What is homocysteine

Homocysteine is a sulfhydryl (sulfur) containing amino acid, which is an intermediate product in the normal biosynthesis of the amino acids methionine and cysteine that is typically present in very small amounts in all cells of your body ¹. Homocysteine is an amino acid produced via demethylation of dietary methionine, which is abundant in animal protein ². Vitamin B6 (Pyridoxine), Folic acid (vitamin B9), Riboflavin, and Vitamin B12 (Cyanocobalamin) are all required for methionine metabolism, and deficiency of each of these vitamins result in elevated plasma homocysteine. That is because your body normally converts homocysteine into other products quickly. Since vitamin B6 (pyridoxine), vitamin B12 (cyanocobalamin) and folate (vitamin B9) are necessary to metabolize homocysteine, increased levels of the homocysteine amino acid may be a sign of deficiency in those vitamins. Elevations in plasma homocysteine are commonly found as a result of vitamin deficiencies, polymorphisms of enzymes of methionine metabolism, and renal disease. Homocysteine test determines the level of homocysteine in the blood and/or urine. A polymorphism of methylenetetrahydrofolate reductase (C-to-T substitution at nucleotide 677), which is quite common in most populations with a homozygosity rate of 10-15 %, is associated with moderate hyperhomocysteinemia, especially in the context of marginal folate intake. Plasma homocysteine is inversely related to plasma creatinine in patients with renal disease. This is due to an impairment in homocysteine removal in renal disease. The role of these factors, and of modifiable lifestyle factors, in affecting methionine metabolism and in determining plasma homocysteine levels.

Note that homocysteine blood level is a more sensitive test for folate and vitamin B12 deficiency than folate and vitamin B12 levels. A normal homocysteine blood level excludes significant folate and vitamin B12 deficiency, though homocysteine blood level has limited specificity because elevations occur in other inherited and acquired disorders.

Homocysteine is present in plasma in four different forms: around 1% circulates as free thiol, 70–80% remains disulphide-bound to plasma proteins, mainly albumin and 20–30% combines with itself to form the dimer homocysteine or with other thiols ³. Homocysteine is a key determinant of the methylation cycle ⁴. It is methylated to methionine, which undergoes S-adenosylation and forms S-adenosylmethionine (SAM) ⁴. S- adenosylmethionine is the principal methyl donor for all methylation reactions in cells ⁴. Condensation of methionine with ATP, leads to the formation of SAM (S- Adenosylmethionine) ⁵. The methyl group attached to the tertiary sulphur of S-adenosylmethionine can be transferred and therefore can cause methylation of other substances. This methylation is accompanied by energy loss, so this reaction is irreversible. The demethyation reaction leads to the formation of SAH (S- adenosylhomocysteine) ⁵. S- adenosylhomocysteine is a thioether (a sulfur bonded to two alkyl or aryl groups) analogous to methionine. The S-adenosylmethionine-to-S- adenosylhomocysteine ratio defines the methylation potential of a cell ⁴. Hydrolysis of SAH leads to the formation of homocysteine and adenosine ⁵. This homocysteine can be used in one of two ways:

• In case of methionine deficiency, homocysteine can be re-methylated to form methionine ⁵. The enzyme N5, N10-methylenetetrahydrofolate reductase converts homocysteine to methionine ¹.
• In presence of sufficient methionine, homocysteine is instead used to produce cysteine ⁵. Cystathionine-β-synthase is an enzyme (with pyridoxine (vitamin B6) as an essential cofactor) that converts homocysteine to cysteine ¹. Homocysteine is synthesized from the essential amino acid methionine, therefore cysteine is not an essential amino acid as long as sufficient methionine is available ⁵.

Figure 1. Homocysteine

Figure 2. Homocysteine metabolism

Homocysteine is an independent cardiovascular disease risk factor modifiable by nutrition and possibly exercise. Elevated homocysteine may be related to a higher risk for coronary heart disease, stroke, peripheral vascular disease (fatty deposits in peripheral arteries), and hardening of the arteries (atherosclerosis). Several mechanisms have been proposed for how homocysteine leads to cardiovascular disease risk, including damaging blood vessel walls and supporting the formation of inappropriate blood clots, but direct links haven not been confirmed. There are also several studies that indicate no benefit or lowering of cardiovascular disease risk with folic acid and B vitamin supplements. So far, the American Heart Association does not consider it a major risk factor for heart disease.

