Corrected QT (QTc) prolongation in COVID-19 is usually multifactorial. Medication is one of the most important implicated causes for causing QTc prolongation during the treatment of COVID-19. There are numerous pathogeneses involving the drug-inducing QTc prolongation on the treatment of COVID-19 [1]. The common mechanism is by inhibiting the human ether-a-go-go-related gene - K+ channel in myocytes, causing a retardation of repolarization with subsequent QT-interval prolongation [1]. There is high risk index of torsades de pointes (TdP) when a QTC of >500-600ms [2,3]. So, QTc prolongation is an inducer hallmark for the developing TdP. Screen for other risk factors for QTc prolongation such as hypokalemia, and renal dysfunction is pivotal. ECGs should be done in all patients with symptomatic arrhythmia and periodically in these at high risk of QT prolongation/TdP [4]. Corrected QT interval is inversely relevant to serum potassium and calcium. QTc interval prolongation is an independent predictor of all-cause mortality [5]. Very strong evidence of QTc-prolonging is found for hypokalemia [6]. Prolongation of the QTc interval in patients with mitral valve prolapse (MVP) has been reported in several studies. Not all investigations, however, have found a correlation between MVP and prolonged QTc intervals [7]. Electrocardiographic (ECG) artifacts are defined as ECG abnormalities, which are a measurement of cardiac potentials on the body surface and identified as ECG alterations, not related to cardiac electrical activity. Spike sign is the artifact in which of small regular or irregular peaks among broad QRS complexes [8,9]. These artifacts are common internal physiological cause due to muscular activity which allows electronic filtration yielding small spikes [10]. Wavy triple an ECG (ECG) sign (Yasser’s sign) is a new specific diagnostic sign seen in 97.3% of the cases of hypocalcemia. Wavy triple an ECG sign can be used as a therapeutic guide in the cases of hypocalcemia [11]. Wavy double ECG sign (Yasser’s sign) was also prescribed in hypocalcemia which is mostly seen with either tachycardia or bradycardia [11]. Epiglottitis is a life-threatening an inflammatory and infection condition of the epiglottis that causes profound swelling of the upper airways which can lead to asphyxia and respiratory arrest [12].

A 15-year-old, adolescent male student Egyptian patient was presented to the intensive care unit with stridor. The patient also gave a history of recent history of COVID19- pneumonia within the past 7 days. Generalized body aches, fatigue, loss of, appetite, severe episodic cough, stridor, loss of smell, tachypnea, numbness, and paresthesia of extremities were associated symptoms. The patient denied a history of other relevant diseases, drugs, or other special habits. Upon general physical examination, generally, the patient appeared irritable and distressed with a regular pulse rate of VR; 78 bpm, blood pressure (BP) of 110/70 mmHg, respiratory rate of 20 bpm, a temperature of 37.8 °C, and pulse oximeter of oxygen (O2) saturation of 92%. Tests for latent tetany were positive. Currently, the patient was admitted to the ICU for stridor and COVID-19 pneumonia. Initially, the patient was treated with O2 inhalation by O2 system line (100%, by simple mask, 5L/min). The patient was maintained treated with cefotaxime; (1000 mg IV TDS), azithromycin tablets (500 mg, OD), oseltamivir capsules (75 mg, BID only for 5 days), and paracetamol (500 mg IV TDS as needed). SC enoxaparin 80 mg, BID), aspirin tablet (75 mg, OD), clopidogrel tablets (75 mg, OD), and hydrocortisone sodium succinate (100 mg IV BID). The patient was daily monitored for temperature, pulse, blood pressure, ECG, and O2 saturation. The initial ECG tracing was done on the second day of the ICU admission showing normal sinus rhythm (NSR of VR of 74), QTc prolongation, Spike sign, Wavy triple ECG sign (Yasser’s sign; II and III) Wavy double ECG sign (Yasser’s sign; aVF) (Figure 1A). The second ECG tracing was taken within 2 minutes of the above ECG showing NSR (of VR of 65) and QTc prolongation (Figure 1B). Azithromycin tablets and oseltamivir capsules were acutely stopped after taking the above ECG tracings due to QTc prolongation. The CXR film, posterior view was done on the first day of the ICU admission showing a vague shadow of consolidation in the right lung and thumb sign shadow in the upper neck that is suggestive of epiglottitis (Figure 2A). The chest CT scan was done on the second day of the ICU admission showing a halo sign and transverse ridge of ground-glass consolidation of the right lung (Figure 2B). The echocardiography was done on the second day of the ICU admission showing prolapsing of AML and good systolic function with EF of 69.18% (Figure 2C). The initial complete blood count (CBC); Hb was 10.8 g/dl, RBCs; 3.69*103/mm3, WBCs; 18.8*103/mm3 (Neutrophils; 82.1 %, Lymphocytes: 7.5%, Monocytes; 6.8%, Eosinophils; 3% and Basophils 0.6%), and Platelets; 340*103/mm3. CRP was high (26.1g/dl). SGPT (41 U/L) and SGOT were normal (37U/L). Serum albumen was normal (4.2gm/dl). Serum creatinine (1.05mg/dl) and blood urea (31 mg/dl) were normal. RBS was (92 mg/dl). Plasma sodium was (139mmol/L). Serum potassium was (3.2mmol/L). Ionized calcium was (1.04 mmol/L). QTc prolongation, epiglottitis, Wavy triple sign, Wavy double sign (Yasser’s signs), and Spike sign post-COVID pneumonia in a mitral valve prolapse was the most probable diagnosis. Within a few days of the above management, the patient finally showed nearly dramatic clinical and electrocardiographic improvement. The patient was discharged and continued on aspirin tablets (75 mg, OD), and clopidogrel tablets (75 mg, OD), oral calcium and vitamin D preparation were prescribed for a few weeks. Further recommended cardiac follow-up was advised.

