One of the risk factors for poor outcome with SARS-CoV-2 infection is diabetes mellitus; diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are the most serious complications of diabetes mellitus. We aimed to explore the clinical characteristics and outcomes of COVID-19 patients presenting with combined DKA/HHS to our institution. Methods: A retrospective, hospital based observation case series was performed on patients with SARS-CoV-2 admitted to Intensive Care Unit between 3/20/2020 and 4/20/2020. Inclusion criteria were: (1) Blood Glucose >250 mg/dL; (2) Serum bicarbonate <18 mmol/L; (3) Anion Gap >10; (4) serum pH <7.3; (5) ketonemia or ketonuria; (6) effective/calculated plasma osmolality >304 mOsm/kg and (7) positive SARS-CoV-2 RT-PCR. Results: We reported 6 patients who presented during this period with combined DKA/HHS. Their median age was 50 years, all males, three Hispanic, and three African American. Hispanic patients, had more severe acidosis, and multiple comorbidities, with a higher mortality. The striking feature was that combined DKA/HHS was the initial presentation for COVID-19 for most of the cases. Discussion: Our observational retrospective case series shows that diabetic patients are at risk of developing combined DKA/ HHS associated with COVID-19 and a substantial mortality. To our knowledge, we are first to report the clinical characteristics and outcome in this group of patients.

INTRODUCTION: Malignant Hypercalcemia (MH) and Tumor Lysis Syndrome (TLS) are considered major oncologic emergencies. MH at initial presentation is associated with a poor prognosis (1). We present a unique case of Mixed Germ Cell tumor with an initial presentation of spontaneous TLS with hypercalcemia instead of hypocalcemia. CASE PRESENTATION:A 24-year-old male with no significant past medical history presented with abdominal pain, vomiting, anorexia, dyspnea for 3 months. Patient had a painless testicular mass for two years. Vital signs were unremarkable except for Temperature 101.8F. Physical exam showed bilateral testicular enlargement (~15cm) with mild tenderness to palpation. A large right-sided abdominal mass was palpated. Labs were significant for elevated creatinine (Cr) 2.0, phosphorus 4.9, calcium 14.4, uric acid (UA) 10.8, Alpha fetoprotein 716, lactate dehydrogenase 772. Parathyroid hormone was low at 2.7; potassium and hCG were normal. CT scans showed 16cm right-sided retroperitoneal mass with areas of necrosis and hemorrhage and mass effect causing right hydronephrosis, multiple lung nodules and diffuse multiple lytic lesions. Aggressive intravenous fluids, bisphosphonates and calcitonin were administered. Patient received Allopurinol for spontaneous TLS. Patient underwent right radical orchiectomy with urethral stent placement. Pathology showed mixed germ cell tumor with extensive sarcomatoid transformation. Serum protein electrophoresis ruled out multiple myeloma. Cr and UA levels normalized, and hypercalcemia significantly improved. Patient is currently on chemotherapy with Cisplatin and Etoposide with plan for retro-peritoneal lymph node resection after 4 cycles of treatment.DISCUSSION: MH is a paraneoplastic syndrome seen in 20-30% of patients with malignancy and is common in solid tumors (2). Paraneoplastic hypercalcemia can be PTHrP mediated, osteolysis due to bone metastasis, ectopic PTH, and calcitriol secretion (3). Osteolytic metastases is a possible cause of malignant hypercalcemia in our case given the normal PTHrP and calcitriol levels with low PTH levels. TLS is rarely associated with subsolid tumors, particularly testicular tumors. Though hypocalcemia is usually seen with TLS, in tumors with high turnover, metastatic burden, or sensitivity to chemotherapy, hypercalcemia can be seen (4) as seen in our case. Treatment of TLS is mainly prevention based on risk stratification (5) and initiating timely therapy with hydration measures, and correcting electrolyte and metabolic disturbances. Initiating Allopurinol or Rasburicase is case dependent. Data suggests surgical resection and chemotherapy for germ cell tumors carries excellent prognosis (5 year survival of 94.9%) (5).CONCLUSIONS: TLS typically presents with hypocalcemia and co-occurrence of spontaneous TLS with MH in Mixed Germ Cell Tumor is rare and carries a poor prognosis.

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