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Human immunodeficiency virus (HIV)-negative, API2-MALT1 fusion-negative bronchus-associated lymphoid tissue (BALT) lymphoma in a young male.

A 22-year-old male presented with multiple bilateral nodular shadows in the lungs by chest radiograph. He had been asymptomatic and showed no significant abnormal findings in laboratory examinations. He underwent a diagnostic partial lobectomy, and was diagnosed as having primary pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma; i.e. bronchus-associated lymphoid tissue (BALT) lymphoma/BALToma. Neither t(11;18)(q21;q21) chromosomal translocation nor API2-MALT1 chimeric transcript was found at diagnosis. Epstein-Barr virus (EBV) was also not detected in lymphoma cells. He had been a nonsmoker, and had also never shown any associated autoimmune disorders, chronic inflammatory lung diseases or human immunodeficiency virus (HIV) infection. However, he had suffered from moderate atopic dermatitis on his arms from childhood. It appears necessary to clarify whether atopy might play a role in the pathogenesis of API2-MALT1(-) BALT lymphoma for HIV(-) young patients who do not exhibit any other antecedent chronic antigenic stimulations.

Adult↗

Human B lymphocytes capable of spontaneous Ig production in short-term cultures: characterization in the circulation and lymphoid tissues.

In the present work we have studied the occurrence and the characteristics of human B lymphocytes which are capable of spontaneous immunoglobulin (Ig) production in short-term cultures. It was found that this type of B cells secreted predominantly IgG and were present in the circulation as well as in the lymphoid tissue (tonsil and lymph node) of normal subjects. Tissular and circulating cell subsets exhibited many similarities: These cells produced Ig during a 3-day culture period without apparent need for T cells or monocytes. Protein and DNA synthesis were required for Ig secretion to occur. In Percoll fractionation experiments these cells showed low density, as they were mainly collected in the 42.5-45% Percoll fractions. These subsets consisted of cells considerably larger in size than the majority of B lymphocytes, as determined by Ig sedimentation. They were commonly defined as SmIg- Ia+ B cells by panning fractionation techniques. All these common characteristics suggest that these B cells have reached an advanced stage of maturation in vivo in both circulation and lymphoid tissue. Further surface marker analysis demonstrated that tissular but not circulating B-cell subset reacted with peanut agglutinin and the BA-2 monoclonal antibody which probably indicates their germinal center origin.

B-Lymphocytes↗

alpha-Defensins 1, 2, and 3 are expressed by granulocytes in lymphoid tissues of HIV-1-seropositive and -seronegative individuals.

alpha-Defensins 1, 2, and 3 exert antiretroviral activity in vitro, but their role in controlling HIV-1 replication in vivo and the cells that produce them are controversial. This study sought to determine whether alpha-defensins are present in HIV-1-infected individuals' lymphoid tissues, the major site of HIV-1 replication, and to identify the cells that express them. alpha-Defensin expression was evaluated by immunostaining inguinal lymph node sections from 19 untreated HIV-1-infected individuals and 8 individuals at low risk or seronegative for HIV-1 infection. Percentages of tissue sections that stained positively for alpha-defensins were not significantly different between HIV-seropositive (median, 7.6%) and -seronegative (median, 5.5%) individuals. Conditions that could have produced lymph node inflammation were present in most seronegative subjects, and their lymph node weights correlated with alpha-defensin expression (Spearman rho = 0.833; P = 0.010). A median of 100% (range, 95%-100%) of alpha-defensin-expressing lymph node cells from 8 subjects coexpressed the granulocyte marker, CD15. CD15 and alpha-defensin staining correlated (Spearman rho = 0.622; P < 0.001). These data suggest that alpha-defensins within lymphoid tissue are expressed by granulocytes and are prevalent in HIV-1-seronegative individuals with inflammatory processes as well as HIV-1-infected individuals. The role of alpha-defensins in controlling HIV-1 replication merits further investigation.

Female↗

In vivo cytokine responses in gut-associated lymphoid tissue (GALT) and spleen following oral administration of staphylococcal enterotoxin B.

