How rare is rare? A literature survey of the last 45 years of paleopathological research on ancient rare diseases

Testing the Digital Atlas of Ancient Rare Diseases (DAARD) using a new case of Legg-Calvé-Perthes disease from Early Byzantine (500-700 CE) Olympia, Greece

OBJECTIVE

The first case of Legg-Calvé-Perthes disease (LCPD) in Greece is presented. LCPD, a rare disease, is discussed using the Digital Atlas of Ancient Rare Diseases (DAARD), which tests the benefits of the database for diagnosing and contextualizing the new case with 42 archaeological cases of LCPD recorded in the DAARD.

MATERIALS

A 30-40-year-old, probable male individual was found at the archaeological site of Olympia, Greece, dating to 500-700 CE.

METHODS

Biological sex, age-at-death and pathological changes were investigated using macroscopic and osteometric methods. The DAARD provided the typical characteristics of LCPD.

RESULTS

Pathological changes in both hip joints without any other related changes in the skeleton corresponded to the skeletal features of LCPD. The DAARD produced 42 cases of LCPD, most of which from Europe, with a preference for male sex and unilateral involvement of the hip joint.

CONCLUSIONS

The DAARD aids in diagnosing rare diseases and interpreting new cases in the context of already known studies.

SIGNIFICANCE

This study shows that the DAARD has the potential to help researchers move beyond the level of single case studies and create a broader picture of the history of rare diseases.

LIMITATIONS

This paper focuses on the benefits of the DAARD in relation to LCPD but not all rare diseases have been included in the database.

SUGGESTIONS FOR FURTHER RESEARCH

More rare diseases from archaeological contexts should be added to the DAARD to create a base for the interpretation of their history and expand our understanding of rare diseases in the past.

The Digital Atlas of Ancient Rare Diseases (DAARD) and its relevance for current research

BACKGROUND

The history of rare diseases is largely unknown. Research on this topic has focused on individual cases of prominent (historical) individuals and artistic (e.g., iconographic) representations. Medical collections include large numbers of specimens that exhibit signs of rare diseases, but most of them date to relatively recent periods. However, cases of rare diseases detected in mummies and skeletal remains derived from archaeological excavations have also been recorded. Nevertheless, this direct evidence from historical and archaeological contexts is mainly absent from academic discourse and generally not consulted in medical research on rare diseases.

RESULTS

This desideratum is addressed by the Digital Atlas of Ancient Rare Diseases (DAARD: https://daard.dainst.org ), which is an open access/open data database and web-based mapping tool that collects evidence of different rare diseases found in skeletons and mummies globally and throughout all historic and prehistoric time periods. This easily searchable database allows queries by diagnosis, the preservation level of human remains, research methodology, place of curation and publications. In this manuscript, the design and functionality of the DAARD are illustrated using examples of achondroplasia and other types of stunted growth.

CONCLUSIONS

As an open, collaborative repository for collecting, mapping and querying well-structured medical data on individuals from ancient times, the DAARD opens new avenues of research. Over time, the number of rare diseases will increase through the addition of new cases from varied backgrounds such as museum collections and archaeological excavations. Depending on the research question, phenotypic or genetic information can be retrieved, as well as information on the general occurrence of a rare disease in selected space-time intervals. Furthermore, for individuals diagnosed with a rare disease, this approach can help them to build identity and reveal an aspect of their condition they might not have been aware of. Thus, the DAARD contributes to the understanding of rare diseases from a long-term perspective and adds to the latest medical research.

Assessing autosomal aneuploidy in ancient genomes

Using genetic methods, aneuploidies can be detected in ancient human remains, which is so far the only way to reliably prove their existence in the past. As highlighted in recent studies by Rohrlach et al. and by Anastasiadou et al., this initial step enables a deeper exploration of the history of rare diseases, encompassing the social and historical contexts of the afflicted individuals.

Cases of trisomy 21 and trisomy 18 among historic and prehistoric individuals discovered from ancient DNA

Aneuploidies, and in particular, trisomies represent the most common genetic aberrations observed in human genetics today. To explore the presence of trisomies in historic and prehistoric populations we screen nearly 10,000 ancient human individuals for the presence of three copies of any of the target autosomes. We find clear genetic evidence for six cases of trisomy 21 (Down syndrome) and one case of trisomy 18 (Edwards syndrome), and all cases are present in infant or perinatal burials. We perform comparative osteological examinations of the skeletal remains and find overlapping skeletal markers, many of which are consistent with these syndromes. Interestingly, three cases of trisomy 21, and the case of trisomy 18 were detected in two contemporaneous sites in early Iron Age Spain (800-400 BCE), potentially suggesting a higher frequency of burials of trisomy carriers in those societies. Notably, the care with which the burials were conducted, and the items found with these individuals indicate that ancient societies likely acknowledged these individuals with trisomy 18 and 21 as members of their communities, from the perspective of burial practice.

