Hypocalcemia-induced Camel-hump T-wave, Tee-Pee sign, and Bradycardia in a Car-painter of a Complexed Dilemma: A Case Report

Rationale: Electrocardiographic is a fundamental tool for a cardiologist, critical care physician, and emergency medicine specialist. The electrolyte imbalance is a very important entity in clinical medicine management. Camel-hump T-wave and the Tee-Pee sign, recently; Wavy triple and Wavy double signs of hypocalcemia (Yasser’s sign) are electrocardiographic findings linked to electrolyte deficiencies. Patient concerns: A middle-aged male car-painter patient presented to the emergency department with atypical severe twisting chest pain, hypocalcemia, hypokalemia, and hypernatremia. Diagnosis: Hypocalcemia-induced Camel-hump T-wave, Tee Pee sign, Wavy double sign of hypocalcemia (Yasser’s sign), and bradycardia in a carpainter. Interventions: Electrocardiography, arterial blood gases, oxygenation, and echocardiography. Lessons: The dramatic reversal of Camel-hump T-Wave, Tee-Pee sign, Wavy double sign of hypocalcemia (Yasser’s sign) after calcium gluconate injection interpret that these signs were due to hypocalcemia. The twisting chest pain and its limited disappearance immediately after calcium gluconate injection indicate the pain can be named as “chest tetany”. Non-atropine bradycardia response is evidence that the management of the cause of bradycardia sometimes is essential e.g. hypocalcemia in the current case. Outcomes: There was a dramatic response of both clinical and electrocardiography including Camel-hump T-wave, Tee Pee sign, the wavy double sign of hypocalcemia, and bradycardia.


INTRODUCTION
Specific and several changes because of electrolyte disturbance may be detected on an electrocardiogram (ECG) [1]. 'Camel hump' T-waves is an innovative expression by Amal Mattu to appointing to T-waves that have a double-peak.
However, there are two causes implicated in a camel hump DOI : https://doi.org/10.35702/card.10007 T-waves: Prominent U waves fused to the end of the T-wave is identified in severe potassium depletion. Hidden P-waves plunged in the T-wave more commonly detected with sinus tachycardia and all degrees of heart block [2]. Anyhow, by its name, the T-waves indicate the shape it exhibits (doublepeaks). Indeed, these T-wave abnormalities may be seen in hypothermia and severe brain damage. So, it is a non-specific sign [3]. Indeed, the T-wave has two humps (like a camelback).
Thus, the highest hump of both should be chosen. If the T-wave has a positive and negative hump (or the other way around), the tallest hump also should be selected (the first hump is always the highest amplitude which needs to draw the tangent) [4]. The prolongation of the QTc-interval is a nonspecific ancient ECG sign for hypocalcemia [5]. However, QTC prolongation will be a risk to serious ventricular arrhythmias [6]. Wavy triple an electrocardiographic sign (Yasser Sign) is a recently a novel diagnostic sign innovated in hypocalcemia.
Related wavy double an electrocardiographic sign also was prescribed in hypocalcemia which is mostly seen with either tachycardia or bradycardia [6]. The "Tee-Pee sign", so-called as it resembles the shape of a traditional Native American Indian's home. Johri AM, et al. found a case in which a combination of hyperkalemia, hypocalcemia, and hypomagnesemia resulted in precordial QRS-complexes with peaked T-waves, prominent U-waves, and prolongation of the descending limb of the T-wave [7]. The T-wave that interlocking the U-wave was the result that is called the "Tee-Pee Sign" due to the shape of the QRS-complexes like the conventional fashion of Native American Indians dwelling. The incorporation of prolongation of both the ST-segment and descending limb of the T-wave resulted in pseudo-prolongation of the QT-interval [7].

CASE PRESENTATION
A 42-year-old married, male, car-painter, Egyptian, heavy smoker patient presented to the emergency department with acute chest pain. The chest pain was severe, twisting, radiating to the right arm, and increasing with effort. He was a heavy  clinical and all above ECG findings but with still evidence of RBBB and VR; 68 bpm occurred ( Figure 2B). The patient was discharged within 12 hours after controlling the chest pain, and electrocardiographic normalization. Oral calcium and vitamin-D preparation were prescribed on discharge. Future serial liver function tests and ionized calcium were advised.
Later follow up with an endocrinologist and nephrologist for electrolytes imbalance will be recommended.

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The secondary objective for my case study was the priority in the management of angina, bradycardia, severe hypocalcemia, severe hypokalemia, and mild hypernatremia.
• The twisting chest pain and its limited disappearance immediately after Calcium gluconate injection indicate the pain may be named as "chest tetany". The chest pain didn't relive after O 2 , anti-ischemic medications, and even after pethidine analgesia.

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The dramatic reversal of Camel-hump T-wave, Tee-Pee sign, Wavy double sign of hypocalcemia (Yasser's sign) after calcium gluconate injection interpret that these signs were due to hypocalcemia.
• Despite hypokalemia-inducing Camel-hump T-wave was mentioned in the above literature as a cause, but it was so far here.
• Still present evidence of right bundle branch block give a possibility for non-pathological normal variant RBBB.

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The negative troponin test with non-conclusive ECG changes for ischemic heart disease (IHD), and normal echocardiography will quietly exclude the presence of IHD.
• Non-atropine bradycardia response is an indicator that the management of the cause of bradycardia sometimes is essential e.g. hypocalcemia in the current case. The etiology of the combination of hypocalcemia, hypokalemia, and hypernatremia in the current case is unknown. car-paint toxicity was the possible cause.
• Primary aldosteronism (Conn's syndrome) was the main differential diagnosis.
• I can't compare the current case with similar conditions. There are no similar or known cases with the same management for near comparison.
• Study questions here; How did you manage the current case? What are the possible causes of the ECG changes?.

LIMITATIONS OF THE STUDY
Because of it was a single case study, consideration of bias or missed cases was excluded. But, regards the current case and hypokalemic-induced Camel-hump T-Wave literature, the author thinks that the link between hypokalemia and Camel- hump T-Wave is controversial. Widening the research at this point will be advised. There was no longer a follow-up. Placebo is not considered in the study.

RECOMMENDATIONS
It is recommended to widening the research in clearing the presence of Camel-hump T-Wave, Tee-Pee sign, and Wavy double sign (Yasser's sign) in hypocalcemia.

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The dramatic disappearance of Camel-hump T-Wave, Tee-Pee sign, Wavy double sign of hypocalcemia (Yasser's sign), and bradycardia means that all these signs and finding were lonely due to severe hypocalcemia.
• Despite, it was a single case report, the author thinks that the study for a similar case report series or research will be recommended for support these results as possible.

CONFLICTS OF INTEREST
There are no conflicts of interest.
ACKNOWLEDGMENT I wish to thank the nurses of the critical care unit in Fraskour Central Hospital who make extra-ECG copies for helping me.