under analysis.
                    Patients had the most frequent symptoms, observed in the cases of Bahia since mid-December: muscular pain mainly in the cervical region, lower and upper limbs, urine with a different color and alteration in the functions of the kidneys.
                    The disease, still without a cause confirmed by researchers and health agencies, accounts for 52 cases in the Metropolitan Region of Salvador. If the cases are confirmed in Ceará, they will be the first out of Bahia. It is necessary to investigate whether the records of states are related to each other.
                    Research and samples
                    Feces samples from nine patients from Bahia were sent to the Oswaldo Cruz Institute (IOC / Fiocruz), in Rio de Janeiro. The organ is a reference in the analysis of samples to identify new diseases. Analyzes are ongoing, but the institute has asked for more serum and urine samples to continue the investigation. There is no deadline for delivery of the award.
                    According to the Bahia State Department of Health, 44 patients had a negative result for bacterial infection.
                    There is also a suspicion that fish consumed in the region have caused intoxication. Therefore, samples consumed by people affected by the disease were referred to the Adolfo Lutz Institute in São Paulo and to a laboratory in the United States.

                    Comment


                    • #11
                      Published Date: 2017-01-13 15:07:16
                      Subject: PRO / PORT> Unidentified disease - Brazil (BA), outbreak, myopathy, update, increase in the number of cases, suspicious deaths, comments
                      Archive Number: 20170113.4759034
                      NON-IDENTIFIED DISEASE - BRAZIL (BAHIA), OUTBREAK, MIOPATHY, UPDATE, INCREASE IN NUMBER OF CASES, SUSPECTED OBITOS, COMMENTS
                      ************************************************** ************************************************** ***********************************
                      A message / A message / from ProMED-PORT
                      Http://www.promedmail.org
                      ProMED-mail and a program from / is a program of the
                      International Society for Infectious Diseases
                      Http://www.isid.org

                      Date: Friday, January 13, 2017

                      [1]
                      Source: G1 [10/01/2017] [edited]
                      Http://g1.globo.com/bahia/noticia/20...-na-bahia.html

                      Number of cases of mysterious disease rises to 52 in Bahia
                      -------------------------------------------------- ------------------------------
                      The number of suspected cases of the mysterious disease that causes intense muscle pain and leaves black urine has reached 52 in Bahia, according to data from the State Health Secretariat (Sesab) released on Tuesday (January / 2017). The accounting is for the period between December 14 [2016] of January 5 of this year [2017]. In the last bulletin released by the agency, with records up to December 30, 2016, the suspected cases were 30. As of December 19 of last year, there were 22.

                      In relation to the last bulletin, there were 22 new registered cases. According to Sesab, it is not possible to state that the situations occurred exactly between the last survey and the current one (December 31 and January 5), since these could be late notifications.

                      All new cases were registered in Salvador, which since the beginning of the survey already counts 50 suspected cases of the disease. Besides the capital, there are also records in Vera Cruz (1) and Lauro de Fretas (1).

                      The investigated cases are being treated by the Directorate of Epidemiological Surveillance (Divep) as "acute myalgia [pain] to clarify", because there is still no information on the causes of the disease. One of the hypotheses is that it may be related to fish consumption.
                      Communicated by: ProMED-PORT http://www.promedmail.org

                      -
                      [2]
                      Source: G1 [10/01/2017] [edited]
                      Http://g1.globo.com/bahia/noticia/20...-na-bahia.html

                      Man with symptoms of the disease that leaves black urine dies in Bahia
                      -------------------------------------------------- ------------------------------------------
                      A man of unknown age, who had symptoms of the mysterious disease that causes intense muscle pain and leaves black urine, died on December 31 in the municipality of Vera Cruz, in the metropolitan region of Salvador. The information was released on Tuesday (10) [January / 2017] by the State Department of Health (Sesab). The State Epidemiological Surveillance investigates whether death was caused by the disease, since the man had other health problems, including hypertension.

                      The investigated cases are being treated by the Directorate of Epidemiological Surveillance (Divep) as "acute myalgia [pain] to clarify", because there is still no information on the causes of the disease. The first suspicions were that fish consumed in the region of the north coast were causing intoxication. Samples from patients analyzed in the virology laboratory of the Federal University of Bahia (UFBA) indicated traces of enterovirus and parechovirus. The coordination of the laboratory expects to have a more accurate diagnosis by Friday (13) [January / 2017].

