Tracking down the White Plague: The skeletal evidence of tuberculous meningitis in the Robert J. Terry Anatomical Skeletal Collection

Chasing the "White Plague" in the Barbaricum of the Carpathian Basin - A case with tuberculous meningitis discovered in a Sarmatian-period (2nd-3rd-century-CE) storage pit from the archaeological site of Kiskundorozsma-Daruhalom-dűlő II (Hungary)

The aim of our paper is to demonstrate a case (KD429) with tuberculous meningitis (TBM) from the 2nd-3rd‒century‒CE Carpathian Basin. The skeleton of KD429 was subject to a detailed macromorphological evaluation, focusing on the detection of pathological lesions likely related to tuberculosis (TB). It was the presence of endocranial alterations, especially the TB-specific granular impressions, based on which the diagnosis of TBM was established in KD429. Besides KD429, only eight cases with TB have been published from the Sarmatian-period (1st-5th centuries CE) Carpathian Basin. Reports of archaeological cases with TB, like KD429, can provide invaluable information about the spatio-temporal distribution of the disease in the past. Nonetheless, to get a more accurate picture about the burden that TB may have put on the Sarmatians, the systematic macromorphological (re-)evaluation of their osteoarchaeological series would be advantageous. Interestingly, the skeleton of KD429 was unearthed from not a grave-pit but a storage pit from the archaeological site of Kiskundorozsma-Daruhalom-dűlő II (Hungary). At the current state of research, the motive behind the exclusion of KD429 from the "normal" burial custom cannot be determined; therefore, it remains an open question whether their disease (TBM) played a role in it or not.

Are endocranial granular impressions pathognomonic of tuberculous meningitis or a marker of tuberculous infection? An investigation on a medieval osteoarcheological assemblage from Italy

OBJECTIVES

In recent paleopathological literature, granular impressions on the endocranial surface are considered pathognomonic of tuberculous meningitis. This study aims to verify the presence of granular impressions and assess their relationship with tuberculosis in an archeological human skeletal assemblage.

MATERIALS

The study analyzed the endocranial surfaces of 212 skulls (38 non-adults and 174 adults) from the medieval site of Pieve di Pava, Italy.

METHODS

Macroscopic and stereomicroscopic examination of the endocranial surface was conducted to evaluate the presence, location, and manifestation of granular impressions.

RESULTS

Granular impressions affected more than half of the individuals, with no statistical difference between males and females.

CONCLUSIONS

The high frequency of granular impressions challenges their interpretation as pathognomonic of tuberculous meningitis, a rare complication of tuberculosis affecting the central nervous system. Instead, these lesions should be considered indicative of bacteremia, when bacilli reach the central nervous system and form tubercles on the meninges. It cannot be established whether these tubercles were quiescent or had ruptured, leading to tuberculous meningitis.

SIGNIFICANCE

Based on the pathogenic life cycle of M. tuberculosis, as defined in clinical settings, it seems prudent to consider granular impressions as a marker of tuberculosis infection, rather than of active tuberculosis disease or tuberculous meningitis in paleopathology.

LIMITATIONS

Research limitations include the smaller number of non-adults compared to adults.

SUGGESTIONS FOR FURTHER RESEARCH

Screening of granular impressions in other large osteoarcheological assemblages could provide new and more reliable data on the spread of tuberculosis infection across different social contexts, geographical settings, and historical periods.

A, Kis L, Király K, Varga S, Marcsik A, Schütz O, Török T, Hunt DR, Tihanyi B. White plague among the "forgotten people" from the Barbaricum of the Carpathian Basin-Cases with tuberculosis from the Sarmatian-period (3rd-4th centuries CE) archaeological site of Hódmezővásárhely-Kenyere-ér, Bereczki-tanya (Hungary)

