- Email: [email protected]
A kidney’s ingenious path to trimillennar preservation: Renal tuberculosis in an Egyptian mummy?
International Journal of Paleopathology 11 (2015) 7–11
Contents lists available at ScienceDirect
International Journal of Paleopathology journal homepage: www.elsevier.com/locate/ijpp
A kidney’s ingenious path to trimillennar preservation: Renal tuberculosis in an Egyptian mummy? Carlos Prates a,∗ , Carlos Oliveira a , Sandra Sousa a , Salima Ikram b a b
IMI Imagens Médicas Integradas, Av da República 99 B, 1050-190 Lisbon, Portugal The American University in Cairo, 113 Kasr El Aini Street, P.O. Box 2511, Cairo 11511, Egypt
a r t i c l e
i n f o
Article history: Received 16 April 2015 Received in revised form 6 July 2015 Accepted 23 July 2015 Keywords: Tuberculosis Kidney Egypt Mummy Computed tomography X-rays Non destructive Nondestructive evaluation
a b s t r a c t Irtieru is a male mummy enclosed in cartonnage, dating to the Third Intermediate Period in the Egyptian collection of the Museu Nacional de Arqueologia in Lisbon. The computed tomography scans of this mummy showed a small dense bean-shaped structure at the left lumbar region. Its anatomical location, morphologic and structural analysis support a diagnosis of end-stage renal tuberculosis. If this diagnosis is correct, this will be the oldest example of kidney tuberculosis, and the first one recorded in an intentionally mummified ancient Egyptian. © 2015 Elsevier Inc. All rights reserved.
1. Introduction
2. Case presentation
The Lisbon Mummy Project (LMP) is a cooperative effort between the Museu National de Arqueologia (MNA) and Imagens Médicas Integradas (IMI), for the noninvasive X-ray investigation of the mummies of the museum’s Egyptian collection. The seven animals and three humans were studied for the first time, with the added assistance of Siemens Portugal and Fundac¸ão Calouste Gulbenkian. The data acquisition was completed in August 2010, using an overtable digital X-ray computed radiography (CR) system and a multidetector computed tomography (MDCT) 64-slice equipment (both from Siemens AG). The use of specially designed protocols (120 KV, mA s ranges between 450 and 700, 1.5 s tube rotation, pitch of 0.45, and 0.6 mm slices, reconstructed with 50% overlap), achieved high-quality results. The data processing was done at a state of the art Siemens workstation and an Apple iMac OS X and Osirix Imaging Software. This paper addresses an unusual finding in one of the humans, Irtieru (E 135), a cartonnage enclosed male mummy from the Third Intermediate Period, with unknown provenance (Fig. 1) (Araujo, 1993; Figueiredo, 2005).
Irtieru’s name appears in his white cartonnage, decorated in polychrome, typical of the Twenty-Second Dynasty (c. 945–712 BC) (Taylor, 2003; Ikram, 2012), albeit with an atypical closing method along the sides, instead of along the back. It is in good condition, save for the wooden foot panel, which was added to the base of the coffin (Taylor, 2003). This is loose and has broken away, revealing the linen wrappings around the feet. The coffin length is 184 cm with a width of 51.5 cm. Radiological analysis shows that Irtieru was an Egyptian male, tall for his time, with a height of 171 ± 4 cm (Trotter, 1970) and an estimated age of death between 35 and 45 years, based on tooth wear, epiphyseal fusion, bone density and cranial suture closure. The overall X-ray investigation showed that Irtieru had a wellpreserved body, his arms lying alongside his body and with his hands over his pubes. An unusually thick layer of resin covers the skin over all of his body, and the embalming technique was of high quality, enabling a good overall preservation of the tissues (Fig. 2). In both the CR (Fig. 3) and the MDCT (Fig. 4) abdominal analysis, our attention was focused on a strange small structure, posteriorly located in the superior left lumbar region. It is well-defined, kidney bean-shaped, and has a principal longitudinal axis of 3.4 cm, a lateral axis of 2.1 cm and a 1.0 cm thickness. It has a denser peripheral, somewhat lobulated, rim and a slightly less dense matrix in the
∗ Corresponding author at: Rua Braamcamp 40C, 4B, 1250-050 Lisboa, Portugal. E-mail address: [email protected] (C. Prates). http://dx.doi.org/10.1016/j.ijpp.2015.07.002 1879-9817/© 2015 Elsevier Inc. All rights reserved.
8
C. Prates et al. / International Journal of Paleopathology 11 (2015) 7–11
Fig. 2. Irtieru’s torso from an MDCT 3D processed view, after digitally discarding part of the cartonnage and the linen wrappings.
Fig. 3. CR of the left lumbar region, showing a dense bean-shaped pattern, along the axial skeleton.
