Background Contemporary physicians described “Medici's gout” to refer to the arthropaties of numerous members of the Renaissance family. In last years, paleopathological studies were performed in the funerary depositions of the Medici Grand Dukes, enabling to establish the nature of their rheumatic diseases. The changes observed met the criteria established for the diagnosis of DISH. Alterations suggesting peripheral arthritis were present concomitantly in some cases. Given the history of cutaneous disease, a DISH-psoriatic arthritis syndrome has been hypothesized.
In the light of up-to-date knowledge, these findings give hints to reconstruct the health and lifestyle of the members of this important family of the Italian Renaissance.
Objectives With this work, we aim to review the risk factors and pathophysiological aspects of DISH that may account for the high prevalence of DISH in this Renaissance family. The association of DISH with other inflammatory arthropaties was also explored.
Methods A Pubmed search was undertaken (up until January 2015), using the key words “DISH”, “risk factors”, “peripheral arthritis”.
Results Many case-control and cohort studies (using a number of different populations) support the link between DISH and metabolic syndrome, diabetes mellitus, hypertension, obesity, waist circumference, hyperuricemia and dyslipidemia. The mechanism linking metabolic syndrome and DISH has not yet been clarified, though some authors proposed that IGF-1 might have a role in increased bone formation. DISH appears almost exclusively in individuals after 50 years, it is more frequent in males and the prevalence increases with age, a fact that has not yet been explained.
The Italian Renaissance aristocratic classes had a diet based on wine and meat, the consumption of vegetables and fruit was scarce. Also, in the 16th century, a life expectancy over 50 years was mainly verified in higher social classes. These two features probably contributed to an increased prevalence of DISH in the higher segments of society.
The peripheral involvement of DISH includes the increased frequency of osteoarthritis (OA) in joints usually not affected and increased hypertrophic changes in the joints affected by OA. Other than exacerbated OA, other causes of arthritis can be present in DISH patients, as studies report an association between DISH and gout, and more recently with calcium pyrophosphate deposition disease, a condition also associated with metabolic disturbances. Moreover, DISH was observed in 8.3% of patients from a cohort with psoriatic arthritis (PsA). Despite surprisingly low evidence available, a few older studies have not found an association of DISH with rheumatoid arthritis (RA). It should also be noted that RA is thought to have emerged in Europe only in the early 19th century, long after the Medici period.
Conclusions The high incidence of DISH in the Medici family is significant. A link between social status, lifestyle and the risk of developing DISH in male family members of mature age can be hypothesized. The presence of peripheral joints changes in some Medici family members can be related to either crystal arthropathy with secondary OA or polyarticular PsA, rather than RA, given the posterior emergence of RA in Europe and the clear preservation of peripheral small joints in one of the Medici with a symmetrical destructive arthritis of medium and large joints.
Disclosure of Interest None declared