Two Roman and medieval cases of symmetrical erosive polyarthropathy from Normandy: anatomico-pathological and radiological evidence for rheumatoid arthritis

With continued archaeological discoveries of skeletal remains in the USA and Europe, discussion of the possible aetiology for recognized cases of symmetrical erosive polyarthropathy include the spondylarthropathies and rheumatoid arthritis. One skeleton from the fourth century site of Lisieux and a second from the eleventh century site of Rouen are characterized by numerous symmetrical marginal erosions, primarily involving the metacarpophalangeal and proximal interphalangeal joints. Results of maroscopic, microscopic and radiological examination are highly suggestive of a modern-day diagnosis of rheumatoid arthritis. These data are consistent with the presence of rheumatoid arthritis before the onset of the fourteenth century. © 1997 John Wiley & Sons, Ltd.     

Antemortem pathological changes suggestive of reactive and degenerative arthritic disorders

The present case displays severe antemortem skeletal malformations suggestive of antemortem reactive arthritis (ReA), spondyloarthropathies and diffuse idiopathic skeletal hyperostosis (DISH). The ossified anterior longitudinal ligament on the right side of the thoracic vertebral bodies, with the presence of extraspinal enthesophytes, together indicates DISH. Fused lumbar vertebrae with costovertebral and sacroiliac joint fusion, combined with numerous large enthesophytes collectively suggest ankylosing spondylosis and ReA. Finally, some vertebrae showed evidence of age related osteoarthritis. However, the anatomical evidence for these conditions displays some inconsistencies with the known pathogenesis; therefore, a definitive account of this individual's antemortem condition remains uncertain. As no biological or medical information is known about the individual, skeletal morphology, irregular skeletal fusion and the presence of enthesophytes have been collectively used to propose the antemortem disorders that appear to have affected this individual's skeleton. Copyright © 2010 John Wiley & Sons, Ltd.     

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.     

High performance liquid chromatography (HPLC) in the investigation of gout in palaeopathology

Gout is a disease caused by the abnormal accumulation of uric acid in the body, which can result in sodium urate crystals forming tophi at joints, with associated erosion of bone and cartilage. Only two examples of tophi have been reported from archaeological individuals, and the diagnosis of gout based on dry bone manifestations can be difficult. This paper presents preliminary results of a new technique to aid the diagnosis of gout in palaeopathology, namely high performance liquid chromatography (HPLC). Five archaeological skeletons with suspected gout (diagnosed using visual and radiological analysis) and three controls were analysed. Two of the gouty individuals had a white powder in their erosive lesions. HPLC showed the presence of uric acid in bone in four of the five individuals with evidence of gouty arthritis and was negative for uric acid in bone from the three controls. The white powder was also positive for uric acid. With reliance on the presence of articular erosions, cases of gout will be missed in archaeological human bone. HPLC measurement of uric acid could prove useful in the differential diagnosis of erosive arthropathy in archaeology. It may also be useful in identifying individuals with an increased body pool of uric acid, linked to conditions included in the term ‘metabolic syndrome’. As a result, HPLC uric acid measurement also has the potential to provide additional information on health and lifestyle in past communities. Copyright © 2008 John Wiley & Sons, Ltd.     

Erosive peripheral polyarthritis in ancient Japanese skeletons: A possible case of rheumatoid arthritis

The antiquity of rheumatoid arthritis (RA) is still in dispute, due to the difficulty of conclusively differentiating peripheral polyarthritis, especially from spondyloarthropathy, in archaeological populations. In view of the importance of genetic factors in developing spondyloarthropathy and of the far lower prevalence of the disease in modern Japanese, a rarity of peripheral polyarthritis would be anticipated in the ancient Japanese population, given that RA had not been present there. One hundred and sixty adult Japanese skeletons of the late and final Jomon period (3400–2400 years bp ) were examined to find peripheral polyarthritis. There was one male skeleton with peripheral polyarthritis, showing marginal and surface erosions in the joints of the hands, feet, ankle and zygoapopheseal joints of the thoracic vertebrae. RA is suggested as the most probable cause of this pathology. This report raises the significance of further studies to consider whether more cases than anticipated exist in skeletal populations that would have been resistant to developing spondyloarthropathy. Copyright © 1999 John Wiley & Sons, Ltd.     

Identification of urate crystals in gouty individuals

In paleopathology cases of gout have traditionally been identified using the character of erosive bony lesions, but in clinical medicine identification of monosodium urate crystals in joint fluid plays a central role in diagnosis. Work undertaken on three skeletal individuals who had been buried, demonstrates that crystals can be identified using polarising microscopy. The crystals were identified as monosodium urate. Results from this study appear to demonstrate that identification of monosodium urate crystals could be used to assist in the diagnosis of gout in paleopathology. Further work is required to establish the full range of spatial and temporal contexts from which such crystals might be found.     