Tuberculosis (TB) is a bacterial infection that is well-known in the palaeopathological record because it can affect the skeleton and consequently leaves readily identifiable macroscopic alterations. Palaeopathological case studies provide invaluable information about the spatio-temporal distribution of TB in the past. This is true for those archaeological periods and geographical regions from when and where no or very few TB cases have been published until now-as in the Sarmatian period (1st-5th centuries CE) in the Barbaricum of the Carpathian Basin. The aim of our paper is to discuss five newly discovered TB cases (HK199, HK201, HK225, HK253, and HK309) from the Sarmatian-period archaeological site of Hódmezővásárhely-Kenyere-ér, Bereczki-tanya (Csongrád-Csanád county, Hungary). Detailed macromorphological evaluation of the skeletons focused on the detection of bony changes likely associated with different forms of TB. In all five cases, the presence of endocranial alterations (especially TB-specific granular impressions) suggests that these individuals suffered from TB meningitis. Furthermore, the skeletal lesions observed in the spine and both hip joints of HK225 indicate that this juvenile also had multifocal osteoarticular TB. Thanks to the discovery of HK199, HK201, HK225, HK253, and HK309, the number of TB cases known from the Sarmatian-period Carpathian Basin doubled, implying that the disease was likely more frequent in the Barbaricum than previously thought. Without the application of granular impressions, the diagnosis of TB could not have been established in these five cases. Thus, the identification of TB in these individuals highlights the importance of diagnostics development, especially the refinement of diagnostic criteria. Based on the above, the systematic macromorphological (re-)evaluation of osteoarchaeological series from the Sarmatian-period Carpathian Basin would be advantageous to provide a more accurate picture of how TB may have impacted the ancestral human communities of the Barbaricum.

Hybrid use of Raman spectroscopy and artificial neural networks to discriminate Mycobacterium bovis BCG and other Mycobacteriales

Even in the face of the COVID-19 pandemic, Tuberculosis (TB) continues to be a major public health problem and the 2nd biggest infectious cause of death worldwide. There is, therefore, an urgent need to develop effective TB diagnostic methods, which are cheap, portable, sensitive and specific. Raman spectroscopy is a potential spectroscopic technique for this purpose, however, so far, research efforts have focused primarily on the characterisation of Mycobacterium tuberculosis and other Mycobacteria, neglecting bacteria within the microbiome and thus, failing to consider the bigger picture. It is paramount to characterise relevant Mycobacteriales and develop suitable analytical tools to discriminate them from each other. Herein, through the combined use of Raman spectroscopy and the self-optimising Kohonen index network and further multivariate tools, we have successfully undertaken the spectral analysis of Mycobacterium bovis BCG, Corynebacterium glutamicum and Rhodoccocus erythropolis. This has led to development of a useful tool set, which can readily discern spectral differences between these three closely related bacteria as well as generate a unique spectral barcode for each species. Further optimisation and refinement of the developed method will enable its application to other bacteria inhabiting the microbiome and ultimately lead to advanced diagnostic technologies, which can save many lives.

Probable cases of tuberculosis in Early Medieval pastoralists of Eastern Europe

Two anthropological collections of the 8-9th century AD from the forest-steppe area of the southern Eastern Europe has been the subject of analysis of the osteo-articular alterations concerning tuberculosis related lesions. According to archaeological data, the Mayaki and Dmitrievka groups are from the territory of Khazar Khaganate, which is well-known by historical data. It was a traditional population with settled pastoral farming. There were studied 292 adult human remains by macroscopic morphological and radiological methods. The completeness of the skeletons could have been better due to the intentional selection of their parts for the museum funds, so there were limitations for the differential diagnosis of TB by morphological criteria. In general, 31 individuals (20 men, 11 women) were marked as possible candidates with skeletal TB. The number of skeletons with possible specific infections from the two series is comparable, but according to sex distribution, there are some significant differences. If in the Dmitrievka group, there was approximately the same distribution of the number of cases of possible infected men and women; in the Mayaki group then there was a significant difference in the prevalence of the male sample. Various reasons can explain the observed differences. Firstly, we cannot rule out an error in the diagnosis of tuberculosis only by morphological methods since the preservation of the skeletons leaves much to be desired. Secondly, as it is known, only a few percent of tuberculosis patients show skeletal alterations, so the direct quantitative comparison cannot be adequate in paleopathological studies. The ambiguity of morphological criteria, particularly for destructive lesions of bone other than vertebrae, does not allow asserting that all identified cases result from TB. However, the results of differential diagnosis can underline that at least half of the skeletons have skeletal alterations most likely related to TB. The final analysis of the remains by aDNA methods will permit more certain confirmation of the diagnosis.

