CELL INJURY,

1&2

Cell Injury, Definitions

When the cell is exposed to an injurious agent or

stress, a sequence of events follows that is loosely
termed cell injury.
Cell injury is reversible up to a certain point
If the stimulus persists or is severe enough from the
beginning, the cell reaches a point of no return and
suffers irreversible cell injury and ultimately cell
death.
Cell death, is the ultimate result of cell injury

Patterns Of Cell Death

There

are two principal patterns of cell

death:
1- Necrosis and
2- Apoptosis.

Necrosis

Necrosis

is the type of cell death that occurs

after ischemia and chemical injury

Necrosis

is always pathologic.

Apoptosis
Apoptosis

occurs when a cell dies through

activation of an internally controlled suicide
program.

Apoptosis

is designed to eliminate
unwanted cells during embryogenesis and in
various physiologic processes and certain
pathologic conditions.

Causes of Cell Injury

1) Oxygen Deprivation (Hypoxia). It is a common
cause of cell injury and cell death.
-Hypoxia can be due to :
A- inadequate oxygenation of the blood due to
Cardiorespiratory failure
B- loss of the oxygen-carrying capacity of the blood, as
in anemia or carbon monoxide poisoning.
Depending on the severity of the hypoxic state, cells
may adapt, undergo injury, or die.

Causes of Cell Injury cont.

2) Physical Agents :
- Mechanical trauma,
- Burns,
- Deep cold
- Sudden changes in atmospheric pressure,
- radiation, and electric shock

Causes of Cell Injury cont.

3) Chemical Agents and Drugs
- oxygen, in high concentrations
- poisons, such as arsenic, cyanide, or mercuric
salts
- environmental and air pollutants
- insecticides, herbicides, industrial and
occupational hazards
- alcohol and narcotic drugs and therapeutic drugs

Causes of Cell Injury cont.

4) Infectious Agents e.g. bacteria, fungi,
viruses and parasites.
5) Immunologic Reactions.
6) Genetic Derangements.
7) Nutritional Imbalances

MECHANISM OF CELL INJURY

1.

DEPLETION OF ATP:

. ATP depletion and decreased ATP synthesis

are associated with both hypoxic and
chemical (toxic) injury.
. ATP is required for many synthetic and
degradative processes within the cell.

MECHANISM OF CELL INJURY cont.

ATP

is produced in two ways.

A- The major pathway is oxidative
phosphorylation of adenosine diphosphate.
B-The second is the glycolytic pathway, which
generate ATP in absence of oxygen using
glucose derived from body fluids or from
glycogen

MECHANISM OF CELL INJURY cont.

Effects of depleted ATP

a) The activity of the plasma membrane
energy-dependent sodium pump is reduced.
It causes sodium to accumulate
intracellularly and potassium to diffuse out of
the cell causing cell swelling, and dilation of
the endoplasmic reticulum.

MECHANISM OF CELL INJURY cont.

b) If oxygen supply to cells is reduced, as in
ischemia, oxidative phosphorylation ceases
and cells rely on glycolysis for energy
production (anaerobic metabolism) resulting in
depletion of glycogen stores. Glycolysis results
in the accumulation of lactic acid which
reduces the intracellular pH, resulting in
decreased activity of many cellular enzymes.

MECHANISM OF CELL INJURY cont.

c) Failure of the Ca2+ pump leads to influx of
Ca2+, with damaging effects on numerous
cellular components
d) Ribosomes detach from the RER and
polysomes breakdown into monosomes,
leading to reduction in protein synthesis.
Ultimately, irreversible damage to
mitochondrial and lysosomal membranes
occurs, and cell undergoes necrosis

MECHANISM OF CELL INJURY cont.

e) In cells deprived of oxygen or glucose,

proteins may become misfolded, and trigger
the unfolded protein response leading to cell
injury and even death.

MECHANISM OF CELL INJURY cont.

2- Mitochondrial Damage:
. Mitochondria are important targets for all
types of injury, including hypoxia and toxins.

MECHANISM OF CELL INJURY cont.

Mitochondria can be damaged by :
A- Increases of cytosolic Ca2+
B- Oxidative stress
C- Breakdown of phospholipids, and by
D- Lipid breakdown products.

MECHANISM OF CELL INJURY cont.

