Chronic lymphocytosis is a condition where your blood contains too many lymphocytes— a type of white blood cell—over a long period. Normally, lymphocytes make up about 20–40% of white blood cells and help fight infections. In chronic lymphocytosis, counts exceed 4,000 cells per microliter for at least three months without falling back to normal levels. This persistence can be poly‑ or monoclonal.
Polyclonal lymphocytosis is often a reactive response to long‑term infections or inflammation (for example, chronic viral infections like hepatitis C).
Monoclonal lymphocytosis usually represents an early form of a blood cancer called chronic lymphocytic leukemia (CLL).
In simple terms, whereas a reactive rise in lymphocytes is your body’s normal safeguard, chronic lymphocytosis means there’s an ongoing imbalance—either from persistent immune stimulation or from the unchecked growth of a single “clone” of lymphocytes as seen in CLL PMC.
Chronic or persistent lymphocytosis is a condition in which the number of lymphocytes—a key type of white blood cell involved in fighting infections—remains consistently higher than normal for an extended period. In adults, a normal absolute lymphocyte count (ALC) ranges from approximately 1,000 to 4,800 cells/µL of blood. Lymphocytosis is generally defined as an ALC exceeding 4 × 10⁹/L (4,000 cells/µL), although some experts use a threshold of >5 × 10⁹/L to emphasize persistent cases NCBIAccessMedicine. When this elevation persists for more than three months despite resolution of any acute illness, it is termed “chronic” or “persistent” lymphocytosis. Identifying the cause is essential, as persistent lymphocytosis may reflect benign reactive processes or serious clonal (neoplastic) disorders.
Chronic lymphocytosis is present when two separate complete blood counts (CBCs) show an absolute lymphocyte count above the age-appropriate normal range—commonly >4 × 10⁹/L—in an otherwise stable patient over a period exceeding three months PMCAccessMedicine. Lymphocytes include B cells (antibody producers), T cells (cell-mediated immunity), and natural killer (NK) cells (innate immunity). These cells typically make up about 20–40% of total white blood cells. In chronic lymphocytosis, one or more subsets may be selectively expanded, reflecting underlying immune stimulation or a monoclonal proliferation.
Pathophysiologically, lymphocytosis arises via three principal mechanisms:
Increased Production – the bone marrow or lymphoid tissues produce extra lymphocytes in response to antigenic or neoplastic stimuli.
Clonal Expansion – a single lymphocyte clone multiplies in a dysregulated fashion, as seen in leukemia and lymphomas.
Redistribution – lymphocytes shift from lymphoid stores into the circulation, sometimes in stress or corticosteroid use NCBI.
Types of Chronic Lymphocytosis
Reactive (Polyclonal) Lymphocytosis
In reactive lymphocytosis, multiple lymphocyte clones expand in response to infections, inflammation, or stress. For example, viral infections such as infectious mononucleosis (Epstein–Barr virus) and cytomegalovirus commonly induce a transient increase in large, atypical “Downey” lymphocytes in peripheral blood Cleveland ClinicWikipedia. Autoimmune diseases (e.g., rheumatoid arthritis), drug reactions, and splenectomy may also trigger reactive lymphocyte elevations.Clonal (Monoclonal) Lymphocytosis
Clonal lymphocytosis arises when a single lymphocyte acquires genetic changes that drive unchecked proliferation. Key entities include:Monoclonal B-cell Lymphocytosis (MBL): An asymptomatic premalignant state with <5 × 10⁹/L clonal B cells in blood, lacking lymphadenopathy or organomegaly. MBL carries a low but real risk (1–2%/year) of progression to chronic lymphocytic leukemia (CLL) PMCWikipedia.
Chronic Lymphocytic Leukemia (CLL): Defined by ≥5 × 10⁹/L monoclonal B cells with characteristic immunophenotype (CD5⁺, CD19⁺, CD23⁺) and often presents with lymphadenopathy and splenomegaly Journal of Renal EndocrinologyPMC.
T-cell Prolymphocytic Leukemia (T-PLL): A rare, aggressive T-cell malignancy marked by high circulating prolymphocytes.
Large Granular Lymphocyte (LGL) Leukemia: Expansion of cytotoxic T cells or NK cells causing cytopenias and autoimmune features.
