Haff disease is a rare syndrome of myalgia and rhabdomyolysis occurring within 24h of consumption of certain types of cooked freshwater fish or crustacean. We describe a case report in a Kidney transplant recipient. Male patient, 43 years old, underwent kidney transplant in 2012 with a deceased donor. On 1/10/2019, he was admitted with myalgia, fatigue, thrush, inappetence and emesis that started suddenly 2 days before. Reports ingestion of fish 3 days earlier. He recently completed his vaccination schedule. His immunosuppression is tacrolimus, sodium mycophenolate and prednisone. No antihypertensive drugs. He arrived at the hospital with an initial CPK of 70.674 U/L, LDH 2.057, phosphorus 7,5 mg/dl, aspartate amino transferase 494 U/L, creatinine (Cr) of 6.5 mg/dl, and acute kidney injury (AKI). Urine analysis showed protein +1, hemoglobinuria +3, in the sediment no erythrocytes or leukocytes increase. During hospitalization, he experienced an episode of agitation and persecutory delusions. After intense hydration with sodium bicarbonate IV, symptoms improved and CPK and Cr levels normalized. In December 2019, 2 months after he was admitted again to hospital. He and his brother informed that he has consumed fries that were cooked in the oil that the same local fish before was prepared. On admission his CPK 14.991 U/L and Cr of 2,5 mg/dl. Patient reported syncope, remaining unconscious for 1h30min. Report feverish spikes, dark urine, and periods of agitation and confusion. He denied using non-steroidal anti-inflammatory drugs, other vaccines, or changing medications. He ran away from the hospital due to auditory and visual hallucinations. He returned to the hospital again to receive care and improved his clinical condition with hydration. Currently, he remains under outpatient follow-up with normal renal function, cr 1.1 mg/dl.
The patient presented two episodes of rhabdomyolysis, acute kidney injury and unexplained organic psychosis after ingesting local fish, or in the second time food cooked in the same oil that the local fish was prepared. Epidemiological: History of fish consumption in the last 24 hours prior to the onset of signs and symptoms; Clinical: Presence of muscle changes (such as intense myalgia, muscle weakness, neck pain, chest pain, muscle stiffness) of unknown etiology and sudden onset and/or presence of dark urine – similar to coffee or black tea (myoglobinuria). Laboratory: The diagnosis of rhabdomyolysis  in this case was significant increase in creatine phosphokinase in both hospitalizations – CPK levels (an increase of at least five times the upper limit of the reference value). All findings from this case report contribute for the Haff Disease diagnosis.