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.

The first probable case with tuberculous meningitis from the Hun period of the Carpathian Basin - How diagnostics development can contribute to increase knowledge and understanding of the spatio-temporal distribution of tuberculosis in the past

The aim of our paper is to demonstrate and discuss in detail the endocranial bony changes suggestive of tuberculous meningitis (TBM) that were recorded in an adult female's (SPF15) skeleton. The bone remains were uncovered from a solitary grave from the Hun period (5th-century-CE) archaeological site of Solt-Polya-fok (Bács-Kiskun county, Hungary). During the macromorphological examination of the very incomplete and poorly preserved skeleton of SPF15, the inner surface of the skull displayed abnormally pronounced digital impressions (APDIs) and granular impressions (GIs). Recently, it was confirmed that endocranial GIs can be considered as specific signs of TBM; and thus, they are sufficient enough on their own to make a definitive diagnosis of the disease in the palaeopathological practice. On the other hand, APDIs are not specific to TBM but can be tuberculous in origin; their concomitant presence with GIs in SPF15 makes their tuberculous origin very likely. Based on the above, it seems that the adult female from the 5th-century-CE archaeological site of Solt-Polya-fok suffered from TBM. SPF15 is the first reported probable case with tuberculosis (TB) from the Hun period of the present-day territory of Hungary, who gives us invaluable information about the spatio-temporal distribution of the disease in the past. Furthermore, it highlights the paramount importance of diagnostics development, especially the identification and refinement of diagnostic criteria, as without the application of APDIs and GIs, the diagnosis of TB could not have been established in SPF15.

Oldest evidence of tuberculosis in the Mediterranean islands: From the mainland to Cyprus

Recent studies combining macroscopical observations and microCT analysis strongly suggested the diagnosis of tuberculosis for a child from the site of Khirokitia (Cyprus, 7th - early 6th millennium cal. BC), whose age at death is between 5 and 7 years. Many single primary burials were discovered at the site where the dead (MNI = 243) are buried in the same way, whatever their age. Nevertheless, the burial of this child presents a unique feature on the site (a male Ovis trophy marking the limit of the burial pit), probably indicating specific attention for this young deceased. This case is the oldest known in the Mediterranean islands and presents a particular interest from a paleoepidemiological point of view. Indeed, considering, on the one hand, the settlement pattern of the island of Cyprus by migrants from the Near East, and on the other hand, the presence of human tuberculosis in the Near East as early as about 10,500 years BP, it is very likely that the prehistoric migrants brought the disease from mainland to Cyprus.

Re-examination of the Subalyuk Neanderthal remains uncovers signs of probable TB infection (Subalyuk Cave, Hungary)

In 1932, skeletal remains of two Neanderthal individuals, a young adult female and a 3-4-year-old child, were discovered in Subalyuk Cave in Northern Hungary [1,2]. Results of the anthropological examination were published some years after this important discovery. Methodological progress encouraged re-examination of the material during the last few years. Radiocarbon dating revealed a chronological age of 39,732-39,076 cal. BP for the adult female and 36,117-35,387 cal. BP for the child [3]. Morphological paleopathological studies of these Neanderthal remains uncovered distinct evidence of skeletal infections. Alterations of the adult individual's sacrum suggest probable early-stage sacroiliitis, while several vertebral bodies indicate superficial osseous remodelling of infectious origin. Traces of pathological lesions were observed on the endocranial surface of the child's skull, reflecting a reaction of meningeal tissues, a consequence of a probable TB-related meningeal infectious process. Results of recent paleomicrobiological examinations - lipid biomarker and aDNA studies - support the morphological diagnosis of probable TB infections [4].

