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Primary B-cell mucosa-associated lymphoid tissue lymphoma presenting as a solitary colorectal polyp.

We describe two patients with low-grade and one patient with mixed low- and high-grade B-cell lymphoma of mucosa associated lymphoid tissue (MALT) type arising in the large intestine. In each patient the lesion occurred as a single polyp. Two patients presented with rectal bleeding and in one the lesion was discovered incidentally. The bone marrow was uninvolved in all three cases but in the patient with mixed low- and high-grade lymphoma involvement of mesenteric lymph nodes and liver was found. CT scan revealed no lymphadenopathy or splenomegaly in any of the patients. Two patients remain well 9 and 24 months respectively after polypectomy whereas the patient with mixed low- and high-grade lymphoma died 7 days after hemicolectomy due to cardiac failure. These previously undescribed solitary polypoid MALT lymphomas can closely resemble both benign lymphoid polyposis of the colon and lymphomatous polyposis (mantle cell lymphoma). Because of their different behaviour accurate diagnosis of polypoid MALT lymphoma is important.

Aged↗

Follicular colonization in B-cell lymphoma of mucosa-associated lymphoid tissue.

The formation of neoplastic B-cell follicles is universally accepted as diagnostic of a follicle centre cell (FCC) lymphoma. Low-grade B-cell lymphomas of mucosa-associated lymphoid tissue (MALT) are characterized by a diffuse infiltrate of cells of uncertain lineage known as "centrocyte-like" cells because of their resemblance to centrocytes (small cleaved cells). Some MALT lymphomas, however, contain numerous follicles and may even have a predominantly follicular appearance. These follicles may be reactive or show immunoglobulin (Ig) light-chain restriction, indicating their neoplastic nature. We have proposed that these neoplastic follicles are not composed of follicle centre cells but result from colonization of reactive follicles by CCL cells. In this study, the immunophenotype and genotype of 10 primary gastrointestinal lymphomas with a follicular component have been determined. One case exhibited the morphological, immunophenotypic, and genotypic features of FCC lymphoma (Ig light-chain restriction, CD10+, KB61 (CDw32)-, Jh, and bcl-2 gene rearrangement). Neoplastic follicles in the remaining nine cases, which showed the features of MALT lymphoma, were of a different phenotype (Ig light-chain restriction, CD10- KB61(CDw32)+), and these lymphomas showed Jh but not bcl-2 gene rearrangement. Taken in conjunction with the morphological features, these findings suggest that in these cases the neoplastic follicles formed as the result of colonization of previously reactive follicles by neoplastic CCL cells. Thus, not all lymphomas containing neoplastic follicles are of FCC origin. Follicular colonization, as seen in low-grade MALT lymphomas, is likely to be a recapitulation of an as yet undescribed normal immunological phenomenon that may involve marginal zone B cells.

Gene Rearrangement↗

The accumulation of p53 abnormalities is associated with progression of mucosa-associated lymphoid tissue lymphoma.

The genetic mechanisms underlying the genesis of low-grade mucosa-associated lymphoid tissue (MALT) lymphomas and their transformation into high-grade lymphoma are poorly understood. p53 inactivation, commonly caused by mutation and allele loss, has been shown to play an important role in the early development and/or the late disease progression of many human tumors including lymphoid malignancies and, thus, may also be important in MALT lymphomagenesis. We examined 75 cases (48 low grade and 27 high grade) of MALT lymphoma for p53 allele loss and mutation as well as protein accumulation. DNA samples prepared from microdissected cell populations were used for the detection of p53 gene abnormalities. Loss of heterozygosity (LOH) of the gene was detected by polymerase chain reaction-based analysis of p53 CA repeat polymorphism, whereas p53 mutation was studied by single-strand conformation polymorphism analysis and direct sequencing. p53 expression was assessed by immunostaining with CM1 polyclonal antibody. p53 allele loss and mutation, which resulted in the alteration in the amino acid sequence, were found in both low-grade (LOH, 3 of 44 [6.8%]; mutation, 9 of 48 [18.8%]) and high-grade (LOH, 6 of 21 [28.6%]; mutation, 9 of 27 [33.3%]) MALT lymphomas, particularly in the latter group. p53 staining was not observed in any low-grade tumors but in 6 high-grade cases that harbored missense mutations. There were also differences in the extent of p53 abnormalities, between low- and high-grade tumors. Of the 11 low-grade tumors showing p53 abnormalities, only 1 tumor showed the concomitance of p53 mutation and allele loss, whereas in high-grade tumors, 6 of 9 affected cases displayed both p53 mutation and allele loss. Our results suggest that p53 partial inactivation may play an important role in the development of low-grade MALT lymphomas, whereas complete inactivation may be associated with high-grade transformation.

