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Mona Lisa Decrypted: Another Premise

      To the Editor:
      In the September 2018 issue of Mayo Clinic Proceedings, Mehra and Campbell
      • Mehra M.R.
      • Campbell H.R.
      The Mona Lisa decrypted: allure of an imperfect reality.
      gave a lovely and elegant review of the Mona Lisa painting and posited a medical explanation for the mystery of the lady as painted by the great master Leonardo da Vinci. Their insights tied hypothyroidism with attendant hyperlipidemia, lipoma, and xanthelasma as the cause of the enigmatic smile and her gaze. There is merit to this diagnosis, and this should be heavily weighted in the differential diagnosis analysis. Other analysts have attributed this to neurosyphilis,
      • Leaf C.
      What sickened Mona Lisa? A 500-year old medical mystery is solved…twice.
      postpartum Bell's palsy,
      • Maloney W.J.
      The answer to the riddle of Leonardo da Vinci's ‘Mona Lisa’.
      dentition problems,
      • Maloney W.J.
      The answer to the riddle of Leonardo da Vinci's ‘Mona Lisa’.
      hyperlipidemia, and strabismus.
      • Maloney W.J.
      The answer to the riddle of Leonardo da Vinci's ‘Mona Lisa’.
      While painting a study of the great master as a learning exercise, several elements of the composition led me to consider other possibilities for the differential diagnosis.
      Bruno Mottin, the curator of the Center for Research and Restoration of Museums of France, and a Canadian team imaged the painting using a new 3-dimensional technology. They noted that the initial da Vinci painting had the left hand “in a clenched rather than relaxed position.” This was later changed to a looser grasp “as if she was going to get up from a chair.”
      • Austen I.
      New look at Mona Lisa yields some new secrets.
      The first iteration would most likely reflect the reality of the moment more accurately.
      I submit that the position of the left arm and hand is more in keeping with paresis, which could be recent or from earlier in her life. The position of the right hand is one of support and is resting after positioning the left side. The flexion of the left hand is consistent with a neurological insult.
      A basilar artery event would tie in hemiparesis of the left arm as well as the intriguing eye and smile effects. A brainstem lesion in the area of the pons could affect the motor nucleus of cranial nerve VII and the cranial nerve V nucleus as well as affect a large bundle of motor tracts. This would encompass the enigmatic gaze, the muscles for mysterious smiling and emotion, and paresis and support of the arm and hand.
      • Kompanje E.J.
      • Walgaard C.
      • de Groot Y.J.
      • Stevens M.
      Historical sources of basilar artery occlusion.
      Brainstem artery occlusions are a subset of the posterior circulatory vascular events accounting for 1% to 4% of these strokes. Emboli, intrinsic basal artery atherosclerosis, and penetrating small artery diseases are the common causes of this event. Embolic causes are more common in younger individuals.
      • Dequeker J.
      • Muls E.
      • Leenders K.
      Xanthelasma and lipoma in Leonardo da Vinci's Mona Lisa.
      Much rarer etiologies are vasculitis, trauma, and infectious processes including neurosyphilis.
      • Dequeker J.
      • Muls E.
      • Leenders K.
      Xanthelasma and lipoma in Leonardo da Vinci's Mona Lisa.
      • Voetsch B.
      • DeWitt L.D.
      • Pessin M.S.
      • Caplan L.R.
      Basilar artery occlusive disease in the New England Medical Center Posterior Circulation Registry.
      • Mattle H.P.
      • Arnold M.
      • Lindsberg P.J.
      • Schonewille W.J.
      • Schroth G.
      Basal artery occlusion.
      • Ferbert A.
      • Brückmann H.
      • Drummen R.
      Clinical features of proven basal artery occlusion.
      • Bauerle J.
      • Zitzmann A.
      • Egger K.
      • Meckel S.
      • Weiller C.
      • Harloff A.
      The great imitator—still today! A case of meningovascular syphilis affecting posterior circulation.
      • Standaert D.G.
      • Galetta S.L.
      • Atlas S.W.
      Meningovascular syphilis with a gumma of the midbrain.
      • Abkur T.M.
      • Ahmed G.S.
      • Alfaki N.O.
      • O'Connor M.
      Neurosyphilis presenting with a stroke-like syndrome.
      I also submit that the position of the lesion of the right wrist is more in keeping with a ganglion cyst than a lipoma.
      The authors have written a wonderful review. Although hypothyroidism may very well be a part of the Mona Lisa story, there may be additional factors to consider in the differential diagnosis.

      References

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        • Campbell H.R.
        The Mona Lisa decrypted: allure of an imperfect reality.
        Mayo Clin Proc. 2018; 93: 1325-1327
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        What sickened Mona Lisa? A 500-year old medical mystery is solved…twice.
        Fortune. September 10, 2018;
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        The answer to the riddle of Leonardo da Vinci's ‘Mona Lisa’.
        J Dent Res. 2011; 90: 580-582
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        New look at Mona Lisa yields some new secrets.
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        Historical sources of basilar artery occlusion.
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        Arch Neurol. 2004; 61: 496-504
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        • Arnold M.
        • Lindsberg P.J.
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        Basal artery occlusion.
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        Clinical features of proven basal artery occlusion.
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        • Zitzmann A.
        • Egger K.
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        J Stroke Cerebrovasc Dis. 2015; 24: e1-e3
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        Meningovascular syphilis with a gumma of the midbrain.
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        BMJ Case Rep. 2015; 2015

      Linked Article

      • The Mona Lisa Decrypted: Allure of an Imperfect Reality
        Mayo Clinic ProceedingsVol. 93Issue 9
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          The iconic portrait of Lisa Gherardini, the enigmatic Mona Lisa, has endured centuries of fascination by artists, scholars, medical professionals, and even thieves.1 A wealthy silk merchant in Florence, Italy, Francesco del Giocondo commissioned Leonardo da Vinci to produce this masterpiece of his wife following the birth of their child, Andrea, in 1502.2 Although evidence is fragmentary, general belief is that work on the painting began in 1503. Subsequently, the painting was taken to France in 1516, completed there, and adorned the court of King Francis I until its permanent display in the Louvre in 1797 (Figure).
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