Rationale: A pandemic COVID-19 virus is still causing a serious ongoing worldwide systemic infection. Premature ventricular contractions represent risk arrhythmia in the existence of COVID-19 pneumonia. Premature ventricular contractions with structural heart disease are considered a way to sudden cardiac death. There is a correlation between the frequency of premature ventricular contractions and a poor prognosis. Hiatus hernia is an uncommon hidden non-straight type of hernia.
Patient Concerns: A 65-year-old married, Egyptian farmer, heavy smoker, male patient was admitted to the critical care unit with COVID-19 pneumonia, premature ventricular contractions, and suspected hiatus hernia.
Diagnosis: Pentagimenal premature ventricular contractions in COVID-19 pneumonia with the Passing phenomenon (Yasser's phenomenon) and suspected hiatus hernia.
Interventions: Electrocardiography, chest CT, oxygenation, and echocardiography.
Outcomes: Dramatic response and a good outcome had happened.
Lessons: Pentagimenal premature ventricular contractions and the Passing phenomenon (Yasser's phenomenon) is a novelty described in COVID-19 pneumonia. The existence of horizontal ST-segment depressions with premature ventricular contractions is a signal for the ischemic type. The associations between COVID-19 pneumonia and hiatus hernia is unknown strictly point. Elderly male sex, cigarette smoking, COVID-19 pneumonia, frequent ischemic premature ventricular contractions, ischemic heart disease, suspected hiatus hernia, and a Wavy triple sign (Yasser’s sign) of hypocalcemia remarkably add other bad prognostic points and is indicating a high-risk condition.
Keywords: COVID-19; Pneumonia; Premature Ventricular Contractions; Passing Phenomenon (Yasser's Phenomenon); Hiatus Hernia

•    COVID-19: Coronavirus disease 2019
•    ECG: Electrocardiogram
•    ICU: Intensive care unit
•    IHD: Ischemic heart disease
•    O2: Oxygen
•    PVCs: Premature ventricular contractions 
•    SGOT: Serum glutamic-oxaloacetic transaminase
•    SGPT: Serum glutamic-pyruvic transaminase 
•    SHD: Structural heart disease 
•    VR: Ventricular rate

The outstanding outbreak of the coronavirus disease 2019 (COVID-19) has suggested enormous provocations for the research, scientific, and medical communities [1]. Patients with SARS-CoV-2 infection are usually present with a wide range of clinical manifestations, from asymptomatic to critical illness [2]. Variable arrhythmias have been recorded in hospitalized COVID-19 patients. However, arrhythmia manifestations and treatment strategies that are applied in the COVID-19 patients have not been well-described [3]. The presence of premature supraventricular and ventricular complexes was reported [4]. Premature ventricular contractions (PVCs) are described as premature and bizarre-shaped QRS-complexes that are unordinary long (typically >120 msec) and seem wide on the ECG. The QRS-complexes are not forwarded by a P-wave, and the T-wave is usually large and directed in the opposite of the major deflection of the QRS [5]. PVC is a type of arrhythmia characterized by premature heart contractions arising in one of the ventricles [6]. PVCs are early depolarization of the myocardium emerging in the ventricle [6] due to an electrical impulse or ectopic rhythm from any part of the ventricles before the sinoatrial impulse has reached the ventricles [6]. Pentagimenal premature ventricular contraction; Penta- is a multiplier suffix that indicates the number (5). So, pentagimenal PVCs is the occurrence of a premature ventricular contraction every the 5th beat or four sinus beats between extra systoles [7].

Whatever PVCs in absent structural heart disease (SHD) is not harmful if there is no risk factors [8]. Indeed, PVCs with SHD are considered a way to sudden cardiac death (SCD) [8]. Unfortunately, more-frequency PVCs carry a poor prognosis [8]. The presences of PVCs in patients with ischemic heart disease (IHD) carry a poor prognosis [8]. However, PVCs with established IHD may be viewed as a marker of disease severity or as an endpoint in the natural history of the disease process [8]. The new Passing phenomenon (Yasser’s phenomenon) is a group of fleeting electrocardiographic (ECG) dynamic changes. These changes are extemporaneously reversed within a few seconds to a few minutes without any medical interventions. They were commonly reported initially as an abnormal diagnosis by cardiologists. The changes are unusual taking the opposite normal side. They may be passing as physiological or even transient changes [9]. Para-esophageal hernias (POH), or rolling hiatus hernias, are an uncommon type of hiatus hernia representing ~10% of all hiatus hernias. It can vary and can include: asymptomatic to gastro-esophageal reflux disease, substernal, post-prandial chest pain, epigastric pain, dysphagia, nausea, vomiting, gastric volvulus, recurrent aspiration, pneumonia, and chronic cough. In a para-esophageal hernia, there is an upward herniation of the gastric fundus above a normally positioned gastroesophageal junction. Generally, a hiatus hernia is classified into four types. Type I-sliding hernia: GEJ migrates into the posterior mediastinum through the esophageal hiatus. Type II-IV-para-esophageal hernias. Surgical management is indicated when medical management fails to control symptoms of gastro-esophageal reflux [10].

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.