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Vertebral infection in a male individual buried in the monastic cemetery (Cemetery 2) at Ghazali (ca. 670–1270 CE), northern Sudan
International Journal of Paleopathology 24 (2019) 34–40
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International Journal of Paleopathology journal homepage: www.elsevier.com/locate/ijpp
Vertebral infection in a male individual buried in the monastic cemetery (Cemetery 2) at Ghazali (ca. 670–1270 CE), northern Sudan
T
Robert J. Starka, , Joanna Ciesielskab ⁎
a b
Department of Anthropology, McMaster University, Chester New Hall Rm. 524, 1280 Main Street West, Hamilton, Ontario, L8S 4L9, Canada Institute of Archaeology, University of Warsaw, Krakowskie Przedmiescie 26/28, 00-927 Warsaw, Poland
ARTICLE INFO
ABSTRACT
Keywords: Spinal pathology Tuberculosis Christian Nubia Makuria Bayuda desert Wadi Abu Dom
Purpose/research question: This article examines pronounced osteoblastic-osteolytic vertebral lesions in a middle adult male (Ghz-2-033), from the Christian Nubian monastic settlement of Ghazali (ca. 670–1270 CE), Sudan, to explore their potential etiology. Methods: Morphological assessments of sex and age were undertaken in conjunction with macroscopic and radiological methods of assessment for the skeletal lesions documented. Results: Macroscopic assessment of Ghz-2-033 identified mixed osteoblastic-osteolytic lesions in L2–L3 with minor foci in T12–L1, while radiological assessment identified no further lesions. This paleopathological analysis considers tuberculosis, brucellosis, pyogenic intervertebral disc infection, neoplastic conditions, and mycotic infections as potential etiologies. Conclusions: Tuberculosis is the most probable etiology for the lesions observed. This assessment is based on the morphology of the lesions in conjunction with the known confined living quarters at Ghazali and the presence of tuberculosis vectors (i.e. cattle) in the region. Contributions to knowledge/originality/value: This brief communication contributes original data documenting the presence of tubercular lesions in a monk buried at the Christian Nubian monastery of Ghazali. On a broader level this study contributes to regional and temporal paleopathological dialogues regarding interactions with pathogens in Christian Nubian monastic contexts. Limitations for this study: The potentiality of co-infection with other pathogens (e.g. brucellosis, Staphylococcus) with similar macromorphological traits in skeletal remains cannot be entirely discounted. Suggestions for further research: The use of biomolecular analyses may help to clarify the potential presence of tuberculosis in individual Ghz-2-033.
1. Introduction The monastic settlement of Ghazali (ca. 670–1270 CE) is located at the entrance to Wadi Abu Dom (18° 26′ N, 31° 56′ E) in Sudan (Fig. 1) (Jeuté, 1994). Ghazali was initially excavated in the 1950s (Shinnie and Chittick, 1961) and subsequently, beginning in 2012, by the Polish Centre of Mediterranean Archaeology (Obłuski, 2014; Obłuski et al., 2015). Part of the medieval Kingdom of Makuria (ca. 6th–14th c. CE), an unknown number of lay individuals and 18–36 monks resided at Ghazali at any one time, many of whom were buried there (Scanlon, 1972; Anderson, 1996, 1999; Godlewski, 2014; Obłuski and Korzeniowska, 2018). In 2015 an individual (Ghz-2-033) exhibiting mixed osteolytic-osteoblastic vertebral lesions was identified within the monastic cemetery (Cemetery 2). This brief communication contributes
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original paleopathological data that may be useful towards developing broader characterizations of encounters with pathogens in Nubian monastic communities. 2. Materials and methods 2.1. Burial of Ghz-2-033 Ghz-2-033 was interred south of the Ghazali monastery in Cemetery 2 (Fig. 2). Of the 66 individuals excavated from Cemetery 2, 64 are male and two indeterminate, providing strong evidence that Cemetery 2 was the monastic burial ground (Ciesielska et al., 2018). A low-lying mudbrick pavement (type FF02c1 of Borcowski and Welsby, 2012) marked the grave and a peaked mudbrick vault covered the supine body
Corresponding author. E-mail addresses: [email protected] (R.J. Stark), [email protected] (J. Ciesielska).
https://doi.org/10.1016/j.ijpp.2018.08.011 Received 31 October 2017; Received in revised form 20 August 2018; Accepted 31 August 2018 1879-9817/ © 2018 Published by Elsevier Inc.
