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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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  • #16
    Published Date: 2017-02-07 10:38:27
    Subject: PRO / ESP> Unknown viral disease - Brazil: (BA) (03) acute myositis, dark urine, outbreak in progress
    Archive Number: 20170207.4821809
    VIRAL DISEASE UNKNOWN - BRAZIL: (BA) (03) ACUTE MYOSITIS, DARK URINES, BREAK IN PROGRESS
    ************************************************** ************************************************
    A ProMED-mail release
    ProMED is the largest publicly-available surveillance system conducting global reporting of infectious diseases outbreaks. Subscribe today.

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    International Society of Infectious Diseases
    The International Society for Infectious Diseases (ISID) brings together a network of individuals from around the world.


    Date: February 07, 2017
    Source: Yahoo News

    [Edited by Jaime Torres and Jorge Gonz?lez]


    Health officials have reported in the state of Bahia, northeast Brazil, 64 cases of a strange myalgia that causes intense muscle pain and leaves black urine, officials said today.

    The state medical services are investigating the still unknown causes that have caused the outbreak of this type of acute myalgia whose first case was notified on December 14, according to a statement from the Bahia Health Ministry.

    Of the total number of patients reported with this strange condition, sixty are from Salvador, capital of Bahia, and 33 are in the definition of sudden acute myalgia, so practically half of the patients have no clear diagnosis.

    The symptoms are intense muscle pains, which affect "mainly the cervical and trapezius region" and the upper and lower limbs, in addition to leaving the black urine, the report added.

    The Government of Bahia, with the support of the Brazilian Ministry of Health, announced an international cooperation agreement with the Centers for Disease Control and Prevention (CDC), in the United States, to intensify the search for causes that Explain this outbreak.

    "It will be necessary to review the file and analyze the data bank built in these two months and, if necessary, listen to the patients and health professionals who attended these people," said State Health Undersecretary Roberto Badaro, quoted In the note.

    Some of the samples are being analyzed by the Brazilian Oswaldo Cruz Foundation, the largest center for health studies in Latin America.

    Communicated by: Jaime R. Torres


    - ProMED-ESP


    -----
    Jg



    [The appearance of muscle pain and dark urine points to rhabdomyolysis (destruction of muscle tissue and release of myoglobin pigment in the urine); But the point is to find the cause. Only the acute appearance of this condition is known, apparently there is no history of trauma, use of drugs (corticosteroids in high doses, for example); And no one knows about any exposure to extreme heat. Among the causes of infectious origin, we should look for conditions that lead to bilirubinuria or hematuria, but these manifestations are usually accompanied by other signs and symptoms that allow narrowing of the fence from the point of view of diagnosis. Another possible cause of the outbreak is Haff's disease in which acute rhabdomyolysis occurs after consuming freshwater fish; A toxin is suspected as the cause. Moderators Jorge Gonz?lez and Jaime R. Torres]

    Comment


    • #17
      The plot thickens; note the bold text:
      Published Date: 2017-02-10 10:50:30
      Subject: PRO/AH/EDR> Haff disease - Brazil (02): (BA) RFI
      Archive Number: 20170210.4829090
      HAFF DISEASE - BRAZIL (02): (BAHIA) REQUEST FOR INFORMATION
      ************************************************** *********
      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: Thu 9 Feb 2017
      From: James M. Wilson [edited]


      The 1st report of 'acute myalgia' appeared in early December [2016] with an initial cluster of 4 members of a family (older father, mother, and children, 20 and 14 years old) who presented with acute pain in the trapezoidal area, back, and legs. The pain was severe enough that the mother could not walk. These patients did not exhibit fever, arthralgia, and no respiratory or gastrointestinal (GI) symptoms. Palpation of the muscles elicited pain. Laboratory values of note: extremely elevated CK [creatine kinase] of 70 000 IU/L. 3+ myoglobinuria, and elevated AST (aspartate aminotransferase), ALT (alanine aminotransferase), and LDH (lactate dehydrogenase). Normal WBCs [white blood cells ] with no bands. CRP (c-reactive protein test) was less than 5. Their urine was a "Coca-Cola" color. Blood, urine, and feces were sampled; PCR test results (in Brazil) were negative for DEN [dengue fever], CHIK [chikungunya], Zika, parechovirus, and enteroviruses. It was noted this family consumed 44 pounds of fish per month that was predominantly 2 species of marine fish: yellowtail amberjack (_Seriola lalandi_) and any of the fish in either the Serranidae and/or Gadidae families of fish. All of the family members indicated their symptoms began within 12 hours of the consumption of these fish.

      The 2nd cluster was 5 more patients: a father, a mother, their son (who lived in a different house), his wife, and [her father] who all ate the same fish (as mentioned above) together. The presentation was similar to the 1st cluster, and the same samples were collected -- all were negative.

      The next cluster was a boyfriend and girlfriend who traveled to the hospital from 40 miles [64.4 km] away after visiting the girlfriend's aunt. The boy and girl were admitted to the hospital and the aunt declined admission. All of them had eaten the same fish as mentioned above.

