Pathogenesis of pneumoperitoneum in a COVID-19 patients

To the Editor:

Gemio del Rey et al.¹ describe a case of spontaneous pneumoperitoneum in a patient with bilateral SARS-CoV-2 pneumonia, with no signs of a systemic inflammatory response and having ruled out an intra-abdominal cause. The authors wisely associated pneumoperitoneum with mechanical ventilation.

In patients with coronavirus 2019 (COVID-19), intestinal pneumatosis and pneumoperitoneum have occasionally been described without observed intestinal perforation.^2–4 In these case, the etiopathogenic cause has been related with direct damage to the intestinal mucosa by SARS-CoV-2—the intestinal epithelium has abundant receptors for angiotensin converting enzyme-2 (ACE-2)—and to ischemic mechanisms secondary to arterial and venous splanchnic thrombosis.^5,6

One of the most striking phenomena in COVID-19 patients are thromboembolic complications at multiple levels, secondary to the severe systemic inflammatory response induced by SARS-CoV-2.^7,8 Therefore, antithrombotic prophylaxis is recommended in most patients with moderate or severe COVID-19.^9,10

Although the case described by Gemio del Rey et al.¹ does not report the progression of fibrinogen or D-dimer levels, we feel that this etiopathogenic possibility should be considered in COVID-19 patients.