Differential diagnosis for two 'holes in the head' of a child from 982 to 904 BP in northern South America.

OBJECTIVE: To present paleopathological evidence of a congenital anomaly with photographic support and a review that will help scholars to diagnose the condition. MATERIALS: Well-preserved skeletal remains of a child from central Colombia, dated 968-1046 CE. METHODS: Macroscopic examination and computerized axial tomography. RESULTS: Two holes were observed in the skull. CONCLUSIONS: The pathology is consistent with a neural tube defect or an inclusion cyst. SIGNIFICANCE: Neural tube defects and inclusion cysts, in paleopathology, are rarely reported in children. The preservation and origin of the individual make this case valuable. The photographic support and the review is useful for other scholars in the field. LIMITATIONS: It was not possible to determine a single cause. SUGGESTIONS FOR FUTURE RESEARCH: Review cases in identified osteological collections.

Demographics and significance of porotic hyperostosis as assessed by surface microscopy.

BACKGROUND: Examination of parietal surface anatomy has been limited because standard techniques have insufficient resolution to identify and characterize the structures of interest. Perspectives derived thereof have not clarified their nature. Surface microscopy is pursued as a nondestructive technique to assess the character and implications of porotic pores (referred to as porotic hyperostosis), which have been subject of much speculation. METHODS: The external surface of the skulls, selected on the basis of age and gender, from the Hamann-Todd human collection are examined by epi-illumination microscopy for surface pores and to assess correlation with age, ethnicity, gender, anemia, infection, cancer, hypertrophic bone disorders, renal disease, and fractures. RESULTS: Pore-like surface defects are present in 2.7%-5% of individuals in the third-fifth decades of life; 7%, in the sixth-eighth; and 25%, in the ninth-11th, but absent in the second decade of life. They are gender and birthdate independent, but slightly more common in African Americans. Fractures are more common among individuals with parietal pores, while tuberculosis, cancer, and hypertrophic bone diseases and anemia are less common. DISCUSSION: This is the first study to actually examine the prevalence of parietal pores as a function of known age, race, and sex and provides a baseline for comparison with populations in which those variables are not clearly identifiable. While some porotic pores may be related to marrow hyperplasia, transcortical circulation may explain the majority.

An Investigation of Micro-CT Analysis of Bone as a New Diagnostic Method for Paleopathological Cases of Osteomalacia.

OBJECTIVE: This paper looks to broaden the methodological possibilities for diagnosing osteomalacia in archaeological bone using micro-CT analysis. Increasing the identification of osteomalacia in paleopathology will provide support for important interpretive frameworks. MATERIALS: Nine embedded and two unembedded rib fragments were sourced from St. Martin's Birmingham and Ancaster, UK, and Lisieux Michelet, France. Of the 11 samples, nine were previously confirmed as osteomalacic, and presented with varying levels of diagenesis and two were non-osteomalacic controls, one of which exhibits diagenetic change. METHODS: Micro-CT, backscattered scanning electron microscopy, and light microscopy were employed. Micro-CT images were evaluated for osteomalacic features using corresponding microscopic images. RESULTS: Micro-CT images from osteomalacic samples demonstrated the presence of defective mineralization adjacent to cement lines, areas of incomplete mineralization, and resorptive bays/borders, three key diagnostic features of osteomalacia. Diagenetic change was also detectable in micro-CT images, but did not prevent the diagnosis of osteomalacia. CONCLUSIONS: Micro-CT analysis is a non-destructive method capable of providing microstructural images of osteomalacic features in embedded and unembedded samples. When enough of these features are present, micro-CT images are capable of confirming a diagnosis of osteomalacia. SIGNIFICANCE: Vitamin D deficiency has important health consequences which operate throughout the life course. Increasing the ability to detect cases of vitamin D deficiency provides researchers with a greater understanding of health and disease in past communities. LIMITATIONS: Only adult rib samples were used. SUGGESTIONS FOR FURTHER RESEARCH: Paleopathologists should look to test the utility of micro-CT analysis in diagnosing active rickets in subadult individuals.

