Skeletal Lesions in Human Tuberculosis May Sometimes Heal: An Aid to Palaeopathological Diagnoses

In three to five percent of active cases of tuberculosis, skeletal lesions develop. Typically, these occur on the vertebrae and are destructive in nature. In this paper, we examined cases of skeletal tuberculosis from a skeletal collection (Galler Collection) with focus on the manifestation of bony changes due to tuberculosis in various body regions in association with antibiotic introduction. This skeletal collection was created in 1925–1977 by a pathologist at the University Hospital in Zürich, Ernst Galler. It includes the remains of 2426 individuals with documented clinical histories as well as autopsies. It contained 29 cases of skeletal tuberculosis lesions. We observed natural healing of vertebral lesions through several processes including fusion of vertebrae, bone deposition and fusion of posterior elements. In these cases, we observed a higher frequency and proportion of bone deposition and fusion of posterior vertebral elements where pharmacological agents were used. There were also four cases of artificial healing through surgically induced posterior spinal fusion. With the introduction of pharmaceutical treatments, the number of individuals with multiple tuberculous foci decreased from 80% to 25% when compared to individuals who did not receive any drug therapy. Investigation of comorbidities showed that pneumonia, pleuritis and being underweight were consistently present, even with pharmaceutical treatment. Our results have applications in palaeopathological diagnoses where healing and consequent bone deposition may complicate differential diagnoses.

urogenital system had been affected by TB. As a result of this, the right kidney was removed.
During the next 20 years, the individual had several operations to help with the problems caused by urogenital TB. Healing in this case has occurred through fusion of the affected vertebrae.
The medical records for this patient do not describe compression fractures, Paget's disease, osteomyelitis or neoplasms. Osteoporosis is mentioned, but this would not have impacted the development of the bone lesions because it is very unlikely this individual had osteoporosis at the age of 1 year, when the spinal TB begun. The anterior regions of the bodies of three vertebrae were destroyed, leading to collapse of the spine. This is consistent with TB and we considered this as a very likely case. bodies. There is no intervertebral disc between these vertebrae. The sacral vertebrae were also involved in the disease process. This individual had general subacute miliary TB, as well as meningitis of tuberculous origin. The left femur was also involved as well as the wing of the ilium. Both were atrophied. The left hip was diagnosed with TB in 1954 (2 years before death) when the individual complained of pain in the hip joint and lower extremities. The femoral head had necrotic areas that extended down into the medial part of the compact bone.
The joint cartilage had been completely eroded away. Healing occurred through fusion of the affected vertebrae in this case.
The medical record of this individual does mention the presence of Paget's disease of the femur and third lumbar vertebra. However, pathological changes are noted on lumbar vertebrae four and five, rather than lumbar three. Additionally, the medical records report the presence of tubercles in tissues surrounding lumbar vertebra four, extending further towards the sacrum. There is also complete destruction of the vertebral disc between lumbar vertebrae four and five. These characteristics indicate that TB was likely responsible for the pathology around lumbar vertebrae four and five. Description: The image shows the section including thoracic vertebrae eleven to lumbar vertebra five (and the sacrum) of an 80 year old male. The anterior regions of lumbar vertebrae three to five have been almost completely destroyed. Lumbar vertebra two has also been involved and is fused to lumbar vertebra 3 on the anterior edge of the vertebral body.
Vertebral bodies are no longer distinct from one another. This individual had pulmonary TB, resulting in spinal lesions. As well as extensive vertebral fusion, healing has occurred by fusion of spinous processes.
The medical records of this individual do not mention compression fractures, Paget's disease, osteomyelitis or neoplasms but does include hip luxation. However, the lesions we were interested in were on the spine, not the hip. The records reported TB as well as osteoporosis. There is also a minor amount of lipping on the vertebra anterior to these two fused vertebrae.
The bony deposit protrudes approximately 6 mm from the vertebral body. The fusion is complete leaving no space between vertebrae.