Homocysteine was first identified as an important biological compound in 1932 and linked with human disease in 1962 when elevated urinary homocysteine levels were found in children with mental retardation. This condition, called homocysteinuria (homocystinuria), was later associated with premature occlusive cardiovascular disease, even in children. Homocystinuria also called cystathionine beta synthase deficiency is a rare inherited condition that can also greatly increase homocysteine in the blood and urine. In homocystinuria, one of several different genes is altered, leading to a dysfunctional enzyme that does not allow the normal breakdown of the precursor to homocysteine, called methionine. Methionine is one of the eleven essential amino acids that must come from your diet because the body cannot produce it. Without the proper enzyme to break them down, homocysteine and methionine begin to build up in the body. Babies with this condition will appear normal at birth but within a few years begin to develop signs such as a dislocated lens in the eye, a long slender build, long thin fingers, skeletal abnormalities, osteoporosis, and a greatly increased risk of thromboembolism and of atherosclerosis that can lead to premature cardiovascular disease. The buildup of homocysteine in the arteries may also cause intellectual disability, mental illness, slightly low IQ, behavioral disorders, and seizures. Some of those may be alleviated if the condition is detected early, which is why all states screen newborns for homocystinuria.

Although homocysteine concentration in plasma is only about 10 micromolar (μM), even moderate hyperhomocysteinemia is associated with increased incidence of cardiovascular disease and Alzheimer’s disease. These observations led to research investigating the relationship of elevated homocysteine levels and cardiovascular disease in a wide variety of populations including middle age and elderly men and women with and without traditional risk factors for cardiovascular disease ⁶, ⁷. Moreover, homocysteine is found to be associated with cystathionine beta-synthase deficiency, cystathioninuria, methylenetetrahydrofolate reductase deficiency, and sulfite oxidase deficiency, which are inborn errors of metabolism.

The homocysteine and the nervous system

In the last decade, epidemiological observations have pointed towards a plausible association between hyperhomocysteinemia and CNS neurodegenerative disorders. Several studies demonstrated that homocysteine is capable of triggering neuronal damage via oxidative stress, DNA damage and activation of pro-apoptotic factors in cell cultures or animal models ⁸. In an experiment, SH-SY5Y neuroblastoma cells were modified to act as neuronal cells, by incubating them with retinoic acid, which induced their differentiation towards a neuronal-like phenotype ⁸. This was followed by incubation with/without D,L-homocysteine in a concentration range from 20 μM to 80 μM ⁸. The exposure to homocysteine induced a time and concentration dependent reduction of cell viability in comparison with controls. The highest cytotoxicity was portrayed by 80 μM homocysteine which produced 80% of cell death after 5 days of incubation ⁸. A significant reduction of cell viability to 35% was also observed after 5 days of incubation with 40 μM homocysteine. Cell exposure to homocysteine for a period of 3 days did not induce any significant change in Reactive Oxygen Species (ROS) levels, but incubation with homocysteine for 5 days resulted in a 4.4-fold increase in ROS production ⁸. Homocysteine notably triggered significant levels of genotoxic stress which was indicated by the assessment of DNA fragmentation by Comet assay. But the levels of genotoxic stress was significant only after a longer time of exposure, as shown by the number of Comet positive cells, which was significantly increased only after 5 days of incubation with homocysteine ⁸. Bax and Bcl-2 mRNA levels in cells showed an increase by two-fold and 14-fold, respectively, in the case of 5 days exposure to homocysteine ⁸. A time-dependent effect of homocysteine was also evident. The mRNA levels for the cyclins D1, E1, and A1 were increased by two-fold, six-fold, and five-fold, respectively, in cells exposed to homocysteine for 3 days, but the mRNA levels in case of cyclin B1 were not affected in the 3 day period ⁸. The mRNA levels of all cyclins returned to the basal levels after 5 days of incubation with homocysteine. A decrease in both mRNA and protein level, of p21, another key protein regulator of DNA damage induced cell death, was noted after 3 days of incubation with homocysteine, followed by a dramatic p21 up-regulation and protein synthesis at 5 days . Further down the timeline, a significant upregulation of p16 was observed, concomitantly with the reduction by 35% of phosphorylated pRB ⁸. These proteins are check-point regulators of G1-S phase progression through the inhibition of cyclin D-cdk4 complex and the direct binding and sequestration of the transcription factor E2F, respectively ⁸. Therefore, this indicates the arrest of cell cycle at G1 phase ⁸. The results suggest that prolonged exposure to mildly elevated homocysteine concentrations triggers oxidative and genotoxic stress in neuronal-like cells ⁸.

The effect of homocysteine on the brain

By adulthood, the folate related enzymes involved in purine and pyrimidine synthesis, decline almost tenfold. Hence, this leads us to believe that the provision of methyl groups for S-adenosylmethionine and methylation reactions coupled with recycling of homocysteine through methionine synthase may be dominant function of adult brain folate metabolism ⁹. The brain has a limited capacity for homocysteine metabolism. Folate plays an important role in the brain so a crucial mechanism is in play to protect the brain from folate deficiency. The level of 5 tetrahydrofolate in the cerebrospinal fluid is 3 times that of the plasma level and there exists an active process to maintain it ⁹. Methionine synthase is the only enzyme in the brain (neural tissue) that is capable of converting homocysteine to methionine. Cobalamin is a cofactor (hence essential) ⁹.