Fig. 1. Irtieru’s cartonnage coffin.
center. Medially its contour shows a small notch at mid-level. Its CT densities are higher at the rim, between 900 and 1.400 Hounsfield Units (HU), ranging in central areas between 400 and 800 HU. These values match the span of bone density and are consistent with high calcium content. It is anatomically posteriorly located, in the left abdominal cavity, lying deeper to the most posterior layers of the intra-abdominal solidified resin. In the axial view, the resin contours define a paravertebral lenticular airspace whose limits match those of the perirenal anatomical fascia, with its original adipose content lost to decay. Centrally located in this space is the
C. Prates et al. / International Journal of Paleopathology 11 (2015) 7–11
9
reniform structure and its location favor the proposal that this is a highly contracted calcified left kidney (eventually hypoplastic), which was not removed during the embalming process.
3. Discussion
Fig. 4. MDCT coronal oblique view of the left lumbar region, further clarifying the local “reniform” formation.
Fig. 5. MDCT axial view of the left lumbar region depicting the location of this calcified structure inside an empty, air-filled, retroperitoneal space.
above-mentioned bean-shaped structure (Fig. 5). It is also worth mentioning that this fairly well preserved left retroperitoneal area is the opposite of what we see on the right, where there are no anatomical landmarks, just a mixture of resin fragments and other filling materials, and no trace of the right kidney. This peculiar
In ancient Egypt there was limited evidence for awareness of the kidneys. These organs did not seem to be well recognized or described in medical texts, although they might have had some religious role (Park, 1994; Salem and Eknoyan, 1999). They do not appear to have consistently been removed from mummies (Smith and Dawson, 1924). This inference is also supported by Greek texts. Diodorus Siculus (I: 91) states that the kidneys were usually not removed, being unimportant and difficult to identify and extract via the embalming cut. It is possible that they might have been inadvertently removed when the liver was extracted, particularly the right kidney. Embalmers took special care to preserve the heart, and little else required removal from that area. This procedural emphasis would also contribute to the preservation of the left kidney. In a recent review of the descriptions of 150 published mummies, kidneys were mentioned as being present in one-third of the sample (Wade and Nelson, 2013). However, this number includes natural and non-eviscerated mummies as well as eviscerated ones, and thus the number of kidneys present is misleading. Results of early nineteenth century public mummy dissections, reported the presence of kidneys in four cases of eviscerated mummies: Granville Mummy, Leeds Mummy, Dr. Lee Mummy, and Mr. Davidson Mummy (Pettigrew, 1934). In the many radiographic CT evaluations of traditional Egyptian mummies, these authors have found no record of kidneys (Raven and Taconis, 2005; Antoine and Taylor, 2014; Taylor, 2004; Teeter and Johnson, 2009). This paucity of kidneys in mummies could also occur because these organs are particularly difficult to differentiate, either due to their complete decay or due to the embalming process, which alters them to the extent that they become indistinguishable from other retroperitoneal remains or debris. It is also possible that kidneys exist in more specimens but simply have gone unnoticed. However, if a kidney had suffered a major antemortem pathologic change, through retraction, compaction, and calcification, it would survive the mummification process and decay, remaining visible when imaged, as seen in Irtieru. The mummification process could also lead to further shrinkage of the diseased organ. The type of antemortem change seen in Irtieru is typical of the fibrous-sclerotic type of tuberculosis, also designated as autonephrectomy (Fischmann, 1951) or end-stage renal tuberculosis, known colloquially as a putty kidney. The pathologic process is a silent and slow progression of fibrous-sclerotic lesions, shrinking and amorphous dystrophic calcifications that may involve the entire kidney (Kenney, 1990; Gibson et al., 2004). http://gamuts.isradiology.org/data/images/ID0439.htm http://sumerdoc.blogspot.pt/2004/10/small-densely-calcifiednonfunctioning.html The outcome matches what we find in Irtieru. A differential paleopathological diagnosis of such a specific finding in a mummy has limited options, and we could only consider two main pathways: the first linked to the embalming process, the second resulting from other kidney pathologies. The first would mean that this object is a material that was inserted into the abdominal cavity at the time of evisceration and embalming, most probably accidentally rather than deliberately. It could be a fragment of stone, a pebble, or a lump of resin. However, none of these options fits the overall structure and CT densities of the object, which additionally shows a very organic, biological form. Furthermore, the retroperitoneal location in a collapsed but otherwise