The mechanisms responsible for oral tolerance have been analyzed using various antigens. The induction of oral nonresponsiveness to low doses of Staphylococcal Enterotoxin B (SEB), in which SEB-reactive clonal anergy and deletion are involved, has also been confirmed. However, few reports have examined the cytokine milieu of the mucosal and peripheral lymphoid tissue during tolerance induction after the oral administration of SEB. In this study, to elucidate the mechanism responsible for the oral tolerance to low dose of SEB, the cytokine responses of the gut-associated lymphoid tissues (GALT) and the spleen were examined using the reverse transcription-polymerase chain reaction (RT-PCR) method. After the oral administration of a single low dose of SEB, the expressions of Th2 and TGF-beta, and to a lesser extent Th1 mRNA were observed in the mucosa. In contrast, following repeated oral low doses of SEB, in a manner different from previous results using conventional antigens, no cytokine enhancements were demonstrated in the GALT or the spleen. In conclusion, the involvement of unknown inhibitory or regulatory cytokines, together with SEB-reactive clonal anergy and deletion, is suggested in the induction of oral tolerance to low dose SEB.

Animals↗

Virus quantification and identification of cellular targets in the lungs and lymphoid tissues of pigs at different time intervals after inoculation with porcine reproductive and respiratory syndrome virus (PRRSV).

Sixteen 6 week old conventional pigs were inoculated by aerosol with a European strain of porcine reproductive and respiratory syndrome virus (PRRSV). Virus replication was followed by virus titration and immunofluorescence in the lungs and in associated and distant lymphoid tissues at 3, 14, 21, 35, 42 and 82 days post-inoculation (DPI). PRRSV replication was detected in alveolar macrophages, lungs, tonsils, spleen, retropharyngeal lymph nodes, bronchial lymph nodes and thoracic aortic lymph nodes at 3 DPI. The same tissues, except retropharyngeal and thoracic aortic lymph nodes, were PRRSV positive at 14 DPI. Lungs and alveolar macrophages were PRRSV positive until 35 DPI. PRRSV was not detected in heart, peripheral blood mononuclear cells and bone marrow cells. Viremia was detected from 3 to 28 DPI. Not more than 2% of alveolar macrophages were PRRSV positive even during the acute stage of infection. 80 to 94% of the PRRSV infected cells in the lungs and in lung lavaged cells were identified as macrophages using a porcine macrophage specific monoclonal antibodies. In the lymph nodes and spleen, 100% of the infected cells were macrophages. Anti-PRRSV antibodies were detected by a blocking ELISA as early as 7 DPI. the antibody titre gradually increased to reach a geometric mean titre (GMT) of 160 at 35 DPI. It remained at that level until the end of the study. These findings clearly demonstrate that PRRSV has a tropism for macrophages. PRRSV mainly replicates in macrophages of the lymphoid tissues and lungs in the acute phase of infection and persists in the lung macrophages.

Aerosols↗

CD4 down-modulation by human immunodeficiency virus type 1 Nef correlates with the efficiency of viral replication and with CD4(+) T-cell depletion in human lymphoid tissue ex vivo.

The human immunodeficiency virus type 1 (HIV-1) Nef protein is an important virulence factor. Nef has several functions, including down-modulation of CD4 and class I major histocompatibility complex cell surface expression, enhancement of virion infectivity, and stimulation of viral replication in peripheral blood mononuclear cells. Nef also increases HIV-1 replication in human lymphoid tissue (HLT) ex vivo. We analyzed recombinant and primary nef alleles with highly divergent activity in different in vitro assays to clarify which of these Nef activities are functionally linked. Our results demonstrate that Nef activity in CD4 down-regulation correlates significantly with the efficiency of HIV-1 replication and with the severity of CD4(+) T-cell depletion in HLT. In conclusion, HIV-1 Nef variants with increased activity in CD4 down-modulation would cause severe depletion of CD4(+) T cells in lymphoid tissues and accelerate AIDS progression.

CD4 Antigens↗

Alymphoplasia (aly)-type nuclear factor kappaB-inducing kinase (NIK) causes defects in secondary lymphoid tissue chemokine receptor signaling and homing of peritoneal cells to the gut-associated lymphatic tissue system.

