Periostitis and osteolysis in a medieval skeleton from South‐West Hungary: (Leprosy,treponematosis, tuberculosis or hypertrophic osteoarthropathy) A diagnostic challenge!

This paper uses macroscopic and radiological examinations to provide differential diagnoses of pathological lesions in the well‐preserved skeleton of a young male from the medieval site of Zalavár in South‐West Hungary. Macroscopic inspection of the skeleton revealed conspicuous thickening of the tibiae and fibulae with ‘tree bark’ appearance of the cortex. Periosteal proliferations are also found on the calcanea and on the posterior part of the femora. The metatarsals showed bony proliferation and bone dissolution. No alteration of the axial skeleton or the skull was noted. Radiographs showed thickening of the cortex of tubular bones due to a multilayered type of periosteal apposition. The likelihood of these symptoms being the result of melorheostosis, hypervitaminosis A, fluorosis, thyroid acropachy, endosteal hyperostosis, tuberculosis (TB), hypertrophic osteoarthropathy (HOA), treponematosis and leprosy is reviewed. None completely explains the entire spectrum of pathological lesions in the current individual, but the individual may have suffered from two co‐existent diseases. As a clinical entity, the changes in the metatarsals are compatible with leprosy, whereas the periosteal proliferations of the lower limbs point to a diagnosis of HOA as a secondary syndrome. Thus, a combination of leprosy and TB is suggested as a potential diagnosis. Although not definitive, our differential diagnosis was able to exclude a number of conditions producing periosteal apposition. Copyright © 2011 John Wiley & Sons, Ltd.     

Metastatic carcinoma in a leper skeleton from a Medieval cemetery in Chichester England

Both leprosy and metastatic cancer are well documented in the literature on human skeletal palaeopathology. The manifestation of both pathological conditions in a single archaeological skeleton has not been reported. A case from a Medieval site in Chichester, England exhibits bone lesions and patterns of skeletal involvement indicative of both these diseases. Evidence of leprosy is largely restricted to the lower tibiae, fibulae and the bones of the feet. Fine destructive foci and reactive fibre bone associated with metastatic cancer are distributed in many of the remaining areas of the skeleton. There is minimal overlap in the areas of the skeleton involved in the two pathological processes.     

Probable early presence of leprosy in Europe in a Celtic skeleton of the 4th–3rd century BC (Casalecchio di Reno,Bologna, Italy)

Examination of the skeleton of an adult male from the Celtic necropolis of Casalecchio di Reno (Bologna, Italy; 4th–3rd century BC) revealed some lesions on the feet, especially bilateral acro‐osteolysis of the metatarsals, and on the tibia, fibula and hand. The morphological and radiographic characteristics of the bones are consistent with a diagnosis of leprosy. Other features of the rhinomaxillary region support this diagnosis. As far as we know, this case could represent the oldest skeletal evidence of leprosy in Europe, indicating the early spread of this disease toward the Western world. Copyright © 2005 John Wiley & Sons, Ltd.     

A case study of possible differential diagnoses of a medieval skeleton from Denmark: leprosy,ergotism, treponematosis,sarcoidosis or smallpox?

This paper uses macroscopic and radiological examinations to provide differential diagnoses of pathological lesions in the skeleton of a young woman, 20–25 years of age, which triggered the Danish palaeopathologist Vilhelm Møller‐Christensen's interest in leprosy. The skeleton was incomplete, but the majority of bones of the upper body, as well as the skull, were present. The pathological changes consisted of medullary and cortical lytic foci, periosteal reaction and enhanced cortical density. The lesions were most extensive on the left side, especially around the elbow, wrist and scapula. Treponematosis, leprosy, smallpox, ergotism, rheumatoid arthritis, tuberculosis and sarcoidosis are all reviewed with regard to bone and joint pathology and their likelihood of being the correct diagnosis. We concluded that the most plausible diagnosis is treponematosis, but neither sarcoidosis nor smallpox can be completely excluded. Copyright © 2007 John Wiley & Sons, Ltd.     