The brain tissue utilizes three mechanisms to maintain a low level of homocysteine ⁹:

1. Efficient recycling through cobalamin dependent methionine synthase (given an adequate supply of cobalamine and folate),
2. Catabolism through cystathione beta synthase to cystathione a non-noxious product,
3. Export to external circulation ⁹.

In the brain and elsewhere disruption of homocysteine metabolism may result from nutritional imbalance, genetic defects or as a result of drug therapy ⁹.

The direct effect of homocysteine on the nervous system

The action of homocysteine as a neurotransmitter: homocysteine and its related compounds may have a role as an excitatory agonist on the NMDA subtype of glutamate receptors and recent evidence also points to the involvement of NMDA modulatory sites ⁹. It has also been shown that homocysteine, besides acting as a partial agonist at glutamate receptors also acts as a partial antagonist of glycine co-agonist site of the NMDA receptor ⁹. In the presence of normal glycine levels and normal physiological conditions homocysteine does not cause toxicity below millimolar concentrations. However in case of a head trauma or stroke, there is an elevation in glycine levels in which instance the neurotoxic effect of homocysteine as an agonist outweighs its neuroprotective antagonist effect. This may cause neuronal damage via calcium ion influx or free radical generation ⁹.

One evaluative experiment to discover the direct effect of homocysteine on the central nervous system involved local application of homocysteine by two different methods of drug delivery to the central nervous system of rats- pressure ejection and ionophoresis ¹⁰. Extracellular recordings were taken from neurons of cerebral cortex, cerebellum and midbrain. The recordings after either method of administration portrayed a dose-dependent increase in neuronal activity by D, L-homocysteine and L-glutamate in 67% of cells tested with both drugs. The similarity in the dose required of D,L-homocysteine and L-Glutamate, points out that D,L-homocysteine seems to be as potent as the latter. This data indicates that homocysteine seems to have an excitatory action on neurons, and this finding may account for neurological symptoms associated with disorders of amino acid metabolism ¹⁰. Some studies also suggest that elevated homocysteine levels may be associated with alterations in mental health such as cognitive impairment, dementia, depression, Alzheimer’s and Parkinson’s disease ⁹.

Homocysteine levels

Normal homocysteine levels: <5 μmol/L (less than 5 μmol/L)

Total concentration of homocysteine in plasma of healthy humans (fasting) is low and its level is between 5.0 and 15.0 μmol/L when assessed with the use of HPLC, or 5.0-12.0 μmol/l when immunoassay methods are used ¹¹.

Elevated homocysteine levels

The definition of hyperhomocysteinemia differs between studies ¹. Hyperhomocysteinemia is defined as a medical condition characterized by an abnormally high level (above 15 μmol/L) of homocysteine in the blood ¹².

• 5-15 μmol/L (Mild elevation)
• 15-30 μmol/L (Moderate elevation) ³
  
• 30-100 μmol/L (Intermediate elevation) ³
  
• >100 μmol/L (Severe elevation) ³
  

What does abnormal homocysteine test result mean?

In cases of suspected malnutrition or vitamin B12 or folate deficiency, homocysteine levels may be elevated. If an individual does not get enough B vitamins and/or folate through diet or supplements, then the body may not be able to convert homocysteine to forms that can be used by the body. In this case, the level of homocysteine in the blood can increase.

Studies from the mid- to late-1990s suggested that people who have elevated homocysteine levels have a much greater risk of heart attack or stroke than those with average levels. Investigating the link between high homocysteine levels and heart disease remains an active area of research. At present, however, the use of homocysteine levels for risk assessment of cardiovascular disease, peripheral vascular disease, and stroke is uncertain given that several trials investigating folic acid and B vitamin supplementation indicate no benefit or lowering of cardiovascular disease risk.

Additionally, a 2012 study of multiple datasets, including 50,000 people with coronary heart disease, called the potential for a cause-and-effect relationship between homocysteine levels and heart disease into question. The American Heart Association does acknowledge the relationship between homocysteine levels and heart attack/stroke survival rates but doesn’t consider elevated homocysteine a major risk factor for cardiovascular disease.

While the American Heart Association does not recommend widespread use of folic acid and B vitamins to reduce risk of heart attack and stroke, it does promote a balanced, healthy diet and advise health practitioners to consider overall risk factors and diet in managing cardiovascular disease.

In newborn testing, greatly increased concentrations of homocysteine in the urine and blood mean that it is likely that an infant has homocystinuria and indicates the need for further testing to confirm the cause of the increase.

When test results suggest homocystinuria, liver or skin biopsy samples are sometimes tested to determine whether the enzyme cystathionine beta synthase is present. The absence of this enzyme is the most common cause of homocystinuria. Genetic tests may be ordered to test for one or more of the most common gene mutations. If someone has a strong family history of early atherosclerosis or a family member has been diagnosed with homocystinuria, then that person should be tested for the gene mutation that was found in the family member.