Alleles↗

The C-terminal heptapeptide of bombesin reduces the deleterious effect of total parenteral nutrition (TPN) on gut-associated lymphoid tissue (GALT) mass but not intestinal immunoglobulin A in vivo.

BACKGROUND: Bombesin, the amphibian analog of mammalian gastrin-releasing peptide, reverses total parenteral nutrition (TPN)-induced atrophy of gut-associated lymphoid tissue and increases intestinal and respiratory immunoglobulin A (IgA) levels. Structure-activity studies suggested that the biologically active portion of bombesin is a C-terminal heptapeptide (7AA). This study investigates the effect of 7AA on lymphocytes counts of the Peyer's patches (PP), the lamina propria (LP) and the intraepithelial layer (IE). METHODS: Forty-eight male mice were randomized to receive chow (n = 13), TPN only (n = 9), TPN + 15 microg 7AA 3 times per day (n = 13) or TPN + 150 microg 7AA 3 times per day (n = 13). After 5 days of feeding, PP, LP, and IE lymphocytes were determined. Intestinal IgA levels were measured with ELISA. Groups were compared with ANOVA. RESULTS: All TPN-fed mice lost more weight than mice fed chow (p < .04). Lymphocyte counts in PP, LP, and IE were significantly lower in the TPN group than in the 3 other groups but did not differ between the groups fed chow, TPN + 15 microg 7AA 3 times per day, or TPN + 150 microg 7AA 3 times per day. Intestinal IgA levels were higher in chow-fed mice (148.4 +/- 16.9) than in mice fed TPN (98.4 +/- 14.0, p = .008), TPN + 15 microg 7AA 3 times per day (96.9 +/- 7.7, p = .003) or TPN + 150 microg 7AA 3 times per day (87.3 +/- 6.7, p = .001). CONCLUSIONS: The C-terminal heptapeptide of bombesin prevented the TPN-induced decrease in intestinal lymphocyte populations but not the reduction in intestinal IgA levels.

Analysis of Variance↗

Characterization of pulmonary macrophages and bronchus-associated lymphoid tissue (BALT) macrophages in the rat. An enzyme-cytochemical and immunocytochemical study.

Three subpopulations of macrophages present in the lung, viz. pulmonary alveolar macrophages (PAM), pulmonary tissue macrophages (PTM), and macrophages in the bronchus-associated lymphoid tissue (BALT), were compared using enzyme-cytochemical and immunocytochemical methods. BALT macrophages can be distinguished from PAM and PTM on the basis of their enzyme reaction products. With three monoclonal antibodies, ED1, ED2, and ED3, that recognize different antigen determinants of rat macrophages, the three subpopulations could be clearly distinguished. PAM are ED1-positive and PTM are ED2-positive. The macrophage subpopulation scattered throughout BALT is ED1-positive; macrophages situated at the peripheral site of BALT, near artery and bronchus, are ED2-positive. No ED3-positive macrophages were observed either in the lung or in BALT. These results are discussed with respect to the possible relationship between the subpopulations of pulmonary macrophages.

5'-Nucleotidase↗

Mucin histochemical analysis of the ileocaecal valve and lymphoid tissues of the terminal ileum: role against tumour invasion.

