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The triad of diarrhea, dementia, and dermatitis constitutes the clinical diagnosis of pellagra. However, most reported cases of pellagra have occurred without all components of the triad. Pellagra was declared eradicated in the United States after an outbreak in the 1920s, and is now considered to be an exceedingly rare diagnosis in developed countries. In this article, we present a case of a 56-year-old man who presented with a significant history of alcohol use and chronic diarrhea. Pellagra was clinically diagnosed based on the triad of diarrhea, cognitive dysfunction, and dermatitis in this malnourished, alcoholic patient. The patient was treated and clinically improved with resolution of his diarrhea and cognitive dysfunction.

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Pulmonary complications from cocaine use can range from bronchospasm to vasospasm leading to pulmonary infarction. Profound vasospasm may also lead to perfusion defects presenting as pulmonary embolism on ventilation-perfusion scan. A 65-year-old patient with a past medical history of substance abuse and chronic kidney disease presents to the emergency department with sudden-onset chest pain and shortness of breath. Ventilation-perfusion scan revealed filling defect most notably in the lingual lobe. He was later discharged on warfarin for the management of pulmonary embolism. The patient presented to the emergency department 2 weeks later with similar complaints; the international normalized ratio was subtherapeutic, and urine drug screen was positive for cocaine. Repeat ventilation-perfusion scan revealed no filling defects. Follow-up bilateral venous Doppler of lower extremities and D-dimer were within normal limits.

Introduction:Cocaine is a widely abused substance globally. It effects on the pulmonary system can range from bronchospasm to pulmonary vasoconstriction. We present a case of cocaine induced pulmonary vasoconstriction mimicking pulmonary embolism on ventilation-perfusion scan. Case summary:A 65 male with a past medical history of hypertension, diabetes, renal call carcinoma status-post nephrectomy and chronic kidney disease stage IV presents to the emergency department with sudden chest pain and shortness of breath. Denies any fever, chills or prior episodes. Social history was significant 20-year pack smoking history, intravenous drug abuse. Vitals were blood pressure 160/95 mmhg, pulse 90 beats per minutes, respiratory rate 18 breaths per minute and temperature 37.8 C. Physical exam was significant for a non-obese male in acute distress and chest wall tenderness on palpation. A 12 lead electrocardiogram obtained revealed no ischemic findings. Laboratory findings revealed creatinine of 4.3 mg/dL with baseline 3.0-4.5. Other labs including troponin, brain natriuretic peptide were normal. Ventilationperfusion (V/Q) scan obtained to revealed a filing defects in the inferior lingual, posterior inferior upper lobe and posterior inferior lower lobe characteristic for pulmonary embolism (PE). Follow up transthoracic echocardiogram revealed no evidence of ventricular strain. The patient was started on heparin drip and admitted for further management. He remained stable throughout admission, was successfully bridged to warfarin and home in stable condition, international normalized ratio (INR) at that time was 2.3. Two weeks later, he presented to the emergency department with similar complains. Vitals were unremarkable and physical examination was unchanged from prior. Significant laboratory findings were INR 1.12. Patient reports non adherence to warfarin. Due to concern for recurrent PE V/Q scan was ordered, however it revealed no filling defects and lower extremity doppler ultrasound revealed no clot. D-dimers was also normal. Urine drug screen obtained was positive for cocaine. With the help of the radiologist we compared both V/Q scans, it was deemed that the filling defect initially identified was due to vasospasm of the pulmonary vessels, likely secondary to cocaine. Warfarin was discontinued, cocaine cessation was advised and his chest pain was managed as a musculoskeletal pain. He was later discharged home in stable condition. Discussion:While ventilation-perfusion scan is a safe screening tool to evaluated for pulmonary embolism, it lacks specificity. Other causes of ventilation or perfusion defects should be considered. In this case it was due to cocaine inhalation.