First Documented Pathologies in Tenontosaurus tilletti with Comments on Infection in Non-Avian Dinosaurs.

In 2001, a nearly complete sub-adult Tenontosaurus tilletti was collected from the Antlers Formation (Aptian-Albian) of southeastern Oklahoma. Beyond its exceptional preservation, computed tomography (CT) and physical examination revealed this specimen has five pathological elements with four of the pathologies a result of trauma. Left pedal phalanx I-1 and left dorsal rib 10 are both fractured with extensive callus formation in the later stages of healing. Left dorsal rib 7 (L7) and right dorsal rib 10 (R10) exhibit impacted fractures compressed 26 mm and 24 mm, respectively. The fracture morphologies in L7 and R10 indicate this animal suffered a strong compressive force coincident with the long axis of the ribs. All three rib pathologies and the pathological left phalanx I-1 are consistent with injuries sustained in a fall. However, it is clear from the healing exhibited by these fractures that this individual survived the fall. In addition to traumatic fractures, left dorsal rib 10 and possibly left phalanx I-1 have a morphology consistent with post-traumatic infection in the form of osteomyelitis. The CT scans of left metacarpal IV revealed the presence of an abscess within the medullary cavity consistent with a subacute form of hematogenous osteomyelitis termed a Brodie abscess. This is only the second reported Brodie abscess in non-avian dinosaurs and the first documented occurrence in herbivorous dinosaurs. The presence of a Brodie abscess, known only in mammalian pathological literature, suggest mammalian descriptors for bone infection may be applicable to non-avian dinosaurs.

Vertebral infection in a male individual buried in the monastic cemetery (Cemetery 2) at Ghazali (ca. 670-1270 CE), northern Sudan.

PURPOSE/RESEARCH QUESTION: This article examines pronounced osteoblastic-osteolytic vertebral lesions in a middle adult male (Ghz-2-033), from the Christian Nubian monastic settlement of Ghazali (ca. 670-1270 CE), Sudan, to explore their potential etiology. METHODS: Morphological assessments of sex and age were undertaken in conjunction with macroscopic and radiological methods of assessment for the skeletal lesions documented. RESULTS: Macroscopic assessment of Ghz-2-033 identified mixed osteoblastic-osteolytic lesions in L2-L3 with minor foci in T12-L1, while radiological assessment identified no further lesions. This paleopathological analysis considers tuberculosis, brucellosis, pyogenic intervertebral disc infection, neoplastic conditions, and mycotic infections as potential etiologies. CONCLUSIONS: Tuberculosis is the most probable etiology for the lesions observed. This assessment is based on the morphology of the lesions in conjunction with the known confined living quarters at Ghazali and the presence of tuberculosis vectors (i.e. cattle) in the region. CONTRIBUTIONS TO KNOWLEDGE/ORIGINALITY/VALUE: This brief communication contributes original data documenting the presence of tubercular lesions in a monk buried at the Christian Nubian monastery of Ghazali. On a broader level this study contributes to regional and temporal paleopathological dialogues regarding interactions with pathogens in Christian Nubian monastic contexts. LIMITATIONS FOR THIS STUDY: The potentiality of co-infection with other pathogens (e.g. brucellosis, Staphylococcus) with similar macromorphological traits in skeletal remains cannot be entirely discounted. SUGGESTIONS FOR FURTHER RESEARCH: The use of biomolecular analyses may help to clarify the potential presence of tuberculosis in individual Ghz-2-033.

Mastoid osteoma in a prehispanic cranium (1390 A.D.) from Northern Chile.

