correspondence Since publication of their video and article, the authors report no further potential conflict of interest. 1. Guidance on personal protective equipment to be used by

healthcare workers during management of patients with Ebola virus disease in U.S. hospitals, including procedures for putting on (donning) and removing (doffing). Atlanta: Centers for Disease Control and Prevention (http://www.cdc.gov/vhf/ebola/hcp/ procedures-for-ppe.html).

2. For general healthcare settings in West Africa: rationale and

considerations for chlorine use in infection control. Atlanta: Centers for Disease Control and Prevention (http://www.cdc.gov/ vhf/ebola/hcp/international/chlorine-solutions.html). 3. Mäkelä EA, Vainiotalo S, Peltonen K. The permeability of surgical gloves to seven chemicals commonly used in hospitals. Ann Occup Hyg 2003;47:313-23. DOI: 10.1056/NEJMc1504851

Case 8-2015: A Man with Multiple Myeloma, Skin Tightness, Arthralgias, and Edema To the Editor: Wigley et al. (March 12 issue)1 discuss the case of a 68-year-old man with multiple myeloma and scleroderma. Notably, autologous stem-cell transplantation had been performed 7 months before the symptoms of scleroderma appeared in the patient. Thus, the diagnosis of autologous graft-versus-host disease (GVHD) should be considered. GVHD is the major complication of allogeneic stem-cell transplantation, and sclerodermatous GVHD accounts for 3.4% of GVHD cases.2,3 There is little difference between sclerodermatous GVHD and scleroderma with regard to clinical and histologic features except the distinct histories. A similar syndrome termed autologous GVHD affects patients after autologous stem-cell transplantation (in particular, those with multiple myeloma), and the incidence has been estimated to be approximately 5 to 20% of recipients.4 Furthermore, GVHD after autologous stem-cell transplantation with sclerotic skin has been reported.5 Therefore, it was sufficient that the patient described by Wigley and colleagues with diffuse systemic sclerosis after autologous stem-cell transplantation had a diagnosis of sclerodermatous GVHD. Fei Han, M.S. First People’s Hospital of Suqian Suqian, China [email protected] No potential conflict of interest relevant to this letter was reported. 1. Case Records of the Massachusetts General Hospital (Case

8-2015). N Engl J Med 2015;372:1056-67.

2. Socié G. Graft-versus-host disease — from the bench to the

bedside? N Engl J Med 2005;353:1396-7.

3. Peñas PF, Jones-Caballero M, Aragüés M, Fernández-Herrera

J, Fraga J, García-Díez A. Sclerodermatous graft-vs-host disease: clinical and pathological study of 17 patients. Arch Dermatol 2002;138:924-34.

4. Kline J, Subbiah S, Lazarus HM, van Besien K. Autologous

graft-versus-host disease: harnessing anti-tumor immunity through impaired self-tolerance. Bone Marrow Transplant 2008; 41:505-13. 5. Nakamura K, Kawakami Y, Oyama N, et al. A case of sclerodermatous graft-versus-host disease following autologous peripheral blood stem cell transplantation. J Dermatol 2006;33:135-8. DOI: 10.1056/NEJMc1504514

To the Editor: In the Case Record involving a patient with multiple myeloma and scleroderma with positivity for anti–RNA polymerase III antibodies (termed anti–RNA polymerase III scleroderma), the authors did not discuss the scleroderma as a paraneoplastic syndrome. Indeed, there was a close temporal relationship between the diagnosis of multiple myeloma in complete remission after autologous stem-cell transplantation and the clinical onset of scleroderma. A strong association between anti–RNA polymerase III scleroderma and cancer is well known. In a recent study involving 2177 patients with scleroderma, the frequency of cancer was 14.2% among patients with anti–RNA polymerase III antibodies as compared with 6.3% among patients with anti–Scl-70 antibodies and 6.8% among patients with anticentromere antibodies (P

Case 8-2015: A Man with Multiple Myeloma, Skin Tightness, Arthralgias, and Edema.

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