“Clinical, Radiological and Therapeutic Characteristics of Patients with COVID-19 in Saudi Arabia”

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36 Coronavirus disease 2019 (COVID-19) is a rapidly spreading global pandemic. The clinical 37 characteristics of COVID-19 has been reported; however, there are limited researches that 38 investigated the clinical characteristics of COVID-19 in the Middle East. The aim of this study is to 39 investigate the clinical, radiological and therapeutic characteristics of patients diagnosed with 40 COVID19 in Saudi Arabia. 41

42 This study is a retrospective single-centre case series study. We extracted data for patients who were 43 admitted to the Al-Noor Specialist hospital with a PCR confirmed SARS-COV-2 between 12th and 44 31st of March 2020. Descriptive statistics were used to describe patients’ characteristics. Continuous 45 data were reported as mean ± SD. Chi-squared test/Fisher test were used as appropriate to compare 46 proportions for categorical variables. 47

48 A total of 150 patients were hospitalised for COVID-19 during the study period. The mean age was 49 46.1 years (SD: 15.3 years). Around 61.0% (n= 90) were males and six patients (3.9%) reported 50 working in the healthcare sector. The most common comorbidities were hypertension (28.8%, n= 42) 51 and diabetes mellitus (26.0%, n= 38). The majority of the patients, 64.4% (n = 96) had a recent 52 contact history with a COVID patient. Regarding the severity of the hospitalised patients, 105 patients 53 (70.0%) were mild, 29 (19.3%) were moderate, and 16 patients (10.7%) were severe or required ICU 54 care. From the 105 mild patients, around 31.3% (n= 47) were asymptomatic. 55

56 This case series provides clinical, radiological and therapeutic characteristics of hospitalised patients 57 with confirmed COVID-19 in Saudi Arabia. 58

59 Clinical Characteristics, COVID-19, Retrospective case series, Radiological SARS-Cov2 60 61 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 15, 2020. ; https://doi.org/10.1101/2020.05.07.20094169doi: medRxiv preprint 3 1. INTRODUCTION 62 In early December 2019, a cluster of acute pneumonia of unknown aetiology has been identified in 63 Wuhan, China (1). The pathogen has been identified as a new RNA virus from the betacoronavirus 64 family, and has been named as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (2). 65 The respiratory illness caused by the 2019 novel coronavirus disease (COVID-19) is highly 66 infectious, and therefore, the World Health Organization (WHO) has characterized the diseases a 67 pandemic infection (3). As of April 25, 2020, more than 2,700,000 confirmed cases were reported 68 worldwide, and it has spread from Wuhan to more than 200 countries across the world (4). 69 The Kingdom of Saudi Arabia (KSA) is the largest country in the Arabian Peninsula and it is located 70 in the South West part of Asia (5). In a historical decision, KSA has suspended Umrah and all 71 religious visits to the country in an attempt to prevent and delay the spread of COVID-19 in KSA. 72 However, in March 2, 2020, Saudi Arabia has confirmed its first case of COVID-19 which was 73 imported from Iran (4). Several other local clusters were identified later with the majority of the cases 74 being linked to recent travel history. 75 In recent studies, the clinical features and severity of COVID-19 has been described to be similar of 76 other respiratory viruses such as severe acute respiratory syndrome (SARS) and Middle East 77 respiratory syndrome (MERS) (6, 7). Symptoms can range from mild flu-like symptoms to acute 78 respiratory distress syndrome (ARDS) (8). However, the characteristics and the course of the disease 79 in Middle Eastern populations remains unclear. Exploring the clinical characteristics of patients 80 diagnosed with COVID-19 in Saudi Arabia is important knowing that there are many visitors who 81 travel to Saudi Arabia for religious purposes. Beside this, there is a high air traffic for other purposes 82 in this country which was estimated to be around 39 million people in 2018. In 2019, around 7.5 83 million Muslim entered the holy city of Mecca for Umrah purposes (9). This highlights how crucial is 84 to have a deeper exploration on the characteristics of patients diagnosed with this widespread 85 infection in this region. To address the above knowledge gaps and giving the ongoing spread of 86 COVID-19 in the Middle East, this study aims to describe the clinical, radiological, and therapeutic 87 characteristics of COVID-19 in a selected cohort of patients in Mecca, Saudi Arabia. 