International Journal of Paleopathology 24 (2019) 34–40
R.J. Stark, J. Ciesielska
Fig. 1. Location of Ghazali in the Wadi Abu Dom of Sudan. Inset image shows the area depicted (in rectangle) in relation to the surrounding region (Map generated from ESRI Imagery by Robert Stark on 10/11/2017 using Scholars GeoPortal, http://geo1.scholarsportal.info).
Fig. 2. Line drawing (left) and kite photograph (right) of the monastic complex, lay settlement area, and associated cemeteries at Ghazali. The location of the burial of individual Ghz-2-033 in Cemetery 2 is shown in red. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
(Fig. 3). With the head to the north-west and having no grave goods, the burial of Ghz-2-033 is typical of Christian Nubia (Adams, 1998; Baker, 2014).
examination. Ancillary plain film radiography to examine for lesions within the vertebrae was undertaken using a Toshiba Rotanode Model E7329 at Karima-Hospital, Sudan.
2.2. Methods of observation
2.3. Preservation, sexing, ageing, and curation of Ghz-2-033
Skeletal lesions were primarily assessed using macromorphological
Aside from skeletal remains (Fig. 4), Ghz-2-033 had fragments of 35
International Journal of Paleopathology 24 (2019) 34–40
R.J. Stark, J. Ciesielska
Fig. 3. The burial of Ghz-2-033, a.) mudbrick pavement indicating the location of the grave shaft; b.) peaked mudbrick vault covering individual Ghz-2-033; c.) vault entrance, located at the western end, showing vault construction and placement of individual Ghz-2-033; d.) the skeletal remains of individual Ghz-2-033, interred in a burial shroud and placed in a typical Christian Nubian burial position: supine with head to the north-west, legs side-by-side, left arm at the side and right arm over the pelvis.
hair, skin, burial shroud, and rope belt with tassel (Fig. 5) preserved. Sex was estimated based on morphology of the greater sciatic notch, ischiopubic ramus, ventral arc, subpubic concavity, and cranial morphology; age was estimated using pubic symphysis and auricular surface morphology, and suture closure (Buikstra and Ubelaker, 1994; Nikita, 2017). Individual Ghz-2-033 is curated in the Gebel Barkal Museum, Sudan.
Tuberculosis, caused by Mycobacterium bacilli, is spread through droplet transmission, close living quarters, consumption of contaminated foodstuffs (e.g. milk/meat), and proximity to tuberculosis vectors (e.g. cattle) (Roberts and Buikstra, 2003, 2007). Hematogenously disseminated tuberculosis affects the skeleton in 15%–30% of extrapulmonary cases, the spine being affected in 25%–50% of skeletal cases; multifocal lesions are common (Kastert and Uehlinger, 1964; Jaffe, 1972; Resnick, 1995; Aufderheide and Rodrίguez-Martίn, 1998). Spinal tuberculosis is typified by significant osteolytic cavitating destruction of the vertebral bodies with preservation of the posterior aspects, often, though not always, leading to collapse and kyphosis (Compere and Garrison, 1936; Ortner, 2003). Tuberculosis most often manifests in the thoracolumbar vertebrae, with L1 being the most commonly affected, and can spread through shared vasculature (e.g. Batson’s plexus) and across the intervertebral disc to adjacent vertebrae (Wiley and Trueta, 1959; Resnick, 1995; Aufderheide and RodrίguezMartίn, 1998; Clamp and Grevitt, 2009). Such alterations are consistent with those seen in Ghz-2-033. Brucellosis, a zoonotic Brucella infection associated with cattle cohabitation, is endemic in Sudan (Ortner, 2003; Rossetti et al., 2017). Skeletal manifestation is variable, with thoracolumbosacral vertebrae being the most common sites (Jaffe, 1972). Vertebral brucellosis typically localizes in the body around the disc resulting in alteration of the intervertebral space and involvement of adjacent vertebrae, with disc penetration and destruction occurring in later phases (Aguilar and Elvidge, 1961; Jaffe, 1972). Focal osteolytic lesions on the anterolateral aspects of the vertebrae with associated sclerotic osteoblastic repair, including bony projections, is common in brucellosis, though vertebral collapse is not (Madkour and Sharif, 1989; Mohan et al., 1990; Ortner, 2003). It is less likely, though not impossible, that the lesions observed resulted from brucellosis. Undulating osteolytic resorption and secondary foci are often encountered in tumorous conditions (e.g. metastatic carcinoma,
