LETTERS 379

tion were already in place. Moreover, the data strongly suggest that persons involved in the disability award process must consider all relevant medical and psychosocial factors (i.e., not solely type of pain onset) in evaluating the individual patient with fibromyalgia and making the appropriate recommenda- tion(s). Bennett provides an excellent guideline for considering these factors throughout the disability evaluation process (Bennett RM. Fibromyalgia and the disability dilemma: a new era in understanding a complex, multidimensional pain syn- drome. Arthritis Rheum 1996;39:1627-34.).

Leslie A. Aaron, MA, MPH Laurence A. Bradley, PhD Graciela S. Alarcon, MD, MPH Mireya Triana-Alexander, BA Ronald W. Alexander, MA Michelle Y. Martin, MA Kristin R. Alberts, BA The University of Alabama at Birmingham

Histiocytes and fibroblastic rheumatism: comment on the article by Romas et al

To the Editor: We read with great interest the report by Romas et al,

describing a patient with destructive arthropathy associated with fibroblastic rheumatism (FR) (1). The authors describe a patient with nodular cutaneous lesions, symmetric polyarthri- tis, and destructive changes on joint radiography. The findings in the clinical photographs are reminiscent of multicentric reticulohistiocytomas (1,2); however, biopsy of skin nodules showed a proliferation of plump, uniform, spindle-shaped cells. Immunohistochemical stains for the myofibroblast mark- ers alpha smooth muscle actin and desmin were positive, thereby leading the authors to conclude that the patient had FR.

Recent studies by Burgdorf and Zelger suggest that non-Ldngerhans cell histiocytoses are linked, and those authors have proposed a unifying concept in which varying phenotypic expressions are all interrelated (3,4). These include non-Langerhans cell histiocytes having a xantho- matized appearance, scalloped appearance, oncocytic appearance, spindle-shape appearance, and vacuolated ap- pearance. It would be very interesting if Dr. Romas and his colleagues performed additional marker studies, such as analyses for factor XIIIa, KP1, HAM 56, and KI-MIP, to determine if FR is in fact yet another expression of pluri- potential histiocytes. Just as myofibroblastic elements may be encountered in dermatofibromas, the myofibroblastic elements of FR may be an expression of histiocytes.

Thomas N. Helm, MD State University of New York at Buffalo Klaus F. Helm, MD Her,shey Medical Center Hershey, PA

1. Romas E, Finlay M, Woodruff T. The arthropathy of fibroblastic rheumatism. Arthritis Rheum 1997;40:183-7.

2. Vignon-Pennamen MD, Naveau B, Foldes C, Wallach D, Bonvalet D, Ryckewaert A, et al. Fibroblastic rheumatism. J Am Acad Dermatol 1986:14:1086-8.

3. Burgdorf WHC, Zelger B. Miscellaneous histiocytic disorders unit 20-17. In: Demis DJ, editor. Clinical dermatology. Vol. 4. 24th ed. Philadelphia: Lippincott-Raven Publishers; 1996. p. 1-16.

4. Burgdorf WHC. The histiocytoses: have we finally moved past the “X”? Med Surg Dermatol 1996;3:63-8.

Destructive arthropathy in fibroblastic rheumatism: comment on the article by Romas et al

To the Editor: I read with interest the article by Romas et a1 on the

arthropathy of fibroblastic rheumatism (FR) (1). I agree with the authors that destructive arthropathy can occur in FR, as illustrated in a case reported by my colleagues and me in 1982 (2). We examined the patient 8 years after the onset of the

Figure 1. Radiograph of the hands, showing osteopenia, narrowing, and erosions of the metacarpophalangeal joints, interphalangeal joints, and wrists.

Figure 2. Radiograph of the feet, showing marginal erosions of the metatarsophalangeal joints.