88 2. METHODS 89 2.1. Study Design and participants 90 This was a retrospective single-centre case series study of 150 patients diagnosed with COVID-19. 91 We extracted data for patients who were admitted to Al-Noor Specialist hospital with a polymerase 92 chain reaction (PCR) confirmed SARS-COV-2 between 12 th and 31 st of March 2020. Al-Noor 93 Specialist hospital in Mecca, Saudi Arabia is a 500-bedder specialist and teaching hospital in the 94 centre of the holy city of Mecca. It delivers tertiary care throughout the Mecca region of Saudi Arabia 95 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 15, 2020. ; https://doi.org/10.1101/2020.05.07.20094169doi: medRxiv preprint 4 and its part of the Ministry of Health services (10, 11). All patients enrolled in this study were 96 diagnosed with COVID-19 through real time (RT)-PCR obtained through nasopharyngeal swabs. All 97 data including outcomes, mortality and length of stay were monitored up to 8th April 2020. 98 2.2. Data Collection 99 Data were extracted from both paper and electronic records using a unique medical record number 100 (MRN) for each patient. All data were reviewed and checked by a medical team including; two 101 medical residents and a consultant Pulmonologist. Extracted data included patients’ demographics, 102 comorbidities, history of recent travel and history of contact with a confirmed COVID19 patient in the 103 past two weeks. In addition, clinical signs, symptoms, radiological findings and pharmacological 104 treatment received were collected. The radiological examinations were interpreted by a certified 105 consultant radiologist who was blinded from the clinical presentation of the patients. The severity 106 assessment of the chest x-ray (CXR) were estimated subjectively. All data were collected at the time 107 of the admission. 108 2.3. Study variables 109 Data regarding the clinical progression and severity of the disease were reported as the worst 110 classification reached at any point during hospitalisation. We further classified the severity of the 111 disease based on the following criteria; 1) mild disease was defined as patients with upper respiratory 112 tract symptoms (as rhinorrhoea, sore throat, headache, myalgia, body pain, low grad fever and or dry 113 cough) with absent of clinical or radiological finding of pneumonia; 2) moderate disease defined as 114 symptomatic patients with radiological sign of pneumonia; 3) severe disease defined as confirmed 115 COVID-19 pneumonia with any of the following respiratory rate ≥ 30/min, blood oxygen saturation 116 ≤ 93% at rest, PaO2/FiO2 ratio 50% of the lung field, and 4) critically sever 117 disease defined as any of the following: respiratory failure required invasive mechanical ventilation, 118 shock or organ failure require admission to the intensive care unit. 119 2.4. Ethics 120 This study was approved by the institutional ethics board at the Ministry of Health in Saudi Arabia 121 (No. H-02-K-076-0420-286). Patients were informed that their clinical data will be used for clinical or 122 research purposes with keeping all their personal information confidential. 123 2.5. Statistical Analysis 124 Descriptive statistics were used to describe patients’ demographic characteristics, radiological 125 findings, medications use, and comorbidities. Continuous data were reported as mean ± SD, and 126 categorical data were reported as percentages (frequencies). Independent sample t test was used to 127 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 15, 2020. ; https://doi.org/10.1101/2020.05.07.20094169doi: medRxiv preprint 5 compare the mean value for continuous variables. Chi-squared test/Fisher test were used as 128 appropriate to compare proportions for categorical variables. Logistic regression analysis was used to 129 identify predictors of clinical characteristics. A confidence interval of 95% (p < 0.05) was applied to 130 represent the statistical significance of the results and the level of significance was assigned as 5%. 