Could any medications I may be taking have an effect on my homocysteine level?

Yes. There are numerous drugs that may either increase or decrease the amount of homocysteine in your body. You should always keep your healthcare provider and pharmacist aware of any medications, traditional or herbal, that you are taking since they may affect the test results. Azaribine, carbamazepine, methotrexate, nitrous oxide, and phenytoin can all cause increased levels of homocysteine. Oral contraceptives can also affect the metabolism of homocysteine.

Possible causes of elevated homocysteine levels

There are two types of hyperhomocysteinemia: (1) the rare but severe forms are due to major genetic mutations of the enzymes implicated in homocysteine metabolism; (2) the more common forms cause moderately elevated homocysteine levels related to a pathogenesis such as genetic and environmental factors ¹.

• Genetic disorders
• Consider vitamin B6 (Pyridoxine), Folic acid (vitamin B9) and Vitamin B12 (Cyanocobalamin) deficiencies
• Renal disease
• Smoking

Homocysteine levels can increase with age, when a person smokes, and with the use of drugs such as carbamazepine, methotrexate, and phenytoin. Homocysteine levels are lower in women than in men. Women’s concentrations increase after menopause, possibly due to decreased estrogen production.

Hyperhomocysteinemia may arise from genetic defects of enzymes involved in homocysteine metabolism. The enzymes involved can be 5, 10-methylene tetrahydrofolate reductase, methionine synthase, and cystathionine-β-synthase ¹³. The most common one that is detected worldwide and has a high incidence in different populations, is single nucleotide polymorphisms of 5,10-methylene tetrahydrofolate reductase which has been associated with mild (13–24 μM) and moderate (25–60 μM) hyperhomocysteinemia ¹³. Hankey et al. ¹⁴ stated that the most common enzyme defect associated with moderately raised total homocysteine is a point mutation (C-to-T substitution at nucleotide 677) in the coding region of the gene for MTHFR, which is associated with a thermo labile MTHFR variant that has about half-normal activity ¹⁴. The most common of the genetic causes of severe hyperhomocysteinemia and classic homocystinuria (congenital homocystinuria) is believed to be homozygous deficiency of CβS (cystathionine-β-synthase) which results in an increase of up to 40-fold in fasting total homocysteine. Other rarer causes of severe hyperhomocysteinemia are considered to be homozygous deficiency of MTHFR, deficiency of methionine synthase, and impaired activity of methionine synthase due to genetic disorders of vitamin B12 metabolism ¹⁴.

Hyperhomocysteinemia can also arise from nutritional deficiencies of folate, vitamin B6, and vitamin B12 ¹³. Blood levels of folate, vitamin B12 and to a lesser extent, vitamin B6 are related inversely to total homocysteine; therefore a person with a nutritional deficiency that leads to low blood concentrations of the aforementioned is at increased risk of hyperhomocysteinemia ¹³. Several diseases such as renal and thyroid dysfunction, cancer, psoriasis, and diabetes as well as various drugs, alcohol, tobacco, coffee, older age and menopause, are believed to be associated with moderately elevated homocysteine concentrations ¹⁵. A rise in serum creatinine also leads to a rise in fasting total homocysteine ¹⁴. The major route of homocysteine clearance from plasma is the kidney, and the rise is due to defective metabolism of homocysteine by the kidney ¹⁴. Total homocysteine levels are found to be considerably higher in patients with chronic renal disease than the moderately raised concentrations commonly found in patients with atherothrombotic vascular disease, and this may be the probable cause that contributes to the high incidence of vascular complications in patients with chronic renal failure ¹⁴. Plasma homocysteine concentrations can be increased by various drugs and diseases that interfere with folate, vitamin B6, and B12 metabolism, hence an abnormal homocysteine concentration may have a probable use as a diagnostic aid for some of these conditions ¹⁴.

There has been an indication towards a significant correlation between hyperhomocysteinemia and cardiovascular disease and its complications such as heart attacks and strokes ¹⁶. It is believed that hyperhomocysteinemia leads to endothelial cell damage, reduction in the flexibility of vessels, and alters the process of haemostasis ¹⁶. Hyperhomocysteinemia may lead to an enhancement of the adverse effects of risk factors like hypertension, smoking, lipid and lipoprotein metabolism, as well as promotion of the development of inflammation ¹⁶. The prevalence of hyperhomocysteinemia may vary significantly between populations, and most likely depend on age, diet, and genetic background as well ¹⁵. Increasing age, male sex, smoking, coffee consumption, high blood pressure, unfavourable lipid profile, high creatinine and faulty diet are some of the factors associated with increased homocysteine levels ¹⁷. On the other hand, physical activity, moderate alcohol consumption, good folate and vitamin B12 status are associated with lower homocysteine levels. Vegetarians may be at a higher risk of hyperhomocysteinemia due to low plasma B12 levels but the difference is likely to be insignificant ¹⁷.