Paleopathological and Molecular Study on Two Cases of Ancient Childhood Leprosy from the Roman and Byzantine Empires

This study is based on the paleaopathology of leprosy on human skeletal remains and the detection of ancient Mycobacterium leprae DNA. Two cases of childhood leprosy were recognized. The first case was in a Roman necropolis at Martellona (Rome, Central Italy), dated to the 2nd to 3rd centuries ce . The skeleton of a child aged 4–5 years, from tomb 162, is the youngest individual in Italy from this time period, with the clear rhino‐maxillary syndrome and other bony changes indicative of leprosy. The second case from a burial at Kovuklukaya, in the Sinop region of Northern Turkey, was from the 8th to the 10th centuries, during the Byzantine era. The endocranium of a 4–5‐month‐old infant with new bone formation—an indication of chronic inflammation—was positive for M. leprae DNA. Infant and childhood leprosy is uncommon today, and there is a scarcity of information in the osteoarchaeological literature of leprosy in the past, especially in children. The significance of these cases is that it adds to an understanding of the history of the disease in the former Roman Empire. It is hoped that over time sufficient data can be obtained to understand the epidemiological dynamics and clinical evolution of leprosy from the ancient period until today. Copyright © 2012 John Wiley & Sons, Ltd.     

Thalassemia: macroscopic and radiological study of a case

Differentiation of the genetic and the acquired anaemias, particularly in areas of the world where they may co‐exist, has been a challenge for palaeopathologists for over 100 years. In this paper we present macroscopic and radiographic skeletal lesions that are associated with the thalassemias in a 14‐year‐old girl from a modern reference collection of the University of Athens. This individual is of known sex, age, cause of death, place and dates of birth and death. The case is examined in terms of epidemiology, growth, distribution and severity of lesions and differential diagnosis. The entire skeleton is affected by marrow hyperplasia: lesions of the axial skeleton are extreme, and the appendicular skeleton is severely affected as well. The odontofacial manifestations that are diagnostic of thalassemia and differentiate it from other anaemias are present and include: maxillary and mandibular hyperplasia, reduced sinuses, displacement of maxillary dental structures, overbite, and generalised osteopenia. The development of extreme bone lesions and the ‘advanced’ age‐at‐death of this individual is explained as either the result of thalassemia major under a low transfusion regimen that was the norm during her lifetime, or to a form of thalassemia intermedia that allows survival to later life at the expense of gross skeletal alterations. The present status of skeletal studies in Greece does not support the identification of a genetic anaemia in past populations. The potential contribution of the current analysis in differentiating the anaemias in antiquity is evaluated. Copyright © 2006 John Wiley & Sons, Ltd.     

A Roman Skeleton with Possible Treponematosis in the North‐East of the Iberian Peninsula: A Morphological and Radiological Study

The main goal of this paper is to describe and discuss pathological lesions observed in a Roman skeleton (between 2^nd and 3^rd century AD) from the north‐east region of the Iberian Peninsula (St Nicasi 18–24 site. Gavà, Barcelona), which may be compatible with treponematosis. Most of the skeleton, with the exception of the neurocranium, was recovered. Only the left tibia was affected, whereas the rest of the recovered skeletal remains were unaffected. Macroscopic examination revealed a male individual between 25 and 30 years of age at death with a sabre‐shaped left tibia. The proximal half of the diaphysis was pitted and the bone overall enlarged. The surface of the tibia showed occasional vascular impressions where, in some instances, small raised plaques of new bone appeared to bridge over them, specifically in the most affected area of the proximal half of the tibia. No destructive lesions were observed. Radiographic examination and gross inspection at the cross section of the tibia showed encroachment into the medullary cavity of coarse cancellous bone and cancellization of the cortex. The observed lesions indicate that the tibia was affected by a chronic infectious disease. Differential diagnoses were considered, and these included other infectious diseases, fibrous dysplasia, Paget's disease, chronic varicose ulcers affecting bone and trauma, with the conclusion that the disease affecting the tibia could have been treponematosis. This could be significant in the history of the treponematoses being one of the oldest examples of treponematosis in pre‐Columbian Europe. Copyright © 2011 John Wiley & Sons, Ltd.     