The frequency and macromorphological classification of abnormal blood vessel impressions and periosteal appositions of the dura mater in an early modern osteological collection from Poland

OBJECTIVE

The macromorphological characteristics and frequency of endocranial abnormal blood vessel impressions (ABVI) and periosteal appositions of dura mater (PADM), and their association with sex, age-at-death and scurvy-like lesions were studied. The possible etiologies of these lesions were discussed.

MATERIALS

A total of 144 adult skulls excavated from an early modern (16th-19th c. CE) cemetery at the Czysty Square in Wrocław (Poland) were examined, most of which were intact.

METHODS

The endocranial surface was inspected with an endoscope for the presence, location, and severity of ABVI and PADM. Frequencies of ABVI and PADM were grouped by sex and age-at-death.

RESULTS

A little more than a half (53.5 %) of the examined skulls were affected by ABVI and/or PADM. PADM were more frequent in females. However, both alteration types occurred with similar frequencies across all age-at-death categories.

CONCLUSIONS

The high frequency of ABVI and PADM suggests that meningeal infections and/or hemorrhage among inhabitants of early modern Wrocław, especially in females, were common.

SIGNIFICANCE

The paper emphasizes the need for using an endoscope in standard anthropological analysis of intact skulls, as it allows for a nondestructive inspection of the endocranial surface.

LIMITATIONS

The endoscope did not allow for an accurate examination of the middle cranial fossa.

SUGGESTIONS FOR FURTHER RESEARCH

Comparative studies with other historical populations are necessary to better understand the possible etiologies of macromorphological and demographic characteristics of ABVI and PADM.

Lumbosacral tuberculosis, a rare manifestation of Pott's disease - How identified human skeletons from the pre-antibiotic era can be used as reference cases to establish a palaeopathological diagnosis of tuberculosis

The macromorphological examination of identified human osteological collections from the pre-antibiotic era (e.g., Terry Collection) can provide invaluable information about the skeletal manifestations of tuberculosis (TB) in individuals who did not receive pharmaceutical therapy. With analysis of such collections, new diagnostic criteria for TB can be recognised which can be used in palaeopathological interpretation. The aim of our paper is to provide a reference and aid for the identification of TB in past populations by demonstrating and discussing in detail the vertebral alterations indicative of one of its rare skeletal manifestations, lumbosacral TB. These changes were detected in two individuals from the Terry Collection (Terry No. 760 and Terry No. 1093). These two case studies furnish palaeopathologists with a stronger basis for diagnosing lumbosacral TB in skeletons which exhibit similar vertebral lesions from osteoarchaeological series. To illustrate this, an archaeological case from Hungary (KK146) is also presented, displaying vertebral alterations resembling that of the two cases from the Terry Collection. Through the demonstrated case studies, we can derive a better insight into the disease experience of people who lived in the past and suffered from TB.

A rare case of calvarial tuberculosis from the Avar Age (8th century CE) cemetery of Kaba-Bitózug (Hajdú-Bihar county, Hungary) - Pathogenesis and differential diagnostic aspects

The aim of our paper is to present and discuss in detail the bony changes indicative of tuberculosis (TB) that were identified in a skeleton (KB67), unearthed from grave 67 of the 8th-century-CE cemetery of Kaba-Bitózug (Hungary). Furthermore, to provide the differential diagnoses of the observed alterations, with special attention to the cranial osteolytic lesions. During the macro- and micromorphological examinations of KB67, the skull revealed three small, well-circumscribed, punched-out osteolytic lesions accompanied by endocranial granular impressions, abnormal blood vessel impressions, periosteal appositions, and cortical erosion. The postcranial skeleton exhibited osteolytic lesions, cortical remodelling and erosion, and signs of hypervascularisation in the spine. Based on the differential diagnosis of the cranial osteolytic lesions and their co-occurrence with endocranial and vertebral bony changes indicative of TB, they most likely resulted from tuberculous involvement of the frontal and left parietal bones. The morphologically established diagnosis was confirmed by a PCR analysis that provided evidence for the presence of Mycobacterium tuberculosis DNA in KB67. KB67, the first reported archaeological case with calvarial TB from the present-day territory of Hungary, gives us a unique insight into the occurrence of a rare manifestation of TB in the Avar Age of the Great Plain.