Management Options

• Consider vitamin supplements in those with genetic hyperhomocysteinemia
  • Nutrients involved in the metabolism of homocysteine include folate, vitamin B₁₂, vitamin B₆, riboflavin, and choline. Although supplementation with folate, vitamin B₆, and vitamin B₁₂ successfully lowers homocysteine concentration in the blood, no significant effect on cardiovascular disease risk has been demonstrated. There is some evidence that riboflavin supplementation may lower homocysteine and blood pressure in individuals with a certain genetic predisposition. The consumption of folic acid supplements or cereals that are fortified with folic acid and to a lesser extent vitamin B6 and vitamin B-12, can lower blood homocysteine levels and may be beneficial in people with even mild genetic hyperhomocysteinemia.
• Manage other cardiovascular risk factors including obesity, exercise, diabetes, hypertension, cholesterol and cigarette smoking

Homocysteine test

The homocysteine test may be used a few different ways:

• A health practitioner may order a homocysteine test to determine if a person has a vitamin B12 or folate deficiency. The homocysteine concentration may be elevated before B12 and folate tests are abnormal. Some health practitioners may recommend homocysteine testing in malnourished individuals, the elderly, who often absorb less vitamin B12 from their diet, and individuals with poor nutrition, such as drug or alcohol addicts.
• Homocysteine may be ordered as part of a screen for people at high risk for heart attack or stroke. It may be useful in someone who has a family history of coronary artery disease but no other known risk factors, such as smoking, high blood pressure, or obesity. However, the exact role that homocysteine plays in the progression of cardiovascular disease has not been established, so the utility of the screening test continues to be questioned. Routine screening, such as that done for total cholesterol, has not been recommended.
• Tests for both a urine and blood homocysteine may be used to help diagnose homocystinuria if a health practitioner suspects that an infant or child may have this inherited disorder. In the U.S., all babies are routinely tested for excess methionine, a sign of homocystinuria, as part of their newborn screening. If a baby’s test is positive, then urine and blood homocysteine tests are often performed to confirm the findings.

When is homocysteine test ordered?

Homocysteine test may be ordered when a health practitioner suspects that a person may have a vitamin B12 and/or folate deficiency. Signs and symptoms are initially subtle and nonspecific. People with an early deficiency may be diagnosed before they experience any overt symptoms. Other affected people may experience a variety of mild to severe symptoms that can include:

• Diarrhea
• Dizziness
• Fatigue, weakness
• Loss of appetite
• Paleness
• Rapid heart rate
• Shortness of breath
• Sore tongue and mouth
• Tingling, numbness, and/or burning in the feet, hands, arms, and legs (with B12 deficiency)

Homocysteine testing may be ordered as part of assessing a person’s risk of cardiovascular disease, depending on the individual’s age and other risk factors. It may also be ordered following a heart attack or stroke to help guide treatment.

Homocysteine test is may be ordered when newborn screening detects an elevated level of methionine or if an infant or child has signs and symptoms of homocystinuria. Babies with this condition will appear normal at birth, but if not treated, they will, within a few years, begin to develop signs such as a dislocated lens in the eye, a long slender build, long thin fingers, and skeletal abnormalities.

Vitamin B12 and folate deficiencies

Vitamin B12 and folate deficiencies are a lack of these two B complex vitamins that the body needs for several important functions. They are required to make normal red blood cells (RBCs), repair tissues and cells, synthesize DNA (the genetic material in cells). B12 is also important for normal nerve cell function. B12 and folate (also known as folic acid or vitamin B9) are nutrients that cannot be produced in the body and must be supplied by the diet. The body stores 3 to 6 years worth of B12 and about a 3 months’ supply of folate in the liver. So a B12 and/or folate deficiency reflects a chronic shortage of one or both of these vitamins.

In the U.S., B12 and folate deficiencies are not common in healthy adults because the body can store sufficient amounts and most adults eat enough foods or take supplements that contain these vitamins to meet their daily requirements. There are, however, people at risk of deficiency, such as the elderly, people with intestinal problems that prevent them from absorbing enough of the vitamins, heavy alcohol drinkers, and pregnant women, who need increased amounts of these vitamins.

B12 and folate deficiencies and their associated signs and symptoms can take months to years to manifest in adults. Infants and children will show signs of deficiency more rapidly because they have not yet had time to store sufficient amounts.

Over time, a deficiency in either B12 or folate can lead to macrocytic anemia, a condition in which red blood cells are enlarged. This production of fewer but larger red blood cells decreases the blood’s ability to carry oxygen. People with anemia may be weak, light-headed, and short of breath. Megaloblastic anemia, a type of macrocytic anemia, is characterized by the production of fewer but larger red blood cells in addition to some cellular changes in the bone marrow. Other laboratory findings associated with megaloblastic anemia include decreased white blood cell (WBC) count and platelet count.