Survival in Mudejar Spain in the Middle Ages (thirteenth-fourteenth centuries): Ancient Rare Diseases-an uncommon diagnosis in archaeological human remains

PURPOSE

The finding of severe skeletal alterations in ancient remains could give us useful information not only about the pathologies of the individual per se, as it could infer the state of health of a population.

METHODS

From the findings of the Mudéjar Cemetery of Uceda (Guadalajara, Central Spain) where a total of 116 burials with almost complete skeleton were recovered, an interesting individual is presented (palaeopathological perspective). The individual 114UC corresponds to a male of 20-25 years old and its age goes back to the thirteenth-fourteenth centuries.

RESULTS

The first inspection showed the presence of serious alterations especially in the lumbar spine and pelvic girdle. Seven vertebrae (from T11 to L5) showed an unusual posterior fusion only in the postzygapophyseal joints. The pelvis, after being accurately assembled and congruence verified by X-ray and CT scan, showed a noticeable asymmetry of both iliac wings together with a coxa magna protusa (Otto's pelvis), severe anteversion of both cup hips and osteochondritis of the right femoral head. The posterior-slope of both tibias reached about 10°.

CONCLUSIONS

The differential diagnoses lead us to think of Arthrogryposis Multiplex Congenita as the most probable diagnosis. We analyzed the same biomechanical aspects after taking into account some patterns that give us information about a possible mobility in the first stage of life. We discuss the very few other cases described both from artworks and in the palaeopathological record. To our knowledge, this case could be the oldest published case of AMC worldwide.

The role of case studies in recent paleopathological literature: An argument for continuing relevance

OBJECTIVE

To critically examine the role that case studies play in recent paleopathological literature, by evaluating their frequency of publication, academic impact, and the public engagement they generate.

MATERIALS

Articles published in International Journal of Paleopathology between 2011 and 2018 (N = 377).

METHODS

Articles were coded as case studies, population studies, methodological studies, or reviews. Case studies were coded as cultural practices, differential diagnosis, historical, or methodological/theoretical. We utilized bibliometric analysis to assess academic impact and altmetric analysis to evaluate public engagement.

RESULTS

Case studies continue to be the most frequently published, but least frequently cited, article type. There are no significant differences in public engagement data between article types. Methodological/theoretical case studies have the most academic impact. Differential diagnosis case studies have the least academic impact and generate the least public engagement.

CONCLUSIONS

The case study genre includes a variety of approaches, some of which hold significant potential for contributing to the discipline of paleopathology and beyond.

SIGNIFICANCE

This study updates Mays' (2012b) citation analysis, pioneers the use of altmetric data to analyze public engagement with paleopathological publications, and identifies less productive approaches and areas of heightened relevance in the case study genre.

LIMITATIONS

Publications in only one journal were analyzed. Only one source was utilized for citation data (Google Scholar) and one source for altmetric data (PlumX).

SUGGESTIONS FOR FUTURE RESEARCH

Expanding the granular analysis of case studies piloted here to additional journals and/or citation indexes to enlarge the sample size and provide keener insights.

Spotted bones in an osteopoikilosis-related disease (Buschke Ollendorff Syndrome): Identifying this rare condition from the lab to the field

OBJECTIVE

To improve the differential diagnosis of osteopoikilosis in past populations using a clinical case as an example of this rare condition.

MATERIALS

A patient referred to our Genetic Service with suspected Buschke Ollendorff Syndrome after finding a connective nevus.

METHODS

Radiological images from different body regions were accompanied by a genetic study using next-generation sequencing.

RESULTS

Small circular-to-ellipsoid sclerotic lesions were found in the epiphysis and metaphysis of long bones, as well as in the pelvis. These lesions were bilaterally distributed and with well-defined margins, compatible with the characteristics of Buschke Ollendorff Syndrome, bone manifestation osteopoikilosis. A heterozygous mutation on LEMD3 (NM_001167614:c.1918 + 1G > C) was identified by next-generation sequencing. Based on this confirmed case, we have discussed the most probable causes of similar bone lesions found in the archaeological record.

CONCLUSION

It has been demonstrated how a current case of a rare disease can provide useful tools to improve the differential diagnosis of this disease in ancient skeletons.

SIGNIFICANCE

This work underlines the great need for multidisciplinary platforms that integrates clinical research into paleopathology in order to successfully address the study of rare diseases from the past.

LIMITATIONS

Since OPK is only detected by X-rays, suspected cases of this bone lesion will only be identified when radiographs are taken for other purposes.

SUGGESTIONS FOR FURTHER RESEARCH

Retrospective and large-scale studies of radiographs from other research in past populations.