OBJECTIVES: We previously reported clinicopathological data on 78 patients who underwent a right hemicolectomy from 1990 to 1997. Our results indicated that the ileocaecal valve [ICV] and lymphoid tissue of the terminal ileum might, together, play a protective and local immune role against carcinoma invasion. Furthermore, we previously reported that mucin histochemical features of the transitional zone [TZ] might also play a role in predicting metastasis and, thus, prognosis. The aim of this study was to examine the clinicopathological correlation between lymphoid infiltration and mucin secretion in the terminal ileum with carcinoma of the right colon. METHODS: According to the proximity of the tumour to the ICV, a total of 16 specimens with lymphoid infiltration to and around [< 1 cm] the ICV were studied in order to identify the mucin expression and histochemical features of the TZ as a prognostic indicator. RESULTS: Patients with sulphomucin-staining tumours in the terminal ileum and ICV had a relatively favourable course. Even when the clinical staging was the same for different tumours, greater lymphoid infiltration in the ICV, greater staining for sulphomucin in the ICV and a relatively favourable course were observed in nine patients. The sulphomucin-type TZ showed a favourable course as well. On the other hand, patients with sialomucin staining of the ICV and the TZ tended to have low-grade lymphoid infiltration and a very poor course, although two patients with moderately high-grade lymphoid infiltration had a favourable course. Overall survival was significantly associated with the mucin type of the ICV [p < 0.01]. CONCLUSIONS: Our results indicated that lymphoid infiltration of the terminal ileum may lead to an alteration in mucin secretion and, thus, play a protective role in the invasive and metastatic process of advanced right colon carcinoma.

Aged↗

A case of primary mucosa-associated lymphoid tissue lymphoma of the vagina.

We report the first case of primary mucosa-associated lymphoid tissue (MALT) lymphoma of the vagina, the diagnosis of which is supported by genetic and immunophenotypic studies. A 65-year-old, para 2 woman presented to our hospital in July 1997 with a history of prolonged vaginal discharge. Although cytologic examination suggested possible malignancy, a biopsy of the vaginal wall was diagnosed as chronic inflammation. In June 2000, she underwent gynecologic examination because of anuria. Excisional biopsy revealed subepithelial infiltration of atypical lymphoid cells that stained for CD20, CD79a, and BCL-2; stained weakly for IgM; and did not stain for CD3, CD5, CD7, CD10, CD56, CD23, and IgD, suggesting marginal zone B-cell lineage. Monoclonality was detected by Southern blot analysis, and this patient was finally diagnosed as having primary MALT lymphoma of the vagina. She received 3 cycles of chemotherapy (THP-COP) and concurrent radiation to the whole pelvis. The patient is alive and well 40 months after treatment. Because the vagina is one of the mucosa-associated tissues, MALT lymphoma, though rare, must be included in the differential diagnosis of the vaginal neoplasms.

Aged↗

Distribution of peptidergic nerve fibers in rat bronchus-associated lymphoid tissue: light microscopic observations.

The localization of neuropeptide Y (NPY), substance P (SP), calcitonin gene-related peptide (CGRP) and vasoactive intestinal polypeptide (VIP) in the nerve fibers of rat bronchus-associated lymphoid tissue (BALT) was investigated by light microscopic immunohistochemistry. Nerve fiber bundles revealing NPY-like immunoreactivity were shown to enter the BALT together with pulmonary artery branches. They frequently reached the central zone of the BALT to give rise to fine, tortuous fibers. On the other hand, nerve fibers immunoreactive for SP and CGRP seemed to distribute in the subepithelial zone of the BALT after dissociating from fiber networks in the walls of bronchi, although small numbers of SP and CGRP fibers were also seen in the BALT central zone. CGRP fibers formed a more intense network than SP fibers in the BALT. Scattered VIP fibers were found only in the subepithelial zone of the BALT. These findings not only suggest that the four kinds of peptidergic fibers act on BALT in multiple ways, but also that these neuropeptides may be involved in the control of mucosal immunity, lymphocyte migration and proliferation within the BALT.

Animals↗

[Morphology of lymphoid tissue from airways in bronchiectasis].

Morphological and morphometrical study is performed on serial and stepped sections of the lungs surgically removed from patients with bronchoectatic disease. As compared to healthy persons, hyperplasia of all structural components with formation of lymphoid and lymphoepithelial follicles was detected. The degree of lymphoid tissue hyperplasia in bronchoectatic disease is determined by inflammation activity and does not depend on the age. The number of interepithelial lymphocytes is significantly increased as well as that of peribronchial and peribronchiolar lymphoid accumulations, and the degree of diffuse infiltration. However, the number of periglandular and periductal lymphoid accumulations and lymphoid follicles is significantly reduced. Bronchoectatic disease with high active inflammation as compared to low activity is characterized by more pronounced hyperplasia with formation of lymphoid and lymphoepithelial follicles with clear centers.

