Knee Ankyloses Associated with Tuberculosis from the Medieval Hungary - Differential Diagnosis Based on Medical Imaging Techniques

Abstract

Osseous ankylosis of large joints that occurs secondary to infection is rarely described in developed countries, thanks to diagnostic techniques that allow early detection and treatment of the underlying infection. Evidence of the natural history and progression of the disease is now primarily studied through the observation and analysis of osteoarcheological specimens, and medical reports or books dating from the pre-antibiotic era. This report illustrates several cases where modern medical imaging techniques and ancient medical literature were successfully interpreted to diagnose rare, advanced-stage tuberculous alterations in osteoarcheological specimens. Two skeletons from the Bátmonostor cemetery (Hungary) demonstrate complete unilateral ankylosis of the knee. Macroscopic and radiographic examinations were undertaken to assess the extent of skeletal changes and determine their cause. Data obtained from computed tomography (CT) were constructed in 2D and 3D. The 2D CT images revealed cavities involving both the metaphyses and the epiphyses. The 3D reconstructions allowed us to reconstruct the more precise volumetric morphology of the circumscribed lytic lesions, as well as clear 'image-mirror' lacunar volumes. On the basis of the macroscopic and radiological analyses, extra-spinal tuberculous infection seems to have been the most probable etiology of these two cases.

Lipid biomarker-based verification of TB infection in mother’s and daughter’s mummified human remains (Vác Mummy Collection, 18th century, CE, Hungary)

“…2A), and abnormal blood vessel impressions (Fig. 2B) (Schultz 1993(Schultz , 1999(Schultz , 2001(Schultz , 2003Aufderheide and Rodríguez-Martín 1998;Marcsik et al, 1999;Pálfi and Marcsik 1999;Hershkovitz et al 2002;Maczel 2003;Ortner 2003;Pálfi and Molnár 2009;Pálfi et al 2012Pálfi et al , 2015Spekker et al 2012;Kajdocsi Lovász 2015;Masson et al 2015;Molnár et al 2015;Paja et al 2015;Schultz and Schmidt-Schultz 2015;Spekker 2018;Spekker et al 2020aSpekker et al , 2020b. Moreover, new bone formation on the long bones and on the visceral surface of ribs are used as TB-related markers (Roberts et al 1994;Marcsik et al 2009;Roberts 2001, 2006;Hershkovitz et al 2002;Maczel 2003;Matos and Santos 2006;Pálfi and Molnár 2009;Pálfi et al 2012Pálfi et al , 2015Kajdocsi Lovász 2015;Masson et al 2015;Molnár et al 2015).…”

Development of lipid biomarker based diagnostic method for TB research in archaeological samples via HPLC-HRMS

“…The diagnosis of ancient mycobacterial disease in archaeological material requires a multidisciplinary approach. Most of the TB-related bony lesions are the result of extrapulmonary TB (Aufderheide & Rodríguez-Martín, 1998;Marcsik et al, 1999Marcsik et al, , 2009Hershkovitz et al, 2002;Maczel, 2003;Ortner et al, 2003;Paja et al, 2015;Pálfi et al, 2012;Mariotti et al, 2015;Spekker, 2018;Spekker et al, 2020a;Spekker et al, 2020b), which was registered only in 16% of all incident cases in 2019 (WHO, 2020). Moreover, only a low proportion of extrapulmonary TB develops specific and detectable bony lesions.…”

“…In the traditional paleopathological practice the signs of osteoarticular TB have served as a good indicator of the presence of TB infection, however in later studies beside the described lesions, periosteal new bone formation on the long bones with a diffuse bilateral appearance has been also proven to be useful indicators of TB (e.g. Aufderheide & Rodríguez-Martín, 1998;Marcsik et al, 1999Marcsik et al, , 2009Hershkovitz et al, 2002;Maczel, 2003;Ortner, 2003;Pálfi et al, 2012;Spekker et al, 2012;Kajdocsi Lovász, 2015;Mariotti et al, 2015;Masson et al, 2015;Paja et al, 2015).…”

Joint fusions in palaeopathology: diagnosis and epidemiology

“…The lytic alterations found in the femorae and tibiae are strongly suggestive of a "tumeur blanche du genou" (Sorrel and Sorrel-Déjerine, 1932), which is corresponding to tuberculous arthritis of the knee. It may be associated with the produce of the tuberculous pus within the metaphyseal trabeculae, the infection may spread to the joint space, later bony ankylosis developed (Paja et al, 2012a(Paja et al, , 2012b). …”

“…In the specimen BMP -993 the utilization of a crutch cannot be excluded either. The wedge shaped anterior bony projection at the level of the original femorotibial joint gap and the superior direction of the kneecap may have developed as a result of the long-term physical stress caused by the utilization of prosthesis (Józsa and Farkas, 2009;Paja et al, 2012aPaja et al, , 2012b.…”