                      According to the state health authorities and Salvador, 44 patients were examined. Samples of blood, faeces and urine were sent to laboratories in Salvador, Rio de Janeiro and São Paulo. Fish samples will be sent by the Ministry of Health to the United States.

                      "We work with four hypotheses: bacterial, virus, heavy metal, and toxin contamination." Our biggest concern is the number of cases, we have 52 cases today, and we do not have a response to give to the population, and this Brings us great anguish, "explained Superintendent of health surveillance Sesab, Ita Cácia Aguiar.

                      -
                      Communicated by: ProMED-PORT http://www.promedmail.org

                      -
                      [3]
                      Source: O Globo [12/01/2017] [edited]
                      Http://oglobo.globo.com/society/saud...preta-20763104

                      Dies second patient with symptoms of disease that leaves black urine
                      -------------------------------------------------- ------------------------------------------
                      A patient who was among 52 people who had symptoms of an as yet unidentified disease, marked by severe muscle pain and black urine, died last Saturday [07 / January / 2017] in Salvador. The Health Secretariat of Bahia (Sesab), which confirmed the death, investigates whether death is related to the mysterious disease, which has been classified as "acute myalgia [muscle pain] to clarify". Another man, who also had symptoms, had already died on the last day [December / 2016].

                      Most of the suspected cases occurred in Salvador (50), but there were also manifestations of symptoms in the cities of Vera Cruz (1) and Lauro de Freitas (1), near the capital of Bahia. Sesab is monitoring and analyzing suspicious cases - among the 44 already investigated, 43 (97%) had sudden onset of intense muscular pain; 21 (47%) dark urine; 19 (43%) pain at the touch of the body; And 16 (36%) joint pains and sweating.

                      Most of the suspected cases occurred in Salvador (50), but there were also manifestations of symptoms in the cities of Vera Cruz (1) and Lauro de Freitas (1), near the capital of Bahia. Sesab is monitoring and analyzing suspicious cases - among the 44 already investigated, 43 (97%) had sudden onset of intense muscular pain; 21 (47%) dark urine; 19 (43%) pain at the touch of the body; And 16 (36%) joint pains and sweating.

                      -
                      Communicated by: ProMED-PORT http://www.promedmail.org

                      [4]
                      Source: G1 [12/01/2017] [edited]
                      Http://g1.globo.com/bemestar/noticia...te-agora.ghtml

                      Black urine disease in Bahia: what we know so far
                      -------------------------------------------------- -------------------------
                      A mysterious disease arrived in Bahia. Patients appear in the Metropolitan Region of Salvador with strong pains and urine of a different color. Doctors do not know if what caused the pain was a virus, a bacterium or an intoxication. In the midst of so many doubts, the G1 joined what we already know about the new disease that hit the Northeastern state.

                      What are the symptoms of the disease?
                      ----
                      In the bulletins disclosed, the disease is treated as "acute myalgia [pain] to clarify". The main symptoms are extreme muscle pain, kidney failure and black color urine. According to the infectologist Antônio Bandeira, coordinator of the arboviroses committee of the Brazilian Society of Infectious Diseases (SBI), who followed some of the cases in Salvador, it is as if the individual "had done a marathon in a few seconds." "It's an acute muscle injury, so the amount of myoglobin that's inside the muscle just goes out and goes into the urine, it ends up giving that Coca-Cola color, which also has a nephrotoxic (kidney-toxic) action, He explained.

                      How many people were affected?
                      ----
                      So far, according to the State Department of Health of Bahia, there were 52 cases of the disease. The government has confirmed 2 deaths. A man who had symptoms died on December 31 [2016], in the municipality of Vera Cruz. The victim, however, had other health problems, such as hypertension, in addition to old age.

                      This Wednesday (11) [January / 2017], the second death was confirmed. The death occurred on Saturday (7) [January / 2017], in Salvador. Details about the patient were not disclosed.

                      What is the region of registered cases?
                      ----
                      All cases were recorded in the metropolitan region of Salvador. In addition to death in Vera Cruz, another case was reported in Lauro de Freitas, and 50 occurred in the state capital of Bahia. The records were counted from December 14 [2016] to January 5 of this year [2017].

                      How is health care research going?
                      ----
                      Feces samples from nine patients were referred to the Oswaldo Cruz Institute (IOC / Fiocruz), in Rio de Janeiro. The organ is a reference in the analysis of samples to identify new diseases. Analyzes are ongoing, but the institute has asked for more serum and urine samples to continue the investigation. There is no deadline for delivery of the award.

