New skeletal tuberculosis cases in past populations from Western Hungary (Transdanubia)

More than one millennium (2nd-16th century CE) of the White Plague in the Carpathian Basin - New cases, expanding knowledge

The causative agent of tuberculosis is still a widespread pathogen, which caused the death of ca. 1.6 million people globally in 2021. The paleopathological study of human remains revealed the antiquity of the disease and its continuous presence throughout the history of humankind. The Carpathian Basin has always been a biocultural melting pot, since it has seen several migrations over the centuries, and served as a location of admixture and interaction for numerous populations of different cultures. Thus, this geographical territory is ideal for the examination of the coevolutionary processes of hosts and their pathogens. We aimed to reveal the spatial and temporal distribution of tuberculosis cases excavated inside the borders of Hungary between the 2nd and 16th centuries CE. We established a comprehensive database by collecting 114 already published cases and introducing 39 new cases. The involved cases include those that have been confirmed by different molecular methods, as well as possible infections that were identified based on the presence of macromorphological and radiological alterations. The progress of future molecular and paleopathological studies can be facilitated by our dataset, as it presents spatial and temporal information concerning the spread of the disease in the Carpathian Basin, as well as the biological profile and detailed paleopathological description of lesions illustrated by photo- and radiographs.

"Tuberculosis on the spot" - Discussion of a probable sternal tuberculosis from a late medieval cemetery from Hungary

Investigations of non-adult remains are particularly suitable for finding epidemic periods in past populations. This study presents a probable unique example of osseous manifestation of tuberculosis on a child's skeletal remains from medieval Hungary. Between 2009 and 2011 the Field Service for Cultural Heritage excavated the exceptional cemetery of Perkáta - Nyúli-dűlő in Hungary, with around 5000+ graves. The analysed skeleton (SNR 948) was located in the medieval (10-16th century) part of the cemetery. Besides the standard macroscopic pathological observation, we also performed radiographic analysis. The remains of the child (13-14 year-old) showed numerous skeletal lesions: the ribs have proliferative lesions (dense nodules) on the visceral surface of the shaft, lytic lesions with rounded edges occurred on the thoracic and lumbar vertebral bodies, and on the facies auricularis of the left ilium we can see pitting and new bone formation. What makes this pathological case exceptional is the significant change in the manubrium. It shows extensive osteolytic lesions, probably due to tuberculous osteomyelitis, which is a unique phenomenon in an archaeological context. This rare type of extra-spinal tuberculous osteomyelitis appears in less than 1% of cases with skeletal TB, and even less in case of children, according to modern medical literature. Although some cases of slight lesions on the manubrium have been described from an archaeological context, no such cases showing advanced lesions have been published so far. In the future, biomolecular analyses should be conducted as well, in order to confirm the presence of TB in this individual.

Tuberculosis in mummies - New findings, perspectives and limitations

The molecular analysis of ancient pathogen DNA represents a unique opportunity for the study of infectious diseases in ancient human remains. Among other diseases, paleogenetic studies have been successful in detecting tuberculous DNA in ancient human remains. In the beginning of ancient DNA (aDNA) studies, the presence of tuberculosis (TB) DNA was assessed using a PCR-based assay targeting specific regions of the Mycobacterium tuberculosis (MTB) complex, such as the repetitive element IS6110. The advent of high-throughput sequencing has enabled the reconstruction of full ancient TB genomes in the field of paleomicrobiology. However, despite the numerous paleopathological and PCR-based studies on the presence of tuberculosis in historic human remains, full genome wide reconstructions are still limited to well-preserved specimens with low environmental contamination and connected with extensive screening efforts. This has led to some controversies regarding the evolutionary history of its causative agent Mycobacterium tuberculosis. In this context, mummies have been shown to be a good source for the detection of MTB complex DNA due to a low exposure to environmental influences and the overall good state of preservation of hard and soft tissues in the human remains. Here, we present the major findings on the presence of TB infections in the 18th century naturally mummified human remains from Vác, Hungary and the current status of the detection of MTB complex DNA in mummified human remains. The future perspectives of detecting tuberculosis in mummies will be discussed in the light of methodological aspects, as well as ethical and curational challenges.

Musculoskeletal tuberculosis revisited: bone and joint tuberculosis in Austria

BACKGROUND

To prevent further spread of the disease and secondary deformity, musculoskeletal tuberculosis (TB) remains a challenge in terms of early diagnosis and treatment. This study gives an overview on TB trends in Austria (pulmonary and extrapulmonary TB) (A) and analyses a retrospective series of musculoskeletal TB cases diagnosed and treated at an Austrian tertiary centre (B).

METHODS

(A) We analysed data obtained from the Austrian national TB registry to provide information on TB patients´ demographics and manifestation sites between 1995 and 2019. (B) Furthermore, we performed an observational study of all patients with a confirmed diagnosis of musculoskeletal TB who were admitted to the Department of Orthopaedics and Trauma, Medical University of Graz (2005-2019). Demographic, diagnostic, clinical and follow-up data were retrieved from the medical records.