Main Causes of Chronic/Persistent Lymphocytosis
Infectious Mononucleosis (EBV): EBV infects B cells, causing atypical reactive lymphocytes and prolonged lymphocytosis Cleveland ClinicWikipedia.
Cytomegalovirus (CMV): Similar to EBV, CMV induces polyclonal lymphocyte activation, with some cases persisting for months.
Viral Hepatitis (B, C): Chronic hepatitis involves ongoing immune activation and lymphocyte elevation PMC.
Human Immunodeficiency Virus (HIV): Early HIV infection may show lymphocytosis before CD4 depletion.
Influenza and Other Respiratory Viruses: Can trigger transient lymphocyte surges that rarely persist.
Whooping Cough (Bordetella pertussis): Notable for profound lymphocytosis due to lymphocyte redistribution rather than marrow overproduction Cap Today.
Chronic Tuberculosis: Persistent antigenic stimulation drives lymphocyte production.
Toxoplasmosis: Parasitic infection with lymphoid response.
Persistent Polyclonal B-cell Lymphocytosis (PPBL): A benign condition predominantly in young female smokers, marked by stable, mildly elevated polyclonal B cells and binucleated lymphocytes Wikipedia.
Asplenia or Splenectomy: Loss of splenic lymphoid pools can cause a relative rise in circulating lymphocytes.
Autoimmune Disorders (e.g., SLE, Rheumatoid Arthritis): Chronic inflammation sustains lymphocyte proliferation.
Drug Reactions: Certain medications (e.g., anticonvulsants) may cause lymphocyte activation or redistribution.
Stress Lymphocytosis: Acute physical stress (e.g., trauma, surgery) temporarily mobilizes lymphocytes to the bloodstream.
Monoclonal B-cell Lymphocytosis (MBL): Pre-CLL state of clonal lymphocyte expansion PMCWikipedia.
Chronic Lymphocytic Leukemia (CLL): Clonal B-cell leukemia with persistent lymphocytosis and organ involvement PMCJournal of Renal Endocrinology.
T-cell Prolymphocytic Leukemia: Neoplastic T-cell proliferation.
Large Granular Lymphocyte Leukemia: Clonal expansion of cytotoxic lymphocytes.
Non-Hodgkin Lymphoma (Leukemic Phase): Some lymphomas spill malignant cells into blood.
Hodgkin Lymphoma (Rarely Leukemic): Uncommon bloodstream involvement can elevate lymphocytes.
Sarcoidosis: Granulomatous inflammation with lymphocyte accumulation in tissues and blood.
Common Symptoms
Persistent lymphocytosis often itself causes no direct symptoms. Instead, manifestations arise from the underlying condition:
Fever: Reflects ongoing infection or malignancy.
Fatigue: Common in chronic illnesses and lymphoid malignancies.
Night Sweats: Classic “B symptom” of lymphomas and CLL.
Unexplained Weight Loss: Seen in chronic infections and cancers.
Painless Lymphadenopathy: Enlarged lymph nodes in CLL or lymphoma.
Splenomegaly: Abdominal fullness or early satiety from enlarged spleen.
Hepatomegaly: Liver enlargement with discomfort under the right ribs.
Recurrent Infections: Despite high lymphocyte counts, underlying dysfunction may impair immunity.
Cough: From pulmonary TB or lymphoma involvement.
Shortness of Breath: Enlarged lymphoid organs or anemia can contribute.
Skin Rash: Autoimmune or drug-induced lymphocyte activation.
Joint Pain/Arthritis: In autoimmune disorders driving lymphocytosis.
Easy Bruising/Bleeding: Bone marrow infiltration in leukemias.
Abdominal Pain: Splenic infarcts or lymphoid masses.
General Malaise: Non-specific symptom of chronic illness.
Further Diagnostic Tests
Below are key evaluations—grouped by category—that help characterize and pinpoint the cause of persistent lymphocytosis:
Physical Examination
Lymph Node Palpation: Assess size, consistency, and tenderness of cervical, axillary, and inguinal nodes.
Splenic Palpation: Detect splenomegaly, which suggests chronic immune or malignant processes.
Hepatic Examination: Evaluate for hepatomegaly indicating systemic involvement. UpToDate
Manual (Morphologic) Tests
Peripheral Blood Smear: Visual inspection of lymphocyte size, shape, and presence of atypical forms.