3. Results A middle adult male, Ghz-2-033 exhibits pathological alteration of L2–L3 vertebral bodies. The inferior surface of L2 and superior surface of L3 exhibit undulating osteolytic destruction, having bony projections and rounded edges compromising the intervertebral disc space. Pathological enlargement in the area of the L2–L3 vascular foramina suggests communication with the vertebral foramina (Wiley and Trueta, 1959; Crock et al., 1973). Rugose woven bone response is present anterolaterally along L2–L3 vertebral bodies, extending onto the left pedicles of both vertebrae with inferiorly projecting bony spicules on L2 (Fig. 6). The posterior aspects of the vertebrae are not similarly affected. Small ovoid osteolytic foci are present on the left lateral vertebral bodies of T12–L1. Vertebral collapse and kyphosis are not apparent, nor is pathological alteration present in the articular facets or associated ribs. No other lesions are present in any other vertebrae, nor elsewhere in the skeleton. Plain film radiography of the vertebrae identified no further lesions (Fig. 7). 4. Discussion The T12–L3 lesions indicate an infectious or tumorous etiology. Destruction of the intervertebral disc space suggests potential spread to the vertebral bodies from a soft tissue origin (e.g. vertebral plexus, spinal vasculature) (Kemp et al., 1973; Vigorita, 1999).
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Fig. 4. Individual Ghz-2-033. Areas in light grey show the elements recovered. The area where the arrow is pointing indicates the region of pathological alteration discussed in the text. Minor focal osteolytic lesions present in the vertebral bodies of T12 and L1 are shown here in dark grey, while severe osteolytic destruction and osteoblastic new bone present in the vertebral bodies of L2–L3 are indicated here in black.
hemangioma, angiolipoma) that manifest in elements with significant haematopoietic marrow, including vertebral bodies (Jaffe, 1958; Ortner, 2003). However, the expansive alteration, destruction of the intervertebral disc space, lack of similar lesions on the neural arches or elsewhere in the skeleton, both macroscopically and radiographically, and absence of pathological fractures make tumorous conditions unlikely in the present case (See Steinbock, 1976; Micozzi, 1991; Dorfman and Czerniak, 1998). Intervertebral disc infection results from introduction of bacteria, most often Staphylococcus aureus, spreading hematogenously via the segmental arterial supply or Batson’s plexus (Ghormley et al., 1940; Hassler, 1970; Clamp and Grevitt, 2009). Persistence of pyogenic infection results in ballooning of the disc space, progressively eroding the vertebral plates and bodies on either side of the disc creating an undulating appearance in conjunction with sclerotic bone generation along the affected surfaces (Kemp et al., 1973). Circumferential bony spicules and bridging are often seen in attempts at healing (Kemp et al., 1973). Intervertebral disc infection cannot be entirely ruled out in Ghz2-033. Mycoses can occur via inhalation, hematogenous dissemination, and direct extension from a soft tissue lesion. Random distribution and varying rates of skeletal lesions are typical (Ortner, 2003). Though rare, mycoses, particularly blastomycosis, aspergillosis, and coccidioidomycosis, may cause vertebral lesions including body and posterior erosion and collapse, paravertebral abscess, and disc destruction (Buikstra, 1976; Resnick, 1995; Ortner, 2003). Coccidioidomycosis can be excluded here as it only occurs in the Western Hemisphere (Ortner, 2003). While eroded areas of resorption usually coincide with periosteal new bone, mycotic vertebral infections typically involve the posterior elements, which is not the case in Ghz-2-033 (Hershkovitz et al., 1998; Mays and Taylor, 2003). The rarity of skeletal lesions coupled with the appearance of the lesions in Ghz-2-033 make mycotic infection unlikely. 