April 11, 2012

Differential Diagnosis of an Unusual Lower Leg Pathology in an Imperial Roman

This week, I'm in Portland, Oregon, at the annual meetings of the Paleopathology Association and the American Association of Physical Anthropologists.  So in this post, I'm presenting my PPA poster.  After you read it, feel free to weigh in on the diagnosis using the poll and/or the comments.

(For those of you at the conference, I'm poster number 48 and will be hanging out, answering questions and chatting, from about 3-4pm in the Pavillion Ballroom West. Please stop by to say hi!)

Differential Diagnosis of an Unusual Lower Leg Pathology in an Imperial Roman

Background and Context

A suite of skeletal pathologies was discovered on the remains of an older adult male from Imperial Rome.

Location of Casal Bertone cemetery
Map by K. Killgrove (2012)
The cemetery of Casal Bertone dates to the 2nd-3rd centuries AD and was situated in a periurban area just outside the city walls of Rome. The burial program included a large necropolis with simple inhumations in pits and a cappuccina as well as an above-ground mausoleum with niches for single and multiple burial. Archaeologically associated with the cemetery are a large villa, a network of plumbing, and a 1,000-square-meter building with almost 100 tubs each one meter in diameter, likely a fullery for cleaning cloth (Musco et al. 2008).

Individual F10A (Male, 50+) was buried in a niche in the mausoleum, suggesting higher social status than those in the necropolis and/or membership in a funeral guild. No grave goods were found associated with him, however.  Over 75% of the skeleton was recovered from the burial.

Skeletal Pathologies

Top - L tibia; both fibulae
Middle - L navicular, cuboid, calcaneus
Bottom - L metatarsals, R metatarsals
Photographs by K. Killgrove (2007)
F10A had a number of pathological conditions. He lost most of his teeth antemortem. Significant arthritic changes (porosity, lipping, osteophytes) were noted in his TMJ, shoulder, elbow, hip, and knee joints, as well as in the thoracic and lumbar spine. No rhinomaxillary changes were seen.

The bones of his legs present pathologies inconsistent with solely age-related changes:
  • L tibia – remodeled periostitis of the postero-medial aspect of the shaft; posterior aspect thickened, with spicules of bone; no evidence of cloacae; tibia is heavier than normal; periostitis and osteophyte formation at fibular notch 
  • R/L fibulae – osteophyte formation on lateral aspect of proximal ends; periostitis on shafts; remodelling of distal ends 
  • Tarsals – osteophytes and porosity of L calcaneus, L navicular, and L cuboid (at the MT4/5 articulation)
  • Metatarsals – resorption of proximal end and destruction of head of L MT5; resorption and porosity at proximal end of two other L MTs; distal end of R MT1 significantly resorbed; resorptive foci in distal R MT5; additional resorptive changes in two other MTs, both proximally and distally
Differential Diagnosis

Several possible diseases could have caused lytic lesions to the feet and legs of F10A (Ortner 2003).
  • Leprosy – Erosive changes in the feet, particularly the tapering of the metatarsal heads, are similar to those seen in leprosy. The classic rhinomaxillary changes associated with leprosy were not seen in the skull, although F10A was missing most of his teeth. Leprosy is unlikely but cannot be ruled out. 
  • Sarcoidosis – Granulomatous bone lesions also occur in the phalanges with sarcoidosis, but the metatarsals are less often affected. F10A has only a few phalanges, but the distribution of lesions does not suggest a diagnosis of sarcoidosis. 
  • Rheumatoid Arthritis – Lytic lesions are common in RA, which often affects the skeleton symmetrically, especially the hands. F10A’s foot lesions are symmetrical and erosive, but tarsal and metatarsal joints are not commonly involved in RA. Still, RA or another erosive arthropathy cannot be ruled out (Killgrove 2010). 
  • Mycetoma – Multiple lytic foci characterize the skeletal involvement in this infection. Most often affected are the metatarsal, tarsal, and ankle joints, but the tibia and fibula can also become infected. The widespread, almost bubbly lytic lesions of F10A’s feet strongly suggest mycetoma.

Saltus fullonicus
Relief from the Museo della Civilta
Romana, taken by K. Killgrove (2007)
Mycetoma (or Madura foot) is a longstanding, progressive infection often found in populations that go barefoot and engage in agricultural work. It is endemic to the region between 15°S and 30°N latitude but has also been reported in southern Italy and Greece (Plehn 1928). Migration during the Roman Empire, including importation of slaves, means that pathogens were not necessarily confined to one location. 

The Roman fullery involved large tubs of caustic liquid, in which fullers would stamp cloth while barefoot–a task called the saltus fullonicus–which suggests a possible link between lower leg pathology and occupation. Yet mycetoma is difficult to diagnose in ancient remains. A possible case from 4th century AD Israel (Hershkovitz et al. 1992) was later found to have leprosy (Spigelman & Donoghue 2001). No such testing has been done on F10A to date.

Osteological data, archaeological context, and geographic location suggest a diagnosis of mycetoma for individual F10A, but it is difficult to conclusively rule out leprosy and rheumatoid arthritis.

Time for a poll!

What disease does this skeleton have?

pollcode.com free polls 

This research was supported by a grant from the NSF (BCS-0622452).  Thanks are extended to the Soprintendenza Archeologica di Roma for access to the skeleton.


Hershkovitz, I., Speirs, M., Katznelson, A., & Arensburg, B. (1992). Unusual pathological condition in the lower extremities of a skeleton from ancient Israel American Journal of Physical Anthropology, 88 (1), 23-26 DOI: 10.1002/ajpa.1330880103

Killgrove, K. 2010. Migration and mobility in Imperial Rome. PhD dissertation, UNC Chapel Hill.

Musco, S. et al. 2008. Le complexe archeologique de Casal Bertone. Les Dossiers d'Archeologie 330:32-9.

Ortner, D. 2003. Identification of Pathological Conditions in Human Skeletal Remains. Academic Press.

Plehn, A. 1928. Madurafuss. In Kolle & von Wasserman, eds., Handbuch der Pathogen Mikrooganismen, pp. 113-132.

Spigelman M, & Donoghue HD (2001). Brief communication: unusual pathological condition in the lower extremities of a skeleton from ancient Israel. American Journal of Physical Anthropology, 114 (1), 92-3 PMID: 11150055 ResearchBlogging.org


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