key: cord-0894722-lktmjary
authors: Fouda, Eman M.; Wahba, Nancy S.; Elsharawy, Asmaa I. M.; Ishak, Sally R.
title: Serum homocysteine level in pediatric patients with COVID‐19 and its correlation with the disease severity
date: 2022-04-22
journal: Pediatr Pulmonol
DOI: 10.1002/ppul.25920
sha: 0f683275be54f9da676ea16333a5b8cd29f3b864
doc_id: 894722
cord_uid: lktmjary

BACKGROUND: Thrombosis and embolism are possible complications in coronavirus disease 2019 (COVID)‐19‐positive pediatric patients. Although the risk is lesser in children than it is in adults, it does exist during acute infection and multi‐inflammatory syndrome in children. Biomarkers such asd‐dimer, prothrombin time, and fibrinogen degradation products are ineffective at detecting disease severity. Homocysteine (Hcy) is a prothrombotic factor that has been reported to be higher in adult COVID‐19 patients, leading to speculation that it could be used as a biomarker for disease severity. PURPOSE: To detect the correlation between serum total homocysteine (tHcy) level and the severity of COVID‐19 in pediatrics. METHODS: A cross‐sectional study was conducted on 40 children with COVID‐19 and 40 healthy control subjects. Serum tHcy was measured by enzyme‐linked immunosorbent assay and correlated with the clinical, laboratory, and radiological parameters of the patients. RESULTS: The median serum tHcy level in COVID‐19 patients was 27.5 (interquartile range [IQR]: 23–31.75) μmol/L, while that in the controls was 1.8 (IQR: 1.6–1.875) μmol/L. There was a statistically significant increase in the tHcy level in cases compared to controls (p < 0.001). There was a statistically significant positive correlation between serum tHcy and d‐dimer, ferritin, alanine transaminase, aspartate transaminase, blood urea nitrogen, and a highly significant positive correlation between tHcy and COVID‐19 reporting and data system score, pediatric intensive care unit admission, and the disease severity classification. CONCLUSION: Hcy could be a biomarker of importance in predicting the severity of COVID‐19 in pediatrics.

To stratify high-risk patients of coronavirus disease 2019 (COVID- 19) , scientists urgently require accurate biomarkers related to COVID-19 illness progression. Vascular injury whether embolism, thrombosis, or infarction affects different organs such as the cardiovascular system, the lungs, and the brain causing significant morbidities and mortality in COVID-19 patients. 1 Importantly, the microvascular changes in COVID-19 are more pronounced than in H1N1-infected lungs, suggesting disease-specific effects not just a common phenomenon of acute respiratory distress syndrome or viral pneumonia. Venous thromboembolism occurs in up to 50% of COVID-19 autopsy series and the reported occurrence of deep-vein thrombosis points to embolic complications in addition to in situ microvascular immunothrombosis. 2 The available biomarkers asDdimer, prothrombin time, and fibrinogen degradation products (FDPs) are not sensitive enough in detecting the severity of the disease. 1 Homocysteine (Hcy) is derived from methionine which is an essential amino acid. It is a prothrombotic factor since it is involved in the generation of reactive oxygen species, which causes oxidative stress, endothelial disruption, and irreversible inactivation of protein C and thrombomodulin. 3 Several potential mechanisms were suggested by which Hcy would trigger severe COVID-19 disease or prevent its control. 4, 5 High Hcy levels cause thrombus development by increasing inflammatory cytokines that are overproduced in cytokine release syndrome or "cytokine storm." They also cause limit nitric oxide generation and promote endothelial dysfunction. All of these pathologies are hallmarks of severe SARS-Cov2. 6 The present study aims to assess the serum level of Hcy and to correlate it with clinical, laboratory, and radiological findings in COVID-19 pediatric patients, evaluating its potential role as a prognostic marker of COVID-19 infection outcomes.

care unit (PICU). The disease was mild in 13 (32.5%), moderate in 9 (22.5%), severe in 7 (17.5%), and critically ill in 11 (27.5%) patients.

