Nitroglycerine and Furosemide in Hypertensive Pulmonary Edema with Wavy Triple Sign (Yasser’s Sign), Tee-Pee Sign, and Camel-Hump T-Wave in Suspected COVID Pneumonia-Interpretations and Prognostication
Yasser Mohammed Hassanain Elsayed*
Critical Care Unit, Kafr El-Bateekh Central Hospital, Damietta Health Affairs, Egyptian Ministry of Health (MOH), Damietta, Egypt
Submission: April 14, 2023; Published: April 24, 2023
*Corresponding author: Yasser Mohammed Hassanain Elsayed, Critical Care Unit, Kafr El-Bateekh Central Hospital, Damietta Health Affairs, Egyptian Ministry of Health (MOH), Damietta, Egypt
How to cite this article: Yasser Mohammed Hassanain Elsayed*. Nitroglycerine and Furosemide in Hypertensive Pulmonary Edema with Wavy Triple Sign (Yasser’s Sign), Tee-Pee Sign, and Camel-Hump T-Wave in Suspected COVID Pneumonia-Interpretations and Prognostication. J of Pharmacol & Clin Res. 2023; 9(2): 555761. DOI: 10.19080/JPCR.2023.09.555761
Rationale: Hypertensive pulmonary edema is a lethal sequence of hypertensive crises. It represents a remarkable presentation in the critical care department for hypertensive patients. ECG abnormalities are frequently identified complications in COVID-19 patients. Wavy triple an electrocardiographic sign (Yasser’s sign) is a new specific diagnostic sign seen in the cases of hypocalcemia. There is a strong link between COVID-19 infection and the Wavy triple ECG sign (Yasser’s sign). Tee-Pee sign and Camel-Hump T-wave are strongly relevant to electrolyte disorders. Nitroglycerine is a strong vasodilator and antihypertensive drug. Furosemide is the strongest diuretic drug.
Patient concerns: A 67-year-old, Farmer, married Egyptian male patient was presented to the intensive care unit with hypertensive pulmonary edema, various new ECG signs, and suspected COVID-19 pneumonia.
Diagnosis: Hypertensive pulmonary edema with Wavy triple sign (Yasser’s sign), Tee-Pee sign, and Camel-Hump T-wave in suspected COVID pneumonia.
Interventions: Chest CT, electrocardiography, and oxygenation.
Outcomes: Good outcomes with dramatic responses in the presence of several remarkable critical risk factors were the results.
Lessons: The association of COVID pneumonia with hypertensive crises, pulmonary edema, bilateral pleural effusion, Wavy triple ECG sign (Yasser’s sign), Tee-Pee sign, and Camel-Hump T-wave in the elderly patient is highly interesting and remarkable. An elder age, male, diabetes, hypertensive crises, pulmonary edema, hypocalcemia, hypokalemia, hypernatremia, pleural effusion, and COVID-19 pneumonia are constellation serious risk factors. Wavy triple ECG sign (Yasser’s sign), Tee-Pee sign, and Camel-Hump T-wave may be transient. Nitroglycerine and furosemide are highly effective in hypertensive pulmonary edema with suspected COVID pneumonia.
Hypertensive crises with acute elevations in blood pressure
that are associated with end-organ damage such as acute
myocardial infarction, cerebrovascular accident, acute pulmonary
edema, or acute renal failure are called is defined as a hypertensive
emergency. Hypertensive crises represent the most immediate
danger to those afflicted and the most dramatic proof of the
lifesaving potential of antihypertensive therapy. Hypertensive
crises are present when markedly elevated blood pressure or >
180/120 mmHg are common issues in the emergency department.
Prompt diagnosis, based primarily on signs and symptoms is
essential. Appropriately aggressive therapy will often result in
a satisfactory outcome . Pulmonary edema is one of the most
common acute respiratory disorders. Its diagnosis and treatment
of the disease are still clinical problems . COVID-19 mortality
is primarily driven by abnormal alveolar fluid metabolism of
the lung, leading to fluid accumulation in the alveolar airspace.
This condition is generally referred to as pulmonary edema and
is a direct consequence of severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) infection. There are multiple potential
mechanisms leading to pulmonary edema in severe Coronavirus
Disease (COVID-19) patients . Nitroglycerin is a vasodilatory
medication. It is currently off-label and non-FDA-approved uses
include acute management of hypertensive crises . Indeed,
nitroglycerin has an arterial and venous vasodilatory effect. But
the more desired effects primarily are caused by venodilation
. Venodilation causes blood pooling inside the venous system,
reducing cardiac preload, decreasing cardiac work, and reducing
anginal symptoms .