Adolescent↗

Non-lymphoid cells of bronchus-associated lymphoid tissue of the rat in situ and in suspension. With special reference to interdigitating and follicular dendritic cells.

Immunohistochemical, enzyme-histochemical and electron-microscopical methods were used to study non-lymphoid cells of control and stimulated rat bronchus associated lymphoid tissue (BALT) in situ and in suspensions. Particular attention was paid to the so-called antigen-handling cells, i.e., the interdigitating cells (IDC), which are situated in the T-cell areas, the follicular dendritic cells (FDC), which appear to be restricted to germinal centers, and macrophages, present both in T-cell and B-cell areas. The interdigitating cells were distinguished by being Ia-positive and by the presence of acid phosphatase and non-specific esterase activity in an area near the nucleus. Follicular dendritic cells could be observed in situ by using a monoclonal antibody and by the in vitro trapping of HRP-anti-HRP complexes. Several types of macrophages were found. At the electron-microscopical level no well-developed IDC and FDC could be detected in control BALT. However, in BALT of lipopolysaccharide-stimulated and mycoplasma-infected rats, well-developed IDC and FDC were found. It can be concluded that IDC's and FDC's can be found in BALT.

Animals↗

The ontogeny of the gut-associated lymphoid tissue in short bowel syndrome.

Newborns suffering from short bowel syndrome (SBS) after massive intestinal resection have numerous infectious complications, which may be due to immunoincompetence from the loss of gut-associated lymphoid tissue (GALT). This study examines the ontogeny of GALT in the rat with SBS. A total of 36 3-week-old rats were divided into two groups: I, sham operated (C, n = 16); and II (SBS, n = 20), with a 50% resection of small intestine with jejunoileostomy. At 4, 5, 6, and 10 weeks of age the animals were sacrificed and the GALT was assessed by video analysis and immunoperoxidase monoclonal antibodies, OX8 (CD8), W-3/25 (CD4), and MARA-2 (IgA). The data were expressed as positive staining lymphocytes per 10(4) microns2 (mean +/- SD). table; see text In the sham group there was an increase in all lymphocyte subsets over time. In the SBS group there was a rapid fall in OX8 and W-3/25 T-lymphocytes by 10 weeks, with no increase in IgA plasma cells at 6 and 10 weeks. This study demonstrates that in the massive bowel resection in the suckling rat decreases the T- and B-lymphocyte populations in the GALT. This lack of development may underlie the associated infectious complications and malabsorption in SBS.

Animals↗

Selective generation of gut tropic T cells in gut-associated lymphoid tissue (GALT): requirement for GALT dendritic cells and adjuvant.

In the current study, we address the underlying mechanism for the selective generation of gut-homing T cells in the gut-associated lymphoid tissues (GALT). We demonstrate that DCs in the GALT are unique in their capacity to establish T cell gut tropism but in vivo only confer this property to T cells in the presence of DC maturational stimuli, including toll-like receptor-dependent and -independent adjuvants. Thus, DCs from mesenteric LNs (MLNs), but not from spleen, supported expression of the chemokine receptor CCR9 and integrin alpha4beta7 by activated CD8+ T cells. While DCs were also required for an efficient down-regulation of CD62L, this function was not restricted to MLN DCs. In an adoptive CD8+ T cell transfer model, antigen-specific T cells entering the small intestinal epithelium were homogeneously CCR9+alpha4beta7+CD62Llow, and this phenotype was only generated in GALT and in the presence of adjuvant. Consistent with the CCR9+ phenotype of the gut-homing T cells, CCR9 was found to play a critical role in the localization of T cells to the small intestinal epithelium. Together, these results demonstrate that GALT DCs and T cell expression of CCR9 play critical and integrated roles during T cell homing to the gut.

Adjuvants, Immunologic↗

Kinetics of CD4+ T cell repopulation of lymphoid tissues after treatment of HIV-1 infection.

