Leprosy in a skeleton from the 7th century necropolis of Vicenne‐Campochiaro (Molise,Italy)

Analysis of the skeleton from tomb 144 of the early medieval necropolis of Vicenne‐Campochiaro in Central Italy revealed several features indicative of leprosy. The skeleton belongs to a male estimated to be between 20 and 25 years of age at death. The distal halves of the 1st and 2nd left metatarsals present acro‐osteolysis and both legs show severe subperiosteal bone reaction. The facial skeleton shows changes compatible with a chronic inflammatory process, possibly due to an infectious disease. The anatomical distribution of the lesions and their association with other skeletal lesions seems to be compatible with a near‐lepromatous form of leprosy. A differential diagnosis is made, and the skeletal traits pathognomonic of leprosy are discussed. Copyright © 2005 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.     

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.     

Skeletal metastatic carcinoma: A case from 15th–20th century Coimbra,Portugal

This paper discusses the differential diagnosis of unusual and distinct pathological changes in the skeletal remains of a 40+‐year‐old female from 15th–20th century Coimbra (Portugal). The most affected area seems to have been the skull, but multiple lesions, lytic and/or blastic, have been found throughout the post‐cranial skeleton, more specifically in the scapulae, clavicles, humerus, sternum, ribs, sacrum, innominates and femurs. The differential diagnosis of the lesions gave rise to several possible pathological conditions, namely, Langerhans cell histiocytosis (granulomatosis or Histiocytosis X), multiple myeloma and metastatic carcinoma. Various macroscopic and radiological aspects lead us to consider metastatic carcinoma as the most probable diagnosis. Despite the argumentative identity of the possible primary lesion, age, sex and the mixed nature of the osseous response are consistent with cancer of the breast but do not exclude other carcinomas, namely lung cancer. With temporal and regional differences emerging in the frequency of malignant tumours, the identification of new cases becomes important, particularly from geographic areas where few cases have been reported. In fact, the present report adds to the only case of metastatic carcinoma detected in non‐identified Portuguese human skeletal remains until now. Copyright © 2009 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.     

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.     

Childhood scurvy in a medieval burial from Mačvanska Mitrovica,Serbia

The type and distribution of abnormalities in the skeleton of a child 2 years of age indicates that the child likely suffered from scurvy at the time of death. The burial is from the archaeological site of Zidine, Mačvanska Mitrovica, Serbia dated to the Medieval Period. Abnormal porosity and reactive woven bone formation are present affecting both the axial and appendicular skeleton. This case of scurvy is important because archaeological evidence of scurvy in this geographical location and at this time period is unknown. It is also important because the relative completeness of the skeleton and the widespread evidence of skeletal abnormalities provide additional insight regarding the skeletal manifestations of scurvy in young children. 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.     

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.     

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.     

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.     

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.     

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.     

Age-dependent cortical bone loss in a medieval population

Age-dependent cortical bone loss was studied in a skeletal assemblage from a British medieval site using metacarpal radiogrammetry. Significant loss of bone was found in the females but not in the males. The magnitude of bone loss in the older females relative to their younger counterparts was found to be similar to that reported for modern European subjects. Low cortical bone was associated with healed fractures of the highly trabecular bone of the axial skeleton, and this observation is suggestive that weakening of the skeleton due to loss of bone substance precipitated such fractures, as it does in modern Western women. The broad similarities between the medieval and modern data may call into question the importance of lifestyle factors in influencing the severity of osteoporosis, at least as far as loss of cortical bone is concerned.     

Skeletal manifestations of vitamin D deficiency osteomalacia in documented historical collections

The frequency with which changes related to vitamin D deficiency are recorded in juvenile bone from archaeological contexts makes it clear that conditions conducive to such deficiency were fairly widespread at a number of points in the past. Although changes will take longer to be manifest in the adult skeleton than in juveniles, and may not be as obvious, the scarcity of reported cases suggests that it is likely that cases of osteomalacia are being overlooked in archaeological human bone. Vitamin D is probably better described as a hormone, rather than a vitamin, and the production of vitamin D within the body following exposure to sunlight allows adequate mineralisation of bone to take place. Lack of exposure to sunlight, which can be caused by a range of factors, is probably one of the main causes of vitamin D deficiency. The result of such a deficiency is a general weakening of the skeleton. The range of skeletal changes recorded across different bones of the skeleton in two documented historical pathology collections (the Galler collection, Basel, and the collection of the Federal Museum for Pathological Anatomy, Vienna), are discussed for scapulae, vertebrae, ribs, sterna, pelves and femora. The likelihood of each feature being preserved in archaeological skeletal material is considered. Although the changes associated with osteomalacia may lead to fragmentation of the skeleton, the presence of characteristic changes on bones from across the skeleton should make the condition identifiable using macroscopic examination, even where the skeleton is not well preserved. The identification of cases of osteomalacia in archaeological skeletal material is potentially significant because of the socio‐cultural information that can be implied from diagnosis of the condition. Copyright © 2005 John Wiley & Sons, Ltd.     

Oral implications of labret use: a case from pre‐Columbian Chile

This paper examines the osteological evidence for a case of long‐term labret use in pre‐Columbian north Chile and the pathological conditions associated with it. The burials from the site of Solcor 3 (AD 400–900) included a complete skeleton associated with two quartz labrets. Analysis of the skeleton of this adult male revealed wear and polish on the labial surface of both mandibular canines, indicating that the labrets were worn as a pair on either side of the midline of the lower lip. In addition to these abrasion facets, there were also areas of periosteal reaction in the alveolar bone of the canines. These patterns were analysed from the perspective of the clinical dentistry literature and compared to archaeological data. It is concluded that this individual's dental health was affected by wearing labrets, although not as seriously as might be expected based on contemporary medical reports. Copyright © 2003 John Wiley & Sons, Ltd.     

Diaphyseal remodelling in leprosy: A radiological and palaeopathological study

Diaphyseal remodelling is a pathological process of the proximal phalanges, metatarsals and metacarpals in all established types of clinical leprosy. It is suggested that the changes are the result of sympathetic neuropathy and alteration of peripheral vascular bed dynamics selectively stimulating extracortical osteoclastic and endosteal osteoblastic activity. There is an overall loss of diaphyseal cortical diameter, either in concentric or knife-edge pattern. There is extracortical absorption of bone and coincident endosteal bone deposition. Ultimately, there is diaphyseal pathological fracture, and subsequent resorption of the distal and proximal remnants due to combined continued diaphyseal remodelling and achroosteolysis.     

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.