4.1. Pathology assessment Based on the findings of Mays and Taylor (2003) and Ortner (2003) it is most probable that the lesions of Ghz-2-033 are tubercular. Cattle were commonly exploited in Makuria (Welsby, 2002; Osypinska, 2003, 2008, 2013), and excavations at Ghazali have identified enclosed workrooms, latrines, a refectory, and 12 dormitory cells, each occupied by 2–3 monks (Obłuski, 2014; Obłuski and Korzeniowska, 2018). Such factors are ideal for tuberculosis transmission (Webber, 2005). Tuberculosis in ancient Egypt and Nubia is well documented, based largely on macroscopic lesions (Morse et al., 1964; Strouhal, 1991; Bedeir, 2004; Nerlich and Lösch, 2009; Perrin, 2015; Roberts, 2015), and more recently biomolecular evidence (Nerlich et al., 1997; Spigelman et al., 2005; Zink et al., 1999, 2001, 2003a, 2003b, 2005, 2007). Tuberculosis in Christian Nubia has been documented at Mis Island (Soler, 2012; Hurst, 2013), Kulubnarti (Spigelman et al., 2005), and Sayala (Strouhal, 1987, 1989, 1991). Though vertebral collapse and kyphosis are not apparent in Ghz-2033, the morphology of the lesions appear most consistent with tuberculosis. We cannot, at this time, however, discount the potentiality of infection/co-infection with brucellar or staphylococcal pathogens
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Fig. 5. Preservation in situ of rope and associated tassel, believed to have been used as a belt to secure the garments worn by individual Ghz-2-033, a.) rope, tassel and associated fabric; b.) size and relative position of the tassel around the waist of individual Ghz-2-033 in proximity to the right forearm. Fig. 6. Pathologically altered vertebrae of Ghz2-033, a.) anterosuperior view of L3 showing extensive osteolytic destruction and a large osteolytic aperture along the posterior area of the vertebral body; b.) inferior view of L2 showing undulating osteolytic cavitation, projecting osteoblastic spicules, and a large osteolytic aperture along the posterior area of the vertebral body; c.) left aspect view of pathological alteration showing articulated position of L2–L3 with associated osteolytic resorption and osteoblastic response in the form of dense sheetlike nodules of new bone. Focal ovoid osteolytic lesions are also visible on the inferior left aspects of the T12–L1 vertebral bodies, and in the area of the intervertebral notch on the left pedicle of L1; d.) anterior view of pathological alteration in L2–L3 vertebral bodies; e.) right aspect view of pathological alteration showing dense sheetlike osteoblastic new bone and a pronounced inferiorly projecting bony spicule on L2.
(Kemp et al., 1973; Vigorita, 1999; Aubin, 2003, 2004a,b). The presence of bony spicules in Ghz-2-033 may indicate an attempt at bridging the destruction zone (Ortner, 2003). Chronic pain, neurological damage, and paresis are common sequelae in vertebral tuberculosis, for which Ghz-2-033 may have been at risk (Clamp and Grevitt, 2009). Biomolecular analyses may help to further identify the pathogen affecting Ghz-2-033. Similar vertebral lesions to those of Ghz-2-033 were confirmed as tubercular through aDNA analysis by Nerlich et al. (1997), and by Mays and Taylor (2003) through a positive IS6110 PCR assay, though the accuracy of this latter method, without further validation, has been challenged (cf. Müller et al., 2016).
Funding The Ghazali Archaeological Site Presentation Project (G.A.S.P) is funded in part by the Qatar-Sudan Archaeological Project (QSAP) program and the Polish Centre of Mediterranean Archaeology (PCMA), University of Warsaw. Declarations of interest None. Acknowledgements
5. Conclusions
The authors would like to thank Dr. Artur Obłuski, Director of the Polish Centre of Mediterranean Archaeology (PCMA) Research Centre in Cairo, The National Corporation for Antiquities and Museums (NCAM) Sudan, the Qatar-Sudan Archaeological Project (QSAP) program, Zaki ed-Din Mahmoud, our colleagues in Sudan and all those involved with the Ghazali project, the staff at the Karima hospital who
Tuberculosis remains the most probable etiology for the lesions of Ghz-2-033. The morphological arguments presented are further supported given well documented evidence for tuberculosis in ancient Nubia in conjunction with the presence of tuberculosis vectors (i.e. cattle) and the close living quarters of the monks at Ghazali.
