Hypercalcemia is a common electrolyte disorder and is typically caused by parathyroid-dependent and parathyroid-independent causes. The most common parathyroid-independent causes include malignancy, granulomatous diseases, over-supplementation with calcium, and hypervitaminosis D. We present an unusual case of a woman who had Stimulan implanted after an artificial knee joint infection. When a washout was done, the patient's serum calcium started rising, peaking at an astounding 21.2 mg/dL (normal range 8.4 - 10.2 mg/dL) with acute kidney injury. After aggressive hydration and treatment with furosemide, bisphosphonates, and calcitonin, the serum calcium dropped to 10.1 mg/dL. A full hypercalcemia workup did not reveal an alternate cause. On further investigation, it was found that Stimulan is calcium based, and the agitation of these beads during washout was hypothesized to result in the observed profound hypercalcemia.

Idiopathic nodular glomerulosclerosis is an unusual histopathological finding that has commonly been observed in male smokers with hypertension. It has remained an enigmatic condition and is best described as a diabetic pattern of glomerular injury seen in non-diabetic patients. It is also one of the few nicotine (smoking)-associated/smoking-associated patterns of renal injury. We present an even more unusual manifestation of this pathological finding in a 59-year-old Hispanic female who presented with chronic kidney disease approaching need for renal replacement therapy. The patient had idiopathic nodular glomerulosclerosis on kidney biopsy, despite no prior history of diabetes, nor smoking history, including no secondhand smoking exposure. The patient did have hypertension. The renal biopsy also showed evidence of chronic thrombotic-microangiopathic changes within arteries and arterioles. Genetic testing of the alternative pathway revealed an unusual and likely pathological variant of thrombomodulin supporting complement dysfunction as having a role in the presentation.

Cetyl Alcohol is a rare cause of acidosis if ingested in large quantities. Hyponatremia with overlapping anion gap and osmolal gap-positive metabolic acidosis may appear to have iso-osmolar serum. This is a case of an unusual toxic exposure.