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Elevation in homocysteine is expected with cobalamin deficiency due to reduced methionine synthase activity even in the face of extreme cobalamin deficiency

References The Lancet (2023) Rosenstock J, et al

Vitamin B12 is naturally present almost exclusively in animal-derived foods, making vegans and strict vegetarians particularly vulnerable unless they consume fortified foods or supplements

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World Health Organization Lee Y-H, Kim H-K, Kim M-S, You H-J, Kim D-W, Lee T-Y (2022) Chemical sterilization of lipoplasty cannula and nontuberculous mycobacteria disinfection: an experimental study