By Doris Loh

On March 11th, 2020 during a media briefing, the World Health Organizati\aon (WHO) declared COVID-19 a pandemic as confirmed COVID-19 cases outside of China increased 13-fold and the number of countries affected tripled.  On that day, 126,000 people around the world contracted COVID-19, while 122 countries around the world reported COVID-19 infections [3].

Even though cases in China and South Korea have declined dramatically, those in Italy and Iran have been rising relentlessly. Italy has the most cases outside China with roughly 12,462 infections, followed by Iran with 9,000 infections and South Korea with 7,775 (March 11th, 2020).  COVID-19 patients in Italy also have the highest case fatality rate, currently at 6.6% [3].

Unofficial reports from doctors and healthcare workers from COVID-19 frontlines in Italy described most patients displayed symptoms of bilateral interstitial pneumonia that required intubation (invasive ventilation) to assist difficulty in breathing. Even young patients without comorbidities have been observed with severe pneumonia that required intensive care in ICUs [4, 5].

These dramatic and shocking accounts of severe pneumonia in Italians infected by COVID-19 strongly support similar evidence presented by scientists and doctors in China where mortality of critically ill patients with SARS-CoV-2 pneumonia is extremely high. In one study,  86% of ICU patients requiring invasive mechanical ventilation did not survive [6].

In general, patients above 65 years of age with comorbidities and ARDS are at a much higher risk of death.  Acute respiratory distress syndrome (ARDS), or acute lung injury (ALI), is a condition when severe lung failure is marked by acute onset of respiratory failure, accompanied by low arterial oxygen levels.  Most often than not, bilateral opacities in the lungs are also observed in ARDS patients [7].

In one recent cohort study from China, 86% of patients with COVID-19 pneumonia showed typical imaging features of ground-glass opacities (GGO) in their lungs [8]; and 64% had mixed GGO and consolidation [9].  Most shocking of all, 70.2% of patients examined in the study were between the ages of 21 to 50 years [8]. Thus, young patients stricken with bilateral interstitial pneumonia in Italy is not inconsistent with the results of COVID-19 patients observed in China.

Why does SARS-CoV-2, the coronavirus responsible for COVID-19 infection, induce pneumonia in adult patients regardless of age?

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