10
C. Prates et al. / International Journal of Paleopathology 11 (2015) 7–11
anatomically preserved space, not showing any resin penetration or other debris strongly suggests an undisturbed left perirenal space. The second option involves looking at other diseases that might cause this type of renal calcification. Within those, the main hypotheses are either nephrolithiasis (kidney stones in the collecting system) or nephrocalcinosis (calcifications in the renal parenchyma). In both cases, the calcified nature of the disease as manifested in the organ would be responsible for resisting the natural renal decay. The higher density of renal calculi or stones isalate and calcium phosphate. They have an average density of 650 UH, and the due to their composition of calcium oxhighest densities at 1140 UH (Nakada et al., 2000). Structurally they can be rather homogeneous, or in some cases clearly laminated due to deposition of distinct alternate layers. They usually have smaller sizes than what we see in Irtieru and distinct, modeled shapes. Nephrocalcinosis refers to the deposition of calcium salts in the parenchyma of the kidney. It is divided into two main types based on its location: medullary and cortical forms. It is this later form, with calcium deposition at the peripheral renal cortex, sparing the parenchyma, that best fits our findings. The most frequent causes are chronic glomerulonephritis and acute cortical necrosis (Schepens et al., 2000). However, the cortical density for this would be lower than the one found in Irtieru, and this pathology does not lead to shrinkage—thus, the overall size of the kidney should be preserved. Furthermore, it is a bilateral disease, but as the right kidney is missing – probably due to evisceration – this cannot be checked. Thus, none of the alternative hypothesis for identifying this kidney shaped lump matches our findings, leaving us with the diagnosis of end-stage renal tuberculosis as the most reliable interpretation of the data. The above-mentioned evolution of renal tuberculosis is long established. It is of a protracted nature and more rare than other types of tuberculosis found in the kidneys (Daher et al., 2013). It is known that renal tuberculosis has a long latency period (5–40 years) after the usual initial lung infection. Irtieru must have resisted this, as neither the radiologic search of the thoracic cavity nor that of the skeleton yielded any evidence of tuberculosis sequelae. Additionally, the remaining mummified tissues also showed no compelling results of this disease. It is believed that the hematogenic dissemination of Mycobacterium tuberculosis originates in the lungs, reaching the kidneys first in the cortex and then the preferred medullary region, causing granulomatous lesions. Renal infection can be part of a disseminated disease or a localized genitourinary form. In this latter condition, it can progress immediately and be symptomatic. It can also remains asymptomatic for years, sometimes advancing to a destructive, silent end-stage kidney (Nishant et al., 2013). Contemporary knowledge indicates that by the time this end-stage renal disease is identified, fewer than 5% of the patients have active lung disease, endorsing Irtieru’s survival of an initial lung infection. Tuberculosis is well documented in ancient Egypt from Early Dynastic times. It has been long diagnosed in skeletal remains as well as by biomolecular studies (Zimmerman, 1979; Nerlich and Lösch, 2009; Donoghue et al., 2010; Dabernat and Crubezy, 2010; Sabbahy, 2015). It has also been discussed within the context of medical papyri and two and three-dimensional representations (Ziskind and Halioua, 2007). A secure identification of renal tuberculosis in Irtieru’s body, albeit not formally implicating the kidney, can only be ascertained through tissue sampling and biomolecular methods (Nerlich et al., 1997; Zink et al., 2001; Zink et al., 2003; Elhay, 2013). However, sampling in general, and especially in this case of a museum exhibit quality wrapped mummy enclosed in its cartonnage carapace, raises ethical issues with regard to mummy studies, which is
the focus of some discussion (Kaufmann and Rühli, 2010; Antoine et al., 2014) but beyond the scope of this case study. 4. Conclusion By contemporary radiological standards, Irtieru’s left retroperitoneal dense structure appears to be a case of tuberculous autonephrectomy or “putty kidney.” If so, this would be the oldest recorded case of this disease in the kidney, and to our knowledge, the first radiological depiction of this organ in an intentionally mummified ancient Egyptian. It is also the first noninvasive diagnostic proposal of this disease in a wrapped and cartonnage encased Egyptian mummy. Acknowledgements The authors acknowledge the following for their valuable support of this project: Luis Raposo, former Director of the MNA; Luis Manuel Araújo, Instituto Oriental, Faculdade de Letras de Lisboa; Alvaro Figueiredo, Bioarchaeologist, MNA; Fernando Torrinha and the IMI Administration; Fernando Cardoso and the IMI radiographers; Siemens Portugal and Fundac¸ão Calouste Gulbenkian. References Antoine, D., Taylor, J., 2014. Ancient Lives, New Discoveries. The British Museum Press, London. Antoine, D., Fletcher, A., Hill, J.D., 2014. Regarding the Dead: Human Remains in the British Museum. The British Museum Press, London. Araujo, L.M., 1993. Antiguidades Egípcias, first ed. Museu Nacional de Arqueologia, Lisboa, pp. 306–308. Dabernat, H., Crubezy, E., 2010. Multiple bone tuberculosis in a child from Predynastic Upper Egypt (3200 BC). Int. J. Osteoarchaeol. 