RESULTS

(A) From 1995 to 2019, a significant linear reduction in overall Austrian tuberculosis incidence rates occurred (p < 0.001). In the period investigated, Austria recorded a total of 307 patients with musculoskeletal TB. (B) Our retrospective case-series included 17 individuals (9 males, 8 females; average follow-up 48.4 months; range 0-116). There was a biphasic age distribution with a peak in elderly native Austrians (median 69, range 63-92), and a second peak in younger patients with a migration background (median 29, range 18-39). Sites of manifestation were the spine (n = 10), peripheral joints (n = 5), and the soft tissues (n = 2). Diagnosis was based on histology (n = 13), PCR (n = 14), and culture (n = 12). Eleven patients underwent surgery (64.7%). Secondary deformities were frequent (n = 9), and more often observed in patients with spinal TB (n = 6).

CONCLUSION

Musculoskeletal TB should be considered if untypical joint infections or nonspecific bone lesions occur in younger patients with a migration background or in patients with specific risk factors.

Severe skeletal lesions, osteopenia and growth deficit in a child with pulmonary tuberculosis (mid-20th century, Portugal)

OBJECTIVE

This case-study provides a summary of skeletal lesions seen in a case of diagnosed juvenile pulmonary tuberculosis with extensive multifocal bony lesions.

MATERIALS

Skeleton of a 9-year-old girl who died in the 1940s in Lisbon, Portugal. The remains of this individual are part of the Lisbon skeletal reference collection curated at the National Museum of Natural History and Science.

METHODS

Lesions and paleopathological conditions were identified and documented through macroscopic, radiographic, computed tomographic, and mammographic analysis.

RESULTS

The skeleton shows a variety of lytic lesions on the ribs and thoracic vertebrae including complete destruction of the bodies and fusion of the vertebral arches of four vertebrae, kyphosis, and scoliosis. Further pathological conditions were identified, including bone erosion, premature fusion of the left femoral head and greater trochanter, and abnormal size and shape changes to the lower limbs including loss of bone mass and stunting of the long bones.

CONCLUSIONS

Skeletal lesions are indicative of spondylitis, Pott's disease, and prolonged bedrest.

SIGNIFICANCE

This case is one of the few examples of confirmed juvenile pulmonary tuberculosis with skeletal lesions prior to the antibiotic era. As such, it provides a reference for the skeletal abnormalities which may be observed in archaeological tuberculosis cases.

LIMITATIONS

Pulmonary tuberculosis was recorded as cause of death, however there is no documentation to know the length of illness period or the existence of any comorbidities.

SUGGESTIONS FOR FURTHER RESEARCH

Consideration of multi-focal lesions is recommended when analyzing individuals with suspected tuberculosis.

Possible cases of leprosy from the Late Copper Age (3780-3650 cal BC) in Hungary

At the Abony-Turjányos dűlő site, located in Central Hungary, a rescue excavation was carried out. More than 400 features were excavated and dated to the Protoboleráz horizon, at the beginning of the Late Copper Age in the Carpathian Basin, between 3780-3650 cal BC. Besides the domestic and economic units, there were two special areas, with nine-nine pits that differed from the other archaeological features of the site. In the northern pit group seven pits contained human remains belonging to 48 individuals. Some of them were buried carefully, while others were thrown into the pits. The aim of this study is to present the results of the paleopathological and molecular analysis of human remains from this Late Copper Age site. The ratio of neonates to adults was high, 33.3%. Examination of the skeletons revealed a large number of pathological cases, enabling reconstruction of the health profile of the buried individuals. Based on the appearance and frequency of healed ante- and peri mortem trauma, inter-personal (intra-group) violence was characteristic in the Abony Late Copper Age population. However other traces of paleopathology were observed on the bones that appear not to have been caused by warfare or inter-group violence. The remains of one individual demonstrated a rare set of bone lesions that indicate the possible presence of leprosy (Hansen's disease). The most characteristic lesions occurred on the bones of the face, including erosion of the nasal aperture, atrophy of the anterior nasal spine, inflammation of the nasal bone and porosity on both the maxilla and the bones of the lower legs. In a further four cases, leprosy infection is suspected but other infections cannot be excluded. The morphologically diagnosed possible leprosy case significantly modifies our knowledge about the timescale and geographic spread of this specific infectious disease. However, it is not possible to determine the potential connections between the cases of possible leprosy and the special burial circumstances.