OBJECTIVE: Osteomas are slow-growing benign tumors that can affect the skull, most frequently the parietal and frontal. Temporal bone osteomas are more common in the external acoustic meatus and exceptional in the mastoid region. The rarity of mastoid osteomas is confirmed by the fact that very few cases have been reported in the clinical and paleopathological literature. The aim of this paper is to report a new paleopathological case of mastoid tumor in a Pre-Hispanic adult cranium. MATERIALS: The skull derives from the Chunchuri (today Dupont-1 site) Pre-Hispanic site in Northern Chile (1390 A.D). METHODS: Macroscopical examination and high-resolution tomography were used to assess the cranium. RESULTS: The CT scan revealed a well demarcated lesion suggestive of a mastoid osteoma. CONCLUSIONS: This case adds new evidence regarding the antiquity of primary neoplasms in ancient populations and reinforces the importance of high resolution imaging in paleopathological research. SIGNIFICANCE: Due to the antiquity of the remains this is probably the oldest reported case of mastoid osteoma. LIMITATIONS: The patrimonial nature of the remains did not allow histopathological studies. SUGGESTIONS FOR FURTHER RESEARCH: Further intensive review of archeological skeletal collections is needed to better understand the epidemiology of neoplastic lesions in past populations.

Analysis of patterning in the occurrence of skeletal lesions used as indicators of vitamin D deficiency in subadult and adult skeletal remains.

Paleopathological investigations of conditions linked to vitamin D deficiency have increased in the last twenty years, and a suite of skeletal lesions has been established to aid in the diagnosis of vitamin D deficiency disease in subadults and adults. This paper analyzes the occurrence of these lesions in a large skeletal series comprising 3541 Roman period individuals (1st-6th century AD). Sixteen lesions reported in rickets in subadults, and 13 associated with residual rickets and osteomalacia in adults, were analyzed. Among subadults, there were clear associations among post-cranial lesions. Porotic cranial changes were associated with each other, but not with post-cranial lesions. A range of conditions could have produced the cranial lesions. There was a general paucity of correlations between indicators found in adults, and the difficulty in recording bending deformities was clear. Pseudofractures appear to provide a useful means of investigating osteomalacia in adults. In general, a simple algorithmic approach using presence or absence of lesions is unlikely to provide an adequate means of diagnosing vitamin D deficiency in paleopathology. Knowledge and consideration of the underlying physiological mechanisms involved in lesion formation, combined with individual judgement, will be required to differentially diagnose cases.

Cribra orbitalia and porotic hyperostosis: A biological approach to diagnosis.

OBJECTIVES: Porotic lesions of the skull (cribra orbitalia and porotic hyperostosis) are one of the most common types of lesion identified in archaeological human bone and have also been found in hominins and non-human primates. Because of the frequency with which such lesions are found there has been extensive debate on the possible causes and whether they are linked, with much of the debate centering on anemia. The biological approach to diagnosis in paleopathology used by Don Ortner and recently proposed more formally as a technique to facilitate diagnosis in paleopathology by Simon Mays may offer a means of answering some of the questions surrounding these lesions. MATERIALS AND METHODS: A review was undertaken of biomedical information on changes in the distribution of marrow type and pattern of conversion of red and mixed marrow, and the potential for re-conversion of yellow marrow with age. The range and type of other conditions that might result in the development of porous lesions were also considered. RESULTS: Combining information from the biomedical literature on marrow type and patterns of conversion with age, with careful evaluation of the type and location of porous lesions in the skull and across the rest of the skeleton will assist in suggesting a diagnosis. DISCUSSION: A wide range of conditions can produce porous lesions in the cranial vault and the orbital roof, but due to anatomical structures and physiological factors such lesions are more likely to occur in the orbital roof. Anemia can produce lesions in both locations, but evidence of marrow expansion is required to confirm it as a cause.

Medical diagnostic methods applied to a medieval female with vitamin D deficiency from the north of Spain.

Vitamin D deficiency is a pathological condition that affects bone metabolism by preventing proper mineralization, which eventually leads to bone deformities and other pathological conditions such as osteoporosis, increased bone fragility and fractures. The aim of this study is to present a case of vitamin D deficiency, but also to note how the application of several complementary techniques is a fundamental step in the establishing an accurate diagnosis. These techniques range from classical palaeopathological analysis to modern clinical practice. After the macroscopic examination of a medieval female skeleton from Palencia (Spain), where various bone deformations were observed, a differential diagnosis could not establish a definitive cause. Radiological, bone density, and histological studies were carried out, finally allowing to confirm a vitamin D deficiency suffered in both childhood and adulthood. This is a clear example, with practical applications, of the importance of interdisciplinarity to reveal insights about the life history and physical health of ancient individuals.