Furosemide is one of the most powerful diuretics but has the
lowest toxicity. It acts as a diuretic by binding to the potassium
sodium cotransporter on the thick ascending limb of the loop
of Henle. Furosemide caused a significant decrease in blood
pressure, with no remarkable effect on heart rate. It improves
the symptoms of pulmonary edema by reducing excess fluid in
the lungs. The reduced liquids will improvement of pulmonary
symptoms . The Wavy triple ECG sign (Yasser Sign) is a recently
novel diagnostic sign innovated in hypocalcemia . The analysis
for this sign in the author’s interpretations is based on the
a) Different successive three beats in the same lead are
b) All ECG leads can be implicated.
c) 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.
d) The elevated beat is either accompanied by ST-segment
elevation or just an elevated beat above the isoelectric line.
e) Also, the depressed beat is either associated with STsegment
depression or just a depressing beat below the
f) 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
g) Mostly, there is no participation among the involved
The author intended that is not conditionally included in a
special coronary artery for the affected leads . The Tee-Pee
sign is a new sign like a shape of a traditional Native American
Indian’s home. It is found in hyperkalemia, hypocalcemia, and
hypomagnesemia. It causes precordial QRS-complexes with
peaked T-waves prominent U-waves, and elongation of the
descending limb of the T-wave . Camel hump T-waves is also
an innovative sign appointing to T-waves that have a double-peak.
Two causes are involved in a camel-hump T-waves: Prominent
U waves fused to the end of the T-wave are identified in severe
potassium depletion. It is more frequently seen with sinus
tachycardia and heart block. Indeed, these T-wave abnormalities
may be seen in hypothermia and severe brain damage. So, it is a
non-specific sign .
A 67-year-old, Farmer, married heavy smoker Egyptian
male patient was presented to the intensive care unit (ICU) with
tachypnea, dyspnea, palpitations, and chest pain. Generalized
body aches, cough, fatigue, anorexia, and loss of smell were
associated symptoms. The patient started to complain of fever 9
days ago. He has direct contact with a confirmed case of COVID-19
pneumonia 10 days ago. Otherwise diabetes on insulin mixture
(60 units daily; BID, 40-20) and hypertension on captopril tablets
(25mg, OD) the patient denied a history of other relevant diseases,
drugs, or other special habits. Informed consent was taken. Upon
general physical examination, generally, the patient appeared
anxious, diaphoretic, centrally cyanosed, irritable, orthopneic,
tachypneic, and distressed with a regular rapid pulse rate of VR;
110 bpm, blood pressure (BP) of 220/140 mmHg, respiratory rate
of 34 bpm, a temperature of 38 °C, and pulse oximeter of oxygen
(O2) saturation of 88%. Coarse generalized chest crepitations
were heard on chest auscultations. Currently, the patient was
admitted to ICU for Hypertensive pulmonary edema with Wavy
triple sign (Yasser’s sign), Tee-Pee sign, and Camel-Hump T-wave
in suspected COVID pneumonia. Initially, the patient was treated
with O2 inhalation by O2 system line (100%, by nasal cannula, 8L/
min) one sublingual isosorbide dinitrate tablets (5 mg, as needed),
3 frusemide IV 3 amps (40 mg), sublingual captopril tablet (25
mg, as needed), and continue nitroglycerine IVI (10 mg/50 ml
solvent, 5 ug/min, and titrated according to BP) were given. The
patient was maintained treated with cefotaxime; (1000 mg IV
TID), azithromycin tablets (500 mg, OD), oseltamivir capsules (75
mg, BID only for 5 days), hydrocortisone sodium succinate (100
mg IV BID), and paracetamol (500 mg IV TID as needed).
After controlling the BP, SC enoxaparin 80 mg, BID), captopril
tablets (25 mg; BID), aspirin tablets (75 mg, OD), frusemide IV amp
(40 mg IV TDS), and nitroglycerin retard capsules (2.5mg, BID)
were added. The patient was daily monitored for temperature,
pulse, blood pressure, ECG, and O2 saturation. The initial ECG
tracing was done on the initial presentation showed sinus tachycardia of VR; 129 with Wavy triple an ECG sign (Yasser’s
sign) in I, II, aVF, aVR, V1, and V6, Tee-Pee sign with Camel hump
T-waves in V2 and V3 (Figure 1A). The second ECG tracing was
taken within 1 minute of the above ECG tracing sinus tachycardia
of VR; 130 with Wavy triple an ECG sign (Yasser’s sign) in V4-V6
leads, there are three premature ventricular contractions (PVCs)
in V1-3 leads and two premature atrial contractions (PACs) in I,
and II leads (Figure 1B). The third ECG tracing was taken within
10 hours of the initial ECG and treatment showing NSR of VR of
86 with the disappearance of all the above abnormalities. There
is evidence of tremor artifacts (Figure 1C). The plain chest-XR film
was done on the day of presentation and ICU admission showing
upper apical right, left, and right parasternal patchy ground-glass
pulmonary consolidations. There is a honeycomb appearance in
the right parasternal area (Figure 2A). The chest CT was done
on the day of presentation and ICU admission showing bilateral
vague multiple patchy ground-glass pulmonary consolidations
and bilateral minimal (right) to trace (left) pleural effusion
(Figure 2B). The initial complete blood count (CBC); Hb was 13.6
g/dl, RBCs; 5.65*103/mm3, WBCs; 9.9*103/mm3 (Neutrophils;
76 %, Lymphocytes: 19%, Monocytes; 4%, Eosinophils; 1%
and Basophils 0%), and Platelets; 214*103/mm3. CRP was high
(24g/dl). SGPT (22 U/L) and SGOT were normal (14U/L). Serum
albumen was normal (4.0gm/dl).