As regards the symptoms of the studied patients; fever(100%), abdominal pain (45%), cough (37.5%), rash (35%), nausea and vomiting (32.5%), dyspnea (30%), runny nose (25%), fatigue (25%), diarrhea (22.5%), conjunctivitis (22.5%), sore throat (20%), muscle ache (17.5%), joint pain (12.5%), seizures (12.5%), headache (10%), and finally 2.5% of patient lost the ability to smell and taste.

General examination revealed that 22 (55%) of patients were toxic and 2 (5%) of them were in shock. Tachycardia for age was recorded in 21 cases (52.5%). Hypoxia was recorded in seven (17.5%) cases. Hypotension was recorded in nine cases (22.5%) and hypertension in two cases (5.0%). Three cases had cyanosis. There were no thromboembolic symptoms in any of our subjects.

According to the weight-for-age z-score, five (12.5%) cases were mildly underweight (−1 to −2) and five (12.5%) were moderately

Laboratory tests results are demonstrated in Table 1 .

According to CO-RADS classification, CT score was 1 in 13 (32.5%) patients, 3 in 1 (2.5%) patient, 5 in 1 (2.5%) patient, and it was 6 in 25 (62.5%) patients.

Echocardiographic (ECHO) findings, cardiomegaly was found in one patient (2.5%), carditis in six (15%), dilated cardiomyopathy in one patient (2.5%), dilated left ventricle in two (5%), aortic stenosis in one patient (2.5%), and mitral and aortic regurge in two patients (2.5%) (5%).

As regards serum Hcy, the COVID-19 group had statistically significantly higher levels (range: 7-64 μmol/L and median [interquartile range, IQR]: 27.5 [23-31.75 ] μmol/L) in comparison to the control group (range: 1.00-2.20 μmol/L and median [IQR]: 1.8 [1.6-1.875 ] μmol/L) (p < 0.001) ( Table 2) .

Serum Hcy levels were significantly higher in PICU admitted COVID-19 cases compared to the ward admitted cases, also they were higher in cases withD-dimer ≥1 mcg/ml compared to cases withD-dimer lower than 1 mcg/ml, and serum Hcy concentration increased as the grade of severity of COVID-19 increased (Table 3 ).

There was a highly significant positive correlation between serum Hcy and CO-RADS score, and the disease severity classification, as well as a statistically significant positive correlation between it and D-dimer, ferritin, alanine transaminase (ALT), aspartate transaminase (AST), and blood urea nitrogen (BUN) ( Table 4) . D-dimer could predict mortality in COVID-19 patients, especially in levels above 2 µg/ml (fourfold increase). 16 ,17 D-dimer levels were elevated in 30 (75%) of the cases in this study, which is consistent with Huang et al.'s 18 finding thatD-dimer values were nearly fivefold higher in those with severe disease than in those with mild disease (p = 0.004). In COVID-19 patients, we found a positive correlation between serum Hcy andD-dimer levels. Furthermore, compared to patients withD-dimer levels below 1 µg/ml, there was a statistically significant rise in the level of Hcy in the group of patients withDdimer levels greater than 1 µg/ml. CT abnormalities were seen in 63% of cases in a review study by de Souza et al. 19 (on 1117 children), which is similar to our findings (67.5%). While Qi et al. 20 conducted a meta-analysis, they found ground-glass opacities of 32.9% of the cases (far lower than our study's 65%). The CO-RADS score was found to be effective in diagnosing COVID-19 patients, even those who had a negative RT-PCR. 21 The current study reported a link between serum Hcy levels and the chest CT grading measured by the CO-RADS score. The findings of Anemia was present in 90% of the patients in our study, and 25%

of the patients were underweight. In a similar study, Kulkarni et al. 25 reported malnutrition and anemia in 23% of the COVID patients investigated. We did not find a significant correlation between Hcy and hemoglobin levels. Sirdah et al., 26 on the other hand, found a link between homocysteine and iron deficiency anemia. We also did not find a significant correlation between body weight and Hcy. Comparably, Xiang et al. 27 found a negative association between being underweight and the risk of developing of hyperhomocysteinemia.

angiotensin-converting enzyme 2 receptors in the liver, or it could be immune-mediated or drug-induced. 28 Previous studies found increased liver enzymes in 25% of children with COVID-19, which reached 50% in severe and critically ill individuals. 29 Omran et al. 30 reported that elevated liver enzymes are predictors of the severity of COVID-19. In the current study, ALT and AST had a positive correlation with Hcy levels, which is consistent with the findings of Lv et al. 31 Although Hcy levels rise in patients with renal failure, we could not detect a link between Hcy and serum creatinine. However, there was a strong link between BUN and Hcy. BUN andD-dimer are also predictors of death in COVID-19 with a sensitivity (85%) and specificity (91%) according to Cheng et al., 24 writingoriginal draft (equal); and writingreview and editing (equal).