131 SPSS (Statistical Package for the Social Sciences) version 25.0 software (SPSS Inc) was used to 132 perform all statistical analysis. 133 3. RESULTS 134 3.1. Patients clinical characteristics 135 Table 1 presents patients’ characteristics at presentation to the hospital. A total of 150 patients were 136 hospitalised for COVID-19. The mean age was 46.1 years (SD: 15.3 years), and ranged between 11 137 and 87. Around 61.0% (n= 90) were males. Six patients (3.9%) reported working in the healthcare 138 sector. The most common comorbidities were hypertension (28.8%, n= 42) and diabetes mellitus 139 (DM) (26.0%, n= 38). The majority of the patients (56.0%; n= 84) were local resident. Around half of 140 the patients (54.1%, n= 80) reported that they had a contact history with a traveller. In addition, the 141 majority of the patients, 64.4% (n = 96) had a contact history with a COVID-19 patient. Regarding the 142 severity of the hospitalised patients, 105 patients (70.0%) were mild, 29 (19.3%) were moderate, and 143 16 patients (10.7%) were severe or required ICU care. Of the 105 mild patients, around 31.3% (n= 47) 144 were asymptomatic. Patients with comorbidities were more likely to have a severe outcome compared 145 to other patients (p<0.05). Patients who reported a contact history with a COVID-19 patient were 146 more likely to have mild to moderate severity of the disease (p<0.05). Mild cases were more prevalent 147 among females, while moderate to severe and or critical were prevalent among males ( Figure 1). For 148 symptomatic patients, the most common symptoms at presentation were fever (49.3%, n= 72), dry 149 cough (48.6%, n= 71), and shortness of breath (19.9%, n= 29) (Table 2) . Furthermore, during 150 admission, fever and cough (28%) were the most common symptoms followed by nausea and 151 vomiting (12%). Most of the asymptomatic patients were females (OR: 0.45 [95%CI 0.22 – 0.92]; p= 152 0.027). In addition, patients who reported travel history or a contact with a traveller recently were 153 three times (OR: 3.13 [95%CI 1.52 – 6.45]; p= 0.002) and four times (OR: 4.03 [95%CI 1.84 – 8.81]; 154 p= 0.000) more likely to be asymptomatic, respectively. Besides, patients who have reported a contact 155 with COVID-19 patients were four times at higher risk of being symptomatic (OR: 4.50 [95%CI 1.84 156 – 10.99]; p= 0.001). 157 3.2. Radiological findings 158 Around half of the patients (49.7%, n= 72) had normal radiological exam at presentation. The severity 159 of the cases was correlated with an increase in the prevalence of GGO at presentation (P=0.002). The 160 predominant pattern of abnormality observed was ground-glass opacification (29.0%, n= 42), 161 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 15, 2020. ; https://doi.org/10.1101/2020.05.07.20094169doi: medRxiv preprint 6 peripheral (57.5%, n= 42), and (bilateral (35.3%, n= 35), which was mainly involving the lower lobes 162 (Figure 2). Most of the patients had stable radiological exams on follow up. Around 64.6% (n= 62) 163 showed progression, half of them belongs to more severe group (Table 3). 164 3.3. Recovery 165 Patients stayed at the hospital for a mean duration of 9.2 days (SD: 3.9). Duration of stay in hospital 166 ranged from two days to 23 days. At the end of the follow-up period a total of 94 patients (63.5%) 167 recovered and 31.8% (n= 47) improved clinically but RT-PCR results were still positive. On the other 168 hand, three patients (2.0%) did not fully recover and four patients (2.7%) deceased. The two patients 169 who had mild cases died due to other reasons. There was no statistically significant difference based 170 on the age regarding the recovery or whether the patient was symptomatic or asymptomatic upon 171 presentation to hospital (p>0.05). The majority of the patients with mild cases improved or recovered, 172 however, there was no statistically significant difference between cases from different severity and 173 recovery rate (p>0.05) (Figure 3). 