An attempt to evaluate the criteria for diagnosing nonspecific inflammatory diseases observed on ancient skeletons

Przegląd A ntropologiczny • tom 60, s. 1 0 3 -1 0 9 , Poznań 1997

An attempt to evaluate the criteria for diagnosing

nonspecific inflammatory diseases observed

on ancient skeletons

Witold Prejzner l, Judyta J. Gladykowska-Rzeczycka

Abstract

T he study presents th e criteria for diagnosing nonspecific inflam m atory diseases observed on ancient bones. It is very im portant to rem em ber about tw o form s o f o stitis - acute and chronic, and a b o u t diseases causing sim ilar changes, e.g. tuberculosis, lues, brucelosis, cysts, osteoid-osteom a.

W itold Prejzner, Judyta J. G ladykow ska-R zeczycka, 1997; A nthropological Review , vol. 60, Poznan 1997, pp. 103-109, figs 2, table 1. ISB N 83-86969-18-0, ISSN 0033-2003

Inflammatory diseases belong to the oldest ones, as the traces o f inflammatory processes were found on the plants from the Carboniferous period. Changes such as necrosis and fistulas were noticed on bones o f fossil animals from different periods [MOODIE 1967] as well as on bones o f pre-human beings, e.g. the man from Rhodesia [HRDLIĆKA 1930]. There are many descriptions o f osteomyelitis in man dating back to the period from pre­ historic times to present. W e would like tomention here some o f the authors writing about ostitis, to show how com­ mon the disease has been - it has been found all over the world: WOOD-JONES

[1910], HOOTON [1935], HRDLIĆKA

[1930], Fr a n k e n b e r g e r [1935], Cr e s-

s m a n, La r s e l l [1945], Je l in e k [1963],

1 Department o f Hematology University Medical School Gdańsk 2 Department o f Anatomy and Anthropology

Academy o f Physical Education Wiejska 1, 80-336 Gdańsk Ro c h l in [1965], Mil e s [1966], Ro n e y jr. [1966], ERY [1967-1968, 1970, 1981], St l o u k a l, Vy h n a n e k [1976], St e in- b o c k [1976], Th u r z o [1969], Ma l l e- g n i, Fo r n a c ia r i [1980], Gl a d y k o w- s k a-Rz e c z y c k a [1980, 1981, 1984, 1989,1993], Or t n e r, Pu t s c h a r [1981], Ha n a k o v a [1983], Ca p a s s o [1985], Cz a r n e t z k y [1985], Win k l e r [1988— 1889], Bl a j e r o v a [1975], Ja k a b [1997], La l l o, Bl a n k [1977], Cw ir k o- Go d y c k i, Sw e d b o r g [1978], De r m u s [1978], Ma r c s ik, Ol a h [1991], Kr a- MAR et al. [1990], TAKAO [1991].

The above-m entioned authors descri­ bed few cases o f ostitis usually found in large skeletal series. In Poland 12 skele­ tons among 1192 ones had changes char­ acteristic for ostitis.

Differentiation o f macro- and micro­ scopic picture o f ostitis makes it difficult to diagnose, especially in paleopathol­ ogy. Therefore, it is important to give basic information about that disease, its

104 W itold Prejzner, Ju d y ta J. G ładykow ska-R zeczycka

forms and differential diagnosis.

B acteria causing ostitis mayoriginate from a urinary infection, bacterial endo­ carditis, a soft tissue infection and other.

Depending on the spreading route ostitis m ay be divided into:

1. hematogenous or prim ary ostitis; 2. secondary ostitis (posttraumatic ostitis and ostitis from a contiguous in­ fection).

In secondary ostitis the source o f the infection is known, whereas in the pri­ mary one it is usually unapparent and infection spreads by the circulatory sys­ tem.

T he m ost com m on clin ica l and patho­ lo g ica l cla ssifica tio n o f ostitis is that based on tim e o f duration and clin ical m anifestation (acute, subacuteand and chronic o stitis) is. T here are also other cla ssifica tio n s o f the hem atogen ou s o sti­ tis, for exam p le th o se con sid erin g e tio l­ o g y or ag e [Tr u e t a 1959].

Ostitis is m ost often caused by Staphylococcus aureus (61%), and stre­ ptococci (9% ) according to DlCH et al. [1975], and affects m ostly such bones as: the fem ur and tibia (80% ) according to

ORTNER and PUTSCHAR [1981), humerus (10% ) according to BOREJKO AND DZIAK

[1988]. Ostitis m ay afflict all bones, but is rarely seen in the ribs, clavicle and

vertebrae [WALDVOGEL, VASEX 1980,

Do n o v a n, Sm a m 1982], Ostitis o f ver­

tebrae may cause a hump. In 9 % o f osti­ tis cases more than two bones are af­ fected [DlCH et al. 1975]. Pathologic findings during the acute phase include inflammation, and bone necrosis. In the subacute phase a new bone formation may occur around necrosis and formation o f fistulas. The chronic phase may mani­ fest itself as smouldering infection in postinflam m atoiy sites and infection may

recur after months or years o f quiescence

[COHEN 1990, TUMEH 1987].