Serum creatinine (1.3mg/dl) and uric acid were normal (5.9
mg/dl). RBS was slightly high (257mg/dl). Plasma sodium was high
(161mmol/L). Serum potassium was slightly low (3.3mmol/L).
Ionized calcium was low (0.7mmol/L). The troponin test was
negative. D-dimer was normal (0.25 mg/dl) ABG showed partially
compensated respiratory alkalosis. Hypertensive pulmonary
edema with Wavy triple sign (Yasser’s sign), Tee-Pee sign, and
Camel-Hump T-wave in suspected COVID pneumonia was the most
probable diagnosis. Within 10 hours of the above management,
the patient finally showed nearly dramatic clinical and mostly
electrocardiographic improvement. The patient was discharged
after clinical stabilizations and continued on aspirin tablets (75
mg, OD), clopidogrel tablets (75 mg, OD), captopril tablets (25
mg; BID), frusemide tablets (40 mg OD), and oral nitroglycerine
capsule (2.5 mg, twice daily). Further recommended cardiac and
chest follow-up was advised.
i. A 67-year-old, Farmer, married Egyptian male
patient was presented to the intensive care unit (ICU) with
hypertensive pulmonary edema, various new ECG signs, and
suspected COVID-19 pneumonia.
ii. The primary objective for my case study was the
presence of hypertensive pulmonary edema, bilateral pleural
effusion with Wavy triple sign (Yasser’s sign), Tee-Pee sign,
and Camel-Hump T-wave in suspected COVID-19 pneumonia
iii. The secondary objective for my case study was the
question; how would you manage this case in the ICU?
iv. Interestingly, the presence of a positive history of
contact with a confirmed COVID-19 case, bilateral vague
ground-glass consolidation, and some laboratory COVID-19
suspicion on top of clinical COVID-19 presentation with fever,
dry cough, generalized body aches, anorexia, and loss of smell
will strengthen the higher suspicion of COVID-19 diagnosis.
v. The existence of respiratory alkalosis is the indicator for
the current Wavy triple sign or (Yasser’s sign) of hypocalcemia.
vi. The T-wave-like shape of a traditional Native American
Indian’s home with hypocalcemia, precordial QRS-complexes
with peaked T-waves prominent U-waves and elongation of
the descending limb of the T-wave supporting the diagnosis
of Tee-Pee sign . But there is hypokalemia and not
vii. The presence of T-waves that have a double-peak with
prominent U waves fused to the end of the T-wave with
hypokalemia and sinus tachycardia suggests the diagnosis of
Camel hump T-waves . But the hypokalemia is mild.
viii. The change of leads of Wavy triple sign (Yasser’s
sign) from I, II, aVF, aVR, V1, and V6 to V4-V6 leads within
one minute indicating the diagnosis of Movable-weaning
off an electrocardiographic phenomenon in hypocalcemia
(changeable phenomenon or Yasser’s phenomenon of
ix. Wavy triple sign (Yasser’s sign), Tee-Pee sign, and Camel-
Hump T-wave disappear without specific treatment.
x. There is dramatic ECG and clinical improvement after IV
nitroglycerine and furosemide.
xi. Acute pulmonary embolism was the most probable
differential diagnosis for the current case study.
xii. I can’t compare the current case with similar conditions.
There are no similar or known cases with the same
management for near comparison.
xiii. The only limitation of the current study was the
unavailability of echocardiography.
a) The association of COVID pneumonia with hypertensive
crises, pulmonary edema, bilateral pleural effusion, Wavy
triple ECG sign (Yasser’s sign), Tee-Pee sign, and Camel-
Hump T-wave in the elderly patient is highly interesting and
b) An elder age, male, diabetes, hypertensive crises,
pulmonary edema, hypocalcemia, hypokalemia,
hypernatremia, pleural effusion, and COVID-19 pneumonia
are constellation serious risk factors.
c) Wavy triple ECG sign (Yasser’s sign), Tee-Pee sign, and
Camel-Hump T-wave may be transient.
d) Nitroglycerine and furosemide are highly effective
in hypertensive pulmonary edema with suspected COVID
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Elsayed YMH (2020) Hypocalcemia-induced Camel-hump T-wave, Tee-Pee sign, and bradycardia in a car-painter of a complex dilemma: A case report. Cardiac 2(1): 1-5.