20, 719–730. Daher, E.D.F., Da Silva Junior, G.B., Barros, E.J.G., 2013. Renal tuberculosis in the modern era. Am. J. Trop. Med. Hyg. 88 (1), 54–64. Diodorus Siculus I: 91. E. Murphy, transl. 1985. Diodorus on Egypt. McFarland North Carolina. Donoghue, H.D., Lee, O.Y.-C., Minnikin, D.E., Besra, G.S., Taylor, J.H., Spiegelman, M., 2010. Tuberculosis in Dr. Granville’s mummy: a molecular re-examination of the earliest known Egyptian mummy to be scientifically examined and given a medical diagnosis. Proceedings of the Royal Society B, Biological Sciences 277, 51–56. Elhay, R.K.I., 2013. Next generation sequencing of DNA extracted from mummified tissue. In: Dissertation der Mathematisch-Naturwissenschaftlichen Fakultat der Eberhard Karls Universitat Tubingen. Figueiredo, A., 2005. The cartonnage mummy-case of Irtieru (Egyptian Collection, Museu Nacional de Arqueologia): a reassessment, O Arqueólogo Português, Série IV 23, 437–449. Fischmann, J., 1951. Two extreme forms of autonephrectomy in renal tuberculosis. Br. J. Urol. 23 (1), 52–55. Gibson, M., Puckett, M., Shelly, M., 2004. Renal tuberculosis. Radiographics 24 (1), 251–256, http://gamuts.isradiology.org/data/images/ID0439.htm http:// sumerdoc.blogspot.pt/2004/10/small-densely-calcified-nonfunctioning.html Ikram, S., 2012. The Lisbon Mummy Project. KMT: Modern J. Archaeol. 23.4, 55–59. Kaufmann, I., Rühli, F., 2010. Without ‘informed consent’? Ethics and ancient mummy research. J. Med. Ethics 36 (10), 608–613. Kenney, P.J., 1990. Imaging of chronic renal infections. AJR. 155 (3), 485–494. Nakada, S., Hoff, D., Attai, S., Heisey, D., Blankenbaker, D., Pozniak, M., 2000. Determination of stone composition by noncontrast spiral computed tomography in the clinical setting. Urology 55 (6), 816–819. Nerlich, A., Haas, C., Zink, A., Szeimeis, U., Hagedorn, H., 1997. Molecular evidence for tuberculosis in an ancient Egyptian mummy. Lancet 350 (9088), 1404. Nerlich, A.G., Lösch, S., 2009. Paleopathology of human tuberculosis and the potential role of climate. Interdiscip. Perspect. Infect. Dis., Article ID 437. Nishant, K., Sharma, B.K., Philipraj, S.J., Singh, V.K., 2013. A case of putty kidney without pulmonary tuberculosis. BMJ Case Reports, 2–5. Park, R., 1994. Kidneys in Ancient Egypt. Discus. Egyptol. 29, 125–129, with up-dated references April 2010 on Academia.edu. Pettigrew, T.J., 1934. A History of Egyptian Mummies and an Account of the Worship and Embalming of the Sacred Animals by the Egyptians Longman, in Adamant Media Corporation, 2007, London 1934; pp. 57-61. Raven, M.J., Taconis, W.K., 2005. Egyptian Mummies: Radiological Atlas of the Collections in the National Museum of Antiquities at Leiden. Brepols Publishers, Turnhout, Belgium. Sabbahy, L., 2015. An overview of the evidence for tuberculosis from Ancient Egypt. In: Metcalfe, R., Cockitt, J., David, R. (Eds.), The Paleopathology of Egypt and Nubia: A Century in Review. Archaeopress, London (in press).
C. Prates et al. / International Journal of Paleopathology 11 (2015) 7–11 Salem, M., Eknoyan, G., 1999. The kidney in ancient Egyptian medicine: where does it stand. Am. J. Nephrol. 19 (2), 140–147. Schepens, D., Verswijvel, G., Kuypers, D., Vanrenterghem, Y., 2000. Renal cortical nephrocalcinosis. Nephrol. Dial. Transplant 15 (7), 1080–1082. Smith, G.E., Dawson, W.R., 1924. Egyptian Mummiesin. Allen & Unwin (Eds.), London. Taylor, J.H., 2003. Theban coffins from the twenty-second to the twenty-sixth dynasty: dating and synthesis of development. In: Strudwick, N., Taylor, J.H. (Eds.), The Theban Necropolis, Past, Present and Future. British Museum, London, pp. 95–115. Taylor, J.H., 2004. Mummy: The Inside Story. London, The British Museum Press. Teeter, E., Johnson, J.H., 2009. The Life of Meresamun: a Temple Singer in Ancient Egypt. The University of Chicago, Chicago.
11
Trotter, M. 1970. Estimation of stature from intact long limb bones. in: T.D. Stewart (Ed.), Personal Identification in Mass Disasters, 71–83. National Museum of Natural History, Smithsonian Institution, Washington DC. Wade, A.D., Nelson, A.J., 2013. Radiological evaluation of the evisceration tradition in ancient Egyptian mummies. HOMO – J. Comp. Human Biol. 64, 1–28. Zink, A., Has, C.J., Reischl, U., Szeimies, U., Nerlich, A., 2001. Molecular analysis of skeletal tuberculosis in an ancient Egyptian population. J. Med. Microbiol. 50, 355–366. Zink, A., Sola, C., Reischl, U., Grabner, W., Rastogi, N., Wolf, H., Nerlich, A., 2003. Characterization of Mycobacterium tuberculosis Complex DNAs from Egyptian Mummies by Spoligotyping. J. Clin. Microbiol. (January), 359–367. Ziskind, B., Halioua, B.C., 2007. La tuberculose en ancienne Égypte. Rev. Mal. Respir. 24, 1277–1283.
