Anatomy of a serial killer: Differential diagnosis of tuberculosis based on rib lesions of adult individuals from the Coimbra identified skeletal collection, Portugal

Abstract

The role of new bone formation on visceral surfaces of ribs in the diagnosis of tuberculosis (TB) in past human populations has been explored by many researchers, using both skeletal remains with known causes of death and archaeological samples. This study focuses, firstly, on adult skeletons from the Coimbra Identified Skeletal Collection in Portugal and investigates the skeletal manifestations of individuals known to have died from TB; secondly, this study focuses on the role of rib lesions in the diagnostic criteria for TB. One hundred and fifty-seven males and 106 females aged between 22-87 years were examined; causes of death were assigned as pulmonary TB, extrapulmonary TB, and pulmonary non-TB; a control group, extrapulmonary non-TB, was selected from the remaining individuals. Of individuals with rib lesions, 85.7% (69/81) had pulmonary or extrapulmonary TB as an assigned cause of death, while 17.8% (16/90) of individuals with rib lesions had a non-TB cause of death. Rib lesions were significantly more common in individuals who had died from TB, although the lesions cannot be considered pathognomonic for TB. In individuals dying from pulmonary TB, ribs in the central part of the rib cage were most affected, at their vertebral ends. The lower part of the rib cage may be a marker for peritoneal TB, and ''corallike'' new bone formation on ribs may be an indicator of neoplastic disease. Further work on rib involvement in TB in clinical contexts, and the study of further documented skeletal collections, are recommended. Am J

Calcified structures associated with human skeletal remains: Possible atherosclerosis affecting the population buried at Amara West, Sudan (1300–800BC)

“…The cause of new bone formation on the visceral surfaces of ribs has been explored by many authors, with varying diagnoses being suggested. Conclusions indicate that a range of chronic pulmonary diseases could be represented, including tuberculosis (TB), lung cancer, chronic bronchitis and pneumonia (Lambert, 2002;Roberts, 1999;Roberts et al, 1994;Santos and Roberts, 2006). The bone changes are not pathognomonic for any one condition.…”

Beyond the cause of death: other pathological conditions in a female individual from the Coimbra Identified Skeletal Collection (Portugal)

“…This condition can be traced by the macroscopic observations of the rib cage that shows new bone formation on the visceral surface. This type of bone alteration is commonly associated with pulmonary tuberculosis (Kelley and Micozzi, 1984; 1994; Santos and Roberts, 2001;Matos and Santos, 2006), and will not be explored in this work since it has already been discussed in other publications (Santos, 2000;Santos and Roberts, 2006).…”

The changing face of tuberculosis: Trends in tuberculosis-associated skeletal changes

“…Although not pathognomonic of TB, a clear correlation has been shown between rib lesions and TB, with reported incidences of up to 91%. 34 It was found that 8.8% of individuals with pulmonary TB in the Hamman-Todd Collection had lesions on the visceral side of their ribs, 35 but this figure was much higher at 61.6% in Terry Collection individuals. 36 Other reported figures for rib involvement are 85.2% (Coimbra), 34 28.0% (Ute Mountain sample), 37 2.0% (Aymyrlyg Cemetery complex) 38 and 1.0% (Wharram Percy village in northeast England).…”

“…34 It was found that 8.8% of individuals with pulmonary TB in the Hamman-Todd Collection had lesions on the visceral side of their ribs, 35 but this figure was much higher at 61.6% in Terry Collection individuals. 36 Other reported figures for rib involvement are 85.2% (Coimbra), 34 28.0% (Ute Mountain sample), 37 2.0% (Aymyrlyg Cemetery complex) 38 and 1.0% (Wharram Percy village in northeast England). 33 Conversely, of individuals with rib lesions in the Coimbra Collection in Portugal, 85.7% had pulmonary or non-pulmonary TB as cause of death, whereas 17.8% of individuals with lesions had other causes of death.…”

“…Recently several studies have been conducted to assess rib involvement, 1,[29][30][31][32][33][34] showing much higher frequencies of skeletal involvement. Although not pathognomonic of TB, a clear correlation has been shown between rib lesions and TB, with reported incidences of up to 91%.…”