Manual Differential Count: Confirms relative and absolute lymphocyte percentages beyond automated analyses.
Downey Classification: Identifies reactive lymphocyte subtypes (Types I–III) typical of viral responses Wikipedia.
Laboratory & Pathological Tests
Complete Blood Count (CBC) with Differential: Quantifies lymphocytes and other blood cell lines NCBI.
Flow Cytometry (Immunophenotyping): Determines clonality, lineage (B vs T vs NK), and abnormal marker patterns KHSC Kingston Health Sciences Centre.
Serum Protein Electrophoresis: Screens for monoclonal protein spikes often seen in lymphoid malignancies.
Immunoglobulin Quantification: Measures IgG, IgA, and IgM levels to detect dysregulation.
Viral Serologies (EBV, CMV, HIV): Identifies chronic or recent viral triggers.
Autoantibody Panels (ANA, RF): Evaluates for autoimmune etiologies.
PCR for Viral DNA (EBV, CMV): Confirms active viral replication when serology is equivocal.
Bone Marrow Biopsy & Histology: Assesses marrow architecture and infiltration by abnormal lymphocytes.
Electrodiagnostic (Electrophoretic) Tests
Immunoelectrophoresis: Further characterizes protein abnormalities detected on SPEP.
Immunofixation Electrophoresis: Pinpoints specific immunoglobulin heavy and light chains.
T-Cell Receptor Gene Rearrangement Studies: Detects clonal T-cell populations in T-cell disorders.
Imaging Studies
Chest X-Ray: Screens for mediastinal lymphadenopathy or pulmonary infections.
CT Scan (Neck, Chest, Abdomen, Pelvis): Maps nodal and organ involvement to guide biopsy.
PET-CT Scan: Assesses metabolic activity of lymphoid masses to distinguish reactive from malignant lesions.
Non‑Pharmacological Treatments
These supportive and lifestyle‑based therapies aim to improve quality of life, bolster general immunity, and may help slow disease progression in chronic lymphocytosis, especially in early or asymptomatic phases.
Watchful Waiting (Active Surveillance)
Description: Regular monitoring without immediate drug intervention.
Purpose: Avoid overtreatment in asymptomatic patients with stable counts.
Mechanism: Periodic blood tests and clinical exams detect progression early so treatment can begin only if needed.
Nutritional Counseling
Description: Tailored diet plan emphasizing anti‑inflammatory foods.
Purpose: Support overall health and immune balance.
Mechanism: Optimizes nutrients (antioxidants, fiber, healthy fats) to reduce chronic inflammation.
Meditation and Mindfulness
Description: Daily practice of focused breathing or guided imagery.
Purpose: Reduce stress and improve immune regulation.
Mechanism: Lowers cortisol release, which can otherwise suppress healthy immune function.
Yoga and Tai Chi
Description: Low‑impact movement sequences with breath control.
Purpose: Enhance physical stamina and reduce fatigue.
Mechanism: Improves circulation and balances autonomic (stress) responses.
Cognitive‑Behavioral Therapy (CBT)
Description: Structured sessions addressing anxiety or depression.
Purpose: Manage emotional burden of chronic disease.
Mechanism: Reframes negative thought patterns, lessening stress hormones that impair immunity.
Acupuncture
Description: Fine-needle stimulation at specific body points.
Purpose: Alleviate pain, fatigue, and chemotherapy‑related side effects.
Mechanism: Triggers release of endorphins and modulates neurotransmitters.
Massage Therapy
Description: Hands‑on manipulation of muscles and soft tissues.
Purpose: Improve circulation, reduce pain, and enhance relaxation.
Mechanism: Stimulates lymphatic flow and reduces inflammatory cytokines.
Physical Exercise Program
Description: Customized moderate aerobic and strength training.
Purpose: Maintain muscle mass, reduce fatigue, and boost mood.
Mechanism: Increases anti‑inflammatory cytokines (IL‑10) and improves immune surveillance.
Hydrotherapy (Warm Baths, Contrast Showers)
Description: Alternating warm and cool water exposure.
Purpose: Promote circulation and lymph drainage.
Mechanism: Vasodilation/vasoconstriction “pumps” lymph fluid.
Photobiomodulation (Low-Level Laser Therapy)
Description: Non‑thermal light applied to skin.
Purpose: Ease localized pain and fatigue.