Contents lists available at ScienceDirect
International Journal of Paleopathology journal homepage: www.elsevier.com/locate/ijpp
A kidney’s ingenious path to trimillennar preservation: Renal tuberculosis in an Egyptian mummy? Carlos Prates a,∗ , Carlos Oliveira a , Sandra Sousa a , Salima Ikram b a b
IMI Imagens Médicas Integradas, Av da República 99 B, 1050-190 Lisbon, Portugal The American University in Cairo, 113 Kasr El Aini Street, P.O. Box 2511, Cairo 11511, Egypt
a r t i c l e
i n f o
Article history: Received 16 April 2015 Received in revised form 6 July 2015 Accepted 23 July 2015 Keywords: Tuberculosis Kidney Egypt Mummy Computed tomography X-rays Non destructive Nondestructive evaluation
a b s t r a c t Irtieru is a male mummy enclosed in cartonnage, dating to the Third Intermediate Period in the Egyptian collection of the Museu Nacional de Arqueologia in Lisbon. The computed tomography scans of this mummy showed a small dense bean-shaped structure at the left lumbar region. Its anatomical location, morphologic and structural analysis support a diagnosis of end-stage renal tuberculosis. If this diagnosis is correct, this will be the oldest example of kidney tuberculosis, and the first one recorded in an intentionally mummified ancient Egyptian. © 2015 Elsevier Inc. All rights reserved.
1. Introduction
2. Case presentation
The Lisbon Mummy Project (LMP) is a cooperative effort between the Museu National de Arqueologia (MNA) and Imagens Médicas Integradas (IMI), for the noninvasive X-ray investigation of the mummies of the museum’s Egyptian collection. The seven animals and three humans were studied for the first time, with the added assistance of Siemens Portugal and Fundac¸ão Calouste Gulbenkian. The data acquisition was completed in August 2010, using an overtable digital X-ray computed radiography (CR) system and a multidetector computed tomography (MDCT) 64-slice equipment (both from Siemens AG). The use of specially designed protocols (120 KV, mA s ranges between 450 and 700, 1.5 s tube rotation, pitch of 0.45, and 0.6 mm slices, reconstructed with 50% overlap), achieved high-quality results. The data processing was done at a state of the art Siemens workstation and an Apple iMac OS X and Osirix Imaging Software. This paper addresses an unusual finding in one of the humans, Irtieru (E 135), a cartonnage enclosed male mummy from the Third Intermediate Period, with unknown provenance (Fig. 1) (Araujo, 1993; Figueiredo, 2005).
Irtieru’s name appears in his white cartonnage, decorated in polychrome, typical of the Twenty-Second Dynasty (c. 945–712 BC) (Taylor, 2003; Ikram, 2012), albeit with an atypical closing method along the sides, instead of along the back. It is in good condition, save for the wooden foot panel, which was added to the base of the coffin (Taylor, 2003). This is loose and has broken away, revealing the linen wrappings around the feet. The coffin length is 184 cm with a width of 51.5 cm. Radiological analysis shows that Irtieru was an Egyptian male, tall for his time, with a height of 171 ± 4 cm (Trotter, 1970) and an estimated age of death between 35 and 45 years, based on tooth wear, epiphyseal fusion, bone density and cranial suture closure. The overall X-ray investigation showed that Irtieru had a wellpreserved body, his arms lying alongside his body and with his hands over his pubes. An unusually thick layer of resin covers the skin over all of his body, and the embalming technique was of high quality, enabling a good overall preservation of the tissues (Fig. 2). In both the CR (Fig. 3) and the MDCT (Fig. 4) abdominal analysis, our attention was focused on a strange small structure, posteriorly located in the superior left lumbar region. It is well-defined, kidney bean-shaped, and has a principal longitudinal axis of 3.4 cm, a lateral axis of 2.1 cm and a 1.0 cm thickness. It has a denser peripheral, somewhat lobulated, rim and a slightly less dense matrix in the
∗ Corresponding author at: Rua Braamcamp 40C, 4B, 1250-050 Lisboa, Portugal. E-mail address: [email protected] (C. Prates). http://dx.doi.org/10.1016/j.ijpp.2015.07.002 1879-9817/© 2015 Elsevier Inc. All rights reserved.
8
C. Prates et al. / International Journal of Paleopathology 11 (2015) 7–11
Fig. 2. Irtieru’s torso from an MDCT 3D processed view, after digitally discarding part of the cartonnage and the linen wrappings.
Fig. 3. CR of the left lumbar region, showing a dense bean-shaped pattern, along the axial skeleton.
