Evidence of Hypertrophic Osteoarthropathy in Human Skeletal Remains from Pre-Hispanic Mesoamerica

Methods

The skeletal remains preserved at the physical anthropology department of the National Museum of Anthropology of Mexico City were studied. A total of 1000 specimens originating from diverse pre-Hispanic sites were examined for the following features: 1) adequate state of preservation; 2) bilateral symmetric periostosis of tubular bones that was evident on visual examination; 3) lack of involvement of the axial skeleton and the skull; and 4) remodeling of the distal phalanges. Those specimens that fulfilled such criteria had a radiographic survey including anteroposterior views of the tubular bones. The charts describing the findings during excavation of the burial sites were reviewed. For comparison, skeletons matched for gender, age range, chronology, and burial site were also studied.

One of the specimens that had hypertrophic osteoarthropathy originated from Jaina Island. Jaina is a Mayan necropolis from the Classic period (300 to 900 A.D.) and is famous for its figurines of persons doing typical daily activities or having signs of diverse illnesses [6]. The museum's collection of figurines from Jaina was studied for evidence of digital clubbing or for any of the illnesses known to be associated with hypertrophic osteoarthropathy [1].

Results

Two specimens fulfilled criteria that were consistent with the diagnosis of hypertrophic osteoarthropathy.

Specimen 1

The bones belonged to a young woman found in burial site 23 during the 1974 exploration of Jaina. A conspicuous thickening of the tibias and fibulas with a “tree bark” configuration of their cortex was evident. A lesser degree of periostosis was found in the femora, radii, and ulnae. Only one distal phalanx was preserved; it was truncated. No alteration of the axial skeleton was noted. Radiographs showed thickening of the cortex of tubular bones due to a multilayered type of periosteal apposition (Figure 1, top). No abnormalities of the medullary cavity were noted. The periosteal changes clearly differed from the condition of the skeletons used for comparison.

Specimen 2

The skeleton of a young man was found in burial site 17 of Ticoman in the central part of Mexico. It belonged to the Formative period (2000 B.C. to 100 A.D.). It had a widespread shaggy periostosis involving tibias, fibulas (Figure 1, middle), femora, radii, ulnae, and metatarsal bones. Two distal phalanges of the feet were preserved. Figure 1, bottom, shows the prominent remodeling changes consistent with digital clubbing, clearly different from the skeletons used for comparison. No alteration of the axial skeleton or the skull was noted. Radiographs showed widespread periosteal proliferation of the tubular bones, without involvement of the marrow.

Review of the Jaina figurines did not indicate any example of digital clubbing; however, these figurines had a crude modeling of the hands. A sculpture of a man depicted massive ascites Figure 2, a gross abdominal deformity usually associated with chronic liver disease, which is a well-known cause of hypertrophic osteoarthropathy [1, 7].

Discussion

The widespread, bilateral, symmetric periostosis of these specimens from two persons strongly suggests hypertrophic osteoarthropathy. Other causes of hyperostosis and periostitis can be ruled out [3]. An infectious disease, such as treponematosis, is unlikely on the basis of the diffuse symmetric involvement and the lack of concomitant destructive lesions of the underlying medullary bone. Melorheostosis is asymmetric and also involves the pelvis and the skull. Osteopoikilosis and osteopathia striata are accompanied by disseminated radio-opaque changes. Hypervitaminosis A and fluorosis also affect the axial skeleton. Chronic venous stasis is found in older persons, and the bone changes are limited to the lower extremities [3]. More unequivocal evidence for the diagnosis of hypertrophic osteoarthropathy was found in specimen 2, which also showed the bone remodeling process of the distal phalanges that is typical of clubbing [5]. The only preserved phalanx of specimen 1 had bone dissolution, an alteration also reported in clubbing [5]; it is not possible to ascertain whether this finding was due to postmortem decay.

With the information gathered, we cannot define which underlying illness caused the hypertrophic osteoarthropathy in these two specimens. It has been recently determined that the shape of the periosteal apposition is not dependent on the underlying disease but rather on its duration. Moreover, primary and secondary hypertrophic osteoarthropathy may feature similar periostosis [2]. The advanced changes seen in our two specimens suggest that the persons had had the disease for a long time. Of additional interest was the Jaina figurine depicting ascites. To recognize most of the illnesses associated with hypertrophic osteoarthropathy, modern diagnostic tools are required. However, ascites is a gross abdominal deformity recognizable by visual examination.

We are aware of no previous studies attempting to identify hypertrophic osteoarthropathy in ancient skeletal remains from any part of the world. A report exists of a prominent hyperostosis occurring in a left femur from the Huari civilization of Peru (about 1000 A.D.) [8]; unfortunately, the femur was the only tubular bone recovered so no further inferences could be made.

Our report shows that hypertrophic osteoarthropathy can be recognized in ancient human skeletal remains and suggests that the disease was present in Mesoamerica near the time of its original description by Hippocrates.