Pentagimenal Premature Ventricular Contractions in COVID-19 Pneumonia with the Passing Phenomenon (Yasser's Phenomenon) and Suspected Hiatus Hernia; the Strange Combina
Mod J Med Biol
Article Type : Case Reports
A 65-year-old married, Egyptian farmer, heavy smoker, male patient was presented to the emergency department (ED) with palpitations, tachypnea, chest pain, and cough. Fever, loss of smell, anorexia, and fatigue were associated symptoms. The chest pain was anginal. The patient had a history of contact with his relative who confirmed a COVID-19 patient in the past 10 days. The patient was brought with his family to the hospital ED after COVID-19 confirmation for consultation. He is a currently heavy smoker (at least 20 cigarettes for about 20 years). He has a history of chronic dyspepsia. The patient denied a history of cardiovascular diseases, the same attack, drugs, or any other special habits. Informed consent was taken. Upon general physical examination; generally, the patient was tachypneic, distressed, with a regular pulse rate (sinus arrhythmia with VR; 72 bpm), blood pressure (BP) of 150/90 mmHg, respiratory rate of 22 bpm, the temperature of 37.8 °C, and pulse oximeter of oxygen (O2) saturation of 94%. He appeared long and thin. Tests for latent tetany were positive. He was admitted to the intensive care unit with acute chest pain and COVID-19 pneumonia. Initially, the patient was treated with O2 inhalation by O2 cylinder (100%, by nasal cannula, 5 L/min). The patient was maintained treated with cefotaxime; (1000 mg IV every 8 hours), azithromycin (500 mg PO single daily dose), oseltamivir (75 mg PO twice daily only for 5 days), and paracetamol (500 mg IV every 8 hours as needed). SC enoxaparin 80 mg twice daily), aspirin tablet (75 mg, once daily), clopidogrel tablet (75 mg, once daily), and hydrocortisone sodium succinate (100 mg IV every 12 hours) were added. The patient was daily monitored for temperature, pulse, blood pressure, and O2 saturation. The initial ECG was done on the initial presentation in the ICU showing uniformed pentigeminal PVCs, rigor artifact in I, II, III, aVR, aVL, and aVF leads, and technical artifacts in V1 and V2 leads (Figure 1A). The second ECG tracing was done on was done within one minute of the above ECG tracing showing the complete disappearance of the above pentigeminal PVCs. There is a Wavy triple sign (Yasser’s sign) of hypocalcemia that appeared in the V6 lead. Rigor artifacts are still seen in I, II, III, aVR, aVL, and aVF leads. Horizontal ST-segment depressions are seen in inferior leads (II, III, and aVF; red arrows) and anterolateral leads (V2-6) leads (Figure 1B). The initial complete blood count (CBC); Hb was 11.4 g/dl, RBCs; 4.06*103/mm3, WBCs; 16.1*103/mm3 (Neutrophils; 88.3 %, Lymphocytes: 7.6%, Monocytes; 3.1%, Eosinophils; 1% and Basophils 0%), Platelets; 165*103/mm3. S. Ferritin was high; 507 ng/ml. D-dimer was high (579 ng/ml). CRP was high (42 g/dl). LDH was normal (424 U/L). SGPT was normal (17 U/L), SGOT was normal (32 U/L). Serum creatinine was normal (0.7 mg/dl) and blood urea was normal (19 mg/dl). Random blood sugar (RBS) was slightly high (218 mg/dl). Ionized calcium was slightly low 0.83 mmol/L). The troponin test was negative. After 15 days of management; RBS was normal (91 mg/dl). CBC; Hb was 10 g/dl, RBCs; 3.8*103/mm3, WBCs; 11.7*103/mm3 (Neutrophils; 51.1 %, Lymphocytes: 38%, Monocytes; 10.9%, Eosinophils; 0% and Basophils 0%), Platelets; 418*103/mm3. Serum ferritin was normal (175 ng/ml). D-dimer was normal (308 ng/ml). CRP was borderline high(0.7 g/dl). LDH was normal (176 U/L). SGPT was normal (44 U/L), SGOT was normal (49 U/L). Serum creatinine (1.2 mg/dl) and blood urea (55 mg/dl) were normal. Ionized calcium was slightly low; 1.07 mmol/L. The troponin test had still negative. A plain CXR film was done on the ICU admission showing bilateral paracentral ground-glass opacities (lime arrows). Shadow of hiatus hernia is seen on the left side (Figure 2A). The first chest CT without contrast was done on the ICU admission showing a shadow of hiatus hernia (Figure 2B). The same above chest CT shows mild bilateral vague hazy variable-sized ground-glass opacities (Figure 2C). Chest CT without contrast was repeated within 26 days of the presentation showing bilateral vague hazy variable-sized ground-glass healing opacities (Figure 2D). Echocardiography showed diastolic dysfunction with normal EF (61%). Pentagimenal premature ventricular contractions in COVID-19 pneumonia with the Passing phenomenon (Yasser's phenomenon) and suspected hiatus hernia were the most probable diagnosis. Within 26 days of the above management, the patient finally showed nearly complete clinical, radiological, and laboratory improvement. The patient was continued on aspirin tablet (75 mg, OD) for three months, longstanding nitroglycerine oral capsules (2.5 mg BID), and calcium with vitamin D oral preparations (OD) for 2 weeks with follow-up. Further cardiac, chest and surgical follow-up were advised. Figure 1: Serial ECG tracings; A. tracing was done on the initial presentation in the ICU showing uniformed pentigeminal PVCs, (orange arrows), rigor artifact in (lime arrows) in I, II, III, aVR, aVL, and aVF leads (lime arrows) and technical artifacts in V1 and V2 (light blue arrows). Figure 2: (A): Plain CXR film was done on the ICU admission showing bilateral paracentral ground-glass opacities (lime arrows). Shadow of hiatus hernia is seen in the left side (orange lining). (B): Chest CT without contrast was done on the ICU admission showing a shadow of hiatus hernia (rose arrow). (C): The same above chest CT shows mild bilateral vague hazy variable-sized ground-glass opacities (lime arrows). (D): Chest CT without contrast was done within 26 days of the presentation showing bilateral vague hazy variable-sized ground-glass healing opacities (lime arrows).
B. tracing was done on was done within one minute of the above ECG tracing showing complete disappearance of the above pentigeminal PVCs. There is a Wavy triple sign (Yasser’s sign; yellow, green, and dark blue arrows) of hypocalcemia that appeared in V6 lead. Rigor artifacts (lime arrows) are still seen in I, II, III, aVR, aVL, and aVF leads (lime arrows). Horizontal ST-segment depressions are seen in inferior leads (II, III, and aVF; red arrows) and anterolateral leads (V2-6; red arrows) leads.