                      According to the Bahia State Department of Health, 44 patients had a negative result for bacterial infection.

                      There is also a suspicion that fish consumed in the region have caused intoxication. Therefore, samples consumed by people affected by the disease were referred to the Adolfo Lutz Institute in São Paulo and to a laboratory in the United States.

                      How is the disease treated?
                      ----
                      As there is no confirmation of the causes, the treatment is done with hydration and analgesic. It is important that the patient does not take anti-inflammatory so as not to worsen the situation of the kidneys. The time for a slightly milder picture of symptoms ranges from three days to a week.

                      -
                      Communicated by: ProMED-PORT http://www.promedmail.org
                      [This post refers to the event initially reported by ProMED-PORT in the post [PRO / PORT> Unidentified disease - Brazil (03) (BA), myopathy, outbreak Archive Number: 20161216.4704355, http://www.promedmail.org / Post / 4704355]. See other posts below.

                      Since then, some hypotheses have been considered infectious and noninfectious, ranging from a variant of Epidemic Myalgia Syndrome - Bornholm's disease (often associated with the Coxsackie virus) - to a fish-related condition (Haff's syndrome).

                      However, so far, there are no conclusive results. Although it has been reported that "enterovirus and parechovirus traces" have been reported in faeces, this finding does not allow for any conclusions at this time, mainly because of the fact that identification in biological samples does not necessarily confirm association with a given disease /syndrome.

                      Another important point: until the opposite is proved, and above all, until a definitive diagnosis is made, both deaths reported above are nothing more than suspicious cases of the myopathic syndrome under investigation. Remembering also that the definition criterion that is being used is quite broad and puts myalgia (symptom quite common to no number of differential diagnoses, infectious or not) and elevation of CPK as only elements; Both very unspecific. In this sense, it is quite possible that among the cases reported as being due to the same syndrome in question more than one etiology may be associated.

                      Question: have the cases that evolved to death have had an immediate cause of death? Has there been involvement of which organs / systems? Was there evidence of myocarditis? What other differential diagnoses are being investigated? Was there necropsy?

                      There is no mention at any time of the analysis of muscle tissue (either by biopsy or by necropsy). There must be and, if not considered, it should have already been. The primary target seems to be restricted to muscle tissues. Kidney damage must be secondary to myoglobinuria. Knowing the histological pattern of injured muscle tissue and possibly conducting direct research of viruses or other agents (by isolation, electron microscopy and immunohistochemistry) could potentially help in better understanding the syndrome-related cases and, possibly, identify Of the etiology / etiologic agent.

                      Let's go with it.

                      Comment


                      • #12
                        While Haff disease appears the most likely possibility, the ProMED moderator raises the possibility of some other type of poisoning. If this is viral and contagious, I would have expected cases in HCW by now.

                        Published Date: 2017-01-19 17:05:30
                        Subject: PRO/EDR> Haff disease - Brazil: (CE) susp, RFI
                        Archive Number: 20170119.4776341
                        HAFF DISEASE - BRAZIL: (CEARA) SUSPECTED, RFI
                        *********************************************
                        A ProMED-mail post
                        http://www.promedmail.org
                        ProMED-mail is a program of the
                        International Society for Infectious Diseases
                        http://www.isid.org

                        Date: Mon 16 Jan 2017
                        Source: Outbreak News Today [edited]
                        http://outbreaknewstoday.com/suspect...a-state-98098/


                        The secretary of health of the state of Ceará in north eastern Brazil announced receiving reports of 3 suspected cases of "black urine disease" last week [week 9 to 15 Jan 2017]. The cases are being investigated by state and municipal health officials and samples were collected for laboratory testing, according to a Rede News 360 report (computer translated).

                        The 3 suspected cases presented with symptoms like those seen in Bahia state last month [December 2016]: muscular pain (mainly in the cervical region, lower and upper limbs), urine with a different color, and alteration in the functions of the kidneys.

                        Black urine disease still does not have an etiology and has been seen in dozens of people in Bahia. If the cases are confirmed in Ceará, they will be the 1st outside Bahia. According to the Bahia State Department of Health, 44 patients had a negative result for bacterial infection.

                        Suspicion has been raised that fish consumed in the region may have caused intoxication. Therefore, samples consumed by people affected by the disease have been sent to the Adolfo Lutz Institute in Sao Paulo and to a laboratory in the United States.