      As of [24 Jan 2017], the case counts stand at 62, 34 of which exhibited myalgia and grossly elevated CK. One patient died, a 65 year old male with significant co-morbidity (cardiac insufficiency). A minority of these patients have reportedly had a fine, very light truncal rash. One patient, a 74 year old woman, ate only 2 fish and was later hospitalized. One patient denied consuming fish but ate a dish that contained byproducts of fish. There was also a physician who had consumed fish and was hospitalized. One patient had a CK of 113 000 IU/L and had acute renal failure but did not require dialysis. There is no report of ICU inundation or high demand for dialysis.

      All of the patients who had eaten fish were of 1 of the 2 types of aforementioned marine fish. These patients had bought fish in different markets and consumed them in different locations.

      The ongoing hypothesis continues to be Haff disease, with notable exceptions:
      - this is the largest documented outbreak of Haff disease in Brazil's history;
      - this may be the 1st documented outbreak of Haff disease that involved marine, as opposed to freshwater, fish; and
      - the clinical finding of dramatically elevated CK values compared to prior reports of Haff disease
      (see https://www.cdc.gov/mmWR/preview/mmwrhtml/00056038.htm)

      We thank Dr Antonio Bandeira, the physician who reported the 1st couple of case clusters for his generosity in sharing this important information with the international community.

      --
      James M Wilson V, MD FAAP
      M2 Medical Intelligence
      Nevada
      USA


      [Dr Wilson's summary of the situation is very much appreciated, as Haff disease is always associated with ingestion of certain types of fish, which he clarified. - Mod.TG]

      ******
      [2]
      Date: Sat 4 Feb 2017
      Source: Espacio de Prensa, Agencia EFE report [in Spanish, trans. KS, edited Mods.JT/JG]
      https://www.espaciodeprensa.com/regi...a-orina-negra/


      Health officials have reported in the state of Bahia, northeast Brazil, 64 cases of a strange myalgia that causes intense muscle pain and black urine, officials said today [7 Feb 2017].

      The state medical services are investigating the still unknown causes of the outbreak of this type of acute myalgia, whose 1st case was notified on 14 Dec 12016, according to a statement from the Bahia Health Ministry.

      Of the total number of patients reported with this strange condition, 60 are from Salvador, capital of Bahia, and 33 fit the definition of sudden acute myalgia, so that practically half of the patients have no clear diagnosis.

      The symptoms are intense muscle pains, which affect "mainly the cervical and trapezius region" and the upper and lower limbs, in addition to the black urine, the report added.

      The Government of Bahia, with the support of the Brazilian Ministry of Health, announced an international cooperation agreement with the Centers for Disease Control and Prevention (CDC), in the United States, to intensify the search for the cause(s) of this outbreak.

      "It will be necessary to review the files and analyze the data bank built in these 2 months and, if necessary, interview the patients and health professionals who attended them," said State Health Undersecretary Roberto Badaro, quoted in the note.

      Some of the samples are being analyzed by the Brazilian Oswaldo Cruz Foundation, the largest center for health studies in Latin America.

      --
      Communicated by:
      ProMED-mail


      [Haff disease, rhabdomyolysis after ingesting certain types of fish, was first reported in 1924 in Europe. There have been a limited number of cases reported in the United States, throughout Brazil, and more farther south. 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

      ​(I'm not sure I agree with Dr. Wilson on the last bullet point. The MMWR report he links says a normal CK reading is below 120, and the previous cases had elevated readings ranging from 2000 to 25.000. One case with a reading of 113,000 in the current outbreak doesn't seem to differ greatly from what was previously reported, especially given the higher number of cases this time. - alert)

      Comment


      • #18
        Published Date: 2017-02-11 11:46:32
        Subject: PRO/AH/EDR> Haff disease - possible model
        Archive Number: 20170211.4831520
        HAFF DISEASE- POSSIBLE MODEL
        ****************************
        A ProMED-mail post
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        ProMED-mail is a program of the
        International Society for Infectious Diseases
        http://www.isid.org

        Date: Fri 10 Feb 2017
        From: "Leighton, Ted"


        In North America, the popular sport-fishing fish, the Walleye (_Sander vitreus_) (formerly _Stizostedion vitreum_) suffers from a condition of muscle necrosis that might, if better understood, shed some light on the cause of Haff disease.

        Walleye live in fresh water and feed on other fish and largish invertebrates such as crayfish. From time to time walleye are caught by anglers and discovered to have large zones of discoloured, firm and sometimes gritty-textured muscle. Such fish usually are rejected as food by anglers but occasionally are brought to fish and wildlife authorities who in turn sometimes convey them to veterinary diagnostic laboratories or to fish biologists.

        Little has been published about this condition, but it has been reported over a broad geographic area that includes western Ontario, the southern prairie zones of Manitoba, Saskatchewan and Alberta, and in adjacent northern states of the USA.

        Histologically, the affected muscle is necrotic (non-living) and undergoing gradual healing through replacement with connective tissue. The necrotic muscle often is quite heavily mineralized. The form presented for examination by anglers is chronic, slowly healing dead muscle and the lesion has been called "myofibrogranuloma" in keeping with a slow inflammatory process directed against a mass of dead muscle. Calling it chronic rhabdomyolysis would be equally appropriate.