Dry bone histology of bone tumours.

This article focuses on the application of dry bone histology in the diagnosis of a series of different bone tumours. It provides a short introduction on bone tumour classification and how tumours may affect the skeleton. To illustrate the value of dry bone histology in the diagnostic process we studied the 'fresh' and 'dry' bone histology of a series of well-documented, recent clinical cases of various benign and malignant bone tumours. We show that histology is a valuable instrument to assess bone tissue architecture, which provides information on the biological behaviour of a tumour. Though histology may reveal the specific 'tumorous' bone deposition of high-grade conventional osteosarcomas, all other bone tumours display common, unspecific features. This holds for the following tumours: osteochondroma, hyperostotic meningioma, high-grade angiosarcoma, grade 2 chondrosarcoma, myoepithelial carcinoma, high-grade osteosarcoma and four carcinoma metastases. We conclude that histology is useful in cases where the biological behaviour of a tumour is to be defined, and is particularly an aide in the diagnosis of high-grade conventional osteosarcomas. Nevertheless, the differential diagnosis on the bone tumours in our series should primarily be based on a combination of physical anthropological patient data (age, sex), gross anatomy (e.g. tumour morphology and location), and radiography.

The utility of 3D medical imaging techniques for obtaining a reliable differential diagnosis of metastatic cancer in an Iron Age skull.

In this report we present a case of neoplastic disease affecting an Iron Age skull that provides some of the earliest evidence of metastatic cancer (MC) in Western Europe. The cranium comes from the indigenous site of Baucina (Palermo, Sicily) and was recovered in a multiple burial context dated to the 6th-5th centuries BCE. The skull was attributed to an adult female and was characterized by numerous perforating lytic lesions. CT and 3D imaging analyses were crucial for obtaining a diagnosis of MC. Based on the morphology of the lytic lesions and the biological profile of our specimen, we can tentatively suggest breast carcinoma as the primary origin of the clinical manifestations recorded on the skull. This work also highlights the importance of utilizing an analytical approach to paleopathology that incorporates up-to-date CT and 3D imaging techniques.

Molecular paleopathology and paleo-oncology-State of the art, potentials, limitations and perspectives.

This paper reviews the current knowledge on molecular paleopathology with respect to oncological information. This covers both the information on the protein level (proteome) as well as the gene level (genome) and includes data on carcinogenic factors - such as molecular evidence for oncogenic viral infections. Currently, relatively little data is available for neoplastic disease in paleopathology. Likewise, few studies describe the biochemical or immunohistochemical analysis of tumors - a tool to potentially classify the tumor type and the underlying primary tumor in metastases. On the gene level, two studies described distinct molecular mutations in either a tumor-driving oncogene or a tumor suppressor gene, both being excellent examples for paleo-oncological studies. The paucity of historic tumor material - particularly when only osseous remains are available - represents the most hindering factor for molecular paleo-oncology. This can only be overcome in future by both the thorough investigation of mummified archaeological biomaterial and the improvement of analytical assays in order to trace even minute amounts of tumor material in osseous lesions.

Neoplasm or not? General principles of morphologic analysis of dry bone specimens.

Unlike modern diagnosticians, a paleopathologist will likely have only skeletonized human remains without medical records, radiologic studies over time, microbiologic culture results, etc. Macroscopic and radiologic analyses are usually the most accessible diagnostic methods for the study of ancient skeletal remains. This paper recommends an organized approach to the study of dry bone specimens with reference to specimen radiographs. For circumscribed lesions, the distribution (solitary vs. multifocal), character of margins, details of periosteal reactions, and remnants of mineralized matrix should point to the mechanism(s) producing the bony changes. In turn, this allows selecting a likely category of disease (e.g. neoplastic) within which a differential diagnosis can be elaborated and from which a favored specific diagnosis can be chosen.

Reprint of-Differential diagnosis: Trepanation.