Possible cases of leprosy and tuberculosis in medieval Sigtuna,Sweden

In Sigtuna, Sweden, a medieval cemetery, including 227 skeletons, was analysed in 2006. On the outskirts of the churchyard, six skeletons with bone changes indicating systemic inflammatory disease were observed. Two out of three individuals with well‐preserved facial bone regions displayed signs of rhinomaxillary remodelling. Four of the afflicted exhibit severe bilateral alterations of the lower legs and phalanges of the feet and concentric atrophy of the metatarsals. In addition, one of the individuals exhibited a kyphosis in the lumbar vertebrae. In a discussion about alternative diagnoses, lepromatous leprosy and tuberculosis were identified as the causes of the destructive lesions in two individuals. Though the skeletal changes of the lower legs and feet in four cases demonstrate a close resemblance to secondary lesions of leprosy, the disease could not be confirmed. The skeletal changes of the last individual were unspecific and the possible causes several, rendering diagnosis difficult. The burial locations imply that the afflicted persons belonged to a lower social stratum. Due to the significantly higher frequency of pathological changes in the cemetery compared to other cemeteries in the town, the individuals could be regarded as fellow sufferers among others with various medical conditions. The bioarchaeological identification of systemic infectious diseases of a group of individuals of this size is unique to north of Scania in Sweden, where only a few cases of leprosy and tuberculosis have previously been diagnosed. The significance of the present study is emphasised by the interconnection between the afflicted, the archaeological context and the knowledge of the medieval society in Sigtuna. Copyright © 2010 John Wiley & Sons, Ltd.     

Metastatic carcinoma in a 14th–19th century skeleton from Constância (Portugal)

During 2002, the extensive archaeological excavations of the ancient Constância necropolis (Centre of Portugal), dated from 14th–19th centuries, resulted in the exhumation of 151 individuals. Among the several paleopathological cases, a middle‐aged female skeleton with osteolytic lesions in her skull, axial skeleton, upper limbs and femurs was observed. These pathological findings are characterised by an asymmetric pattern with osteolytic focus of distinct size and irregular shape. Some skeletal elements display both osteolytic and osteoblastic lesions. The latter exhibit deposition of fine layers of woven bone. Lesions were observed macroscopically and radiology was used as a complementary method of scrutiny, especially in cases of unclear observation. The case was diagnosed as that of a probable metastatic carcinoma due to the multifocal distribution of the lesions in areas of intense haematopoietic activity, their morphology and some osteoblastic responses, as well as the presence of pathological fractures in the ribs. The skeleton's sex and age at death are in agreement with the proposed diagnostic, constituting the first case of malignant carcinoma detected in non‐identified Portuguese human skeletal remains. Copyright © 2009 John Wiley & Sons, Ltd.     

A leprous skeleton of the 7th century from Eccles,Kent, and the present evidence of leprosy in early Britain

A male skeleton of 7th century date from the Anglo-Saxon cemetery at Eccles, Kent, is described. Certain skeletal changes associated with leprosy are manifest. The disease is discussed in its palaeopathological context and this case in relation to the few other cases of the disease hitherto diagnosed in Great Britain.     

Porotic hyperostosis in a Late Upper Palaeolithic skeleton (Villabruna 1, Italy)

Porotic hyperostosis (PH) is a well‐recognised skeletal indicator of physiological stress occurring during the early years of childhood growth. Although frequently found starting from the Neolithic, PH is poorly documented among earlier Palaeolithic hunter–gatherers. This study reports a case of PH in a Late Upper Palaeolithic skeleton (Villabruna 1) from northern Italy. Macroscopic and radiographic examinations of the skeleton show symmetric porotic lesions of the cranial vault, hair‐on‐end appearance, thinning of the cortical bone, diploic expansion and very slight cribra orbitalia (CO). All lesions are highly remodelled and suggest a condition suffered long before death. A differential diagnosis, carried out in order to discriminate between infectious and acquired conditions, points to anaemia as likely aetiology for the changes observed. Absence of postcranial involvement, lesion healing and survival to adulthood suggest a diagnosis of acquired anaemia. Among acquired anaemias, both dietary and infectious models are discussed in light of the individual's skeletal characteristics, as well as geographic location, paleoenvironmental data, subsistence modality and dietary information. The combined analysis of these data suggests that parasitic infestation resulted in megaloblastic anaemia in this individual. Copyright © 2009 John Wiley & Sons, Ltd.     

Intervertebral chondrocalcinosis: an exercise in differential diagnosis in palaeopathology

Intervertebral chondrocalcinosis (calcification of intervertebral discs and associated structures) may arise from a variety of causes. This work presents a discussion of intervertebral chondrocalcinosis and the identification of its most probable cause in skeletal remains, using as a case study a skeleton of an elderly male from medieval Ipswich, UK. The skeleton is examined using gross observation and radiography, and the intervertebral calcifications are subject to chemical analysis. In addition to intervertebral chondrocalcinosis (which has resulted in ankylosis of lumbo‐sacral segments), lesions identified include chondrocalcinosis at some synovial joints, various soft tissue calcified bodies, and severe osteoarthritis particularly at the gleno‐humeral joints. Interpretation of the results of the chemical analysis of the calcified deposits is complicated by diagenesis, but they are most consistent with apatite and/or whitlockite. Arriving at a most probable cause of the lesions in this case is difficult, but it is tentatively suggested that ochronosis may be the best diagnostic option. Copyright © 2008 John Wiley & Sons, Ltd.     