174 3.4. Therapeutic management 175 Beside supportive care, there were three main types of therapies that were prescribed to the patients 176 for the management of COVID-19, this includes: a) antiviral therapy, b) antibiotics, and c) 177 antimalarial medications (Table 4). 178 4. DISCUSSION 179 To the best of our knowledge, this is the first and largest study to examine the clinical characteristics 180 of COVID-19 in the Middle East region. We investigated clinical, radiological, and therapeutic 181 characteristics of COVID-19 in a 150 hospitalised patients in Saudi Arabia. We found that around 182 89.0% of the cases were either mild or moderated and only 11.0% were either severe or critical. Our 183 finding showed that the clinical severity of COVID-19 were of a milder presentation compared to 184

from China (12), Italy (13) and the United States (14, 15). These finding could be attributed to 185 several factors including age and other demographics differences. The mean age in our study was 46.1 186 years (SD: 15.3) which was younger than the age reported in other studies. Several studies have 187 reported poorer outcome among older population and patients with COVID-19 and comorbidities (16-188 18). However, it is difficult to draw a causal inference and we urge for further studies to investigate 189 this association. In addition, it is important to highlight that the majority of the Saudi Arabian 190 population are younger than 44 years (19). 191 Male patients with COVID-19 were more prevalent in our study compared to females, this was also 192 similar to previous reports which highlight more males to be infected with COVID-19 (2, 14). These 193 numbers could be because of men sex-based immunological differences or it could also be because of 194 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 15, 2020. ; https://doi.org/10.1101/2020.05.07.20094169doi: medRxiv preprint 7 behavioural patterns such as smoking (20). In addition, comorbidities are more prevalent in men 195 which could also be a reason for this difference (21), However, more researches must focus on gender 196 differences and clinical outcomes with COVID-19. 197 Our study highlighted that around 28.8% and 26.0% of the study population had hypertension (HTN) 198 and DM, these results were similar to previous reports that investigated the clinical characteristics of 199 COVID-19 (1). Patients with DM and hypertension have an increased risk of complication of 200 COVID-19 including acute respiratory distress syndrome (ARDS) (22), however, the mechanism of 201 this remains un-investigated and it is unclear whether patients with uncontrolled blood pressure have a 202 poorer outcomes of COVID-19 compared to patients with controlled blood pressure. In addition, 203 Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) are two 204 commonly prescribed medications for the management of HTN, and since SARS-CoV-2, binds to 205 ACE2 in the lung, some theoretical theories have been raised about the benefits of these medications 206 in the treatment of COVID-19 (23). 207 SARS-COV2 has been described to be similar to seasonal influenza, SARS-COV and MERS, this 208 includes the fact that it is transmitted through respiratory droplets (24, 25). In addition, SARS-COV2 209 has similar symptoms to SARS-COV and MERS such as; fever, cough, and shortness of breath. This 210 was reported in our study and it was also in line with previous studies (6, 13), however, SARS-COV2 211 has a higher case fatality rate in comparison to seasonal flu (0.1%) while it is also milder in 212 comparison to other respiratory viruses such as SARS-COV (9.5%) and MERS (34.3%) (26). Besides 213 this, COVID-19 is a highly infectious pathogenic (27, 28), with some reports suggested that half of 214 the United Kingdom (UK) population has been infected without showing any symptoms or with 215 having a mild course of the disease (29). Our study demonstrated that around 31.3% of the study 216 sample were asymptomatic and had a mild disease. Mostly, these patients were identified through 217 contact tracing and were isolated in the earlier course of the disease, whether this approach have any 218 impact on the clinical course psychologically, this might need to be addressed in future studies. In 219 addition, the majority of these patients had a contact with a confirmed COVID-19 patients which may 220 raise concerns regarding the mechanism and the underlying inflammatory response in these patients. 