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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 …