                        [byline: Robert Herriman]

                        --
                        communicated by:
                        ProMED-mail


                        [Black or dark urine are usually a sign of increased bilirubin. This can be caused by many diseases, but hemolysis with excreting of free hemoglobin is an obvious reason. If there is a massive hemolysis kidney function will be affected. It will be important to know if the patients were icteric. The outbreak nature seems to exclude porphyria.

                        Previously, "black water fever" was a hemolysis seen in malaria patients treated with natural quinine. The absence of fever and no suspicion of malaria seem to rule out this possibility. ProMED-mail will be happy to post further information from knowledgeable sources. - Mod.EP

                        Haff disease, rhabdomyolysis after ingesting certain types of fish, was 1st reported in 1924 in Europe. There have been a limited number of cases reported in the United States, and more farther south to Brazil and throughout Brazil. Symptoms of rhabdomyolysis can occur after eating cooked buffalo fish purchased at a suburban grocery market, or fresh from markets or the ocean. This suggests the substance responsible for rhabdomyolysis is not changed, denatured, or altered by the heat of cooking. A toxicological agent has not been identified. If there is an outbreak of this disease in Brazil we would appreciate an authoritative comment regarding the situation.

                        "...According to the Government of Bahia [Directorate of Epidemiological Surveillance, Health Secretariat of the State of Bahia 16 Dec 2016], up to now, 12 people have had symptoms such as myelitis and urine with black coloration. [The black coloration of the urine is often due to the breakdown of the muscles and release of myoglobin associated with rhabdomyolysis.]"

                        The enigma remains as to whether the clinical picture described in the previous posts is more consistent with a viral disease leading to Bornholm disease or more consistent with Haff disease. - Mods.TG/MPP

                        Comment


                        • #13
                          It is possible there is more than one thing going on here. It is also possible that surveillance for the wider outbreak has picked up a few unrelated cases. Either way, the cluster of three cases in bold below needs an explanation other than Haff disease.

                          Published Date: 2017-01-26 16:48:09
                          Subject: PRO / PORT> Unidentified disease - Brazil (03) (BA, CE), myopathy, outbreak, suspected cases, update, comments
                          Archive Number: 20170126.4793442
                          UNIDENTIFIED DISEASE - BRAZIL (03) (BAHIA, CEARÁ), MYOPATHY, OUTBREAK, SUSPECTED CASES, UPDATE, COMMENTS
                          ************************************************** ************************************************** ******************
                          A message / A message / from ProMED-PORT
                          Http://www.promedmail.org
                          ProMED-mail and a program from / is a program of the
                          International Society for Infectious Diseases
                          Http://www.isid.org

                          Date: Thursday, January 26, 2017
                          Source: G1 [24/01/2017] [edited]
                          Http://g1.globo.com/bemestar/noticia...problema.ghtml

                          'Black urine disease': what science has [not yet] discovered about the problem
                          -------------------------------------------------- -------------------------------------------------- -----
                          In December 2016, residents of Salvador and two municipalities in the metropolitan region of the capital began to seek health services with strong muscular pains and dark urine [PRO / PORT> Unidentified disease - Brazil (03) (BA), myopathy, outbreak
                          "Since then, more than 50 people have had the symptoms, two of which have died," he said.

                          See what doctors and researchers already know about the mysterious disease so far:

                          How many people were affected?
                          ----
                          There were 57 cases. In Bahia, 52 presented symptoms: 50 in Salvador, 1 in Vera Cruz and 1 in Lauro de Freitas, both municipalities in the metropolitan region of the capital. In Ceará, 5 cases were registered. Two people from Bahia died with symptoms [PRO / PORT> Unidentified disease - Brazil (BA), outbreak, myopathy, update, increase in number of cases, suspicious deaths, comments Archive Number: 20170113.4759034, http: //www.promedmail .org / post / 4759034].

                          Are new cases still popping up?
                          ----
                          There have been no new notifications since January 5 [2017] in Bahia. The most recent cases were registered in Ceará [PRO / PORT> Unidentified disease - Brazil (02) (CE), myopathy, outbreak, suspected cases Archive Number: 20170120.4781359, http://www.promedmail.org/post/4781359 - Mod. RNA].

                          What are the symptoms?
                          ----
                          Patients have severe pain in the neck and muscles. In some cases, they have dark urine and kidney failure.

                          Because of these symptoms, the disease has been treated in the epidemiological bulletins as "acute myalgia to clear up" (myalgia means muscle pain).

                          What is the profile of the patients?
                          ----
                          According to the infectious agent Tiago Lobo, who treated several patients with the condition, most of the people affected are from the upper middle class, which suggests that the disease is not related to lack of basic sanitation [not necessarily. Belonging to classes with higher purchasing power, not necessarily, protects people against environmental exposures in all locations ... - RNA Mod.].