Paleomicrobiology of Human Tuberculosis

Tuberculosis is a significant global disease today, so understanding its origins and history is important. It is primarily a lung infection and is transmitted by infectious aerosols from person to person, so a high population density encourages its spread. The causative organism is Mycobacterium tuberculosis, an obligate pathogen in the M. tuberculosis complex that also contains closely related species, such as Mycobacterium bovis, that primarily infect animals. Typical bone lesions occur in about 5% of untreated infections. These can be recognized in historical and archaeological material, along with nonspecific paleopathology such as new bone formation (periostitis), especially on ribs. Based on such lesions, tuberculosis has been found in ancient Egypt, pre-Columbian America, and Neolithic Europe. The detection of M. tuberculosis ancient DNA (aDNA) by using PCR led to the development of the new field of paleomicrobiology. As a result, a large number of tuberculosis cases were recognized in mummified tissue and bones with nonspecific or no lesions. In parallel with these developments, M. tuberculosis cell wall lipid biomarkers have detected tuberculosis suggested by paleopathology and confirmed aDNA findings. In well-preserved cases, molecular typing has identified M. tuberculosis lineages and genotypes. The current interest in targeted enrichment, shotgun sequencing, and metagenomic analysis reveals ancient mixed infections with different M. tuberculosis strains and other pathogens. Identification of M. tuberculosis lineages from samples of known age enables the date of the emergence of strains and lineages to be calculated directly rather than by making assumptions on the rate of evolutionary change.

Ancient DNA analysis - An established technique in charting the evolution of tuberculosis and leprosy

Many tuberculosis and leprosy infections are latent or paucibacillary, suggesting a long time-scale for host and pathogen co-existence. Palaeopathology enables recognition of archaeological cases and PCR detects pathogen ancient DNA (aDNA). Mycobacterium tuberculosis and Mycobacterium leprae cell wall lipids are more stable than aDNA and restrict permeability, thereby possibly aiding long-term persistence of pathogen aDNA. Amplification of aDNA, using specific PCR primers designed for short fragments and linked to fluorescent probes, gives good results, especially when designed to target multi-copy loci. Such studies have confirmed tuberculosis and leprosy, including co-infections. Many tuberculosis cases have non-specific or no visible skeletal pathology, consistent with the natural history of this disease. M. tuberculosis and M. leprae are obligate parasites, closely associated with their human host following recent clonal distribution. Therefore genotyping based on single nucleotide polymorphisms (SNPs) can indicate their origins, spread and phylogeny. Knowledge of extant genetic lineages at particular times in past human populations can be obtained from well-preserved specimens where molecular typing is possible, using deletion analysis, microsatellite analysis and whole genome sequencing. Such studies have identified non-bovine tuberculosis from a Pleistocene bison from 17,500 years BP, human tuberculosis from 9000 years ago and leprosy from over 2000 years ago.

A case of spinal tuberculosis from the middle ages in Transylvania (Romania)

STUDY DESIGN

Case report.

OBJECTIVE

To characterize the paleopathology presented in the skeleton of a 45- to 50-year-old man indicative of tuberculous spondylitis and to confirm by the detection of ancient DNA.

SUMMARY OF BACKGROUND DATA

Tuberculosis (TB) is an infectious disease prevalent in both present and ancient human populations. The disease is primarily located within the lungs; although characteristic bone lesions can lead to a clear diagnosis, skeletal TB occurs in only 5% to 6% of TB infections, even in historical cases. In addition, the visual appearance of human skeletal remains may be influenced by the environmental conditions at the burial site. However, it is important to recognize ancient skeletal TB because it can provide important data on the history of Mycobacterium tuberculosis and give a unique opportunity for physicians to observe the natural outcome of the infection of the preantibiotic era.

METHODS

Paleopathological analysis was carried out using careful visual observation supported by ancient DNA analysis. Approximately 60 mg of bone powder from rib fragments was examined and DNA from the M. tuberculosis complex was detected by polymerase chain reaction (PCR) targeting specific genetic loci of the IS6110 and IS1081 regions.

RESULTS

The skeleton is part of a human osteoarchaeological collection (n = 274) from the 12th- to 13th-century Transylvanian archaeological site of Peteni, in modern-day Romania. The individual, a 45- to 50-year-old man, showed gross pathology typical of tuberculous spondylitis. The paleopathological diagnosis was supported by analysis for M. tuberculosis complex ancient DNA.

CONCLUSIONS

This case demonstrates that TB was present in Transylvania (Romania) during the 12th and 13th centuries and adds to the growing body of knowledge on the history of this disease.

Evolution of human tuberculosis: a systematic review and meta-analysis of paleopathological evidence

Tuberculosis is a re-emerging disease and is a major problem in both developing and developed countries today. An estimated one third of the world's population is infected and almost two million people die from the disease each year. Bone lesions occur in 3-5% of active tuberculosis cases and can be used to diagnose the disease in ancient skeletal remains. A meta-analysis was conducted on 531 palaeopathological tuberculosis cases from 221 sites (7250 BCE to 1899) on all continents for the purpose of testing two hypotheses; (1) the frequency of bone lesions does not change through time and (2) the distribution of lesions throughout the skeleton does not change over time. The frequency of bone lesions was found to significantly decrease over time (P<0.05). The distribution of bone lesions was found to change from mainly spinal in earlier time periods to include more cases in other regions of the skeleton (long bones, joints, hands, feet) in later time periods. This difference in distribution was evaluated using a Chi-squared test and found to be significant (P<0.01). These findings are an important addition to the current knowledge of the evolution of the disease and the Mycobacterium tuberculosis.