Mechanism: Enhances mitochondrial function and reduces oxidative stress.
Support Groups and Peer Counseling
Description: Regular meetings with fellow patients.
Purpose: Share experiences and coping strategies.
Mechanism: Emotional support lowers stress, benefiting immune health.
Sleep Hygiene Optimization
Description: Establishing regular sleep routines.
Purpose: Ensure restorative sleep.
Mechanism: Supports nightly immune cell “reset” cycles.
Mind‑Body Integrative Programs
Description: Combined modalities (yoga, meditation, art therapy).
Purpose: Holistic stress reduction.
Mechanism: Synergistic lowering of stress hormones.
Music Therapy
Description: Listening to or creating music.
Purpose: Manage anxiety and improve mood.
Mechanism: Modulates limbic (emotional) brain circuits.
Occupational Therapy
Description: Techniques to adapt daily tasks.
Purpose: Maintain independence and reduce fatigue.
Mechanism: Ergonomic adjustments lower energy expenditure.
Vitamin D Optimization
Description: Guided sun exposure or supplementation.
Purpose: Correct deficiency linked to worse prognosis.
Mechanism: Calcitriol modulates CLL cell survival pathways ASH Publications.
Probiotic Supplementation
Description: Daily intake of beneficial bacteria.
Purpose: Support gut–immune axis.
Mechanism: Enhances regulatory T‑cell development and reduces systemic inflammation.
Mindful Eating Practices
Description: Slow, attentive meals focusing on hunger/fullness cues.
Purpose: Improve digestion and nutrient uptake.
Mechanism: Reduces overeating and metabolic stress on immune function.
Cold‐Water Immersion (Contrast Therapy)
Description: Brief cold exposures after warm bathing.
Purpose: Stimulate immune response and circulation.
Mechanism: Activates cold shock proteins, boosting lymphocyte activity.
Adaptive Exercise Devices (e.g., arm ergometers)
Description: Low‑impact machines for limited mobility.
Purpose: Maintain physical activity despite fatigue.
Mechanism: Improves cardiovascular health and lymph flow.
Drug Treatments
Below are the cornerstone medications used in monoclonal chronic lymphocytosis (CLL), with dosage, class, administration, and common side effects:
Ibrutinib
Class: Bruton’s tyrosine kinase (BTK) inhibitor
Dosage: 420 mg orally once daily until disease progression or toxicity www2.tri-kobe.orgWikipedia
Side Effects: Diarrhea, fatigue, muscle cramps, bleeding risk, atrial fibrillation
Acalabrutinib
Class: Second‑generation BTK inhibitor
Dosage: 100 mg orally twice daily until progression FDA Access DataWikipedia
Side Effects: Headache, cytopenias, pneumonia
Zanubrutinib
Class: BTK inhibitor
Dosage: 160 mg orally twice daily (or 320 mg once daily) until toxicity Drugs.comFDA Access Data
Side Effects: Neutropenia, bleeding, upper respiratory infections
Venetoclax
Class: BCL‑2 inhibitor
Dosage: Ramp-up weekly from 20 mg to 400 mg orally once daily; then 400 mg daily until progression Drugs.comvenclexta.com
Side Effects: Tumor lysis syndrome risk, neutropenia, diarrhea
Obinutuzumab
Class: Anti‑CD20 monoclonal antibody
Dosage: 100 mg IV Day 1, 900 mg Day 2, 1000 mg Days 8 & 15 of Cycle 1; 1000 mg Day 1 Cycles 2–6 Medscape Reference
Side Effects: Infusion reactions, neutropenia
Rituximab
Fludarabine
Cyclophosphamide
Bendamustine
Class: Alkylating agent with purine analog properties
Dosage: 70 mg/m² IV Days 1–2 of each 28‑day cycle gazyva
Side Effects: Nausea, myelosuppression
Idelalisib
Class: PI3Kδ inhibitor
Dosage: 150 mg orally twice daily until progression Medscape Reference
Side Effects: Diarrhea/colitis, hepatotoxicity, pneumonitis
Dietary Molecular Supplements
These supplements have laboratory or preliminary clinical data suggesting supportive roles in CLL. Always discuss with your doctor before starting.
