Osteomyelitis variolosa: A probable mediaeval case combined with unilateral sacroiliitis

Two cases of smallpox from 1540 CE circum-contact (early colonial) Northern Coastal Peru

OBJECTIVE

This project seeks to create a differential diagnosis for lesions found on the skeletal remains of two children as a means to explore the presence of viral disease in 16th- century Peru.

MATERIALS

Extremely well-preserved human remains of two children who died between the ages of 1-2 years old, recovered from the circum-contact (∼1540 CE) cemetery in Huanchaco, Peru.

METHODS

Macroscopic and radiographic analysis.

RESULTS

Both individuals present with cortical thickening, symmetrical destructive lesions, metaphyseal expansion, perforations, exposure of the medullary cavity, resorption of metaphyseal ends and necrosis of the long bones, and deposited reactive new bone. These features are consistent with osteomyelitis variolosa and bacterial osteomyelitis.

CONCLUSIONS

Three features of Individuals IG-124 and IG-493 suggest a highly consistent diagnosis of osteomyelitis variolosa: multiple skeletal lesions, the historical context of the area, and the high mortality rate of non-adults in the circum-contact cemetery.

SIGNIFICANCE

Although viral infections are ubiquitous and well documented historically, their etiologies are often difficult to determine in archaeological populations. Orthopoxvirus variola (smallpox) is one of the many viruses whose archaeological impact is still under explored in skeletal remains.

LIMITATIONS

The absence of smallpox in other children from the Huanchaco cemetery creates difficulty in ascertaining true prevalence rates or information on potential outbreaks.

SUGGESTIONS FOR FURTHER RESEARCH

Further research analyzing aDNA from calculus and/or residues using a DIP-GC-MS method might create a better understanding of how smallpox spread through the region.

Guidance for the identification of bony lesions related to smallpox

OBJECTIVE

This research aimed to address the underrepresentation of smallpox (osteomyelitis variolosa) in palaeopathology, providing a synthesis of published literature and presenting guidance for the identification of osteomyelitis variolosa in non-adult and adult skeletal remains.

MATERIALS AND METHODS

Literature regarding smallpox and published reports of individuals with osteomyelitis variolosa were synthesised and critiqued to produce clear diagnostic criteria for the identification of smallpox osteologically.

RESULTS

Associated osteological changes begin in non-adults, where skeletal morphology is rapidly changing. Characteristic lesions associated with non-adult osteomyelitis variolosa include inflammation and destructive remodelling of long-bone joints and metaphyses. Where childhood infection was survived, residual osteomyelitis variolosa lesions should also be visible in adults in the osteoarchaeological record.

CONCLUSIONS

Despite long-term clinical recognition, only limited osteological and archaeological evidence of osteomyelitis variolosa has yet emerged. With improved diagnostic criteria, osteomyelitis variolosa may be more frequently identified.

SIGNIFICANCE

This is the first synthesis of osteomyelitis variolosa encompassing both clinical and palaeopathological literature, providing detailed guidance for the identification of osteomyelitis variolosa in skeletal remains. It will lead to the increased identification of smallpox osteologically.

LIMITATIONS

Differential diagnoses should always be considered. The archaeological longevity of smallpox, and the potential for archaeological VARV to cause clinically recognised smallpox, is currently unknown. Characteristic bone changes in the archaeological record may be other, extinct human-infecting-orthopoxviruses.

SUGGESTIONS FOR FURTHER RESEARCH

Further consideration of the implications of age of smallpox contraction on bony pathology: whether epiphyses are affected differently due to state of fusion. Reassessment of individuals previously identified with smallpox-consistent lesions, but otherwise diagnosed.

Osteomyelitis variolosa, an issue inherited from the past: case report and systematic review

Background

Osteomyelitis variolosa is a self-limiting disease triggered by variola virus that cannot be prevented or repaired. Smallpox has been eradicated for 40 years, and complications that remain after smallpox has been cured have become a remarkable diagnostic challenge for contemporary physicians. In this systematic review, we searched PubMed (MEDLINE), Web of Science, and Google Scholar for cases on complications, diagnosis, and treatment for osteomyelitis variolosa between January 1980 and February 2021.

Results

Ten papers and eleven finished cases, all patients from India, were included for comparison with the present case. In total, 100% of patients presented with bilateral elbow deformities, the ankle was the second most common site of lesion in 50%, and knee lesions accounted for 25% in this study. Flexion contracture, joint instability, secondary arthritis, and fracture are common complications of osteomyelitis variolosa, and most patients receive conservative treatment, while internal fixation has good results for combined fractures.

Conclusions

Although osteomyelitis variolosa is not a direct threat to the safety of patients, severe skeletal deformities can have a significant impact on quality of life. With advances in surgical techniques, clinicians are offering an increasing number of treatment options for patients with osteomyelitis variolosa. However, most importantly, smallpox has basically been removed from the historical arena, and for areas where smallpox was once endemic, physicians need to deepen the understanding of this disease again.

Disease as a Factor in the African Archaeological Record

It is clear from their natural histories that various kinds of diseases would have affected African communities in the distant past. Climatic factors may have reduced the impact of plague-like epidemics across much of the continent. Because of the link between environment and disease vectors, the presence of a disease may have been a stimulus for some group movements in the African past. Evidence of the direct effects of diseases on human populations is generally elusive. Paleopathologists can identify some endemic diseases, but evidence from Africa is sparse. Paleogenomics research can also identify some (not all) endemic and epidemic disease vectors. Recent African aDNA discoveries of inherited resistance to endemic diseases suggest that future paleogenomic research may help us learn much more about the impact of diseases on the African past.

Compressive Ulnar Neuropathy Due to a Ganglion Cyst and Thickened Cubital Tunnel Retinaculum Fifty Years After Osteomyelitis Variolosa of the Elbow: A Case Report

CASE

Ulnar neuropathy developed acutely in a fifty-four-year-old man with an arthritic and deformed elbow as the result of osteomyelitis variolosa, a complication of smallpox, which he contracted at the age of five years. Intraoperatively, a ganglion cyst arising from the joint and a pathologically thick cubital tunnel retinaculum were found to be compressing the nerve. Surgical excision of the ganglion, release of the cubital tunnel retinaculum, and anterior transposition of the ulnar nerve resulted in substantial clinical improvement at one year.

CONCLUSION

The deformity and limited motion that can develop in the elbow over time following osteomyelitis variolosa may predispose the patient to ulnar neuropathy caused by a ganglion cyst arising in the compromised cubital tunnel.