Potent combinations of antiretroviral drugs diminish the turnover of CD4+ T lymphocytes productively infected with HIV-1 and reduce the large pool of virions deposited in lymphoid tissue (LT). To determine to what extent suppression of viral replication and reduction in viral antigens in LT might lead correspondingly to repopulation of the immune system, we characterized CD4+ T lymphocyte populations in LT in which we previously had quantitated viral load and turnover of infected cells before and after treatment. We directly measured by quantitative image analysis changes in total CD4+ T cell counts, the CD45RA+ subset, and fractions of proliferating or apoptotic CD4+ T cells. Compared with normal controls, we documented decreased numbers of CD4+ T cells and increased proliferation and apoptosis. After treatment, proliferation returned to normal levels, and total CD4+ T and CD45RA+ cells increased. We discuss the effects of HIV-1 on this subset based on the concept that renewal mechanisms in the adult are operating at full capacity before infection and cannot meet the additional demand imposed by the loss of productively infected cells. The slow increases in the CD45RA+ CD4+ T cells are consistent with the optimistic conclusions that (i) renewal mechanisms have not been damaged irreparably even at relatively advanced stages of infection and (ii) CD4+ T cell populations can be partially restored by control of active replication without eradication of HIV-1.

Adult↗

[Histochemical and immunohistochemical study of the lymphoid tissue of swine: lymphatic ganglia, spleen and thymus].

Immunohistological (S-100, cIg) and enzyme histochemical (ANAE/ANBE, beta-glu, ATPase, AcP) investigations were carried out to identify lymphocyte and reticular cell subpopulations "in situ", in pig lymphoid tissue (lymph node, spleen, and thymus) of a 6 months old group, and a 6-9 days old one. By means of immunohistological techniques, in the 6 month old pigs we could detect S-100 protein (PAP), chiefly in T-areas lymphocytes, but we also found some S-100 positive lymphocytes in spleen follicles. Also S-100 protein were detected at Follicular Dendritic Cells (FDC) in lymph node and spleen; and Reticular Fibroblastic Cells (RFC) only in the first one. Finally, S-100 were noted in Hassall corpuscles (thymus), nervous fibres, and endothelial cells too. Using PAP (IgG, IgM) and IPI (IgA) techniques we could detect lymphocyte cytoplasmatic surface immunoglobulins (cIg) in lymphocytes, lymphoblastoid and plasmacytoid cells in nearly all tissue compartments. By means of histochemical techniques we could identify T-area lymphocytes ANAE/ANBE and beta-glu positives (cytoplasmatic spots) and B-area lymphocytes ATPase positive; macrophages, and polymorphonuclear eosinophiles PHNE being ANAE/ANBE and beta-glu positives (diffuse cytoplasmic stain); and Hassall corpuscles ANAE/ANBE and AcP positives. Concerning to reticular cells, we found FDC and RFC in lymphoid follicles, and Interdigitating Reticular Cells (IDC) in lymphoid diffuse tissue, with enzyme activity (all the enzymes studied) in nearly all the cases. In piglets, the immunohistological and histochemical pattern was nearly the same.

Animals↗

Primary duodenal low-grade mucosa-associated lymphoid tissue lymphoma presenting with outlet obstruction.

Low-grade lymphoma arising in mucosa-associated lymphoid tissue (MALT) of the duodenum represents a very rare neoplasm. We report an unusual presentation of primary duodenal MALT lymphoma in a 78-year-old man. The patient initially presented with a suspected pulmonary embolus and was anticoagulated, which precipitated a major gastrointestinal hemorrhage. A large atypical ulcer with narrowing of the duodenum beyond the bulb was seen on endoscopy. Biopsies revealed atypical lymphoid cells. Abdominal CT scan revealed a mass in either the duodenum or head of the pancreas. An endoscopic retrograde cholangiopancreatography (ERCP) was performed, which revealed a normal pancreatic duct with a large calculus in the common bile duct, which was extracted after sphincterotomy. Elective surgery was planned for suspected lymphoma of the duodenum. The patient developed severe nausea, vomiting, and fullness after meals. The patient underwent pancreaticoduodectomy for a neoplastic mass causing duodenal obstruction. Pathological examination of the resected specimen revealed a low-grade B-cell lymphoma (MALToma) arising in the duodenum and invading the pancreas. Flow cytometry confirmed the phenotype typical of MALT lymphoma. Celiac, peripancreatic, pelvic, and cervical nodes were also involved with tumor. Bone marrow was also positive for metastasis. The patient was postoperatively treated with chemotherapy for stage IV disease.

Aged↗

Serum antibody response and nasal lymphoid tissue (NALT) structure in the absence of IL-4 or IFN-gamma.