Fig. 1. Irtieru’s cartonnage coffin.
center. Medially its contour shows a small notch at mid-level. Its CT densities are higher at the rim, between 900 and 1.400 Hounsfield Units (HU), ranging in central areas between 400 and 800 HU. These values match the span of bone density and are consistent with high calcium content. It is anatomically posteriorly located, in the left abdominal cavity, lying deeper to the most posterior layers of the intra-abdominal solidified resin. In the axial view, the resin contours define a paravertebral lenticular airspace whose limits match those of the perirenal anatomical fascia, with its original adipose content lost to decay. Centrally located in this space is the
C. Prates et al. / International Journal of Paleopathology 11 (2015) 7–11
9
reniform structure and its location favor the proposal that this is a highly contracted calcified left kidney (eventually hypoplastic), which was not removed during the embalming process.
3. Discussion
Fig. 4. MDCT coronal oblique view of the left lumbar region, further clarifying the local “reniform” formation.
Fig. 5. MDCT axial view of the left lumbar region depicting the location of this calcified structure inside an empty, air-filled, retroperitoneal space.
above-mentioned bean-shaped structure (Fig. 5). It is also worth mentioning that this fairly well preserved left retroperitoneal area is the opposite of what we see on the right, where there are no anatomical landmarks, just a mixture of resin fragments and other filling materials, and no trace of the right kidney. This peculiar
In ancient Egypt there was limited evidence for awareness of the kidneys. These organs did not seem to be well recognized or described in medical texts, although they might have had some religious role (Park, 1994; Salem and Eknoyan, 1999). They do not appear to have consistently been removed from mummies (Smith and Dawson, 1924). This inference is also supported by Greek texts. Diodorus Siculus (I: 91) states that the kidneys were usually not removed, being unimportant and difficult to identify and extract via the embalming cut. It is possible that they might have been inadvertently removed when the liver was extracted, particularly the right kidney. Embalmers took special care to preserve the heart, and little else required removal from that area. This procedural emphasis would also contribute to the preservation of the left kidney. In a recent review of the descriptions of 150 published mummies, kidneys were mentioned as being present in one-third of the sample (Wade and Nelson, 2013). However, this number includes natural and non-eviscerated mummies as well as eviscerated ones, and thus the number of kidneys present is misleading. Results of early nineteenth century public mummy dissections, reported the presence of kidneys in four cases of eviscerated mummies: Granville Mummy, Leeds Mummy, Dr. Lee Mummy, and Mr. Davidson Mummy (Pettigrew, 1934). In the many radiographic CT evaluations of traditional Egyptian mummies, these authors have found no record of kidneys (Raven and Taconis, 2005; Antoine and Taylor, 2014; Taylor, 2004; Teeter and Johnson, 2009). This paucity of kidneys in mummies could also occur because these organs are particularly difficult to differentiate, either due to their complete decay or due to the embalming process, which alters them to the extent that they become indistinguishable from other retroperitoneal remains or debris. It is also possible that kidneys exist in more specimens but simply have gone unnoticed. However, if a kidney had suffered a major antemortem pathologic change, through retraction, compaction, and calcification, it would survive the mummification process and decay, remaining visible when imaged, as seen in Irtieru. The mummification process could also lead to further shrinkage of the diseased organ. The type of antemortem change seen in Irtieru is typical of the fibrous-sclerotic type of tuberculosis, also designated as autonephrectomy (Fischmann, 1951) or end-stage renal tuberculosis, known colloquially as a putty kidney. The pathologic process is a silent and slow progression of fibrous-sclerotic lesions, shrinking and amorphous dystrophic calcifications that may involve the entire kidney (Kenney, 1990; Gibson et al., 2004). http://gamuts.isradiology.org/data/images/ID0439.htm http://sumerdoc.blogspot.pt/2004/10/small-densely-calcifiednonfunctioning.html The outcome matches what we find in Irtieru. A differential paleopathological diagnosis of such a specific finding in a mummy has limited options, and we could only consider two main pathways: the first linked to the embalming process, the second resulting from other kidney pathologies. The first would mean that this object is a material that was inserted into the abdominal cavity at the time of evisceration and embalming, most probably accidentally rather than deliberately. It could be a fragment of stone, a pebble, or a lump of resin. However, none of these options fits the overall structure and CT densities of the object, which additionally shows a very organic, biological form. Furthermore, the retroperitoneal location in a collapsed but otherwise