221 More researches are encouraged to investigate the characteristics of asymptomatic patients and if 222 early detection and supportive treatment have a role in the clinical progression of the disease. 223 In our study, and unlike previous reports, nearly half of the patients presented with normal CXR, most 224 of them were asymptomatic or had a mild disease. Furthermore, normal CXR at presentation may 225 have a prognostic rule as only few numbers of those patients progressed into more severe cases. On 226 the other hand, presence of ground glass opacity is linked with more aggressive course. The patterns 227 found in abnormal exams were similar to the previously published reports and findings where 228 peripheral, bilateral ground glass opacification (30). 229 Our study highlighted that around 26.7% of the patients received antimalarial treatment and around 230 9.0% received antiviral treatment, these medications have been suggested to have some beneficial 231 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 15, 2020. ; https://doi.org/10.1101/2020.05.07.20094169doi: medRxiv preprint 8 effect to reduce the viral load and eliminate the disease, however, there are also uncertainties 232 regarding their safety (31, 32). In addition, there has been debate about their efficacy in the treatment 233 of COVID-19 with several trials are now in pipeline for the testing of these medications (33). To date, 234 there is no treatment for COVID-19, and the main approach in the management of the disease is to 235 provide supportive treatment and to control the symptoms including mechanical ventilator for critical 236 cases (34). This study has some limitations. First, the number of patients included in the study were 237 small. Second, the study population only included patients from a single-centre hospital in Saudi 238 Arabia. 239 5. CONCLUSION 240 This case series provides clinical, radiological, and therapeutic characteristics of hospitalised patients 241 with confirmed COVID-19 in Saudi Arabia. Our study demonstrates similar characteristics of 242 COVID-19 to previously reported studies worldwide. 243 Conflict of interest 244 The authors have stated explicitly that there are no conflicts of interest in connection with this article. 245 Authors contribution 246 Shabrawishi, Naser, Ghazawi and Alwafi had full access to all the data in the study and take 247 responsibility for the integrity of the data and the accuracy of the data analysis. Shabrawishi and 248 Alwafi had the original idea for this study. Shabrawishi, Naser and Alwafi contributed to the design of 249 the study. Obaid and Alsharif contributed to the data collection. Naser and Alwafi contributed in the 250 statistical analysis. Shabrawishi, Naser, Ekram and Alwafi wrote the first draft. All the authors 251 contributed to interpretation and edited the draft report. 252 Data availability statement 253 The data that support the findings of this study are available from the corresponding author upon reasonable 254 request. 255

256 1. Wang D, Hu B, H u C, Z hu F, Liu X , Zhan g J, et al. C linic al Ch arac te r i s tics o f 138 Hos pi t a lize d 257 Pati e nts Wi th 2 019 Nove l Co rona v irus – In fe ct ed P neumo nia in Wuh a n, C hina . J AMA . 258 2020 ;323(11):10 61 -9. 259 2. Guan W-j, Ni Z -y , Hu Y, L iang W-h, O u C - q, H e J-x , e t al. Cl inic al Cha ra cte ri s tic s o f Cor o n aviru s 260 Di sea se 2019 in C hina . 2020 . 261 3. WHO . C orona viru s d i s ea se 2019 ( CO VI D -1 9 )Situ atio n R ep ort –9 6 2020 [Av ailable from : 262 http s : / /www .who.in t/doc s/d ef ault - s o u r c e/cor onav ir u se / s i t u a t i on -rep ort s/ 20 200 425- sitre p -96-263 co vid-19.pd f ? sfvrsn =a33 836bb _2 . 