A deficiency in B12 can also result in varying degrees of neuropathy or nerve damage that can cause tingling and numbness in the person’s hands and feet. In severe cases, mental changes that range from confusion and irritability to dementia may occur.

Pregnant women need increased folate for proper fetal development because of the added stress of rapidly growing fetal cells. A folate deficiency during pregnancy, especially in the early weeks when a woman might not know she is pregnant, may lead to premature birth and neural tube birth defects  such as spina bifida in the child. To help prevent neural tube birth defects, the Food and Drug Administration mandated increased folate supplementation of grain products a number of years ago, which led to about a 50% decrease in neural tube defects in the U.S. Even so, it can be difficult sometimes to get enough folate from foods, so it is recommended that all women who may become pregnant take 400 micrograms of folate every day.

Figure 3. Folate-rich food sources

Figure 4. Vitamin B12 rich food sources

Vitamin B12 and folate deficiencies signs and symptoms

The initial signs and symptoms associated with B12 and folate deficiencies may be subtle and nonspecific. They may be related to the resulting megaloblastic anemia, nerve damage, and/or gastrointestinal changes. People with an early deficiency may be diagnosed before they experience any noticeable symptoms. Other affected people may experience a variety of mild to severe signs and symptoms that can include:

• Diarrhea
• Dizziness
• Fatigue, muscle weakness
• Loss of appetite
• Pale skin
• Rapid heart rate, irregular heartbeats
• Shortness of breath
• Sore tongue and mouth
• Tingling, numbness, and/or burning in the feet, hands, arms, and legs (with B12 deficiency)
• Confusion or forgetfulness
• Paranoia

Vitamin B12 and folate deficiencies causes

There are a variety of causes of B12 and/or folate deficiencies. They include:

Insufficient dietary intake

B12 is found in animal products such as red meat, fish, poultry, milk, and eggs. Folate, also called folic acid or vitamin B9, is found in leafy green vegetables, citrus fruits, dry beans, yeast, and fortified cereals.

The human body stores several years’ worth of B12 in the liver. Since a variety of foods consumed by Americans contain B12, a dietary deficiency of this vitamin is extremely rare in the U.S. It may be seen, for example, in people with generally poor nutrition or malnutrition, in vegans who do not consume any animal products, including milk and eggs, and in breastfed infants of vegans. In adults, dietary deficiencies do not usually cause symptoms until stores of the vitamins within the body have been depleted. Deficiencies in children and infants, however, show up fairly quickly since they have not had time to store as much of the vitamins as adults.

Folate deficiency used to be a common, but in 1997 the U.S. government mandated supplementation of cereals, breads, and other grain products with folic acid. Because folate is stored in tissue in smaller quantities than B12, folate must be consumed more regularly than B12.

Malabsorption

Both B12 and folate deficiencies may be seen in people who have conditions that interfere with absorption of the vitamins in the small intestine. Vitamin B12 absorption occurs in a series of steps. B12 is normally released from food by stomach acid and then, in the small intestine, is bound to intrinsic factor (IF), a protein made by parietal cells in the stomach. This B12-IF complex is then absorbed by the small intestine, bound by carrier proteins (transcobalamins), and enters the circulation. If a disease or condition interferes with any of these steps, then B12 absorption is impaired.

Some examples of these conditions include:

• Pernicious anemia is the most common cause of B12 deficiency. A protein called intrinsic factor, made by parietal cells that line the stomach, is needed for B12 absorption. In pernicious anemia, inflammation damages the parietal cells, leading to little or no intrinsic factor, thus preventing the intestines from absorbing B12. With insufficient B12, the body produces enlarged but fewer RBCs. Because of the larger than normal RBCs, this is often referred to as megaloblastic or macrocytic anemia.
• Celiac disease
• Inflammatory bowel disease, including Crohns disease and ulcerative colitis
• Bacterial overgrowth or the presence of parasites in the intestines
• Reduced stomach acid production; stomach acid is necessary to separate B12 from the protein in food. This is the most common cause of B12 deficiency in the elderly and in individuals on drugs that suppress gastric acid production.
• Surgery that removes part of the stomach (and the parietal cells) or the intestines may greatly reduce absorption of nutrients. This is a concern that is considered when gastric by-pass procedures are performed.
• Chronic pancreatitis

Increased need

All pregnant women need increased amounts of folate for proper fetal development. If a woman has a folate deficiency prior to pregnancy, it will be intensified during the pregnancy and may lead to premature birth and neural tube defects in the child. It is recommended that women with any chance of becoming pregnant take folic acid supplements because neural tube defects can develop in the first few weeks of pregnancy, before many women realize they are pregnant.

People with cancer that has spread (metastasized) or with a chronic hemolytic anemia such as due to sickle cell disease have an increased need for folate.