10
C. Prates et al. / International Journal of Paleopathology 11 (2015) 7–11
anatomically preserved space, not showing any resin penetration or other debris strongly suggests an undisturbed left perirenal space. The second option involves looking at other diseases that might cause this type of renal calcification. Within those, the main hypotheses are either nephrolithiasis (kidney stones in the collecting system) or nephrocalcinosis (calcifications in the renal parenchyma). In both cases, the calcified nature of the disease as manifested in the organ would be responsible for resisting the natural renal decay. The higher density of renal calculi or stones isalate and calcium phosphate. They have an average density of 650 UH, and the due to their composition of calcium oxhighest densities at 1140 UH (Nakada et al., 2000). Structurally they can be rather homogeneous, or in some cases clearly laminated due to deposition of distinct alternate layers. They usually have smaller sizes than what we see in Irtieru and distinct, modeled shapes. Nephrocalcinosis refers to the deposition of calcium salts in the parenchyma of the kidney. It is divided into two main types based on its location: medullary and cortical forms. It is this later form, with calcium deposition at the peripheral renal cortex, sparing the parenchyma, that best fits our findings. The most frequent causes are chronic glomerulonephritis and acute cortical necrosis (Schepens et al., 2000). However, the cortical density for this would be lower than the one found in Irtieru, and this pathology does not lead to shrinkage—thus, the overall size of the kidney should be preserved. Furthermore, it is a bilateral disease, but as the right kidney is missing – probably due to evisceration – this cannot be checked. Thus, none of the alternative hypothesis for identifying this kidney shaped lump matches our findings, leaving us with the diagnosis of end-stage renal tuberculosis as the most reliable interpretation of the data. The above-mentioned evolution of renal tuberculosis is long established. It is of a protracted nature and more rare than other types of tuberculosis found in the kidneys (Daher et al., 2013). It is known that renal tuberculosis has a long latency period (5–40 years) after the usual initial lung infection. Irtieru must have resisted this, as neither the radiologic search of the thoracic cavity nor that of the skeleton yielded any evidence of tuberculosis sequelae. Additionally, the remaining mummified tissues also showed no compelling results of this disease. It is believed that the hematogenic dissemination of Mycobacterium tuberculosis originates in the lungs, reaching the kidneys first in the cortex and then the preferred medullary region, causing granulomatous lesions. Renal infection can be part of a disseminated disease or a localized genitourinary form. In this latter condition, it can progress immediately and be symptomatic. It can also remains asymptomatic for years, sometimes advancing to a destructive, silent end-stage kidney (Nishant et al., 2013). Contemporary knowledge indicates that by the time this end-stage renal disease is identified, fewer than 5% of the patients have active lung disease, endorsing Irtieru’s survival of an initial lung infection. Tuberculosis is well documented in ancient Egypt from Early Dynastic times. It has been long diagnosed in skeletal remains as well as by biomolecular studies (Zimmerman, 1979; Nerlich and Lösch, 2009; Donoghue et al., 2010; Dabernat and Crubezy, 2010; Sabbahy, 2015). It has also been discussed within the context of medical papyri and two and three-dimensional representations (Ziskind and Halioua, 2007). A secure identification of renal tuberculosis in Irtieru’s body, albeit not formally implicating the kidney, can only be ascertained through tissue sampling and biomolecular methods (Nerlich et al., 1997; Zink et al., 2001; Zink et al., 2003; Elhay, 2013). However, sampling in general, and especially in this case of a museum exhibit quality wrapped mummy enclosed in its cartonnage carapace, raises ethical issues with regard to mummy studies, which is
the focus of some discussion (Kaufmann and Rühli, 2010; Antoine et al., 2014) but beyond the scope of this case study. 4. Conclusion By contemporary radiological standards, Irtieru’s left retroperitoneal dense structure appears to be a case of tuberculous autonephrectomy or “putty kidney.” If so, this would be the oldest recorded case of this disease in the kidney, and to our knowledge, the first radiological depiction of this organ in an intentionally mummified ancient Egyptian. It is also the first noninvasive diagnostic proposal of this disease in a wrapped and cartonnage encased Egyptian mummy. Acknowledgements The authors acknowledge the following for their valuable support of this project: Luis Raposo, former Director of the MNA; Luis Manuel Araújo, Instituto Oriental, Faculdade de Letras de Lisboa; Alvaro Figueiredo, Bioarchaeologist, MNA; Fernando Torrinha and the IMI Administration; Fernando Cardoso and the IMI radiographers; Siemens Portugal and Fundac¸ão Calouste Gulbenkian. References Antoine, D., Taylor, J., 2014. Ancient Lives, New Discoveries. The British Museum Press, London. Antoine, D., Fletcher, A., Hill, J.D., 2014. Regarding the Dead: Human Remains in the British Museum. The British Museum Press, London. Araujo, L.M., 1993. Antiguidades Egípcias, first ed. Museu Nacional de Arqueologia, Lisboa, pp. 306–308. Dabernat, H., Crubezy, E., 2010. Multiple bone tuberculosis in a child from Predynastic Upper Egypt (3200 BC). Int. J. Osteoarchaeol. 