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Fig. 7. Vertebral column of individual Ghz-2-033, a.) right aspect lateral radiograph showing pathological destruction and a lack of further lesions within the vertebral bodies; b.) anterior macroscopic view showing severe osteolytic resorption and associated osteoblastic response at L2–L3. Vertebral collapse and kyphosis are not apparent.
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Vertebral infection in a male individual buried in the monastic cemetery (Cemetery 2) at Ghazali (ca. 670–1270 CE), northern Sudan
T
Robert J. Starka, , Joanna Ciesielskab ⁎
a b
Department of Anthropology, McMaster University, Chester New Hall Rm. 524, 1280 Main Street West, Hamilton, Ontario, L8S 4L9, Canada Institute of Archaeology, University of Warsaw, Krakowskie Przedmiescie 26/28, 00-927 Warsaw, Poland
ARTICLE INFO
ABSTRACT
Keywords: Spinal pathology Tuberculosis Christian Nubia Makuria Bayuda desert Wadi Abu Dom
Purpose/research question: This article examines pronounced osteoblastic-osteolytic vertebral lesions in a middle adult male (Ghz-2-033), from the Christian Nubian monastic settlement of Ghazali (ca. 670–1270 CE), Sudan, to explore their potential etiology. Methods: Morphological assessments of sex and age were undertaken in conjunction with macroscopic and radiological methods of assessment for the skeletal lesions documented. Results: Macroscopic assessment of Ghz-2-033 identified mixed osteoblastic-osteolytic lesions in L2–L3 with minor foci in T12–L1, while radiological assessment identified no further lesions. This paleopathological analysis considers tuberculosis, brucellosis, pyogenic intervertebral disc infection, neoplastic conditions, and mycotic infections as potential etiologies. Conclusions: Tuberculosis is the most probable etiology for the lesions observed. This assessment is based on the morphology of the lesions in conjunction with the known confined living quarters at Ghazali and the presence of tuberculosis vectors (i.e. cattle) in the region. Contributions to knowledge/originality/value: This brief communication contributes original data documenting the presence of tubercular lesions in a monk buried at the Christian Nubian monastery of Ghazali. On a broader level this study contributes to regional and temporal paleopathological dialogues regarding interactions with pathogens in Christian Nubian monastic contexts. Limitations for this study: The potentiality of co-infection with other pathogens (e.g. brucellosis, Staphylococcus) with similar macromorphological traits in skeletal remains cannot be entirely discounted. Suggestions for further research: The use of biomolecular analyses may help to clarify the potential presence of tuberculosis in individual Ghz-2-033.
1. Introduction The monastic settlement of Ghazali (ca. 670–1270 CE) is located at the entrance to Wadi Abu Dom (18° 26′ N, 31° 56′ E) in Sudan (Fig. 1) (Jeuté, 1994). Ghazali was initially excavated in the 1950s (Shinnie and Chittick, 1961) and subsequently, beginning in 2012, by the Polish Centre of Mediterranean Archaeology (Obłuski, 2014; Obłuski et al., 2015). Part of the medieval Kingdom of Makuria (ca. 6th–14th c. CE), an unknown number of lay individuals and 18–36 monks resided at Ghazali at any one time, many of whom were buried there (Scanlon, 1972; Anderson, 1996, 1999; Godlewski, 2014; Obłuski and Korzeniowska, 2018). In 2015 an individual (Ghz-2-033) exhibiting mixed osteolytic-osteoblastic vertebral lesions was identified within the monastic cemetery (Cemetery 2). This brief communication contributes
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original paleopathological data that may be useful towards developing broader characterizations of encounters with pathogens in Nubian monastic communities. 2. Materials and methods 2.1. Burial of Ghz-2-033 Ghz-2-033 was interred south of the Ghazali monastery in Cemetery 2 (Fig. 2). Of the 66 individuals excavated from Cemetery 2, 64 are male and two indeterminate, providing strong evidence that Cemetery 2 was the monastic burial ground (Ciesielska et al., 2018). A low-lying mudbrick pavement (type FF02c1 of Borcowski and Welsby, 2012) marked the grave and a peaked mudbrick vault covered the supine body
Corresponding author. E-mail addresses: [email protected] (R.J. Stark), [email protected] (J. Ciesielska).
https://doi.org/10.1016/j.ijpp.2018.08.011 Received 31 October 2017; Received in revised form 20 August 2018; Accepted 31 August 2018 1879-9817/ © 2018 Published by Elsevier Inc.