Trepanation is the scraping, cutting, or drilling of an opening (or openings) into the neurocranium. World surveys reveal that a number of ancient cultures experimented with cranial surgery, and that in some areas these practices continued into modern times. Archaeological discoveries of possible trepanations continue to be made, often from geographic areas or time periods from which the practice was not previously known. Unfortunately, most of these reports describe single crania with healed defects interpreted as trepanations. When evaluating a possible trepanation in a skull that lacks medical history or comes from an archaeological context where there is no other evidence that such operations were performed, a thorough differential diagnosis is essential. Identification of unhealed trepanations is a relatively straightforward exercise, since tool marks provide direct evidence of surgical intervention. A confident diagnosis is more difficult in healed defects of the skull, where the mechanism that produced an opening may be obscured by bone remodeling. There are many possible causes of defects of the skull vault, including congenital and developmental anomalies, trauma, infection, neoplasm, and taphonomic damage. For this reason, a careful differential diagnosis is essential for identifying surgical intervention and distinguishing it from cranial defects caused by other mechanisms.

Intestinal parasites from the 2nd-5th century AD latrine in the Roman Baths at Sagalassos (Turkey).

The aim of this research was to determine the species of intestinal parasite present in a Roman Imperial period population in Asia Minor, and to use this information to improve our understanding of health in the eastern Mediterranean region in Roman times. We analyzed five samples from the latrines of the Roman bath complex at Sagalassos, Turkey. Fecal biomarker analysis using 5ß-stanols has indicated the feces were of human origin. The eggs of roundworm (Ascaris) were identified in all five samples using microscopy, and the cysts of the protozoan Giardia duodenalis (which causes dysentery) were identified multiple times in one sample using ELISA. The positive G. duodenalis result at Sagalassos is particularly important as it represents the earliest reliable evidence for this parasite in the Old World (i.e. outside the Americas). As both these species of parasite are spread through the contamination of food and water by fecal material, their presence implies that Roman sanitation technologies such as latrines and public baths did not break the cycle of reinfection in this population. We then discuss the evidence for roundworm in the writings of the Roman physician Galen, who came from Pergamon, another town in western Asia Minor.

Differentiating between rhinosinusitis and mastoiditis surgery from postmortem medical training: A study of two identified skulls and hospital records from early 20th century Coimbra, Portugal.

Differentiating between medical procedures performed antemortem, perimortem or postmortem in skeletal remains can be a major challenge. This work aims to present evidence of procedures to treat rhinosinusitis (RS) and mastoiditis, suggest criteria for the diagnosis of frontal sinus disease, and frame the individuals described in their medical historical context. In the International Exchange collection, the skull (878) of a 24-year-old male, who died in 1933 due to frontal sinusitis and meningitis, presents evidence of a trepanation above the right frontonasal suture, and micro/macroporosity on the superciliary arches. The available Coimbra University Hospitals archives (1913-1939) reported that 46 females and 59 males (aged 15 months-84 y.o., x̄=35.33) underwent surgery to treat RS, primarily by trepanation (94.3%). In a search for similar evidence in the collection, the skull of a 42-year-old female (85), who died in 1927 due to sarcoma in the abdomen, shows four quadrangular holes located above the right supraorbital notch, right and left maxilla, and left mastoid process. The number/location of the holes and cut marks point to postmortem medical training (possible dissection). This paper discusses the value of information from historical contexts to differentiate between surgery and medical training in the paleopathological record.

A giant urinary bladder stone in the mummy of Lebanese Maronite Patriarch Joseph Tyan (1760-1820) and its environmental and nutritional implications.

INTRODUCTION: Historical sources and anthropological investigations, with the indispensable support of radiology, bring to light pathological evidence of the past. CASE PRESENTATION: The purpose of this article is to present the radiological investigation conducted on the mummy of the Maronite Joseph Tyan (1760-1820), a famous patriarch who guided the Lebanese Maronite community during a critical period of its history. The natural mummy of the Patriarch was temporarily removed from its burial site to certify the degree of preservation. Conventional radiography was necessary to determine the state of the internal organs and any physical abnormalities, and to clarify the degree of conservation of the mummy. DISCUSSION: Radiological analysis uncovered an exceptional case of a large urinary bladder stone. This pathological evidence confirms historical documentary sources that in the last years of his life the Patriarch suffered from abdominal pain and urinary problems. We can suppose that the environment and diet of the Maronite community, limited by restricted agricultural resources, was the possible cause of the urinary bladder stone, as today the epidemiology of these diseases demonstrates links with mainly cereal diets in rural areas.