Alymphoplasia (aly) mice, which carry a point mutation in the nuclear factor kappaB-inducing kinase (NIK) gene, are characterized by the systemic absence of lymph nodes and Peyer's patches, disorganized splenic and thymic architectures, and immunodeficiency. Another unique feature of aly/aly mice is that their peritoneal cavity contains more B1 cells than normal and aly/+ mice. Transfer experiments of peritoneal lymphocytes from aly/aly mice into recombination activating gene (RAG)-2(-/-) mice revealed that B and T cells fail to migrate to other lymphoid tissues, particularly to the gut-associated lymphatic tissue system. In vivo homing defects of aly/aly peritoneal cells correlated with reduction of their in vitro chemotactic responses to secondary lymphoid tissue chemokine (SLC) and B lymphocyte chemoattractant (BLC). The migration defect of aly/aly lymphocytes was not due to a lack of expression of chemokines and their receptors, but rather to impaired signal transduction downstream of the receptors for SLC, indicating that NIK is involved in the chemokine signaling pathway known to couple only with G proteins. The results showed that the reduced serum levels of immunoglobulins (Igs) and the absence of class switch to IgA in aly/aly mice are due, at least in part, to a migration defect of lymphocytes to the proper microenvironment where B cells proliferate and differentiate into Ig-producing cells.

Animals↗

In vitro immune response of cells of various lymphoid tissues in (NZB X NZW)F1 mice: evidence for abnormality of the mesenteric lymph node cells.

Autoimmune-prone (NZB X NZW)F1 (B/W) mice have been shown to have a variety of immunologic perturbations. However, most studies have been performed with spleen cells. By using the Mishell-Dutton culture system, we examined the in vitro immune response of the various lymphoid tissue to determine whether an imbalance at a selective lymphoid site may exist in B/W mice. It was shown that the ability of mesenteric lymph node (MLN) cells of B/W mice to generate plaque-forming cells (PFC) in response to sheep red blood cells was consistently less than that of the spleen cells. This relationship held true in the aged mice. In contrast, the ability of the MLN cells of other strains not prone to develop autoimmunity to generate PFC was higher than that of the spleen cells. No significant difference in the mitogenic response of the lymphoid cells from various lymphoid tissue in the young B/W mice was seen, as compared with normal lymphoid cells from control mice. However, it was demonstrated that a relative decrease of B cells and immunoregulatory Lyt-123+ cells in the MLN in the B/W mice occurred early in life, and it was concluded that this abnormality may account for the low PFC response observed.

Aging↗

T cell engraftment in lymphoid tissues of human peripheral blood lymphocyte reconstituted SCID mice with or without prior activation of cells.

The reconstitution of severe combined immunodeficiency (SCID) mice with human PBL (Hu-PBL-SCID) was assessed using fresh unstimulated PBL and anti-CD3-stimulated PBL. Mice were reconstituted with PBL by intraperitoneal injection of 1-2.5 x 107 PBL in PBS; controls received PBS. Successful engraftment of human PBL in SCID mice was determined by measurement of human IgG in mouse sera, polymerase chain reaction (PCR) detection of human-specific HLA-DRbeta DNA in SCID periphery, and immunohistochemical staining of mouse tissues (spleen, lymph nodes, thymus, liver and lung) with antibodies specific for human CD45 and CD3. Human IgG was detected 1 week after reconstitution in sera of all animals that received at least 1 x 107 PBL and continued to increase for 8 weeks. Human-specific HLA-DRbeta DNA was detected in the majority of mice 3 weeks after reconstitution but not in controls. Moreover, immunohistochemical analysis of Hu-PBL-SCID mouse tissues revealed the presence of human CD45+ cells in all tissues examined. CD3+ T cell engraftment was observed in lymphoid tissues irrespective of whether PBL had been activated prior to transfer or not.

Animals↗

Mucosa-associated lymphoid tissue (MALT) of the gallbladder: a clinicopathological correlation.