Other causes:

• Heavy alcohol drinking and chronic alcoholism can cause B12 and/or folate deficiency through a combination of poor nutrition and a decrease in the amount of B12 released from dietary proteins.
• Some drugs can cause B12 deficiency. For example, the diabetes drug metformin prevents B12 from being absorbed, while omeprazole (an acid reflux drug also known as Prilosec) reduces gastric acids and prevents B12 release from food.
• Anti-seizure medications such as phenytoin can decrease folate by blocking folate absorption.
• Methotrexate, an anti-cancer drug, affects body metabolism and use of folate.

Vitamin B12 and folate deficiencies diagnosis

Laboratory testing is used to detect a vitamin deficiency, determine its severity, establish it as the underlying cause of someone’s symptoms, and to monitor the effectiveness of treatment. The anemia and large red blood cells (RBCs) associated with a vitamin B12 or folate deficiency are often initially detected during a routine complete blood count (CBC). Additional laboratory testing is performed as follow up to identify the specific deficiency.

Laboratory Tests

To diagnose or monitor B12 and folate deficiencies:

• B12 blood level. If low, a deficiency is indicated, but it does not identify the cause. A low level of intrinsic factor may be a cause, for example. This test also may be ordered to monitor the effectiveness of treatment.
• Folate level. Either serum or RBC folate levels may be tested; if either is low, it indicates a deficiency. The tests may also be ordered to monitor the effectiveness of treatment. Pregnant women may be given this test at prenatal checkups.
• Complete blood count (CBC). This group of tests is ordered routinely to evaluate the health of blood cells. It determines the number of cell types and can give an indication of the physical characteristics of some of the cells. With both B12 and folate deficiencies, the amount of hemoglobin and the red blood cell count may be low and the RBCs are abnormally large (macrocytic or megaloblastic), resulting in an anemia. White blood cells and platelets also may be decreased.
• Methylmalonic acid (MMA). This test may be ordered to help detect mild or early B12 deficiency.
• Homocysteine. This test is seldom ordered but may be elevated in both B12 and folate deficiency.

To help determine the cause of a B12 deficiency:

• Intrinsic factor antibody. The antibody prevents intrinsic factor from carrying out its function, that is, to carry vitamin B12 and allow B12 to be absorbed at a specific segment of the small intestine.
• Parietal cell antibody. An antibody against the parietal cells that produce intrinsic factor. This antibody can disrupt the production of intrinsic factor and is present in a large percentage of those with pernicious anemia, but it may also be seen in other autoimmune disorders.
• Gastrin. A hormone that regulates the production of acid in the stomach during the digestive process. Increased gastrin is sometimes seen in pernicious anemia.
• Schilling test. Once frequently ordered to confirm a diagnosis of pernicious anemia, this test is generally no longer available.

Vitamin B12 and folate deficiencies treatment

Treatment for B12 and folate deficiencies frequently involves supplementation, which may be long-term or lifetime, depending on the underlying cause. People who lack intrinsic factor or have conditions causing general malabsorption require injections of B12. Folate is given as an oral supplement.

It is generally recommended that all women contemplating having a child or who may become pregnant take folic acid supplements to ensure that they have a sufficient store for normal fetal development and to prevent neural tube defects.

Individuals deficient in both B12 and folate will require replenishment of both. If someone with a B12 deficiency only takes folic acid supplements, the macrocytic anemia may be resolved but the underlying neuropathy caused by the B12 deficiency will persist. Appropriate treatment should resolve symptoms but may not reverse all of the nerve damage.

Homocystinuria

Homocystinuria is an inherited disorder in which the body is unable to process certain building blocks of proteins (amino acids) properly. There are multiple forms of homocystinuria, which are distinguished by their signs and symptoms and genetic cause. The most common form of homocystinuria is characterized by nearsightedness (myopia), dislocation of the lens at the front of the eye, an increased risk of abnormal blood clotting, and brittle bones that are prone to fracture (osteoporosis) or other skeletal abnormalities. Some affected individuals also have developmental delay and learning problems.

Less common forms of homocystinuria can cause intellectual disability, failure to grow and gain weight at the expected rate (failure to thrive), seizures, problems with movement, and a blood disorder called megaloblastic anemia. Megaloblastic anemia occurs when a person has a low number of red blood cells (anemia), and the remaining red blood cells are larger than normal (megaloblastic).

The signs and symptoms of homocystinuria typically develop within the first year of life, although some mildly affected people may not develop features until later in childhood or adulthood.

The most common form of homocystinuria affects at least 1 in 200,000 to 335,000 people worldwide. The disorder appears to be more common in some countries, such as Ireland (1 in 65,000), Germany (1 in 17,800), Norway (1 in 6,400), and Qatar (1 in 1,800). The rarer forms of homocystinuria each have a small number of cases reported in the scientific literature.

