To the Editor: We have read with interest the article by Balamtekin et al (1) suggesting symptoms related to Helicobacter pylori (HP) infection in patients with coronavirus disease 2019 (COVID-19) that we praise for innovation.
According to the Maastricht-V Consensus Report (2), the diagnosis of HP should not be based on stool antigen tests and at least confirmed by a second test (13C-urea breath test) performed following a negative COVID-19 test. Moreover, the omission of eradication therapy raises an ethical concern regarding the reason for testing for HP.
Angiotensin-converting enzyme-2 (ACE-2) is expressed in cells of the gastrointestinal tract (3), and several conditions (diabetes, hypertension, obesity and autoimmune diseases) increase the expression of ACE-2 receptors independently from HP (4). The authors state to have evaluated comorbidities, but no mention is given in the results. Concerning the adult age of patients, these conditions should have been considered or patients excluded. Moreover, there was no mention of symptoms before HP or after COVID-19 infection nor a control group of COVID-19 negative patients.
The study misses a power calculation and even considering the relative prevalence of each symptom in HP positive/negative patients as correct, the study would be under-powered; at least 55 patients per arm are needed to have a power of 80% (α-error = 0.05). Finally, other factors related to HP (5) might be responsible for the increased rate of symptoms (6).
Abdominal pain and diarrhea, widespread in the pediatric population, could lead to an overestimation of the suspicion of HP infection during the COVID-19 pandemic that might further overload the health system already at collapse.
REFERENCES
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