The medical records for this individual state that he had TB spondylitis but not any of the other diseases we considered in our differential diagnoses (compression fractures, Paget's disease, osteomyelitis or neoplasms). We had a limited number of bones available for examination; however we do notice the involvement of only two vertebrae. Fusion has occurred between the vertebral bodies of these. Based on the vertebrae, there would have been a mild degree of kyphosis. Based on medical records and these limited observations, we can suggest a possible cause of the vertebral fusion as TB, but we cannot be certain. The medical records for this individual do not mention any of the other diseases we considered (compression fractures, Paget's disease, osteomyelitis or neoplasms). There is mention of TB spondylitis, however. In this case, we only had a single lumbar vertebra available for examination. Destruction of the central part of the vertebral body is not uncommon in TB and the destruction affected only a single lumbar vertebra. We could not tell anything about potential kyphosis for this case; however, with the bone destruction observed, it would be unlikely that the spine would have collapsed. This individual died at an earlier than average age of 43 years (average was 62±2 years) of a haemorrhage in the brain. Thoracic vertebrae eight to ten have healed through fusion of the vertebrae as well as posterior elements.
The medical records for this individual describe TB spondylitis of multiple vertebrae in detail as well as the presence of osteoporosis. There were two separate foci for skeletal lesions; the first of four thoracic vertebrae and the second involved two lumbar vertebrae. Although a total of six vertebrae were affected, atypical for TB, these vertebrae were not adjacent to one another, making TB still a potential cause of the lesions. Additionally, for the thoracic vertebrae, there was extensive destruction of the anterior region of the vertebral bodies. One vertebra has been almost completely destroyed. This has led to collapse of the spine and fusion of the affected vertebrae. Although posterior elements were involved, the most probable cause of these lesions is likely to be TB. Medical records for this individual report bone TB, osteoporosis and kyphoscoliosis of lumbar vertebrae two to four. There is no mention of compression fractures, Paget's disease, osteomyelitis or neoplasms. It may be that the visible vertebral malformations are a result of aging. We had limited skeletal material available for examination in this case, which excluded lumbar vertebrae two to four. Based on the material we did have available, we observed some damage to the vertebrae and no evidence of other diseases. In this case, we had to base most of the diagnosis from the medical records, but considered this individual to have TB as described in the reports. Description: The image shows three thoracic vertebrae of an 89 year old female. We were unable to determine which vertebrae these were specifically; however, none of them were the fifth thoracic vertebra. There was fusion and bone deposition around several costovertebral joints as well as small amounts of bone deposition between vertebrae. The anterior region of two thoracic vertebrae (lower two shown in the image) have fused together, however, this fusion is not complete between vertebral bodies. The medical records also describe TB spondylitis of the fifth thoracic vertebra, with small abscesses and kyphosis. The vertebra is almost completely destroyed. Healing in this case is a result of bone deposition.
Medical records for this individual describe TB spondylitis of the fifth thoracic vertebra as well as osteoporosis, but not compression fractures, Paget's disease, osteomyelitis or neoplasms. The fifth thoracic vertebra was not available for examination; the medical reports indicated that it had been almost completely destroyed by the disease process. Kyphosis Description: The image shows a single vertebra of a 31 year old female, though we were unable to determine the specific vertebra. It is slightly compressed but this may not be related to a tuberculosis disease process. This patient had chronic TB that also showed evidence of involvement of the psoas muscle, which had healed by bone deposition on the femur.
Medical records for this individual describe chronic TB as well as several cardiac conditions. This individual may not have developed spinal TB as she died at 31 years, much earlier than the average for the sample (62±2 years). In this case, we considered the individual to have TB of the hip joint and psoas muscle, but not of the spine. The cause of death was pneumonia and may have been the result of complications arising from TB. Lipping and bone deposition has occurred on several vertebrae. Between two vertebrae (right) enough bone has been deposited to fuse the two together at the anterior edge of the vertebral body. There is also bone deposition on several ribs. One costovertebral joint is fused.
Medical records for this individual reported osteoporosis, kyphosis, spondylosis and chronic TB, but not compression fractures, Paget's disease, osteomyelitis or neoplasms. Observations from the vertebrae show damage to vertebral bodies as well as bone deposition. There is a mild kyphosis (as observed in the left image). In the absence of any other evidence, it was difficult to diagnose this case. The most likely cause of these lesions is a combination of TB and osteoporosis.