Vitamin D (Cholecalciferol)
Dosage: 1,000–2,000 IU daily (adjust based on blood level)
Function: Regulates immune signaling pathways critical for CLL cell survival PubMed
Mechanism: Binds vitamin D receptor, modulating PI3K/AKT and TLR pathways
Omega‑3 Fatty Acids (EPA/DHA)
Dosage: 1–3 g/day of combined EPA/DHA
Function: Anti‑inflammatory, may reduce C‑reactive protein Wiley Online Library
Mechanism: Shifts eicosanoid production toward resolvins, lessening chronic inflammation
Curcumin (Turmeric Extract)
Dosage: 500–2,000 mg standardized extract daily
Function: Induces CLL cell apoptosis in vitro hematologyandoncology.net
Mechanism: Inhibits NF‑κB, STAT3, and Akt; promotes PARP cleavage
EGCG (Green Tea Extract)
Dosage: 400–800 mg EGCG daily
Function: Synergistic apoptosis inducer with curcumin PMC
Mechanism: Proteasome inhibition, downregulates antiapoptotic proteins
Quercetin
Dosage: 500 mg twice daily
Function: Triggers both intrinsic/extrinsic apoptosis pathways Oncotarget
Mechanism: Inhibits PI3K/AKT, downregulates Mcl‑1
Resveratrol
Dosage: 100–500 mg daily
Function: Induces G₀/G₁ arrest and apoptosis in CLL cells PubMed
Mechanism: Modulates caspase‑3 activity and oxidative stress pathways
Selenium
Dosage: 100 µg daily
Function: Antioxidant, may support immune function
Mechanism: Cofactor for glutathione peroxidase, reducing oxidation
Zinc
Dosage: 15–30 mg daily
Function: Supports T‑cell development and function
Mechanism: Cofactor for thymic hormone activity
N‑Acetylcysteine (NAC)
Dosage: 600 mg twice daily
Function: Boosts glutathione, reduces oxidative stress
Mechanism: Replenishes intracellular cysteine for antioxidant defense
Probiotic Blend (Lactobacillus + Bifidobacterium)
Dosage: As per product label (~1–10 billion CFU daily)
Function: Enhances gut–immune axis, may improve regulatory T‑cells
Mechanism: Modulates gut microbiota composition and systemic cytokines
Regenerative/Stem Cell‑Mobilizing Agents
Filgrastim (G‑CSF)
Dosage: 5 µg/kg SC daily until neutrophil recovery
Function: Stimulates neutrophil production
Mechanism: Binds G‑CSF receptor on progenitors to promote differentiation
Pegfilgrastim
Dosage: 6 mg SC once per chemotherapy cycle
Function: Long‑acting G‑CSF analog
Mechanism: Same as filgrastim with extended half‑life
Sargramostim (GM‑CSF)
Dosage: 250 µg/m² SC daily
Function: Broad myeloid growth factor
Mechanism: Stimulates granulocyte and macrophage progenitors
Plerixafor
Dosage: 0.24 mg/kg SC for stem cell mobilization
Function: Enhances collection of hematopoietic stem cells
Mechanism: CXCR4 antagonist, releasing stem cells into blood
Lenalidomide
Dosage: 5–10 mg daily (CLL research doses)
Function: Immunomodulatory, anti‑angiogenic
Mechanism: Cereblon E3 ligase modulation, cytokine shifts
Thalidomide
Dosage: 50–200 mg nightly (research use)
Function: Immune modulation, reduces microenvironment support
Mechanism: Inhibits TNF‑α production, alters adhesion molecule expression
Surgical/Procedure‑Based Interventions
Splenectomy
Why: Relieves symptomatic splenomegaly causing pain or cytopenias
Lymph Node Biopsy
Why: Diagnostic confirmation and clonality assessment
Bone Marrow Biopsy
Why: Evaluate marrow infiltration percentage
Central Venous Catheter Placement
Why: Facilitates repeated infusions and blood draws
Leukapheresis
Why: Rapid cytoreduction in high‐count symptomatic patients
Hematopoietic Stem Cell Harvest
Why: Collect stem cells for autologous transplant
Allogeneic Hematopoietic Stem Cell Transplant
Why: Potentially curative in high‑risk or refractory disease
Splenic Irradiation
Why: Palliate splenomegaly when surgery isn’t feasible
Radiation to Bulky Nodes
Why: Shrink masses causing discomfort or organ compression
Port‑a‑Cath Implantation
Why: Long‑term vascular access for multiple treatments
Preventive Measures
Hand Hygiene
Up‑to‑Date Vaccinations (influenza, pneumococcal)
Avoiding Active Smoking
Limiting Alcohol Intake
Safe Food Handling (prevent food‑borne infections)
Regular Dental Care (reduce oral infections)
Balanced Diet Rich in Fruits & Vegetables
Moderate Sun Exposure (vitamin D synthesis)
Stress Management Techniques