Madelung-type deformity in a female individual from the Merovingian Period in Central Germany: A rare finding or a rare disease?

OBJECTIVE

This paper presents a probable case of Madelung-type deformity of the right lower arm in an individual from the Merovingian burial ground (7th and 8 th century CE) from Gotha-Boilstädt (Germany).

MATERIALS

A female individual with an age-at-death of 40-50 years was investigated.

METHODS

Macroscopic, osteometric and radiographic analyses were performed using standard methods.

RESULTS

The individual exhibits an unusual case of dysmelia of the right upper extremity. The shoulder and upper arm displayed gracile muscle attachment marks and less robustness compared to the left side. The ulna was shortened and distorted and the radius was severely deformed.

CONCLUSIONS

The results indicate that the individual might have been affected by a unilateral Madelung-type deformity. The severity of this case is greater than that reported in the clinical literature.

SIGNIFICANCE

This study places an ancient rare disease into archaeological and paleopathological contexts, allowing for the evaluation of the term "ancient rare disease." It also highlights the importance of reporting rigorously diagnosed cases in order to raise our level of awareness of the incidence and course of this rare condition in the past.

LIMITATIONS

The diagnosis cannot be stated with certainty, and only a handful of possible diagnoses can be offered. Congenital and acquired etiologies must be considered, especially when compared with clinical cases where severity of conditions may be modified by medical intervention.

SUGGESTIONS FOR FURTHER RESEARCH

Genetic analysis might be helpful in the determination of the etiology of the observed Madelung-type deformity.

A possible case of Langerhans-cell histiocytosis? Differential diagnosis in a rare case from the Late Antiquity Bavaria (Germany)

OBJECTIVE

To outline the importance of accurate diagnosis in ancient rare diseases by presenting a possible case of Langerhans-cell histiocytosis.

MATERIALS

Skeletal elements from a well-preserved skeleton of a nine to eleven-year-old, probably female child who lived around 300-400 AD Late Roman Neuburg / Donau (Germany).

METHODS

Macroscopic, radiologic, light and scanning-electron microscopic and physical techniques were used.

RESULTS

Resorptive defects, particularly in the cranium, but also in the left hip bone and the right femur, suggest the presence of Langerhans-cell histiocytosis macroscopically and radiologically. The presence of morphological changes along the edges of osteolytic lesions and in the diploic spaces appear to be post-mortem artifacts based on microscopic investigation and elemental analysis.

CONCLUSIONS

Re-evaluation of morphological structures and elemental constitution of lesions is critical to differential diagnosis. In the case examined here, the identification of post-mortem structures rules out the former diagnosis of Langerhans-cell histiocytosis. Re-evaluation of cases of rare diseases require applying a range of methods during the analysis, as every single case makes a difference in the numbers of this very small group of diseases.

SIGNIFICANCE

This study emphasizes the importance of utilizing different analytical techniques to avoid false diagnoses.

LIMITATIONS

Not all morphological features can reliably be diagnosed using microscopic and elemental techniques.

SUGGESTIONS FOR FURTHER RESEARCH

In the case of rare diseases that are difficult to diagnose, the widest possible spectrum of techniques should always be used, particularly microscopy.

A critical review of the anthropological and paleopathological literature on osteopetrosis as an ancient rare disease (ARD)

OBJECTIVE

A reappraisal of the available evidence of osteopetrosis in the archaeological record as first step in promoting new approaches to rare diseases in paleopathology.

MATERIALS AND METHODS

Three different approaches are combined: a survey of the last 50 years of bioarchaeological publications; an online search addressing six of the more widely used search engines; macroscopic and radiographic analyses of the human remains from the Neolithic site of Palata 2 (Italy).

RESULTS

The combined results of the literature survey and the online search identified six cases of osteopetrosis. The majority of search hits place this disease into differential diagnoses. The investigation of the remains from Palata 2, one of the six cases in literature, indicates a non-specific sclerosis of the cranial vault.

CONCLUSIONS

Of the six cases of osteopetrosis, only two, one of the autosomal-recessive type (ARO) and one of the autosomal-dominant type (ADO), are supported by direct osteoarchaeological evidence. Therefore, inaccurate differential diagnoses generate an inflated number of cases in the paleopathological record.

SIGNIFICANCE

This reappraisal calls for a more informed and evidence-based approach to osteopetrosis and, more generally, to rare diseases in paleopathology.

LIMITATIONS

Lack of specific publications on osteopetrosis; more case studies may be present in "gray literature".

SUGGESTIONS FOR FURTHER RESEARCH

Cases of osteopetrosis from archaeological and historical collections as well as medical literature are needed to increase knowledge about this rare disease. More precise differential diagnoses are required, particularly when dealing with rare diseases.