Variable nucleotide tandem repeat (VNTR) typing of two palaeopathological cases of lepromatous leprosy from Mediaeval England

Using ancient DNA methods, we have examined in detail two archaeological cases of leprosy from Mediaeval England. The first was a child skeleton with rhino-maxillary changes typical of lepromatous leprosy (LL). The second case was the skeleton of a male adult who showed both typical rhino-maxillary changes and osteitis/periostitis on the leg and foot bones. Bone powder was sampled from both cases and DNA extracts were prepared. These were subjected to a series of polymerase chain reactions (PCRs) specific for regions on the Mycobacterium leprae genome. The repetitive element RLEP was used for confirmation of M. leprae DNA and then three polymorphic regions were successfully amplified and sequenced to determine the number of variable nucleotide tandem repeats (vntr) at these loci. These were the microsatellite regions ML2344 and ML2172 and the minisatellite region ML0058. Genotyping data from the strains preserved within the skeletal remains were compared with those obtained for a reference strain of M. leprae. Variation at these three loci was found between both burials and the reference strain, indicating that vntr typing of LL cases from the archaeological record is a useful way of confirming disease and an additional means of authenticating aDNA data. This demonstrates the feasibility of targeting multiple loci for phylogenetic studies of leprosy strains from archival sources.     

Multicentric osteosarcoma associated with DISH,in a 19th century burial from England

Osteosarcoma is a rare type of malignant neoplasm that is most frequent in adolescents and young adults although it can develop at any age. It can metastasize from a primary site in bone to other bones and soft tissues. Usually the disorder causes a single bone‐forming lesion (unicentric) but some cases have multicentric, bone‐forming lesions. Some of these lesions develop at different sites at different times. In a second variant of multicentric osteosarcoma, synchronous bone‐forming lesions develop at multiple sites. Distinguishing between these two types of multicentric osteosarcoma is challenging in a clinical context and the criteria for doing so are unlikely to be met in an archaeological burial. Wolverhampton burial HB 39 was excavated from an early‐nineteenth century cemetery site in England. It consists of the incomplete skeleton of an adult male of at least 45 years of age with multicentric osteosarcoma. The individual represented by this burial also had diffuse idiopathic skeletal hyperostosis (DISH). Three of the bone‐forming lesions associated with osteosarcoma developed on the bony outgrowths related to DISH. Copyright © 2010 John Wiley & Sons, Ltd.     

An Unusual Erosive Arthropathy from Medieval England

In palaeopathology, diagnosis of skeletal disease is classically made with reference to changes wrought by known diseases in modern or recent cases. This report presents a skeleton from medieval England which shows a form of erosive arthropathy. A more precise diagnosis is problematic because the alterations appear inconsistent with any of the principle forms of erosive arthropathy in current clinical classification. The distribution of lesions in the axial and appendicular skeleton resembles that in seronegative spondyloarthropathies. The nature of the lesions however, which are almost entirely lytic and concentrated principally at synovial articulations rather than entheses, is inconsistent with seronegative spondyloarthropathies and is more consistent with pathophysiology of rheumatoid arthritis. These observations raise the possibility that the manifestations of erosive arthropathies may have altered over time and/or that our clinical understanding of the skeletal distribution of lesions in these diseases may be incomplete. These scenarios would have profound implications for our ability to identify the various forms of erosive arthritis in archaeological populations, but further work investigating erosive arthritis in patients, together with systematic studies of skeletal cases, would be required before firm conclusions can be made. Copyright © 2016 John Wiley & Sons, Ltd.     