Avoidance of Unnecessary Hospital Visits (reduce exposure)
When to See a Doctor
Lymphocyte count > 10,000/µL or rapidly rising
New or worsening B symptoms (fever > 38 °C, drenching night sweats, unexplained weight loss > 10% in 6 months)
Enlarging lymph nodes or spleen causing discomfort
Recurrent or severe infections
Signs of anemia (fatigue, shortness of breath) or thrombocytopenia (easy bleeding)
Dietary Recommendations
What to Eat
Leafy greens (spinach, kale)
Berries (antioxidants)
Fatty fish (salmon, mackerel)
Nuts and seeds (omega‑3 source)
Cruciferous vegetables (broccoli, cauliflower)
Whole grains (fiber)
Legumes (protein + fiber)
Yogurt with live cultures
Olive or canola oil
Lean poultry and beans
What to Avoid
Processed meats (high nitrates)
Trans fats (fried, packaged snacks)
Excessive sugar (sugary drinks, sweets)
High‑salt processed foods
Alcohol binging
Raw or undercooked meats/fish
Unpasteurized dairy
Artificial sweeteners (controversial)
Excessive caffeine
High‑dose omega‑6 oils (corn, soybean)
Frequently Asked Questions
What is the difference between reactive and chronic lymphocytosis?
Reactive lymphocytosis resolves when the underlying cause (like infection) is treated, whereas chronic lymphocytosis persists for months and may indicate a blood cancer like CLL.Can chronic lymphocytosis be cured?
Polyclonal forms often resolve; monoclonal CLL is usually managed chronically, with transplant as the only curative option.Is treatment always needed?
No—many patients with early CLL remain under surveillance until symptoms or count rises.How often are blood counts checked?
Typically every 3–6 months in stable cases; more frequently if counts change or symptoms emerge.Can diet alone control lymphocytosis?
Diet supports overall health but cannot replace necessary medical therapies in malignant cases.Are supplements safe?
Some have benefits, but interactions or side effects exist—always consult your healthcare team.When is bone marrow biopsy required?
At diagnosis or when transformation to an aggressive lymphoma is suspected.Can infections trigger lymphocytosis worsening?
Yes—acute infections can spike counts and worsen symptoms temporarily.What vaccines are recommended?
Annual flu shot, pneumococcal vaccines (PCV13 then PPSV23), possibly meningococcal in certain cases.Is exercise allowed during treatment?
Yes—moderate activity is encouraged to combat fatigue and maintain function.What is Richter’s transformation?
Change of CLL into a fast‑growing lymphoma; watch for rapid node growth or B symptoms.How does age affect treatment?
Older adults may tolerate aggressive therapies less well; targeted agents are often safer.Can chronic lymphocytosis affect quality of life?
Fatigue, frequent infections, and anxiety about progression can impact daily life—supportive care is key.Are there clinical trials?
Yes—trials of novel targeted therapies and combination regimens regularly open at centers worldwide.Where can I find support?
Patient advocacy groups (e.g., CLL Society), local cancer support centers, online forums.
Disclaimer: Each person’s journey is unique, treatment plan, life style, food habit, hormonal condition, immune system, chronic disease condition, geological location, weather and previous medical history is also unique. So always seek the best advice from a qualified medical professional or health care provider before trying any treatments to ensure to find out the best plan for you. This guide is for general information and educational purposes only. Regular check-ups and awareness can help to manage and prevent complications associated with these diseases conditions. If you or someone are suffering from this disease condition bookmark this website or share with someone who might find it useful! Boost your knowledge and stay ahead in your health journey. We always try to ensure that the content is regularly updated to reflect the latest medical research and treatment options. Thank you for giving your valuable time to read the article.
The article is written by Team RxHarun and reviewed by the Rx Editorial Board Members
Last Updated: July 29, 2025.