On the history of gout: paleopathological evidence from the Medici family of Florence.

OBJECTIVES: Throughout history, gout has been referred to as the "disease of the kings", and has been clearly associated with the lifestyle of the aristocratic social classes. According to the written sources, several members of the famous Medici family of Florence suffered from an arthritic disease that contemporary physicians called "gout". A paleopathological study carried out on the skeletal remains of some members of the family, exhumed from their tombs in the Church of San Lorenzo in Florence, offered a unique opportunity to directly investigate the evidence of the arthritic diseases affecting this elite group. METHODS: The skeletal remains of several members of the family were examined macroscopically and submitted to x-ray investigation. RESULTS: The results of the study allowed us to ascertain that the so-called "gout of the Medici" should be considered the clinical manifestation of three different joint conditions: diffuse idiopathic skeletal hyperostosis, rheumatoid arthritis and uratic gout. In particular, uric acid gout was diagnosed in the Grand Duke Ferdinand I (1549-1609). Recently, a new case of this disease was diagnosed in Anton Francesco Maria (1618-1659), a probable illegitimate member of the family. CONCLUSIONS: With this new case, uratic gout was observed in 2 out of 9 adult males, leading to suppose that the disease should have been a common health problem within the family. The aetiology of the disease has to be searched in environmental factors, since both historical and paleonutritional studies demonstrated that the diet of this aristocratic court was rich in meat and wine.

New paleoradiological investigations of ancient human remains from North West Lombardy archaeological excavations.

OBJECTIVE: Since its birth in 1895, radiology has been used to study ancient mummies. The purpose of this article is to present paleoradiological investigations conducted on several medieval human remains in Varese province. Anthropological (generic identification) and paleopathological analyses were carried out with the support of diagnostic imaging (X-ray and CT scans). MATERIALS AND METHODS: Human remains were discovered during excavations of medieval archaeological sites in northwest Lombardy. Classical physical anthropological methods were used for the macroscopic identification of the human remains. X-ray and CT scans were performed on the same scanner (16-layer Hitachi Eclos 16 X-ray equipment). Results Radiological analysis permitted investigating (1) the sex, (2) age of death, (3) type of trauma, (4) therapeutic interventions and (5) osteomas in ancient human remains. In particular, X-ray and CT examinations showed dimorphic facial traits on the mummified skull, and the same radiological approaches allowed determining the age at death from a mummified lower limb. CT analyses allow investigating different types of traumatic lesions in skulls and postcranial skeleton portions and reconstructing the gait and functional outcomes of a fractured femur. Moreover, one case of possible Gardner's syndrome (GS) was postulated from observing multiple osteomas in an ancient skull. CONCLUSION: Among the medical tests available to the clinician, radiology is the most appropriate first-line procedure for a diagnostic approach to ancient human remains because it can be performed without causing any significant damage to the specimen.

Paleopathological Study of Dwarfism-Related Skeletal Dysplasia in a Late Joseon Dynasty (South Korean) Population.

Skeletal dysplasias related to genetic etiologies have rarely been reported for past populations. This report presents the skeletal characteristics of an individual with dwarfism-related skeletal dysplasia from South Korea. To assess abnormal deformities, morphological features, metric data, and computed tomography scans are analyzed. Differential diagnoses include achondroplasia or hypochondroplasia, chondrodysplasia, multiple epiphyseal dysplasia, thalassemia-related hemolytic anemia, and lysosomal storage disease. The diffused deformities in the upper-limb bones and several coarsened features of the craniofacial bones indicate the most likely diagnosis to have been a certain type of lysosomal storage disease. The skeletal remains of EP-III-4-No.107 from the Eunpyeong site, although incomplete and fragmented, provide important clues to the paleopathological diagnosis of skeletal dysplasias.