it is a common practice in south east asia to consume alternative medicine which may include toxic metals or animal products for various health reasons . herein we report a case of anuric acute renal failure with dyspnea and hemoptysis following volitional consumption of rohu fish ( labeo rohita ) gall bladder . forty two year old male chronic alcoholic , smoker and marijuana addict presented with history of diffuse abdominal pain with profuse vomiting followed by oliguria . he was treated with intravenous fluids and diuretics in a primary health centre near nagpur . as he developed edema feet , puffiness of face , breathlessness and hemoptysis he was transferred to our tertiary care hospital . there was no history of fever , joint pains , rash , jaundice or bleeding from other sites . on admission , examination revealed medium frame , poorly nourished patient with pallor and no icterus . investigations revealed hemoglobin-11.4 gm / dl with total white blood cell count-9600/cumm and platelet count-80000/cumm . urine routine showed protein 2 + with 20 - 25 red blood cells and 70 - 80 white blood cells per high power field . renal chemistry revealed blood urea nitrogen-160 mg / dl , serum creatinine-16.8 mg / dl , serum sodium-113 meq / l , serum potassium-3.3 meq / l , total proteins-6.6 g / dl with albumin 3.4 g / dl , ast / alt-56/42 iu / l , serum bilirubin-1.1 mg / dl , serum uric acid-11.6 mg , serum calcium-8 mg / dl and serum phosphate-5.5 mg / dl . ultrasonography of the abdomen showed normal size kidney with no dilatation of pelvi - calyceal system . as patient had hemoptysis and acute kidney injury there was a strong suspicion of pulmonary renal syndrome . however his igg anti - glomerular basement membrane ( gbm ) antibody was 1.8 u / ml ( negative < 12 u / ml ) . a plain computerized tomography ( ct ) of the chest showed patchy perihilar ground glass opacities with peribronchial cuffing , segmental atelectasis of bilateral lower lobes with bilateral pleural effusion . persistent enquiry as regards a possible toxic etiology for his acute onset complete anuria revealed he had consumed the entire bile from a raw fish gall bladder ( rohu or labeo rohita ) a day prior to the onset of symptoms as a cure for his general debility . in view of his pulmonary edema and deteriorating renal function he was dialysed once on admission after which there was a gradual increase in urine output over 6 days . he improved symptomatically with a decrease in serum creatinine from 16.8 mg / dl to 10 mg / dl on day 5 to 4.8 mg / dl on day 15 . he was eventually discharged after 18 days of in - hospital treatment with serum creatinine of 2.5 mg / dl . subsequent follow - up after 15 days showed serum creatinine was 1.08 mg / dl . fish gall bladder is considered a traditional medicine to treat rheumatism , decreased visual acuity , and urticaria and to increase sexual vitality . however it can lead to acute renal failure and acute liver injury as reported in cases of fish poisoning from india , japan and hong kong . the ichthyotoxic effects of fish gall bladder is attributed to the presence of a toxin , sodium cyprinol sulfate which is a c27 bile acid . the toxin is heat stable and insoluble in alcohol as cases are reported even after consumption of cooked bile . the family includes grass carp ( c idellus ) , common carp ( cyprinuscarpio ) , silver carp ( hypophthalmichthysmolitrix ) , mylopharyngodonpiceus , labeorohita and aristichthys nobilis . amongst these , fish of the grass carp variety has been commonly reported for its toxicity but xuan et al . also reported toxicity secondary to ingestion of shark ( minnow ) fish ( m chrysophekadion ) and the bony - lipped barb fish ( o melanopi ) . even though fish gall bladder can cause severe systemic complications , toxicity does not occur in all cases . in rural vietnam , gall bladder from smaller fish are consumed regularly without evident toxicity . thus it can be said that toxicity is directly proportional to the size and quantity of gall bladder or bile consumed . following ingestion almost all patients develop gastrointestinal symptoms within a few hours as reported by xuan et al . in his series of 17 cases from vietnam . has also reported extra - renal manifestations of the toxin with deleterious effects on the heart and liver with eventual multi - organ dysfunction syndrome . however patients usually seek therapy for renal failure which has an incidence of 55 - 100% . renal failure is mostly secondary to acute tubular necrosis which may be a direct effect of the toxin . kidney biopsy has shown the presence of proximal tubular cell damage with focal destruction of epithelial cells on light microscopy . the toxin is believed to damage lysosomes and inhibit cytochrome oxidase thus blocking cellular metabolism , leading to cell necrosis . this in addition to loss of fluid can lead to decreased effective circulating blood volume and eventually renal failure . however the exact mechanism of systemic injury especially renal failure is not known and needs further study . our patient had reported hemoptysis prior to admission and had an abnormal ct scan of the chest . the cause for the same in such a setting could include fluid overload - pulmonary edema ( anuria ) or pulmonary renal syndrome . toxic bile is also reported to cause pulmonary renal syndrome however the patient 's primary workup including ana , c3 , c4 and igg anti gbm was normal . toxin induced pulmonary renal syndrome remains a possibility however a workup for the same including kidney biopsy and bronchoalveolar lavave was not done in view of steady improvement in his condition . most of the reported cases till date have undergone hemodialysis in view of renal failure pandey et al . in their case good awareness programs can aid diagnosis and prevent death from such a dangerous preventable cause of acute kidney injury which is the aim of international society of nephrology  0 by 25 initiative  .
a forty two year old male was admitted with history of anuria and breathlessness following consumption of raw rohu fish gall bladder . he had azotemia and required hemodialysis . 
 his renal failure improved over a period of about four weeks . 
 incidences have been reported from south east asian countries associating consumption of raw rohu fish gall bladder with acute renal failure .