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Fig. 1. Location of Ghazali in the Wadi Abu Dom of Sudan. Inset image shows the area depicted (in rectangle) in relation to the surrounding region (Map generated from ESRI Imagery by Robert Stark on 10/11/2017 using Scholars GeoPortal, http://geo1.scholarsportal.info).
Fig. 2. Line drawing (left) and kite photograph (right) of the monastic complex, lay settlement area, and associated cemeteries at Ghazali. The location of the burial of individual Ghz-2-033 in Cemetery 2 is shown in red. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
(Fig. 3). With the head to the north-west and having no grave goods, the burial of Ghz-2-033 is typical of Christian Nubia (Adams, 1998; Baker, 2014).
examination. Ancillary plain film radiography to examine for lesions within the vertebrae was undertaken using a Toshiba Rotanode Model E7329 at Karima-Hospital, Sudan.
2.2. Methods of observation
2.3. Preservation, sexing, ageing, and curation of Ghz-2-033
Skeletal lesions were primarily assessed using macromorphological
Aside from skeletal remains (Fig. 4), Ghz-2-033 had fragments of 35
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Fig. 3. The burial of Ghz-2-033, a.) mudbrick pavement indicating the location of the grave shaft; b.) peaked mudbrick vault covering individual Ghz-2-033; c.) vault entrance, located at the western end, showing vault construction and placement of individual Ghz-2-033; d.) the skeletal remains of individual Ghz-2-033, interred in a burial shroud and placed in a typical Christian Nubian burial position: supine with head to the north-west, legs side-by-side, left arm at the side and right arm over the pelvis.
hair, skin, burial shroud, and rope belt with tassel (Fig. 5) preserved. Sex was estimated based on morphology of the greater sciatic notch, ischiopubic ramus, ventral arc, subpubic concavity, and cranial morphology; age was estimated using pubic symphysis and auricular surface morphology, and suture closure (Buikstra and Ubelaker, 1994; Nikita, 2017). Individual Ghz-2-033 is curated in the Gebel Barkal Museum, Sudan.
Tuberculosis, caused by Mycobacterium bacilli, is spread through droplet transmission, close living quarters, consumption of contaminated foodstuffs (e.g. milk/meat), and proximity to tuberculosis vectors (e.g. cattle) (Roberts and Buikstra, 2003, 2007). Hematogenously disseminated tuberculosis affects the skeleton in 15%–30% of extrapulmonary cases, the spine being affected in 25%–50% of skeletal cases; multifocal lesions are common (Kastert and Uehlinger, 1964; Jaffe, 1972; Resnick, 1995; Aufderheide and Rodrίguez-Martίn, 1998). Spinal tuberculosis is typified by significant osteolytic cavitating destruction of the vertebral bodies with preservation of the posterior aspects, often, though not always, leading to collapse and kyphosis (Compere and Garrison, 1936; Ortner, 2003). Tuberculosis most often manifests in the thoracolumbar vertebrae, with L1 being the most commonly affected, and can spread through shared vasculature (e.g. Batson’s plexus) and across the intervertebral disc to adjacent vertebrae (Wiley and Trueta, 1959; Resnick, 1995; Aufderheide and RodrίguezMartίn, 1998; Clamp and Grevitt, 2009). Such alterations are consistent with those seen in Ghz-2-033. Brucellosis, a zoonotic Brucella infection associated with cattle cohabitation, is endemic in Sudan (Ortner, 2003; Rossetti et al., 2017). Skeletal manifestation is variable, with thoracolumbosacral vertebrae being the most common sites (Jaffe, 1972). Vertebral brucellosis typically localizes in the body around the disc resulting in alteration of the intervertebral space and involvement of adjacent vertebrae, with disc penetration and destruction occurring in later phases (Aguilar and Elvidge, 1961; Jaffe, 1972). Focal osteolytic lesions on the anterolateral aspects of the vertebrae with associated sclerotic osteoblastic repair, including bony projections, is common in brucellosis, though vertebral collapse is not (Madkour and Sharif, 1989; Mohan et al., 1990; Ortner, 2003). It is less likely, though not impossible, that the lesions observed resulted from brucellosis. Undulating osteolytic resorption and secondary foci are often encountered in tumorous conditions (e.g. metastatic carcinoma,