Homocystinuria Causes

Homocystinuria is inherited in families as an autosomal recessive trait. This means that the child must inherit a non-working copy of the gene from each parent to be seriously affected. Most often, the parents of an individual with an autosomal recessive condition each carry one copy of the mutated gene, but do not show signs and symptoms of the condition.

Although people who carry one mutated copy and one normal copy of the CBS gene do not have homocystinuria, they are more likely than people without a CBS mutation to have shortages (deficiencies) of vitamin B12 and folic acid.

Homocystinuria has several features in common with Marfan syndrome, including skeletal and eye changes.

Homocystinuria Genetic Changes

Mutations in the CBS, MTHFR, MTR, MTRR, and MMADHC genes cause homocystinuria. The CBS gene provides instructions for making an enzyme called cystathionine beta-synthase. This enzyme acts in a chemical pathway and is responsible for using vitamin B6 to convert building block of proteins (amino acid) called homocysteine and serine to a molecule called cytathionine. Another enzyme then converts cystathionine to the amino acid cysteine, which is used to build proteins or is broken down and excreted in urine. Additionally, other amino acids, including methionine, are produced in this pathway.

Mutations in the CBS gene cause the most common form of homocystinuria. The CBS gene provides instructions for producing an enzyme called cystathionine beta-synthase. This enzyme acts in a chemical pathway and is responsible for converting the amino acid homocysteine to a molecule called cystathionine. As a result of this pathway, other amino acids, including methionine, are produced. Mutations in the CBS gene disrupt the function of cystathionine beta-synthase, preventing homocysteine from being used properly. As a result, this amino acid and toxic byproducts substances build up in the blood. Some of the excess homocysteine is excreted in urine.

Rarely, homocystinuria can be caused by mutations in several other genes. The enzymes made by the MTHFR, MTR, MTRR, and MMADHC genes play roles in converting homocysteine to methionine. Mutations in any of these genes prevent the enzymes from functioning properly, which leads to a buildup of homocysteine in the body. Researchers have not determined how excess homocysteine and related compounds lead to the signs and symptoms of homocystinuria.

Homocystinuria Prevention

Genetic counseling is recommended for people with a family history of homocystinuria who want to have children. Prenatal diagnosis of homocystinuria is available. This involves culturing amniotic cells or chorionic villi to test for cystathionine synthase (the enzyme that is missing in homocystinuria).

If there are known gene defect in the parents or family, samples from chorionic villus sampling (CVS) or amniocentesis can be used to test for these defects.

Homocystinuria Signs and Symptoms

Newborn infants appear healthy. Early symptoms, if present, are not obvious.

Symptoms may occur as mildly delayed development or failure to thrive. Increasing visual problems may lead to diagnosis of this condition.

The health care provider may notice that the child is tall and thin.

Other signs include:

• Curved spine (scoliosis)
• Deformity of the chest
• Dislocated lens of the eye

If there is poor or double vision, an eye doctor (ophthalmologist) will perform a dilated eye exam to look for dislocation of the lens or nearsightedness.

There may be a history of blood clots. Intellectual disability or mental illness is also possible.

Other symptoms include:

• Chest deformities (pectus carinatum, pectus excavatum)
• Flush across the cheeks
• High arches of the feet
• Intellectual disability
• Knock knees
• Long limbs
• Mental disorders
• Nearsightedness
• Spidery fingers (arachnodactyly)
• Tall, thin build

Possible Complications

Most serious complications result from blood clots. These episodes can be life threatening.

Dislocated lenses of the eyes can seriously damage vision. Lens replacement surgery may be needed.

Intellectual disability is a serious consequence of the disease. But, it can be reduced if diagnosed early.

Homocystinuria Diagnosis

Exams and Tests

Tests that may be ordered include any of the following:

• Amino acid screen of blood and urine
• Genetic testing
• Liver biopsy and enzyme assay
• Skeletal x-ray
• Skin biopsy with a fibroblast culture
• Standard ophthalmic exam

Homocystinuria Treatment

There is no cure for homocystinuria. About half of people with the disease respond to vitamin B6 (also known as pyridoxine).

Those who do respond will need to take vitamin B6 (pyridoxine), B9 (folate), and B12 supplements for the rest of their lives. Those who do not respond will need to eat a low-methionine diet. Most will need to be treated with trimethylglycine (a medicine also known as betaine).

Neither a low-methionine diet nor medicine will improve existing intellectual disability. Medicine and diet should be closely supervised by a doctor who has experience treating homocystinuria.

Figure 6. Pyridoxine vitamin B6 rich food sources

Homocystinuria Outlook (Prognosis)

Although no cure exists for homocystinuria, vitamin B therapy can help about half of people affected by the condition.

If the diagnosis is made in childhood, starting a low-methionine diet quickly may prevent some intellectual disability and other complications of the disease. For this reason, some states screen for homocystinuria in all newborns.

People whose blood homocysteine levels continue to rise are at increased risk for blood clots. Clots can cause serious medical problems and shorten lifespan.

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