264 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 15, 2020. ; https://doi.org/10.1101/2020.05.07.20094169doi: medRxiv preprint 9 4. Who. Cor onav iru s d i s e a s e ( C O VI D-19 ) ou tbr eak 2020 [Ava ila ble f r o m: 265 http s : / /www .who.in t/eme rge ncie s /di s e a s e s /novel-c oro naviru s-2019 . 266 5. MOFA . About S a udi Arabia 2020 [Ava ilable fro m: 267 http s : / /www .mofa.gov . sa /si te s /mo fa en /abou t Ki ngD om/P age s / Ki ngdomGeogr ap hy 46466. as p x . 268 6. Chen N, Zhou M, Dong X, Q u J , Go ng F , Han Y, et al. Epi demiolog ical a nd cli nica l 269 ch aracte ri st i c s of 99 c a se s o f 2 019 n ovel coro na viru s pn eumon ia i n Wuhan, C hina : a de sc riptiv e 270 st u d y. L ance t (L ondon, E nglan d ) . 2020;3 9 5(10223):50 7 -13. 271 7. Li vingston E, Buche r K. Coro naviru s Di se a s e 2019 ( CO VI D -19) in I taly. J AMA . 2020. 272 8. Chan g D, Lin M, We i L, Xi e L , Zhu G , D ela Cr u z CS , e t al . E pidemiol ogic a nd Cli nica l 273 Char ac te ristic s o f N o vel Co ronav ir u s In f ec t i on s Inv ol ving 1 3 Pati ent s Ou t s ide W uha n, China . JAM A. 274 2020 ;323(11):109 2 -3. 275 9. Ebrahi m SH, Memi sh Z A. CO VI D- 1 9 : pr epa r in g f or s upe r spre ader p ot e ntial am ong Umr a h 276 pilg r i ms to S audi Ar abi a. The Lanc et. 202 0 ;395(1022 7) . 277 10. Za glool DA, Khod a r i YA, Gaz zaz ZJ , D hafa r KO, Sha ke r HA, F arooq M U. Pr eva lence o f 278 Inte s tinal Pa r a si te s among Pati ent s o f Al -No or Spe cial ist Ho s p i t a l, Makk ah , Sa udi Arabia . O man Me d 279 J. 201 1;26(3 ):182 -5. 280 11. Health M o. Al No or Spe c ial ist Ho s p it a l 2020 [Av ailab l e from : 281 http: //n sh.me d. sa /P age s/H om e .a s p x . 282 1 2 . W u Z , M cG oog a n JM . C h a ra ct er is t i c s o f an d I m p o rt a nt L ess ons Fr o m t h e C o r ona v i r us 283 Di sea se 2019 ( C OV ID -19) Outb r e ak in C hi na: S ummary of a R epor t of 72Aijj 314 Ca se s From t he C hi ne se 284 Cen ter for Di sea se Con trol an d P rev entio n. JAM A. 202 0;323 (13):12 39 -42. 285 13. Li vingston E, Bu cher K. Coron av iru s Di s e a se 201 9 ( CO V ID-19 ) in I ta ly. JAM A. 286 2020 ;323(14):133 5 -. 287 14. Goyal P, Ch oi JJ , P inhei ro LC, Sc henck E J , Chen R, Jabri A , e t al. Cli nic al Cha ra c t e r i s tic s o f 288 Cov id-19 in N ew York Ci t y . 2020. 289 15. Ric hard s on S, Hir s c h J S, N ara simhan M, C r a wfo rd J M, Mc Ginn T, D a vid son KW, et al. 290 Pre s enting Ch aract eri s tics , Co mor b i diti e s, and Ou t c ome s Among 570 0 Pa t i ent s H ospit ali z ed Wi th 291 CO VI D -19 in the N ew York City Area . JA MA . 2020. 292 1 6 . M a h a s e E . C o v i d - 1 9 : d e a t h r a t e i s 0 . 6 6 % a n d i n c r e a s e s w i t h a g e , s t u d y e s t i m a t e s . 293 2020 ;369:m132 7. 294 1 7 . V e r i t y R , O k e l l L C , D o r i g a t t i I , W i n s k i l l P , W h i t t a k e r C , I m a i N , et a l. E s t i m a t e s o f t h e s e v er i t y 295 of c or o n aviru s dis ea se 2019 : a mod e l-ba s e d a nalysi s. T he L ance t I nfe ctiou s di s ea s es. 2020. 296 18. Dowd JB , And rian o L, B raz el D M, Ro tond i V, Bl oc k P, Ding X, e t al. Demo gra phic s ci ence aid s 297 in u nder s t andin g the sp read a n d fa tali ty rate s o f C O VI D-19 . 2020 :202004 911. 298 19. Stati s tics G A f. S tati s tical Y ea rb ook of 2016 20 16 [Availa ble fr o m : 299 http s : / /www .s t at s.gov. s a/ en/5305 . 300 20. Wenham C, Smith J, Mo rga n R. CO VI D- 19: the gend e red impa ct s o f t h e out br eak . L anc e t 301 (Lon don, Eng land ). 20 20;395 (102 27):846 -8. 302 21. The L . The gende r e d di men s i on s of COVI D -19. L ance t (Lon don, Englan d). 303 2020 ;395(1023 1):1168 . 304 22. Fa ng L , K ar akiula ki s G, R ot h M. A re pa tient s with hyper ten sion a nd di ab et e s mell itu s at 305 inc r e a s e d ri s k for COVI D-19 i n fec tion? Th e L ance t Re s p i r a tory medic ine . 20 20;8(4 ) :e21. 306 23. Sc hiff rin E L, Fla ck JM, I t o S , Mun tne r P , Webb R C. Hyper ten sion and COVI D -19 . Americ a n 307 Journa l of H y pe rt e n s i on. 2020. 