        Nothing appears to be known about the acute phase of the condition in Walleye or of the range of clinical signs or pathological effects on the fish. No evidence of infectious agents or physical injury has been associated with this condition. A toxic element in the diet is one plausible hypothetical cause, hence the possible parallel with Haff disease.

        Perhaps this species could serve as an animal model for Haff disease in people.

        See: Holloway and Smith. 1982. Myopathy in North Dakota Walleye (Stizostedion vitreum). Journal of Fish Diseases. 5(6): 527-530.

        --
        Communicated by:
        Ted Leighton
        Professor emeritus
        Western College of Veterinary Medicine
        University of Saskatchewan
        Canada


        [It is an interesting theory. Hopefully someone with research dollars will want to look into this situation with fresh water fish and see if it sheds any mechanistic light on Haff's disease.

        The one note of concern is that in people, they all eat the fish. Therefore what do the fish eat to cause this syndrome? Further, has anyone ever looked at the fish associated with Haff disease to see if they have any muscle lesions? - Mod.TG]

        Comment


        • #19
          Published Date: 2017-03-11 18:04:51
          Subject: PRO / PORT> Unidentified disease - Brazil (05) (BA), myopathy, update, Haff's syndrome, probable
          Archive Number: 20170311.4894531
          UNIDENTIFIED DISEASE - BRAZIL (05) (BAHIA), MYOPATHY, UPDATE, HAFF SYNDROME, PROBABLE
          ************************************************** ************************************************** **
          A message / A message / from ProMED-PORT
          ProMED is the largest publicly-available surveillance system conducting global reporting of infectious diseases outbreaks. Subscribe today.

          ProMED-mail and a program from / is a program of the
          International Society for Infectious Diseases
          The International Society for Infectious Diseases (ISID) brings together a network of individuals from around the world.


          Date: Saturday, March 11, 2017
          Source: G1 [10/03/2017] [edited]


          Black urine disease caused by intoxication after fish ingestion, study says
          -------------------------------------------------- -------------------------------------------------- ----------
          The same researchers who identified the zika virus in Bahia have just completed a study on "black urine disease," which recorded more than 50 cases in the same state between December 2016 and January 2017. RNA]. Doctors concluded, by exclusion, that cases occurred due to intoxication after eating fish, which triggers the so-called Haff's disease.

          The study was based on the results of feces, urine and blood samples from 15 patients analyzed. Fourteen of the 15 people who reported symptoms reported consuming fish - most bulls eye (_Seriola spp_) and whiting (_Mycteroperca spp_). The fifteenth person said they ate Bahian food, which could possibly include these species.

          According to Antonio Carlos Bandeira, of the Federal University of Bahia (UFBA), one of the authors of the article, the possibility of a new virus or bacteria related to the disease is practically discarded in the region.

          In the samples, however, it was not possible to determine the substance that caused the intoxication. According to Bandeira, a piece of fish that was ingested by a patient was referred to the Ministry of Health, which in turn sent the material to a laboratory in the United States. The result has not yet been released.

          Together with Bandeira, 11 other researchers signed the article that was sent to international journals. In the same study are also included the results of researcher Gubbio Soares, also from UFBA, who at first had strong suspicion for a virus.

          Haff's disease is characterized by an abrupt onset of intense muscle pain associated with elevated levels of the enzyme creatine phosphokinase (CPK). These symptoms appear less than 24 hours after eating fish - in addition to pain, urine turns black and there is kidney failure. In previous cases, a toxin in the fish is thought to have caused the disease, but most investigations failed to identify the agent of the poisoning.

          The first cases of Haff's disease were first described in 1924 in Russia and Sweden and involved the consumption of different freshwater fish. In the United States, there were reports in Texas in 1984 after consumption of boiled freshwater buffalo (_Ictiobus cyprinellus_), and in 1997, the Centers for Disease Control and Prevention (CDC) reported six additional cases of disease in California and Missouri.

          In 2001, two cases were recorded following the ingestion of cooked Atlantic salmon in North Carolina and in 2014, individual case reports were published. China also reported some occurrences of the disease in 2010 due to ingestion of Norway lobster.

          In Brazil, an outbreak of 27 cases of Haff's disease occurred in 2008, during 4 months in the northern state of Amazonas. Freshwater fish pacu-butter (_Mylossoma duriventre_), tambaqui (_Colossoma macropomum_) and pirapitinga (_Piaractus brachypomus_) were the cause.

          There is a difference between the previous cases of the disease and the most recent in Bahia: according to Bandeira, the fish consumed this time are saltwater, unlike previous reports in the United States, Sweden, Russia and even in Brazil.

          So far, the Ministry of Health has not released other results of research concerning cases found in Bahia.

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

          [ProMED-PORT, since the initial reports of the cases attributed to the myopathic syndrome that was being detected in Bahia, has been pointing to toxins as a more probable hypothesis. According to the above news the association with toxins, in fact, more and more probable, although it will be, for now, of difficult proof.

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