3. Results A middle adult male, Ghz-2-033 exhibits pathological alteration of L2–L3 vertebral bodies. The inferior surface of L2 and superior surface of L3 exhibit undulating osteolytic destruction, having bony projections and rounded edges compromising the intervertebral disc space. Pathological enlargement in the area of the L2–L3 vascular foramina suggests communication with the vertebral foramina (Wiley and Trueta, 1959; Crock et al., 1973). Rugose woven bone response is present anterolaterally along L2–L3 vertebral bodies, extending onto the left pedicles of both vertebrae with inferiorly projecting bony spicules on L2 (Fig. 6). The posterior aspects of the vertebrae are not similarly affected. Small ovoid osteolytic foci are present on the left lateral vertebral bodies of T12–L1. Vertebral collapse and kyphosis are not apparent, nor is pathological alteration present in the articular facets or associated ribs. No other lesions are present in any other vertebrae, nor elsewhere in the skeleton. Plain film radiography of the vertebrae identified no further lesions (Fig. 7). 4. Discussion The T12–L3 lesions indicate an infectious or tumorous etiology. Destruction of the intervertebral disc space suggests potential spread to the vertebral bodies from a soft tissue origin (e.g. vertebral plexus, spinal vasculature) (Kemp et al., 1973; Vigorita, 1999).
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Fig. 4. Individual Ghz-2-033. Areas in light grey show the elements recovered. The area where the arrow is pointing indicates the region of pathological alteration discussed in the text. Minor focal osteolytic lesions present in the vertebral bodies of T12 and L1 are shown here in dark grey, while severe osteolytic destruction and osteoblastic new bone present in the vertebral bodies of L2–L3 are indicated here in black.
hemangioma, angiolipoma) that manifest in elements with significant haematopoietic marrow, including vertebral bodies (Jaffe, 1958; Ortner, 2003). However, the expansive alteration, destruction of the intervertebral disc space, lack of similar lesions on the neural arches or elsewhere in the skeleton, both macroscopically and radiographically, and absence of pathological fractures make tumorous conditions unlikely in the present case (See Steinbock, 1976; Micozzi, 1991; Dorfman and Czerniak, 1998). Intervertebral disc infection results from introduction of bacteria, most often Staphylococcus aureus, spreading hematogenously via the segmental arterial supply or Batson’s plexus (Ghormley et al., 1940; Hassler, 1970; Clamp and Grevitt, 2009). Persistence of pyogenic infection results in ballooning of the disc space, progressively eroding the vertebral plates and bodies on either side of the disc creating an undulating appearance in conjunction with sclerotic bone generation along the affected surfaces (Kemp et al., 1973). Circumferential bony spicules and bridging are often seen in attempts at healing (Kemp et al., 1973). Intervertebral disc infection cannot be entirely ruled out in Ghz2-033. Mycoses can occur via inhalation, hematogenous dissemination, and direct extension from a soft tissue lesion. Random distribution and varying rates of skeletal lesions are typical (Ortner, 2003). Though rare, mycoses, particularly blastomycosis, aspergillosis, and coccidioidomycosis, may cause vertebral lesions including body and posterior erosion and collapse, paravertebral abscess, and disc destruction (Buikstra, 1976; Resnick, 1995; Ortner, 2003). Coccidioidomycosis can be excluded here as it only occurs in the Western Hemisphere (Ortner, 2003). While eroded areas of resorption usually coincide with periosteal new bone, mycotic vertebral infections typically involve the posterior elements, which is not the case in Ghz-2-033 (Hershkovitz et al., 1998; Mays and Taylor, 2003). The rarity of skeletal lesions coupled with the appearance of the lesions in Ghz-2-033 make mycotic infection unlikely. 