SARS, the COVID-19 Pandemic and Obesity

SARS (Severe Acute Respiratory Syndrome), was first discovered on February 26, 2003. A man from Vietnam was admitted to the hospital with a high fever, dry cough, myalgia, and mild sore throat. Over the days, he developed increasing respiratory difficulties, severe thrombocytopenia, and signs of Adult Respiratory Distress Syndrome, which required ventilator support. Despite intensive therapy he died 15 days later.

In March 2003, seven health care workers who had cared for the SARS patient also became ill (high fever, myalgia, headache, and less often sore throat). The onset of illness ranged from 4 to 7 days after admission of the first contact case.

By March 15, 2003, forty-three people became sick in Vietnam. At least five of these patients required ventilator support. Two patients died; With the exception of one case (the son of a health care worker), all cases have had direct contact with the hospital where the first case had received treatment. While much has been learned about SARS since it was brought to international attention in March 2003, there remain many unanswered questions about where it came from and how it was spread to humans. 

In May 2004, the epidemic was contained, a total of 167 cases were identified with 4 deaths. The infectious agent was identified as coronavirus. 

Coronaviruses are a large group of viruses that cause diseases in animals and humans. They often circulate among bats, and can sometimes evolve and infect people. In humans, the viruses can cause mild respiratory infections, like the common cold, but can lead to serious illnesses, like pneumonia.

Coronaviruses are named for the crown-like spikes on their surface. Tyrrell and Bynoe1 first identified human coronaviruses in the mid-1965, leading a group of virologists they discovered a group of viruses causing bronchitis, hepatitis and gastroenteritis in animals. These groups of viruses were also discovered in the tracheobronchial secretions of humans with respiratory infections and were all named coronaviruses. 

In December 2019, unknown caused pneumonia was first detected in Wuhan, China. The agent was quickly identified as the coronavirus variant and was named SARS-COV-2 or COVID-19. Genetically, the virus ID close to the coronavirus in bats (BatCov RatG13) and coronavirus in the Pangolins, but not exact.

The lungs are the organs most affected by COVID-19 because the virus accesses host cells via the enzyme angiotensin-converting enzyme 2 (ACE2), which is most abundant in type II alveolar cells of the lungs. The virus uses a special surface spike to connect to ACE2 and enters the host cell.

The virus can cause acute myocardial injury and chronic damage to the cardiac system. Acute cardiac injury was found in 12% of infected people admitted to hospitals. Rates of cardiovascular symptoms are high, owing to the systemic inflammatory response and immune system disorders during disease progression, but acute myocardial injury may also be related to ACE2 receptors in the heart.

Additionally, people with COVID-19 and acute respiratory distress syndrome (ARDS) have classical serum biomarkers of CRS including elevated C-reactive protein (CRP), lactate dehydrogenase (LDH), D-dimer, and ferritin.

Interestingly, it has been discovered that the virus protein sticks to heme, displaces oxygen, releases iron, free iron leads to toxicity, and causes inflammation of the Alveoli and lung disease. Iron also is converted to Porphyrin and this disrupts heme function furthering the hypoxia and insult to the lungs.

Many discussions in current literature regarding ACE2 and ARB medications for the treatment of hypertension, Also, these medications have been used in diabetic Type 2 patients. The argument is that these medications increase the ACE receptors in the body (ACE receptors is the entry door for the virus); increasing ACE receptors may worsen the severity of COVID infection.

Obesity is closely linked to all the above. Obesity is a significant cause of hypertension, diabetes type 2, kidney disease, and cardiac disease. Many obese patients are on ACE medications and ARBs. Obesity is closely associated and a cause for obstructive sleep apnea (OSA). OSA decreases lung capacity; decrease lung capacity becomes very serious in a patient with COVID-19 infection, due to difficult ventilation and a significant decrease in lung reserve and the ability to fight the virus.

Many obese patients suffer from asthma and on steroids; studies show that steroids worsen COVID-19 infection. Also, asthma makes respiratory caring for COVID-19 patients a challenge. Obesity is the most common cause of significant complications from COVID-19 in patients under 60 years of age.

About 78% of patients admitted to the ICU with COVID-19 infections, between February 12th to March 28th, reported having one or more of the following conditions.

1. Hypertension, HTN

2. Diabetes, DM2

3. Chronic Lung Disease, OSA, COPD

4. Cardiovascular disease

All of the above are closely linked to obesity.

Once again, obesity becomes a significant health issue, linked to so many serious diseases and infections. It is time to take obesity seriously and treat aggressively, we only offer surgical treatment to 1% of patients who are candidates for surgical treatment. This number should shame us as health care professionals, we are required to do more, educate more, and cure more.