A possible case of coccidioidomycosis from the Los Muertos site,Tempe, Arizona

Coccidioidomycosis is a fungal disease endemic to southwestern North America and parts of Central and South America. Coccidioidomycosis frequently disseminates to the human skeleton and produces mostly lytic skeletal lesions. However, this disease is infrequently described within archaeological populations. As a result, it is important to report potential cases in order to improve current understanding of the appearance and distribution of lesions resulting from coccidioidomycosis in archaeological specimens. This study describes skeletal lesions in an adult male recovered from the Los Muertos site, Tempe, Arizona (AD 500–1450). These lesions are present on the inferior border of the left scapular spine, the medial portion of the left first metacarpal head, and the medial portion of the right first metatarsal. The lesions are predominantly lytic with sclerotic and, in some cases, healed cortical bone distributed around their margins. Evidence of skeletal healing is recorded within the destructive focus of one lesion. Geographical information on pathogen endemism, overall lesion distribution, and agricultural‐era Hohokom behaviour suggest that coccidioidomycosis is the most likely diagnostic option for these lesions. Mounting evidence for possible infections in the palaeopathological literature, combined with high frequencies of nutritional stress levels in endemic regions, suggests that coccidioidomycosis contributed at least moderately to morbidity in the American Southwest. Copyright © 2006 John Wiley & Sons, Ltd.     

The First Evidence for Leprosy in Early Mediaeval Scotland: Two Individuals from Cemeteries in St. Andrews,Fife, Scotland,with Evidence for Normal Burial Treatment

The study of skeletal material recovered from excavations at two distinct early mediaeval cemeteries in St. Andrews, Scotland, resulted in the diagnosis of one individual from each cemetery as having had facies leprosa (leprosy). Radiocarbon dating gave a likely date in the 8th century ad for the Hallow Hill skeleton, and the Kirkhill skull was probably from the same period. Both skulls displayed the full range of classic signs of facies leprosa. The bone changes were slightly different in the two, the maxillary alveolus having been more severely affected in the Hallow Hill skull, whereas the posterior palatal area showed greater damage in the skull from Kirkhill. The skeletons were not segregated but buried in the middle of cemeteries used for the general population, thus supporting previous research in both the history of medicine and human bioarchaeology that suggests that people with leprosy were not necessarily stigmatised in the past. Copyright © 2011 John Wiley & Sons, Ltd.     

Pre-Columbian treponematosis in medieval Britain

There has been much debate regarding the origins of treponemal disease and, in particular, acquired syphilis. Greater numbers of skeletons with apparently diagnostic bone lesions in the New World than in the Old have given rise to the postulate, particularly advanced by American workers, that the disease originated there prior to AD 1492 and was carried back to the Old World by Columbus's sailors. This paper presents evidence for the presence of treponemal disease in medieval Norwich prior to AD 1492, however. The dating of the site is good and the skeleton concerned comes from a well-sealed context. Others in the group have similar lesions and there are four individuals with evidence of leprosy. All were buried in a communal cemetery. The individual has widespread, bilateral, florid periostitis, especially of the tibiae and fibulae, and the radiographic changes support the diagnosis of treponemal disease. Differential diagnosis and geographical situation suggest that this skeleton displays evidence of syphillis.     

Further aspects of fur trade life depicted in the skeleton

Osteobiographies were reconstructed from the skeletal remains of four adults from Fort Edmonton, a 19th century trading post of the Canadian fur trade. Three males were Caucasoid and probably ethnic Scots, given the usual origin of fur traders in this region. The lone adult female in the sample was Mongoloid, either Indian or Métis, and likely the ‘country wife’ of a fur trader, since she was buried in the European tradition in the fort cemetery. The cause of death is not discernible from any of the skeletal remains and none of these individuals exhibit any evidence of chronic infectious disease, malnutrition or neoplasia. Trauma, arthritis and other indicators of physical stress do appear, however, and present an opportunity to expand our understanding of the effects of fur trade life on the skeleton. Viewed in the context of historical accounts of life at the fort in the early 19th century, stress markers on the skeletons of three males have led to the conclusion that they were voyageurs who engaged in trading trips by canoe or boat. Lesions of the capsule attachment area at the proximal tibio‐fibular articulation appear unilaterally in two males and may be associated with ‘mushing’ or driving a dog sled in winter. The musculoskeletal lesions on the one preserved female skeleton are consistent with the arduous domestic activities documented at the fort, which include milking cows, churning butter, stirring lye soap, and harvesting grain and root vegetables by hand. Since specific occupations or behaviours cannot be precisely determined from muscular attachment and other stress markers, these interpretations are made cautiously and only in the culture‐historical context of the skeletal sample. Copyright © 1999 John Wiley & Sons, Ltd.