4.1. Pathology assessment Based on the findings of Mays and Taylor (2003) and Ortner (2003) it is most probable that the lesions of Ghz-2-033 are tubercular. Cattle were commonly exploited in Makuria (Welsby, 2002; Osypinska, 2003, 2008, 2013), and excavations at Ghazali have identified enclosed workrooms, latrines, a refectory, and 12 dormitory cells, each occupied by 2–3 monks (Obłuski, 2014; Obłuski and Korzeniowska, 2018). Such factors are ideal for tuberculosis transmission (Webber, 2005). Tuberculosis in ancient Egypt and Nubia is well documented, based largely on macroscopic lesions (Morse et al., 1964; Strouhal, 1991; Bedeir, 2004; Nerlich and Lösch, 2009; Perrin, 2015; Roberts, 2015), and more recently biomolecular evidence (Nerlich et al., 1997; Spigelman et al., 2005; Zink et al., 1999, 2001, 2003a, 2003b, 2005, 2007). Tuberculosis in Christian Nubia has been documented at Mis Island (Soler, 2012; Hurst, 2013), Kulubnarti (Spigelman et al., 2005), and Sayala (Strouhal, 1987, 1989, 1991). Though vertebral collapse and kyphosis are not apparent in Ghz-2033, the morphology of the lesions appear most consistent with tuberculosis. We cannot, at this time, however, discount the potentiality of infection/co-infection with brucellar or staphylococcal pathogens
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Fig. 5. Preservation in situ of rope and associated tassel, believed to have been used as a belt to secure the garments worn by individual Ghz-2-033, a.) rope, tassel and associated fabric; b.) size and relative position of the tassel around the waist of individual Ghz-2-033 in proximity to the right forearm. Fig. 6. Pathologically altered vertebrae of Ghz2-033, a.) anterosuperior view of L3 showing extensive osteolytic destruction and a large osteolytic aperture along the posterior area of the vertebral body; b.) inferior view of L2 showing undulating osteolytic cavitation, projecting osteoblastic spicules, and a large osteolytic aperture along the posterior area of the vertebral body; c.) left aspect view of pathological alteration showing articulated position of L2–L3 with associated osteolytic resorption and osteoblastic response in the form of dense sheetlike nodules of new bone. Focal ovoid osteolytic lesions are also visible on the inferior left aspects of the T12–L1 vertebral bodies, and in the area of the intervertebral notch on the left pedicle of L1; d.) anterior view of pathological alteration in L2–L3 vertebral bodies; e.) right aspect view of pathological alteration showing dense sheetlike osteoblastic new bone and a pronounced inferiorly projecting bony spicule on L2.
(Kemp et al., 1973; Vigorita, 1999; Aubin, 2003, 2004a,b). The presence of bony spicules in Ghz-2-033 may indicate an attempt at bridging the destruction zone (Ortner, 2003). Chronic pain, neurological damage, and paresis are common sequelae in vertebral tuberculosis, for which Ghz-2-033 may have been at risk (Clamp and Grevitt, 2009). Biomolecular analyses may help to further identify the pathogen affecting Ghz-2-033. Similar vertebral lesions to those of Ghz-2-033 were confirmed as tubercular through aDNA analysis by Nerlich et al. (1997), and by Mays and Taylor (2003) through a positive IS6110 PCR assay, though the accuracy of this latter method, without further validation, has been challenged (cf. Müller et al., 2016).
Funding The Ghazali Archaeological Site Presentation Project (G.A.S.P) is funded in part by the Qatar-Sudan Archaeological Project (QSAP) program and the Polish Centre of Mediterranean Archaeology (PCMA), University of Warsaw. Declarations of interest None. Acknowledgements
5. Conclusions
The authors would like to thank Dr. Artur Obłuski, Director of the Polish Centre of Mediterranean Archaeology (PCMA) Research Centre in Cairo, The National Corporation for Antiquities and Museums (NCAM) Sudan, the Qatar-Sudan Archaeological Project (QSAP) program, Zaki ed-Din Mahmoud, our colleagues in Sudan and all those involved with the Ghazali project, the staff at the Karima hospital who
Tuberculosis remains the most probable etiology for the lesions of Ghz-2-033. The morphological arguments presented are further supported given well documented evidence for tuberculosis in ancient Nubia in conjunction with the presence of tuberculosis vectors (i.e. cattle) and the close living quarters of the monks at Ghazali.
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Fig. 7. Vertebral column of individual Ghz-2-033, a.) right aspect lateral radiograph showing pathological destruction and a lack of further lesions within the vertebral bodies; b.) anterior macroscopic view showing severe osteolytic resorption and associated osteoblastic response at L2–L3. Vertebral collapse and kyphosis are not apparent.
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