308 24. Ot t er JA, Don s k ey C , Ye z li S, Dou thwait e S , G ol d enbe rg SD, Webe r D J. Tr an smissi on of S ARS 309 and MERS coron av ir u se s and i nflu en z a vi r us in h ea lt h c are se t ti ng s: th e po s s i ble r o le o f dr y s ur fac e 310 co nt a mina tion. The Journ al of h ospi t a l in fec t i on. 2016 ;92 (3):235 -50. 311 25. WHO . Mod e s o f tran smis sio n of v irus c ausing COVI D-19 :implicatio n s for I P C preca ut i o n 312 recom menda tion s 2020 [ Availa bl e from: ht tp s: / /www .who. in t/publicati o ns -de tail/mode s -o f-313 tran s m i ssion -o f-viru s -cau sing -c ovid-19 -i mplica t i on s - fo r-ipc -pr ec au tion -recom me ndation s . 314 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 15, 2020. ; https://doi.org/10.1101/2020.05.07.20094169doi: medRxiv preprint 10 2 6 . R a j go r D D , Le e M H , A r ch u le t a S, B a g das ar i an N , Q u e k SC . Th e ma n y es ti m at es of t h e COV I D-315 19 c ase fat ali t y ra te. Th e Lanc et In fec t i ou s d i s ea se s. 20 20. 316 27. Zha ng S, Dia o M, Yu W, Pei L, L in Z, Che n D . E s tima t io n o f t h e r e pro ductive num ber o f nove l 317 co r ona viru s ( COV ID -19) and t h e pro bable outb rea k s i ze o n t h e Diamond Princ es s c r ui se ship: A d at a-318 drive n analy s is . In tern ation al journal of inf ec t i ou s di s ea se s : I JI D : o ffic ial pu blica t i on o f t h e 319 Inte rna tiona l Soc i ety fo r In fec ti ou s D i se a se s . 2020 ;93:201 -4. 320 28. Li u Y, G a yle AA, Wilder -Smi t h A, Roc klö v J. The rep r oduc tive numb e r of C OV ID -19 i s hig her 321 co mpared t o SARS coro nav iru s . Jou r na l o f Trav el Medic in e. 2 020;27 (2) . 322 29. Sa yburn A . C ovid-19 : expert s que s t i on ana ly si s s ug ge st i ng ha l f UK p opula t i o n ha s b ee n 323 infec t ed. 202 0;368 :m121 6. 324 30. Shi H , H a n X, Jian g N, Cao Y , Alwal id O, Gu J , et al. Ra diol ogi cal f i nding s from 81 p a t i en ts w ith 325 CO VI D -19 pn e umonia in Wuhan, Ch i n a: a descri ptive s tudy. The L ance t In fe cti ou s Di sea s es . 326 2020 ;20(4) :425-34 . 327 31. Fe r ne r RE , Aron son J K. Chloroq uine and hyd r ox yc hloroquine i n cov id-19 . 20 20;36 9:m1 432. 328 32. Cor tegia ni A, I ngogli a G, Ipp oli to M, G iarra tano A, Eina v S . A sy st ematic revi ew on t he 329 ef fic acy and s af ety of chlo roqui n e fo r the tr e a tment of CO VI D -19 . Jou rnal o f c r i t i c al care. 2 020. 330 33. Tac con e F S, G o rham J, Vincen t JL. Hydr oxyc hloroquine in th e manag ement o f critic ally il l 331 patie n ts wi t h C O V ID -19: the ne ed f or an e viden ce ba s e . The L ance t R e s pi r a t ory m edic ine. 20 20. 332 34. NICE . C O V ID -19 rapid gu id eline : ma nagi ng su spect ed or con firme d pneumo ni a in adult s i n 333 the c ommunity 2020 [Ava ilabl e fr om: h ttps: / / w ww.ni ce.org .u k/ g uidanc e/ng165 . 334 TABLES LEGENDS 335 Table 1: Patients demographic characteristics at presentation. 336 Table 2: Patient signs and symptoms at presentation and during admission. 337 Table 3: Radiological findings. 338 Table 4: Initial treatment characteristics. 339 FIGURES LEGENDS 340 Figure 1: Clinical severity stratified by gender. 341 Figure 2: CXR’s of two different patients showing the most common abnormalities: bilateral, 342 peripheral ground glass opacities and consolidation 343 Figure 3: Recovery rates stratified by case severity 344 TABLES 345 Table 2: Patients demographic characteristics at presentation. 346 Demographics All patients (n=150) Mild cases (n= 105) Moderate cases (n= 29) Severe/Intensive care unit cases (n= 16) P-value Age (years; mean (SD)) 46.1 years (15.3) 45.4 years (±16.0) 46.7 years (±12.1) 49.8 years (±15.7) 0.550 Gender Female No. (%) 60 (40.0) 47 (44.8) 10 (34.5) 3 (18.8) 0.112 Healthcare worker Yes No. (%) 6 (4.0) 6 (5.8) 0 0 0.110 Place of residency No. (%) Kingdom of Saudi Arabia 84 (56.0) 57 (54.3) 15 (51.7) 12 (75.0) 0.084 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 15, 2020. ; https://doi.org/10.1101/2020.05.07.20094169doi: medRxiv preprint 11 Other countries 66 (44.0) 48 (45.7) 14 (48.3) 4 (25.0) 0.239 Comorbidities No. (%) Hypertension 42 (28.8) 29 (27.6) 10 (35.7) 3 (23.1) 0.627 Diabetes mellitus 38 (26.0) 20 (19.0) 11 (39.3) 7 (53.8) 0.005** Coronary artery disease 11 (7.5) 5 (4.8) 3 (10.7) 3 (23.1) 0.094 Renal disease 10 (6.8) 5 (4.8) 1 (3.6) 4 (30.8) 0.018* Thyroid gland problem (hypothyroidism) 9 4 (8.2) 2 (11.1) 3 (37.5) 0.123 Asthma 4 (2.7) 3 (2.9) 0 1 (7.7) 0.306 Cancer 2 (1.4) 0 0 2 (15.4) 0.007** CVA 1 (0.7) 1 (1.0) 0 0 0.718 COPD 1 (0.7) 0 0 1 (7.7) 0.086 CLD 1 (0.7) 0 0 1 (7.7) 0.086 Tracing history No. (%) Recent travel history (Yes) No. (%) 65 (43.9) 47 (45.6) 14 (48.3) 4 (25.0) 0.263 Contact with traveller (Yes) No. (%) 80 (54.1) 57 (55.3) 18 (62.1) 5 (31.3) 0.124 Contact with COVID-19 patient (Yes) No. (%) 96 (64.4) 71 (68.3) 20 (69.0) 5 (31.3) 0.013* Outcome (n= 148) No. (%) Deceased 4 (2.7) 2 (1.9) 0 2 (12.5) 0.086 Improved 47 (31.8) 37 (35.2) 6 (22.2) 4 (25.0) 0.358 Not recovered 3 (2.0) 2 (1.9) 1 (3.7) 0 0.615 Recovered 94 (63.5) 64 (61.0) 20 (74.1) 10 (62.5) 0.434 Abbreviations; COVID-19: coronavirus disease-2019; CVA: cerebrovascular accident; COPD: chronic 347 obstructive pulmonary disease; CLD: chronic liver disease; SD: Standard deviation; No: Number (frequency) 348 Table 2: Patient signs and symptoms at presentation and during admission. 349 Variable Symptoms P-vale At presentation No. (%) During admission No. (%) Fever 72 (49.3) 28 (19.2) 0.029* Cough 71 (48.6) 28 (19.2) 0.024* Shortness of breath 29 (19.9) 7 (4.8) 0.000*** Sore throat 24 (16.4) 2 (1.4) 0.269 Runny nose 9 (6.2) 0 (0.0) >0.99 Sputum 5 (3.4) 1 (0.7) 0.034* Headache 4 (2.7) 0 (0.0) >0.99 Myalgia 4 (2.7) 1 (0.7) 0.813 Diarrhea 2 (1.4) 5 (3.4) 0.068 Nausea/vomiting 1 (0.4) 12 (8.2) 0.678 Haemoptysis 1 (0.4) 1 (0.7) 0.887 Fatigue 1 (0.4) 1 (0.7) 0.907 * p<0.05; **p<0.01; ***p<0.000 350 Table 3: Radiological findings. 351 Radiological findings (CXR) upon admission All patients (n=150) Mild cases (n= 105) Moderate cases (n= 29) Severe/Intensive care unit cases (n= 16) P-value Predominant finding Normal 72 (49.7) 62 (60.2) 7 (25.9) 3 (20.0) 0.000*** Ground glass opacity 42 (29.0) 21 (20.4) 13 (48.1) 8 (53.3) 0.002* Consolidation 26 (17.9) 16 (15.5) 6 (22.2) 4 (26.7) 0.488 Linear atelectasis 3 (2.1) 3 (2.9) 0 0 0.354 Diffusion reticular 1 (0.7) 1 (1.0) 0 0 0.795 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 15, 2020. ; https://doi.org/10.1101/2020.05.07.20094169doi: medRxiv preprint 12 opacities Reticulation 1 (0.7) 0 1 0 0.183 Distribution within the lobe Central 10 (13.7) 6 (14.6) 2 (10.0) 2 (16.7) 0.833 Diffuse 21 (28.8) 14 (34.1) 4 (20.0) 3 (25.0) 0.494 Peripheral 42 (57.5) 21 (51.2) 14 (70.0) 7 (58.3) 0.378 Distribution within the lung Lower 24 (32.9) 12 (29.3) 6 (30.0) 6 (50.0) 0.385 Lower middle 22 (30.1) 10 (24.4) 9 (45.0) 3 (25.0) 0.236 Lower and middle and upper 10 (13.7) 8 (19.5) 2 (10.0) 0 0.089 Diffuse 10 (13.7) 6 (14.6) 2 (10.0) 2 (16.7) 0.833 Peripheral 2 (2.7) 2 (4.9) 0 0 0.309 Middle 2 (2.7) 2 (4.9) 0 0 0.309 Upper 1 (1.4) 1 (2.4) 0 0 0.559 Upper and middle 1 (1.4) 0 0 1 (8.3) 0.159 No zonal predominance 1 (1.4) 0 1 (5.0) 0 0.269 Laterality Bilateral 53 (35.3) 27 (25.7) 16 (55.2) 10 (62.5) 0.000*** Unilateral right 12 (16.4) 10 (24.4) 2 (10.0) 0 0.035* Unilateral left 8 (11.0) 4 (9.8) 2 (10.0) 2 (16.7) 0.805 Progression Stable 62 (64.6) 49 (74.2) 11 (57.9) 2 (18.2) 0.001** Worsen 34 (35.4) 17 (25.8) 8 (42.1) 9 (81.8) CXR: chest x-ray 352 Table 4: Initial treatment characteristics. 353 Treatment therapy Frequency (%) Antiviral therapy Combination of antiretroviral (lopinavir and ritonavir) and ribavirin 14 (9.3) Antimalarial therapy Hydroxychloroquine 25 (16.7) Chloroquine 15 (10.0) Antibiotics therapy 58 (38.7) 354 FIGURES 355 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 15, 2020. ; https://doi.org/10.1101/2020.05.07.20094169doi: medRxiv preprint 356 357 Figure 1: Clinical severity stratified by gender. 358 359 360 Figure 2: CXR’s of two different patients showing the most common abnormalities: bilateral, 361 peripheral ground glass opacities and consolidation 362 363 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 15, 2020. ; https://doi.org/10.1101/2020.05.07.20094169doi: medRxiv preprint 364 365 Figure 3: Recovery rates stratified by case severity 366 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 15, 2020. ; https://doi.org/10.1101/2020.05.07.20094169doi: medRxiv preprint