The oldest case of lymphoma? Insights from a XIII century fresco.

Abstract

A fresco painted by an unknown artist in the mid XIII century and displayed in the “Gothic Hall” of the Four Crowned Saints' seclusion cloister in Rome (left panel) is interesting not only for its undisputed beauty, but also for a possible clinical enigma that can be seen on careful examination. The fresco shows a young woman with a readily detectable swollen area (roughly of walnut size) in the right cervical part of her neck (shown in higher magnification in the right panel). In the absence of other clinical information, our (independently reached) interpretation is that this may represent an early (perhaps the earliest) example of a lymphoma shown in a painting. Based on strict semeiotic principles, the size of the lymph node is sufficient to rule out, at least at a first glance, underlying infectious diseases such as mononucleosis or toxoplasmosis, which do not usually cause lymphadenopathy of that size. Similarly, chronic lymphatic leukemia may be excluded since it affects predominantly older patients. Yersinia pestis (the gram-negative coccobacillus causing plague or bubonic plague) infection is unlikely for at least two reasons: (a) the skin overlaying the swollen lymph node does not appear to be erythematous; (b) the plague pandemic, called “the black death”, arose in Crimea and then reached Europe in 1346,1 about a century after the fresco was painted. Mycobacterium tuberculosis may be suspected in this case since it typically involves latero-cervical region (i.e. cervical lymphadenitis also referred to as scrofula). However, a tuberculosis origin is unlikely in the woman in this painting since it gives rise to an early erythema of the overlaying skin,2, 3 which in this painting is lacking. These simple clinical considerations lead us to believe that the most probable cause of the swollen lymph node of this young woman painted in the mid XIII century is a lymphoma, and that this fresco is the earliest representation of such disease. Open Access Funding provided by Universita degli Studi di Ferrara within the CRUI-CARE Agreement.