                          What causes the disease?
                          ----
                          There is still no definitive conclusion. The two main hypotheses considered are:

                          - Fish poisoning
                          Of the 52 patients from Bahia, 44 reported having eaten fish and 8 said they did not eat. The fish consumed were bulls and whiting.

                          There are cases reported in several parts of the world of patients with symptoms similar to those in Bahia and Ceará caused by fish ingestion, classified as Haff's disease. In 2008, an outbreak of Haff's disease linked to consumption of pacu-butter fish reached 27 people in the Amazon. Since 1924, when the disease was first described, there have been outbreaks in Sweden, the former Soviet Union, the United States, and China.

                          - Parechovirus
                          Researchers also check whether the parechovirus could have triggered the symptoms. Stool samples from some of the patients evaluated by the Federal University of Bahia (UFBA) indicated the presence of the virus, but further investigation is still awaited. Cases of virus infection have occurred previously in Brazil, the United States and Australia.

                          Who is investigating the cases?
                          ----
                          Analysis of urine, serum and faeces samples are being conducted by the Federal University of Bahia (UFBA), the Oswaldo Cruz Foundation (Fiocruz) in Rio de Janeiro, the Adolfo Lutz Institute (IAL) in São Paulo and the Centers for Disease Control and Prevention (CDC) in the United States.
                          Can the disease spread throughout Brazil?
                          ----
                          The disease was first identified in Bahia and later cases appeared in Ceará. Four of the five cases in Ceará occurred in the same family and are connected to a person who was in Salvador. As the cause of the disease has not yet been identified, it is not yet possible to know if it can spread throughout the country. If it is a virus, there is a chance the disease will spread. If it is an intoxication, cases tend to be punctual.

                          A case registered in the city of Alagoinhas, Bahia, shows signs that point to the virus transmission. According to the infectologist Gúbio Soares, of the Federal University of Bahia (UFBA), a pregnant woman developed the symptoms after contacting her sister. She says she did not eat fish. A 5-year-old child, from the same family, was also infected. "These cases show that the transmission may be fecal / oral. It may be from a family of viruses that spread in this way," said the doctor.

                          -
                          Communicated by: ProMED-PORT http://www.promedmail.org

                          [Some hypotheses have been considered, infectious and non-infectious, ranging from a variant of Epidemic Myalgia Syndrome - Bornholm's disease (often associated with the Coxsackie virus) - to a fish-related condition (Haff's syndrome).

                          However, so far, there are no conclusive results. Although it has been reported that "enterovirus and parechovirus traces" have been reported in faeces, this finding does not allow for any conclusions at this time, mainly because of the fact that identification in biological samples does not necessarily confirm association with a given disease /syndrome.

                          Another important point: until the opposite is proved, and above all, until a definitive diagnosis is made, both deaths reported above are only suspected cases of myopathic syndrome under investigation. Remembering also that the definition criterion that is being used is quite broad and puts myalgia (symptom quite common to no number of differential diagnoses, infectious or not) and elevation of CPK as only elements; Both very unspecific. In this sense, it is quite possible that among the cases reported as being due to the same syndrome in question more than one etiology may be associated.

                          Question: have the cases that evolved to death have had an immediate cause of death? Has there been involvement of which organs / systems? Was there evidence of myocarditis? What other differential diagnoses are being investigated? Was there necropsy?

                          There is no mention at any time of the analysis of muscle tissue (either by biopsy or by necropsy). There must be and, if not considered, it should have already been. The primary target seems to be restricted to muscle tissues. Kidney damage must be secondary to myoglobinuria. Knowing the histological pattern of injured muscle tissue and possibly conducting direct research of viruses or other agents (by isolation, electron microscopy and immunohistochemistry) could potentially help in better understanding the syndrome-related cases and, possibly, identify Of the etiology / etiologic agent.