OBJECTIVE: Lymph follicles are frequently found on histological examination of a surgically removed gallbladder. The significance of these lymph follicles is not clearly understood. The aim of this study was to examine the clinicopathological correlation between the lymph follicles in the gallbladder morphologically and the mucosa-associated lymphoid tissue (MALT) in the gut. METHODS: The gallbladders were fixed and cut serially. The tissue slices were processed in the routine manner for a histological examination. The histological criteria for MALT in this study was defined as the presence of lymph follicles with germinal centers in the lamina propria mucosae in approximately equal numbers in all portions of the gallbladders from the neck to the fundus. Biliary bile obtained at surgery was cultured for a bacteriological examination in the hospital laboratory. The types of gallstones were classified according to the Classification of Gallstones by the Japanese Society of Gastroenterology. RESULTS: Of the 1341 patients, 158 (11.8%) patients fulfilled the histological criteria, including 64 men and 94 women with an average age of 64.2 years. Gallstones were present in 89.2% of the patients, and 74.5% of these were calcium bilirubinate gallstones. Cultures of the bile were positive in 95.4% of the patients. A variety of bacterial species were thus found, most commonly Escherichia coli and Klebsiella spp. Grossly, the gallbladders usually showed a granular appearance of the mucosa. CONCLUSION: The MALT in the gallbladder is not a rare condition and is frequently encountered in clinical practice. This lymphoid tissue may represent a mucosal and morphological immune phenomenon for infection rather than a substrate for the development of low-grade B-cell lymphoma.

Adult↗

The spectrum of mucosa-associated lymphoid tissue lesions in pediatric patients infected with HIV: A clinicopathologic study of six cases.

Mucosa-associated lymphoid tissue (MALT) lesions in nonimmunocompromised individuals include reactive lymphoid proliferations and both low- and high-grade lymphoid neoplasms. These lesions occur at extranodal mucosal sites, such as the gastrointestinal tract, bronchus, salivary gland, and other locations. The spectrum of MALT lesions in children with HIV infection had not been previously described. In this study, six cases that demonstrated the spectrum of MALT lesions in pediatric patients, aged 28 months to 23 years, who had HIV infection were described. Half the patients acquired the infection perinatally, and half acquired it by transfusion. Mucosal sites of involvement included the salivary gland (4 patients), bronchiolar mucosa (2 patients), and oropharyngeal mucosa (1 patient). One patient had lesions in lung and oropharynx sequentially; all others had involvement of solitary sites. The histologic diagnoses included myoepithelial sialadenitis (MESA), MESA with low-grade MALT lymphoma, typical low-grade MALT lymphoma, diffuse large cell lymphoma (DLCL), and atypical pulmonary lymphoid hyperplasia and lymphoid interstitial pneumonitis complex. The two cases of high-grade DLCL were confined to mucosal sites (tonsil and parotid); in one of these patients, a previous biopsy specimen showed a MALT lesion with low-grade features. In two cases, quantitation of the Epstein-Barr virus (EBV) genome by the polymerase chain reaction showed a very high copy number in peripheral blood mononuclear cells but a low copy number in the MALT lesion, which suggested that MALT lesions may not be directly associated with EBV infection. Two patients who had high-grade tumors (DLCL) were successfully treated with chemotherapy and radiation therapy. The remaining patients, all of whom had low-grade MALT lesions, received either corticosteroids or alpha-interferon or no specific therapy; in all patients, the lesions followed an indolent clinical course. Clinicians and pathologists should be alert to the possibility that MALT lesions, including MALT lymphomas, may be present in children who have AIDS.

Adolescent↗

Localization in situ of the co-stimulatory molecules B7.1, B7.2, CD40 and their ligands in normal human lymphoid tissue.

Functional interactions between B and T lymphocytes are known to depend on the expression of co-stimulatory molecules B7.1/CD80, B7.2/CD86 and their counter-receptors CD28 and CTLA4, as well as CD40 and its ligand CD40L. To study the role of these molecules in situ, an immunohistochemical analysis was carried out on normal human lymphoid tissue. In the germinal centers (GC), B7.1 and B7.2 were differentially expressed. In the dark zone, centroblasts were predominantly B7.1+, while centrocytes in the light zone were B7-2+, resulting in reversed gradients of both markers in GC. Follicle mantle cells were negative for B7.1 and B7.2. Macrophages and interdigitating dendritic cells (IDC) in T cell zones both expressed B7.1 and B7.2. Moreover, clusters of B7.2+ T cells were demonstrated in interfollicular areas. Intrafollicular CD4+ T cells in GC, predominantly in the apical light zone, expressed CD28 and CTLA4, as did the majority of interfollicular T cells. CTLA4 showed a striking excentric cytoplasmic staining, which was also seen on T cells activated in vitro. CD40 was expressed on all B cells and more strongly on macrophages and IDC. Moreover, small clusters of T cells in a rim outside the GC showed CD40 expression. CD40L was expressed both on intrafollicular CD4+ T cells as well as on T cells in T cell zones. The differential distribution of co-stimulatory molecules in different compartments of normal human lymphoid tissue in situ indicates that these interactions play a distinctive role in different stages of B cell differentiation and in the immune response.