In the acute phase o f ostitis bacteria reach the bone and cause inflammation: vascular congestion and purulent exu­ date. Because o f the bone rigidity, in­ creased intramedullary pressure devel­ ops, compressing the blood supply and causing ischemia and necrosis. The push spreads via the Volkmann canals to reach periosteum, beneath which abscesses may form. The suppurative and ischemic injuries may cause fragmentation o f bones into devitalized segments called sequestra. A fter 4 -6 weeks the new bone formation and proliferation begin. Os­ teogenesis from the periosteum may sur­ round the inflammation to form the bone envelope or involucrum. A fter many years, distension, diffuse sclerosis o f the bone and sequestra in different phase o f sequestration may occur [ŁAKOMSKI

1976, ŻAK 1983].

Brodie’s abscess and ostitis chronica scleroticans typus Garre are considered as chronic osteomyelitis [MALAWSKI

1976],

Brodie’s abscess is usually located in the tibia, rarely in the femur. It is placed intramedullary, close to epiphysis. It is usually a single cyst, cherry-size, and no periosteum changes are observed.

G a rre ’s sclerosing ostitis affects mainly children and young adults and is located in the proximal part o f tibia. This form o f ostitis is characterized by regular fusiform distension and thickening o f the proximal part o f the bone without leading to suppuration, sequestration and fistulization. The radiological picture shows pronounced sclerosis and dis­ tention o f the affected bone and no m edullary cavity [COLLERT, ISACSON

A n attem pt to evaluate th e criteria for diagnosing nonspecific inflam m atory diseases ₁₀₅

The bone changes observed in active osteomyelitis (with sequestrum and fistu­ las) are very characteristic and do not cause problems with diagnosis. However, the bone changes at the beginning o f ostitis are not typical thus creating many diagnosing troubles [MURCZYNSKI 1952].

The bone changes in the chronic form o f ostitis may resemble the bone changes caused by tuberculosis, brucellosis or syphilis. Brodie’s abscess may cause confusion with cyst or osteoid-osteoma (Tab. 1).

Tuberculosis - in comparison to osti­ tis - is an infectious disease, in which usually more than one bone is affected and most often the process is located in vertebrae and joints. Tuberculosis does not affect medullary cavity. Because tuberculosis affects the spongy part o f the bone it may cause great destruction, sometimes changing the bone’s shape. Ostitis usually affects shafts o f long bones and abscessus very rarely pene­ trates to the joint. In tuberculosis neither periostitis nor destruction o f the bone is found. Tuberculous sequestra are more round - shaped, smaller and with smoother surfaces than sequestra in osti­ tis. Tuberculous sequestra are located in the spongy bone, whereas ostitis’ ones are found mainly in the compact bone.

As regards tertiary syphilis, it usually affects many bones at the same time; very often the skull is affected, whereas in ostitis the skull is very rarely affected and in that case the process is limited to the m axilla and the jaw . The lesions caused by syphylis are wide-spread and found in the spongy and compact bone, where many osteolitic foci occur. The medullary cavity also may be affected by the syphilitic process. There is irregular

shape o f the bone with periostitis, se­ questra are not found or are found very rarely. If they are present - they are very small, disc-shaped and located in spongy bone. N o fistulas are present.

Brucellosis is a disease which is transmitted to humans from domestic animals. Human infection results from ingestion o f affected animal tissue or milk products. M any bones may be af­ fected, but most commonly the vertebrae, jaw , and ribs. The lesions with osteolitic foci are found in the spongy bone. The medullary cavity is not affected. No se­ questra and fistulas are found.

Benign cysts may imitate B rodie’s ab­ scess. They m ay be single or rarely sev­ eral in the bone. They are larger in com­ parison to B rodie’s abscess. They may be found in spongy as well as in compact bone, whereas B rodie’s abscess is lo­ cated in spongy bone alone. They may cause deformation o f the m edullary cav­ ity or o f the shaft o f the bone. There is no sclerotic capsule in the X-ray picture, which differs benign cysts from B rodie’s abscess. Fistulas and sequestra have been never found.

Osteoid-osteoma is very sim ilar to B rodie’s abscess as well as to ostitis scleroticans. It is a benign carcinoma, m ost often located in the compact bone o f the tibia or in the femur. This lesion is usually single, small (ca. 1 cm in diam e­ ter), oval-shaped, composed o f osteolitic focus and sclerotic capsule. It is similar to ostitis scleroticans or when only os­ teolitic focus is present, it resembles Brodie’s abscess. The m edullary cavity is not involved, but localized thickening shaft o f the bone may be found.