Tracking down the White Plague. Chapter three: Revision of endocranial abnormally pronounced digital impressions as paleopathological diagnostic criteria for tuberculous meningitis

Abnormally pronounced digital impressions (APDIs) on the endocranial surface develop secondary to a prolonged rise in the intracranial pressure. This can result from a number of pathological conditions, including hydrocephalus due to tuberculous meningitis (TBM). APDIs have been described with relation to TBM not only in the modern medical literature but also in several paleopathological studies. However, APDIs are not pathognomonic for TBM and their diagnostic value for identifying TBM in past human populations has not been evaluated in identified pre-antibiotic era skeletons. To assess the diagnostic value of APDIs for the first time, a macroscopic investigation was performed on skeletons from the Terry Collection (Smithsonian Institution, Washington, DC, USA). Our material consisted of 234 skeletons with tuberculosis (TB) as the cause of death (TB group) and 193 skeletons with non-tuberculous (NTB) causes of death (NTB group). The macroscopic examination focused on the stage of the prominence and frequency of APDIs in the TB group and NTB group. To determine the significance of difference (if any) in the frequency of APDIs between the two groups, χ2 testing of our data was conducted. We found that APDIs were twice as common in the TB group than in the NTB group. The χ2 comparison of the frequencies of APDIs revealed a statistically significant difference between the two groups. In addition, APDIs with more pronounced stages were recorded more frequently in the TB group. Our results indicate that APDIs can be considered as diagnostic criteria for TBM in the paleopathological practice. With suitable circumspection, their utilization provides paleopathologists with a stronger basis for identifying TB and consequently, with a more sensitive means of assessing TB frequency in past human populations.

Mutations of folC cause increased susceptibility to sulfamethoxazole in Mycobacterium tuberculosis

Previous studies showed that mutation of folC caused decreased expression of the dihydropteroate synthase encoding gene folP2 in Mycobacterium tuberculosis (M. tuberculosis). We speculated that mutation of folC in M. tuberculosis might affect the susceptibility to sulfamethoxazole (SMX). To prove this, 53 clinical isolates with folC mutations were selected and two folC mutants (I43A, I43T) were constructed based on M. tuberculosis H37Ra. The results showed that 42 of the 53 clinical isolates (79.2%) and the two lab-constructed folC mutants were more sensitive to SMX. To probe the mechanism by which folC mutations make M. tuberculosis more sensitive to SMX, folP2 was deleted in H37Ra, and expression levels of folP2 were compared between H37Ra and the two folC mutants. Although deletion of folP2 resulted in increased susceptibility to SMX, no difference in folP2 expression was observed. Furthermore, production levels of para-aminobenzoic acid (pABA) were compared between the folC mutants and the wild-type strain, and results showed that folC mutation resulted in decreased production of pABA. Taken together, we show that folC mutation leads to decreased production of pABA in M. tuberculosis and thus affects its susceptibility to SMX, which broadens our understanding of mechanisms of susceptibilities to antifolates in this bacterium.