Immunization via the nasal route is effective for inducing not only mucosal immunity but also antibody (Ab) response in serum. Nasal lymphoid tissue (NALT) is important for induction of systemic immunity. It remains controversial which T effector cell response is important for serum Ab response after nasal immunization. We investigated serum Ab responses and NALT structures in interleukin (IL)-4 gene targeted (IL-4(-/-)) and interferon (IFN)-gamma gene targeted (IFN-gamma(-/-)) mice. Mice were immunized via nostrils with ovalbumin (OVA) and cholera toxin as adjuvant and serum Ab titers were measured 1 week after final antigen challenge. OVA-specific IgG titers in sera of IL-4(-/-) mice indicated a Th(1) type response, whereas titers in IFN-gamma(-/-) mice and wild-type mice indicated a Th(2) type response. Enhanced serum Ab responses were observed in IL-4(-/-) mice but not IFN-gamma(-/-) mice. OVA-specific Ab-forming cells were detected in the cervical draining lymph nodes but were rare or absent in and around the NALT of all strains of mice. Numbers of OVA-specific Ab-forming cells in cervical lymph nodes were significantly higher in IL-4(-/-) mice than in wild-type and IFN-gamma(-/-) mice. Germinal centers of lymphoid follicles were present in NALT of IL-4(-/-) and other mice. Immunohistochemistry for B and T cell markers revealed that NALT of all mice had approximately the same cellular compositions. Although the absence of IL-4 had no effect on NALT structure, IL-4 may suppress induction of serum Ab responses by nasal immunization.

Animals↗

Histologic evaluation of lung and bronchus-associated lymphoid tissue in young turkeys infected with Bordetella avium.

One-day-old turkeys were inoculated intranasally with Bordetella avium. Noninoculated hatchmates were housed separately. At postinoculation weeks 1, 2, 3, 4, and 5, B avium-infected (BA+) and B avium-free (BA-) turkeys were necropsied; specimens of tracheas, intrapulmonary primary bronchi, and lung adjacent to primary bronchi were bacteriologically cultured. Lung tissue was collected for histologic examination. Lungs perfused with acetic acid were collected for evaluation to determine the size, number, and distribution of lymphoid nodules associated with primary bronchi. Bordetella avium was isolated from trachea and primary bronchi of all BA+ turkeys, but was never isolated from lung parenchyma. Acute purulent bronchitis was associated with colonization of the primary bronchi by B avium from postinoculation weeks 1 to 3. Macrophages and lymphocytes persisted in the peribronchial connective tissue for 5 weeks after inoculation. Bronchus-associated lymphoid tissue consisted of discrete lymphoid nodules protruding into the lumens of primary bronchi. Lymphoid nodules, morphologically similar in BA+ and BA- turkeys, were composed of nonciliated, cuboidal epithelium covering a zone of loosely arranged lymphocytes and macrophages and a deeper, sharply demarcated lymphoid follicle. Compared with bronchus-associated lymphoid tissue of BA- turkeys, lymphoid nodules of bronchus-associated lymphoid tissue in BA+ turkeys were more numerous and widely distributed along primary bronchi. In both BA- and BA+ turkeys, the mean diameter of lymphoid nodules doubled between 1 and 5 weeks of age.

Animals↗

The Fas/FasL system and T cell apoptosis in HIV-1-infected lymphoid tissue during highly active antiretroviral therapy.

Apoptosis has been proposed as a mechanism responsible for T cell depletion in HIV-1 infection. In the present study we have phenotyped apoptotic T cells in tonsillar lymphoid tissue from 11 HIV-1-infected patients by flow cytometry light-scatter characteristics during 48 weeks of highly active antiretroviral therapy (HAART). We found that the decline in tonsillar viral load was associated with a decrease in the proportion of apoptotic CD4+ and CD8+ T cells. CD4 cell apoptosis was predominantly seen within the memory CD28+ Fas+ FasL+ population. The increased level of apoptotic CD8+ T cells was found among activated Fas+ memory cells irrespective of CD28 and FasL expression. These T cell subsets were expanded in untreated infection, but normalized with therapy. We conclude that HIV-1 triggers FasL-mediated apoptosis of uninfected CD4+ T cells, whereas CD8+ T cell apoptosis is driven by chronic immune activation. Virus suppression reverses both of these mechanisms, contributing to immune reconstitution during HAART.

Acquired Immunodeficiency Syndrome↗