At admission, all patients presented with signs of systemic inflammatory response syndrome, defined as two or more of the signs and symptoms described in Table 2 . All patients had fever or hypothermia and tachypnea. Leukocytosis was present in 75% of cases. At admission, only two patients were hypotensive (25%). However, hypoxemia was present in 100% of cases, and four patients (50%) had oxygen saturation <90% at admission (Table 2) . Initially, lung disease was in most cases localized in one or two quadrants of lung (75%). However, most patients developed a more extensive and progressive In all the eight patients, the diagnosis of acute respiratory distress syndrome (ARDS) could be established based on the presence of bilateral pulmonary infiltrates, a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (PO 2 /FiO 2 ) £200 and no clinical evidence for an elevated left atrial pressure. Due to rapidly progressive hypoxemia (PO 2 /FiO 2 117) and the rapid worsening of lung infiltrates (Figure 1 ), five patients (62.5%) needed invasive mechanical ventilation. Four patients were intubated in the first 24 h of ICU and one patient 48 h after unsuccessful noninvasive ventilation (NIV). NIV was successfully used in three patients (37.5%), who had milder forms of disease as showed by a computerized tomography that revealed sparse bilateral infiltrate ( Figure 2 ).