The authors would like to thank the patients and their caregivers for accepting to participate in the study. They would also like to thank the managers, professors, and doctors of Children's Hospital, Ain

Shams University for their tremendous effort in following the patients during the COVID-19 pandemic. 

Biomarkers associated with COVID-19 disease progression

Autopsy findings and venous thromboembolism in patients with COVID-19: a prospective cohort study

Mechanisms of homocysteine toxicity in humans

Homocysteine as a potential predictor of cardiovascular risk in patients with COVID-19

Homocysteine (Hcy) assessment to predict outcomes of hospitalized Covid-19 patients: a multicenter study on 313 Covid-19 patients

Homocysteine and the SARS-CoV-2 Coronavirus-the X factor of severe disease and death. SSRN

Life-threatening course in coronavirus disease 2019 (COVID-19): Is there a link to methylenetetrahydrofolic acid reductase (MTHFR) polymorphism and hyperhomocysteinemia?Med Hypotheses

Homocysteine and psychiatric disorders

Diagnosis, treatment, and prevention of 2019 novel coronavirus infection in children: experts' consensus statement

CO-RADS-a categorical CT assessment scheme for patients with suspected COVID-19: definition and evaluation

Assessment of serum homocysteine, endothelin-1, and nitric oxide levels in behçet's disease

Pulmonary vascular endothelialitis, thrombosis, and angiogenesis in Covid-19

Homocysteine and thrombosis: from basic science to clinical evidence

Covid-19 and major organ thromboembolism: Manifestations in neurovascular and cardiovascular systems

Association of low molecular weight plasma aminothiols with the severity of coronavirus disease 2019

Prognostic genetic markers for thrombosis in COVID-19 patients: a focused analysis on D-dimer, homocysteine and thromboembolism

Course of COVID-19 based on admission D-dimer levels and its influence on thrombosis and mortality

Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The lancet

Clinical manifestations of children with COVID-19: a systematic review

Clinical, laboratory, and imaging features of pediatric COVID-19: A systematic review and meta-analysis

Use of the COVID-19 reporting and data system (CO-RADS) classification and chest computed tomography involvement score (CT-IS) in COVID-19 pneumonia

Predictors for imaging progression on chest CT from coronavirus disease 2019 (COVID-19) patients

Homocysteine and D-dimer levels and multilayer computed tomography for diagnosing pulmonary artery thromboembolism. Vessel Plus

Ferritin in the coronavirus disease 2019 (COVID-19): a systematic review and meta-analysis

Severe malnutrition and anemia are associated with severe COVID in infants

Homocysteine and vitamin B12 status and iron deficiency anemia in female university students from Gaza Strip

Association of obesity with the risk of hyperhomocysteinemia among the Chinese community residents: a prospective cohort study in Shanghai

Hepatic complications of COVID-19 and its treatment

COVID-19 and pediatric fatty liver disease: is there interplay?

Predictors of severity and development of critical illness of Egyptian COVID-19 patients: a multicenter study

Plasma levels of homocysteine is associated with liver fibrosis in health check-up population

Predictive values of blood urea nitrogen/creatinine ratio and other routine blood parameters on disease severity and survival of COVID-19 patients

Homocysteine metabolism in children and adolescents: influence of age on plasma biomarkers and correspondent genotype interactions

Homocysteine: cardiovascular risk factor in children and adolescents?

Potential role of vitamin B6 in ameliorating the severity of COVID-19 and its complications

Dietary determinants of plasma homocysteine concentrations

The authors declare no conflicts of interest.

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

Sally R. Ishak https://orcid.org/0000-0001-9210-8331