Figure 1: Serial ECG tracings; A. tracing was done on the second day of the ICU admission showing normal sinus rhythm (NSR of VR of 74), QTc prolongation, Spike sign (orange arrows), Wavy triple ECG sign (Yasser’s sign; II and III; blue, green, and red arrows) Wavy double ECG sign (Yasser’s sign; aVF; green, and red arrows). B. tracing was taken within 2 minutes of the above ECG showing NSR (of VR of 65) and QTc prolongation (U-shape rectangles in lead II).

Figure 2: A. CXR film, posterior view was done on the first day of the ICU admission showing a vague shadow of consolidation in the right lung (red circle) and thumb shadow in the upper neck (blue lining) that is suggestive of epiglottitis. B. Chest CT scan was done on the second day of the ICU admission showing a halo sign (red arrow) and transverse ridge of ground-glass consolidation (lime arrow) of the right lung. C. Echocardiography was done on the second day of the ICU admission showing prolapsing of AML (lime arrow) with EF of 69.18% (blue arrow).

Overview:

A 15-year-old, adolescent Egyptian male student patient was presented to the intensive care unit with stridor with QTc prolongation, hypocalcemia, and hypokalemia after COVID-19 pneumonia.

The primary objective: for my case study was the presence of an adolescent male student Egyptian patient was presented to the intensive care unit with stridor with QTc prolongation, hypocalcemia, and hypokalemia after COVID-19 pneumonia to the ICU.

The secondary objective: for my case study was the question of; how would you manage this case at the ICU?

Interestingly, a positive contact history to a case of COVID-19 pneumonia, COVID-19 suggested symptoms, laboratory evidence (CBC and CRP), and radiological evidence of ground-glass consolidation with halo sign are directed signals for a suspected COVID-19 pneumonia. Thumb sign shadow in the upper neck is of COVID-19 suggestive of epiglottitis (Figure 2A). The presence of Spike sign ECG artifact indicates there is a patient irritability. Its disappearance had happened after a reassurance of the patient. Clinically, tachypnea, numbness, and paresthesia of extremities with positive tests for latent tetany, laboratory lower ionized calcium, Wavy triple ECG sign, and Wavy double ECG sign (Yasser’s signs) are more parallel to hypocalcemia (Figure 1A).

Movable phenomenon: or Yasser’s phenomenon of hypocalcemia is a signal for associated tachypnea in the current case (Figure 1A and 1B). The presence of a changeable Wavy triple sign in ECG is a hallmark of the Movable phenomenon (Yasser’s phenomenon) of hypocalcemia [13]. The Wavy triple ECG sign (Yasser’s sign) is a recently innovated diagnostic sign in hypocalcemia [11]. The author's interpretations are based on the following: 1. Different successive three beats in the same lead are affected. 2. All ECG leads can be implicated. 3. An associated elevated beat is seen with the first of the successive three beats, a depressing beat with the second beat, and an isoelectric ST-segment in the third one. 4. The elevated beat is either accompanied by ST-segment elevation or just an elevated beat above the isoelectric line. 5. Also, the depressed beat is either associated with ST-segment depression or just a depressing beat below the isoelectric line. 6. The configuration for depressions, elevations, and isoelectricities of the ST segment for the subsequent three beats are variable from case to case. So, this arrangement is non-conditional. 7. Mostly, there is no participation among the involved leads. The author intended that is not conditionally included in a special coronary artery for the affected leads [11,13]. Tachypnea was a possible cause of hypocalcemia and subsequent Wavy triple ECG sign, Wavy double ECG sign, and Movable-weaning phenomenon of hypocalcemia [11,13]. Idioventricular rhythm is the most probable ECG differential diagnosis for the current case study. However, there is no widening of QRS complexes and present P-waves. I can’t compare the current case with similar conditions. There are no similar or known cases with the same management for near comparison. The only limitation of the current study was the unavailability of laryngoscopy.

QTc prolongation, epiglottitis, Wavy triple sign of hypocalcemia, Wavy double sign of hypocalcemia (Yasser’s signs), hypokalemia, and Spike sign post-COVID pneumonia in a mitral valve prolapse are serious constellation serious risk factors.

QTc prolongation is multifactorial.

COVID pneumonia, hypocalcemia, hypokalemia, mitral valve prolapses, azithromycin, and oseltamivir are often implicated causes of the current QTc prolongation.

Conflicts Of Interest

 There are no conflicts of interest.

Acknowledgment

I want to thank my wife for saving time and improving the conditions for supporting me.

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