20, 719–730. Daher, E.D.F., Da Silva Junior, G.B., Barros, E.J.G., 2013. Renal tuberculosis in the modern era. Am. J. Trop. Med. Hyg. 88 (1), 54–64. Diodorus Siculus I: 91. E. Murphy, transl. 1985. Diodorus on Egypt. McFarland North Carolina. Donoghue, H.D., Lee, O.Y.-C., Minnikin, D.E., Besra, G.S., Taylor, J.H., Spiegelman, M., 2010. Tuberculosis in Dr. Granville’s mummy: a molecular re-examination of the earliest known Egyptian mummy to be scientifically examined and given a medical diagnosis. Proceedings of the Royal Society B, Biological Sciences 277, 51–56. Elhay, R.K.I., 2013. Next generation sequencing of DNA extracted from mummified tissue. In: Dissertation der Mathematisch-Naturwissenschaftlichen Fakultat der Eberhard Karls Universitat Tubingen. Figueiredo, A., 2005. The cartonnage mummy-case of Irtieru (Egyptian Collection, Museu Nacional de Arqueologia): a reassessment, O Arqueólogo Português, Série IV 23, 437–449. Fischmann, J., 1951. Two extreme forms of autonephrectomy in renal tuberculosis. Br. J. Urol. 23 (1), 52–55. Gibson, M., Puckett, M., Shelly, M., 2004. Renal tuberculosis. Radiographics 24 (1), 251–256, http://gamuts.isradiology.org/data/images/ID0439.htm http:// sumerdoc.blogspot.pt/2004/10/small-densely-calcified-nonfunctioning.html Ikram, S., 2012. The Lisbon Mummy Project. KMT: Modern J. Archaeol. 23.4, 55–59. Kaufmann, I., Rühli, F., 2010. Without ‘informed consent’? Ethics and ancient mummy research. J. Med. Ethics 36 (10), 608–613. Kenney, P.J., 1990. Imaging of chronic renal infections. AJR. 155 (3), 485–494. Nakada, S., Hoff, D., Attai, S., Heisey, D., Blankenbaker, D., Pozniak, M., 2000. Determination of stone composition by noncontrast spiral computed tomography in the clinical setting. Urology 55 (6), 816–819. Nerlich, A., Haas, C., Zink, A., Szeimeis, U., Hagedorn, H., 1997. Molecular evidence for tuberculosis in an ancient Egyptian mummy. Lancet 350 (9088), 1404. Nerlich, A.G., Lösch, S., 2009. Paleopathology of human tuberculosis and the potential role of climate. Interdiscip. Perspect. Infect. Dis., Article ID 437. Nishant, K., Sharma, B.K., Philipraj, S.J., Singh, V.K., 2013. A case of putty kidney without pulmonary tuberculosis. BMJ Case Reports, 2–5. Park, R., 1994. Kidneys in Ancient Egypt. Discus. Egyptol. 29, 125–129, with up-dated references April 2010 on Academia.edu. Pettigrew, T.J., 1934. A History of Egyptian Mummies and an Account of the Worship and Embalming of the Sacred Animals by the Egyptians Longman, in Adamant Media Corporation, 2007, London 1934; pp. 57-61. Raven, M.J., Taconis, W.K., 2005. Egyptian Mummies: Radiological Atlas of the Collections in the National Museum of Antiquities at Leiden. Brepols Publishers, Turnhout, Belgium. Sabbahy, L., 2015. An overview of the evidence for tuberculosis from Ancient Egypt. In: Metcalfe, R., Cockitt, J., David, R. (Eds.), The Paleopathology of Egypt and Nubia: A Century in Review. Archaeopress, London (in press).
C. Prates et al. / International Journal of Paleopathology 11 (2015) 7–11 Salem, M., Eknoyan, G., 1999. The kidney in ancient Egyptian medicine: where does it stand. Am. J. Nephrol. 19 (2), 140–147. Schepens, D., Verswijvel, G., Kuypers, D., Vanrenterghem, Y., 2000. Renal cortical nephrocalcinosis. Nephrol. Dial. Transplant 15 (7), 1080–1082. Smith, G.E., Dawson, W.R., 1924. Egyptian Mummiesin. Allen & Unwin (Eds.), London. Taylor, J.H., 2003. Theban coffins from the twenty-second to the twenty-sixth dynasty: dating and synthesis of development. In: Strudwick, N., Taylor, J.H. (Eds.), The Theban Necropolis, Past, Present and Future. British Museum, London, pp. 95–115. Taylor, J.H., 2004. Mummy: The Inside Story. London, The British Museum Press. Teeter, E., Johnson, J.H., 2009. The Life of Meresamun: a Temple Singer in Ancient Egypt. The University of Chicago, Chicago.
11
Trotter, M. 1970. Estimation of stature from intact long limb bones. in: T.D. Stewart (Ed.), Personal Identification in Mass Disasters, 71–83. National Museum of Natural History, Smithsonian Institution, Washington DC. Wade, A.D., Nelson, A.J., 2013. Radiological evaluation of the evisceration tradition in ancient Egyptian mummies. HOMO – J. Comp. Human Biol. 64, 1–28. Zink, A., Has, C.J., Reischl, U., Szeimies, U., Nerlich, A., 2001. Molecular analysis of skeletal tuberculosis in an ancient Egyptian population. J. Med. Microbiol. 50, 355–366. Zink, A., Sola, C., Reischl, U., Grabner, W., Rastogi, N., Wolf, H., Nerlich, A., 2003. Characterization of Mycobacterium tuberculosis Complex DNAs from Egyptian Mummies by Spoligotyping. J. Clin. Microbiol. (January), 359–367. Ziskind, B., Halioua, B.C., 2007. La tuberculose en ancienne Égypte. Rev. Mal. Respir. 24, 1277–1283.