Abatacept↗

Extramedullary hand mirror cells in pathologic conditions of lymphoid tissue.

The hand mirror (HM) cell phenomenon, which usually affects pathologic cells of lymphoid tissue in bone marrow, especially in acute lymphoblastic leukemia (ALL), was seen in B-cell lymphoma cells in cerebrospinal fluid (CSF). It was subsequently detected not only in the bone marrow, but also in extramedullary sites of the lymphoma. Subsequent phase-contrast microscopic study of 45 consecutive specimens of CSF revealed lymphoid cells with HM features in a case of ALL (in which HM cells were subsequently found in the bone marrow) and in a case of acute viral meningoencephalitis. These observations demonstrate that the HM cell phenomenon, which is considered to be a cellular alteration resulting from incorporation in the cell of antigen-antibody complexes, is not unique to bone marrow. It can be present in extramedullary sites and can be seen in exfoliated cells in CSF, where its detection is facilitated by the use of phase-contrast microscopy.

Acquired Immunodeficiency Syndrome↗

Human mucosal addressin cell adhesion molecule-1 is preferentially expressed in intestinal tract and associated lymphoid tissue.

Lymphocyte homing to normal tissues and recruitment to inflammatory tissue sites are controlled, in part, by the selective expression of chemokines, pro-inflammatory cytokines and mediators, and various adhesion proteins and molecules. In the mouse, mucosal addressin cell adhesion molecule-1 (MAdCAM-1) is selectively expressed on endothelium of high endothelial venules in gut and gut-associated lymphoid tissue. By interaction with its integrin ligand, alpha 4 beta 7, lymphocytes presumed to be involved in mucosal immunity are selectively recruited to these intestinal sites. After generating monoclonal antibodies against a murine cell line expressing recombinant human MAdCAM-1, we qualitatively and semiquantitatively assessed MAdCAM-1 expression in human tissue sections from various normal and inflammatory disorders. We found that human MAdCAM-1, as in the mouse, is expressed in a tissue-selective manner. In normal tissues, MAdCAM-1 is constitutively expressed to endothelium of venules of intestinal lamina propria. Interestingly, using computer-assisted morphometric analysis, the proportion of venular endothelium within lamina propria that expresses MAdCAM-1 is increased, compared with normal tissues, at inflammatory foci associated with ulcerative colitis and Crohn's disease. Moreover, for the most part, MAdCAM-1 is not detected in the majority of normal or inflamed extra-intestinal tissues, including those with mucosal surfaces. These results are consistent with a role, as originally defined in the mouse, for human MAdCAM-1 in the localization of alpha 4 beta 7+ lymphocytes in the gastrointestinal tract and associated lymphoid tissue. As such, the pathway defined by MAdCAM-1/alpha 4 beta 7 may be a relevant tissue-specific therapeutic target for the modulation of inflammatory bowel disease activity.

Animals↗

Isolation of cytomegalovirus-specific cytotoxic T-lymphocytes from gut-associated lymphoid tissue (GALT) of HIV type 1-infected subjects.

Cytomegalovirus (CMV) can be an important opportunistic infection in HIV-1-infected patients, particularly when the CD4+ T-cell count drops below 50 lymphocytes/mm3. CMV-associated disease, including retinitis, pneumonitis, gastroenteritis, and encephalitis, is estimated to affect up to 40% of AIDS patients. We have studied the cellular immune response to CMV in gut-associated lymphoid tissue (GALT) of HIV-1-infected patients. Two patients with chronic diarrhea of unknown etiology were examined by flexible sigmoidoscopy and upper endoscopy. Biopsy specimens were obtained from lymphoid-associated tissue sites in rectum and duodenum. Both patients were seropositive for CMV IgG, but had not been treated with ganciclovir, and neither had clinical signs of CMV disease. Mononuclear cell cultures were established from GALT and blood and assayed for the presence of CMV-specific CD8+ T cells. CD8+ T-cell phenotype and function were assessed by MHC Class I tetramer staining, using an HLA-A*0201 tetramer complex specific for peptide 495-503 (NLVPMVATV) of CMV lower matrix protein pp65, and by a standard 51Cr release assay. CMV pp65-specific cytotoxic lymphocytes (CTL) were detected in GALT and blood MNC from both patients. These results demonstrate that HIV-1-infected subjects seropositive for CMV, but without active CMV gastrointestinal disease, harbor CMV-specific CTL in intestinal lymphoid tissue. This is the first report of isolation of CMV-specific CTL in GALT and will lead to greater understanding of the pathogenesis of CMV disease in human mucosal tissue.