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.     

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.     

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.     

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.     

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.     

Possible rheumatoid arthritis found in the human skeleton collected from the tomb of Joseon Dynasty,Korea, dating back to the 1700s AD

We report a possible rheumatoid arthritis (RA) case found in a Korean Joseon Dynasty (1392–1910) tomb encapsulated by a lime‐soil mixture barrier (LSMB). The tomb is thought to have been constructed during the 1700s AD (1760 AD by carbon dating). In our anthropological examination, joint destruction, erosion or fusion (signs of polyarthritis) were identified mainly in the peripheral skeleton. Especially in both sides of the wrist bones, severe destruction/joint fusion possibly caused by polyarthritis was observed. A similar polyarthritis pattern also was seen in the right foot bones, even though we failed to confirm this symmetry due to the missing left foot bones. Despite these findings, signs suggestive of polyarthritis are very rarely seen in axial bones, even though bony fusions are found in the atlanto‐occipital joint or thoracic vertebrae (TV) 9–10. By the osteological signs observed in this case, the individual, a female, might have been suffering from a very late stage of RA and died in her 40s, even though other forms of chronic arthritis could not be ruled out completely. Though the current case could not provide evidence to decisively settle the debates on the antiquity of RA, our report could be a stepping stone for forthcoming studies on RA cases found in East Asian countries. Copyright © 2009 John Wiley & Sons, Ltd.     

Better a Broader Diagnosis Than a Misdiagnosis: The Study of a Neoplastic Condition in a Male Individual who Died in Early 20th Century (Coimbra,Portugal)

The paleopathological record of neoplastic conditions in the past is considered scarce. The detection of tumours in ancient populations is hindered by the quality and quantity of signs visible on the skeleton, the methodological approach, the preservation of remains, and by difficulties of differential diagnosis. The aims of this paper are to report the extensive and multiple osteolytic lesions observed in an adult male and to discuss the possible etiology of these lesions. The individual, a 71‐year‐old male who died in 1932, is part of the Coimbra Identified Skeletal Collection. Records indicate that he died of a ‘heart lesion’. The present study used macroscopic, radiological, and computerized tomography examinations to analyse the skeletal remains of the individual number 439. The type and pattern of the lesions detected, which were most prominent on the skull, were compared with both clinical and paleopathological diagnostic criteria for different nosologic groups. The differential diagnosis addresses problems expressed both in clinical and in paleopathological literature with regard to the difficulties in distinguishing metastatic tumours from multiple myeloma. The nature of the lesions represented by this individual precludes an exact diagnosis. Therefore, we employed a broader category, neoplastic condition, instead of choosing a more specific diagnosis that would likely have resulted in a misdiagnosis due to overlapping features on this individual's condition. Further investigations are necessary to establish more replicable indicators and to improve confidence in retrospective diagnosis of these types of conditions. Copyright © 2011 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 pathology of a high‐ranking official from Thrace (Turkey,last quarter of the 4th century BC)

A male human skeleton from Thrace dated at around 320 BC was found in a wealthy tomb 12 km from what is now Tekirdağ, Turkey. The occupant of the tomb died at the age of 40–45 years and has a pathologic left humerus caused most probably by traumatic injury. It is 9 cm shorter than the right humerus. A drainage fistula penetrating into the medullary cavity occurs at its proximal end. Due to severe arthritic destruction, the left humeral head has completely lost normal articulation, with the glenoid cavity of the left scapula displaying, in turn, severe erosive lesions and important reduction in its articular surface. A marked abscess is discernible bilaterally on the chondro‐costal sternal end. The individual also has a hip with a total sacroiliac joint fusion and shows slight or moderately developed exostoses on different parts of his skeleton. These joint destructions most likely indicate that he suffered from chronic osteomyelitis and septic arthritis. Copyright © 2005 John Wiley & Sons, Ltd.     

A possible case of spondyloarthropathy in a prehistoric Japanese skeleton

Palaeopathology helps to define the migration of past diseases. Genetic and environmental factors play a role in the development of spondyloarthropathy (SpA). We report skeletal remains with SpA from the Jomon period in Japan. The skeleton is of a female who died at a young adult age. The skeleton had characteristic features seen in SpA as follows: (1) polyarticular arthritis; (2) erosions accompanying some bone formation; (3) enthesial ossification; and (4) periostitis in lower long bones. The findings suggest that SpA was present in prehistoric Japan before contact with European civilisation, and the present example of SpA is the oldest in Asia and the Old World. Copyright © 2004 John Wiley & Sons, Ltd.     

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.