Verification of tuberculosis infection among Vác mummies (18th century CE, Hungary) based on lipid biomarker profiling with a new HPLC-HESI-MS approach

Tuberculosis (TB) was a large burden of infections that peaked during the 19th century in Europe. Mummies from the 18th century CE, discovered in the crypt of a church at Vác, Hungary, had high TB prevalence, as revealed by amplification of key fragments of TB DNA and genome-wide TB analysis. Complementary methods are needed to confirm these diagnoses and one approach uses the identification of specific lipid biomarkers, such as TB mycocerosic acids (MCs). Previously, MC derivatives were profiled by specialised gas chromatography-mass spectrometry (GC-MS), so an alternative more direct approach has been developed. Underivatized MCs are extracted and analysed by high-performance liquid chromatography linked to a mass spectrometer, in heated electrospray ionisation mode (HPLC-HESI-MS). The method was validated using representatives of the Mycobacterium tuberculosis complex and other mycobacteria and tested on six Vác mummy cases, previously considered positive for TB infection. Analysing both rib and soft tissue samples, four out of six cases gave profiles of main C32 and major C29 and C39 mycocerosates correlating well with those of M. tuberculosis. Multidisciplinary methods are needed in the diagnosis of ancient tuberculosis; this new protocol accesses important confirmatory evidence, as demonstrated by the confirmation of TB in the Vác mummies.

Tuberculosis diagnostics: overcoming ancient challenges with modern solutions

Rapid, sensitive, accurate and portable diagnostics are a mainstay of modern medicine. Tuberculosis is a disease that has been with us since time immemorial and, despite the fact that it can be treated and cured, it still remains the world's biggest infectious killer, taking the lives of millions annually. There have been important developments in the diagnostic devices for tuberculosis however, these are often prone to error, expensive, lack the necessary sensitivity or accuracy and, crucially, not sufficiently portable and thus not applicable in the remote, rural areas, where they are most needed. Modern solutions have been emerging in the past decade, seeking to overcome many of the inhibiting issues in this field by utilising recent advances in molecular biology, genetics and sequencing or even completely ‘reinventing the wheel’, by developing novel and unprecedented diagnostic techniques. In this mini review, the issues and challenges arising from the historical methods of diagnosing tuberculosis are discussed, followed by outlaying their particular lack of appropriateness for regions of the world where tuberculosis still remains endemic. Subsequently, more recent developments of new methods and technological advancements as ‘modern weapons’ in the battle to defeat this disease and associated challenges are reviewed, and finally an outlook is presented, highlighting the future of the modern solutions under development, which are envisioned to lay the platform for improvements in delivering timely intervention, reduce immense expense and burden on healthcare systems worldwide, while saving millions of lives and eventually, may enable the eradication of this ancient disease.

Tracking down the White Plague. Chapter two: The role of endocranial abnormal blood vessel impressions and periosteal appositions in the paleopathological diagnosis of tuberculous meningitis

Although endocranial abnormal blood vessel impressions (ABVIs) and periosteal appositions (PAs) have been considered as paleopathological diagnostic criteria for tuberculous meningitis (TBM) based on findings of previous studies, they are not pathognomonic for tuberculosis (TB). Therefore, their utilization in the paleopathological practice can be questioned, especially in consideration that most of the previous studies were not performed on identified skeletal collections but on osteoarchaeological material and did not include statistical data analysis. To fill the aforementioned research gap, for the first time, a macroscopic investigation was conducted on identified pre-antibiotic era skeletons from the Terry Collection. A sample set of 234 individuals who died of TB (TB group) and 193 individuals who died of non-tuberculous causes (NTB group) were examined. The frequency of ABVIs and PAs, as well as other probable TB-related lesions was recorded. To determine the significance of difference (if any) in the frequencies of ABVIs and PAs between the two groups, χ² testing of our data was performed. We found that ABVIs, PAs, and their co-occurrence with each other and with other probable TB-related lesions were more common in the TB group than in the NTB group. In addition, the χ² comparative frequencies of ABVIs and PAs revealed a statistically significant difference between individuals who died of TB and individuals who died of NTB causes. Our findings strengthen those of previous studies that ABVIs and PAs are not specific to TBM but can be of tuberculous origin. Therefore, they do have a diagnostic value in the identification of TB in human osteoarchaeological material, especially when they simultaneously occur with other probable TB-related lesions. Their prudent utilization provides paleopathologists with a stronger basis for diagnosing TB and consequently, a more sensitive means of assessing TB frequency in past human populations.