Acquired Immunodeficiency Syndrome↗

Enteral nutrition modifies gut-associated lymphoid tissue in rat regardless of the molecular form of nitrogen supply.

BACKGROUND: It has been suggested that beneficial effect of elemental enteral diets in the treatment of inflammatory bowel diseases could be mediated by the suppression of protein dietary antigens. The objective of the present work was to study the effect of enteral diet on gut associated lymphoid tissue and on gastric Lactobacillus flora, in rat. METHODS: The effects of three molecular forms of nitrogen supply: amino acids, oligopeptides or whole casein, were compared in rats on continuous enteral diet. Frozen sections of small bowel were studied with monoclonal antibodies anti-CD5, -CD4, -CD8, -CD25, -macrophages, -MHC II. The Lactobacillus flora was also enumerated in the stomach, in order to assess the effect of ED on rat flora. RESULTS: Growth and mucosa morphology were identical in control and enteral groups. Rats on enteral diet showed, whatever was the molecular form of nitrogen supply, a decrease in CD5+, CD4+ and CD8+ intraepithelial cell numbers, but not in lamina propria cell number, and a decreased MHC II epithelial expression, when compared to control rats. The enterally fed rats also showed a decrease in Lactobacillus gastric contents. CONCLUSIONS: The current study demonstrates that continuous enteral nutrition modifies MHC II epithelial expression and gut associated lymphoid tissue cell number in rat, whatever is the molecular form of nitrogen supply. Intestinal flora could be responsible, at least for part, for these results.

Animals↗

Porcine gamma/delta T lymphocyte subsets differing in their propensity to home to lymphoid tissue.

Three types of T cell receptors (TcR) gamma/delta were identified in swine, all of which are disulfide-bonded cell surface heterodimers. The first, a 38/40-kDa molecule, is related to the TcR gamma/delta of sheep and cattle, and defines in swine a subset of CD4-CD8- T lymphocytes that is enriched in the circulating T lymphocyte pool. The other two receptors are private to swine. The second, a 37/40-kDa molecule, is expressed by the major subset of CD2-CD4-CD8- T lymphocytes that is neither enriched in nor excluded from lymphoid tissue. By contrast, the third type of TcR gamma/delta, a 40/46-kDa molecule, is found on CD2+CD4-CD8- T lymphocytes accumulating in lymphoid tissue. Thus, TcR gamma/delta T lymphocyte subsets differing in homing propensity are typified by the expression of distinct molecular forms of the TcR gamma/delta.

Animals↗

Influence of dietary protein restriction on immune competence. II. Effect on lymphoid tissue.

Weanling mice fed a 4 percent diet showed a generalized loss of lymphoid tissue which was greater than the loss of total body weight. This effect was greatest in the thymus greater than spleen greater than mesenteric lymph node. Cell loss was most pronounced during the 1st week on diets, then remained at stable levels for 3 weeks and showed a gradual rise thereafter. The effect was shown to be mediated partly by a cessation of growth in lymphoid organs due to the low protein intake and, secondly, an adrenal corticosteroid induced lympholysis which actually reduced cell numbers. Recirculating T cells and resident B cells were amongst the least affected cells whereas stem cells, non-migratory T cells and other reticuloendothelial cells were most depressed in numbers. At no stage was the germinal centre forming capacity of the mesenteric node lost although cell recruitment to antigenically stimulated nodes was diminished. During nutritional repletion the spleen, thymus and mesenteric node all showed different and characteristic regrowth. The spleen was most active initially and rapidly reconstituted haemopoietic cells and B cells. This was followed by the thymus which showed a delayed reinitiation of its normal growth kinetics which had been interrupted by the diet. The evidence suggested that full rehabilitation of the immune apparatus took place even after 2 months of nutritional deprivation.

Adrenal Cortex Hormones↗