Two typical lesions for osteomyelitis are shown on fig. 1 and 2.

Ta b le 1. D if fe re n ti a ti o n B e n in g b o n e I c y s ts 0 - a d u lts on e or s o m e v a rio u s m a in ly m e ta p h y s is la rg e bo th d e s tr o y e d lo c al d e fo rm a ti o n d is te n s io n thi n la c k la c k la c k ve ry th in w a ll 1 i O st e o id -o s te o m a 1 0 -a d u lt s on e v a rio u s s m a ll both d e st ru c t. n o rm al lo c a l th ic k e n ra th e r d ic re e t la c k la c k no in fl a m m a ­ to ry p roc es s lit hi c fo cu s J th ic k w al l 1 1 local B ru c e llo s is 0 - s e n ili s m a n y m a n d ib u le v erte b., ribs s p o n g y o s te o li ti c ir re g . foc i no rm a l v a rio u s d is c re e t la c k la c k la c k 1 1 rare 1 la c k S yp h ili s II I 0 - s e n ili s m a n y v a rio u s e x te n s iv e bo th o s te o lit ic fo c i la c k le si o n irre g th ic k . e xt e n siv e o r lo c a l th ic k la ck or sm a ll, re s o rb la c k v a ry in g 1 1 ra re ; 1 lo c a l 1 T u b e rc u lo s is 0 - s e n ili s m or e tha n on e jo in ts v e rte ­ b ra lim it ed s p o n g y d e s tro y e d n o rm al d e s tru c. th ic k e n . ra th e r no rm al sm a ll, sm o o th bad d e fin e d p re s e n t s m a ll 1 1 p re s e n t 1 low B ro d ie s a b s c e ss o CO 1 <o o n e m e ta p h y s is or d ia p h y s is s m a ll s p o n g y c h a n g e d n o rm a l lo c a l th ic k e n . lo c a l la c k la c k g re a t s u rro u n d e d by s c le ro ti c la y e r 1 la c k 1 e x te n s iv e O st iti s G a rré a d o le s c e n c e o n e d ia p h y s is 2/ 3 m e ta ­ p h y s is ■fô c h a n g e d la c k fu si - fo rm ro ug h s m a ll, m a n y w e ll d e fi n e d la c k g re a t s u rro u n d e d by s c le ro ti c la y e r 1 la c k 1 e x te n s iv e O s tit is c h ro n ic a d u lts on e or mo re d ia p h y si s jo in ts e x te n s iv e 15 c h a ng ed na rr o w irr e g u la r u nt ypi cal la te n t o r a c ti v e re m a in s g re a t s u rr ou n de d by s c le ro ti c la y er 1 la c k 1 e x te ns iv e O s ti ti s a c u te 0 -2 0 M : W = 3 :1 P E R IO D S IN W E E K S >6 I 1 (8 0 % ) d ia p h y s is e x te n s iv e n i ch a n g e d j n a rr o w ir re g u la r e x te n s iv e in v o lu c ru m we ll d e fi n e d or la te n t m a n y o r tr a c e s in te n s iv e 1 1 ra re 1 e x te n s iv e 4 -5 I 1 (8 0%) d ia p h y s is e x te n s iv e c o m p a c t ch a n g e d c h a n g e d irr e g u la r e x te n s iv e in v o lu c ru m b ig , irre g. w e ll d e fi n e d on e or m a n y g re a t 1 1 la c k 1 g o od 1-2 I 1 (8 0%) m e ta p h y s is lim it ed s p o n g y ch a n g e d j c h a n g e d d is te n sio n o f m e ta ph . d is c re e t ve ry ra re la c k s m a ll 1 1 la c k 1 d is c re e t F e a tu re s A g e S e x Num ber o f b o n e s L o c a li z a ti o n S iz e C h a n g e d bo ne ti s s u e S tr u c tu re j M e d u ll a ry c a v it y S h a p e of th e b o n e P e ri o s te u m (c h a n g e s ) S e q u e s tr u m F is tu la s R e g e n e ra ti o n C a vi ty of th e a b s c e s s / s e q u e s tr u m 1 G ib b u s 1 C a lc if ic a ti o n [106]

A n attem pt to evaluate the criteria for diagnosing nonspecific inflam m atory diseases ₁₀₇

Fig. 1. T ibia o f a maturus m an, w ith characteristic Fig. 2. Bones o f an adultus m an w ith well m arked traces changes o f ostitis chronica scleroticans Garrei (Czersk, o f healed ostitis (Czersk, district W arsaw )

Warsaw province)

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Streszczenie

Przedstaw iono krótki rys historyczny chorób zapalnych niesw oistych znanych z piśm iennictw a, genezę, postacie, fazy, przebieg, obraz m akroskopow y i radiologiczny oraz różnicow anie z innym i chorobam i pozostaw iającym i na kościach podobny obraz.