                          Comment


                          • #14
                            Published Date: 2017-02-02 23:52:01
                            Subject: PRO / PORT> Unidentified disease - Brazil (04) (EC), myopathy, new suspected cases
                            Archive Number: 20170202.4810028
                            UNIDENTIFIED DISEASE - BRAZIL (04) (CEARÁ), MYOPATHY, NEW SUSPECTED CASES
                            ************************************************** *******************************
                            A message / A message / from ProMED-PORT
                            Http://www.promedmail.org
                            ProMED-mail and a program from / is a program of the
                            International Society for Infectious Diseases
                            Http://www.isid.org

                            Date: Thursday, February 02, 2017
                            Source: G1 [31/01/2017] [edited]
                            Http://g1.globo.com/ceara/noticia/20...ina-preta.html

                            Ceará registers 9 suspected cases of 'black urine disease'
                            -------------------------------------------------- ----------------------------
                            The Health Department of the State of Ceará (Sesa) reported that it has raised to 9 the number of reports of suspected "acute myalgia to clarify", known as the "black urine disease." These cases refer to the period between January 5 and 26 [2017].

                            Among the cases, 7 are residents of Fortaleza, 1 resident in Salvador and 1 resident in São Paulo. Five patients are men, and four are women. According to Sesa, all patients evolved to cure after medical treatment.

                            The date of onset of symptoms in the first case was on December 18, 2016 and the date of the last reported case on January 22, 2017 [2017]. The median age was 40 years - the patients were between 23 and 70 years old.

                            Patients with suspected disease had the following signs and symptoms: sudden onset of intense muscular pain, mainly affecting the cervical region, lower and upper limbs, changes in urine tonality (ranging from dark red to brown), significant elevations in Cretinphosphokinase (CPK) and [hepatic [liver enzyme] levels (TGO and TGP). There was no report of fever, headache, arthralgia or rash.

                            -
                            Communicated by: ProMED-PORT http://www.promedmail.org

                            Comment


                            • #15
                              http://www.gazetadabahia.com/website...para-64-na-ba/

                              Number of cases of disease that leaves black urine rises to 64 in BA
                              February 2, 2017 admin 0 Comments




                              Email
                              The number of cases of acute myalgia, a mysterious disease known to cause intense muscular pain and to leave black urine, rose from 52 to 64 in Bahia. The data refer to the period between December 14, 2016 and January 24 and this year. The new bulletin was released on Wednesday (1st) by the Secretary of Health of the State of Bahia (Sesab). So far, two people have died with suspicions of the disease in the state.
                              The first records of symptoms of the disease were recorded in Bahia in December 2016. According to Sesab, of the 64 cases recorded in the survey, 60 occurred in Salvador. Thirty-three may already be classified as suspects because of blood sample results. Besides the capital of Bahia, the municipalities of Vera Cruz, Dias D'Avila, Camaçari and Alcobaça registered one case each.
                              The bulletin that indicated 52 cases in the state was released by the agency at the beginning of the year and took into account the period until January 5. Before that, the last survey, carried out six days earlier, took into account 30 cases.
                              The symptoms of the disease are intense muscular pain, of sudden onset, mainly affecting the cervical and trapezius region, associated with pain in the arms and / or back, thighs, calves with no apparent cause and elevated creatine phosphokinase. Patients may also develop kidney failure and therefore have dark urine.
                              A couple of tourists from São Paulo (SP) who spent holidays in Bahia also presented the symptoms of the mysterious disease. Sibely and Robson Rodrigues arrived in the state on January 18 and ingested fish in the first three days, in Praia do Forte and Barra do Pojuca. The couple's children, aged 7 and 11, also ate but had no symptoms.
                              "First, I started with the symptoms: a very strong pain in the musculature on the back of the thigh, up the lumbar, the back, the neck and, finally, the arms. Next I did not move. I was paralyzed, "said Sibely.
                              The husband presented the symptoms about an hour later. Both had kidney problems and had black urine. "The intensity of the pain is very strong. To give you an idea, I've had dengue. And to me, it was much stronger than dengue. And the color of the urine was the color of Soda Coke, "the tourist added.
                              Robson had a greater degree of kidney failure, while Sibely had a swelling in the liver. They needed care at a health post and a hospital in the city of Lauro de Freitas, in the metropolitan region of Salvador. Upon returning to São Paulo, the couple were admitted to the Paulistano Hospital. The treatment was based on hydration.
                              According to the infectious physician Antônio Bandeira, who also investigates the disease in Bahia, the most likely cause is fish poisoning. Another expert, the doctor Gubbio Soares, believes in the possibility of a virus - he analyzed the case of a woman who would have developed the symptoms of the disease after contacting her sister.
                              The disease remains under investigation by the Ministry of Health. Samples were sent to a laboratory of the Centers for Disease Control and Prevention (CDC) in the United States, the Adolfo Lutz Institute in São Paulo, and the Oswaldo Cruz Foundation (Fiocruz), in Rio de Janeiro.

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