. Mitochondrial damage results in the formation of a
high-conductance channel, called mitochondrial
permeability transition, present in the inner
mitochondrial membrane. In the initial phase it is
reversible but once mitochondrial permeability
transition is irreversble it becomes a deathblow to
the cell.
Mitochondrial damage can also be associated with
leakage of cytochrome c into the cytosol.

3.INFLUX
OF
INTRACELLULAR
CALCIUM
&
MECHANISM OF CELL INJURY cont.
LOSS OF CALCIUM HOMEOSTASIS.
. Ischemia causes an increase in cytosolic calcium
concentration. Increased Ca2+ in turn activates a
number of enzymes, e.g.
- ATPases (thereby hastening ATP depletion),
-Phospholipases (which cause membrane damage),
- Proteases (which break down both membrane and
cytoskeletal proteins), and
-Endonucleases (which are responsible for DNA and
chromatin fragmentation).

MECHANISM OF CELL INJURY cont.

4. ACCUMULATION OF OXYGEN-DERIVED FREE
RADICALS (OXIDATIVE STRESS)
- Small amounts of partially reduced reactive oxygen
forms are produced as a byproduct of mitochondrial
respiration.
- Some of these free radicals can damage lipids,
proteins, and nucleic acids.
- They are referred to as reactive oxygen species.

MECHANISM OF CELL INJURY cont.

- Cells have defense systems to prevent
injury caused by these products.
- An imbalance between free radicalgenerating and radical-scavenging systems
results in oxidative stress causing cell injury.

MECHANISM OF CELL INJURY cont.

Free radical-mediated damage are seen in
- chemical and radiation injury
- ischemia-reperfusion injury
- cellular aging, and
- microbial killing by phagocytes.

MECHANISM OF CELL INJURY cont.

-

Free radicals are chemical species that have single

unpaired electron in an outer orbit.
They are initiated within cells in several ways:

a) Absorption of radiant energy (e.g., ultraviolet light, xrays).

b) Enzymatic metabolism of exogenous chemicals or
drugs .

MECHANISM OF CELL INJURY cont.

c) The reduction-oxidation reactions that occur during
normal metabolic processes. During normal
respiration, small amounts of toxic intermediates are
produced; these include superoxide anion radical
(O2-), hydrogen peroxide (H2O2), and hydroxyl ions
(OH).
d) Transition metals such as iron and copper
e) Nitric Oxide (NO), an important chemical mediator
generated by various cells, can act as a free radical.

MECHANISM OF CELL INJURY cont.

-The main effects of these reactive species are
Lipid peroxidation of membranes: result in extensive
membrane, organellar, and cellular damage.
Oxidative modification of proteins. resulting in protein
fragmentation.
Lesions in DNA. This DNA damage has been
implicated in cell aging and malignant transformation
of cells

MECHANISM OF CELL INJURY cont.

-Cells have developed multiple mechanisms to
remove free radicals and thereby minimize
injury.
1- Antioxidants. Examples vitamins E and A and
ascorbic acid.
2- Enzymes which break down hydrogen
peroxide and superoxide anion e.g. Catalase,
Superoxide dismutases,and Glutathione
peroxidase.

MECHANISM OF CELL INJURY cont.

5. Defects In Membrane
Permeability:
- In ischemic cells, membrane damage may be
the result of ATP depletion and calciummodulated activation of phospholipases.
- It can also be damaged directly by certain
bacterial toxins, viral proteins etc.

MECHANISM OF CELL INJURY cont.

The biochemical mechanisms which contribute
to membrane damage are:
Mitochondrial

dysfunction
Cytoskeletal abnormalities
Reactive oxygen species
Lipid breakdown products

Figure 1-10 Cellular and biochemical sites of damage in cell injury.

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Figure 1-11 Functional and morphologic consequences of decreased intracellular ATP during cell injury.

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Reversible & Irreversible Cell Injury

Earliest changes associated with cell injury are :
decreased generation of ATP,
loss of cell membrane integrity,
defects in protein synthesis, cytoskeletal
damage, and
DNA damage.

Reversible and Irreversible Cell Injury

Within

limits, the cell can compensate for

these derangements and,
If the injurious stimulus is removed the
damage can be reversed.
Persistent or excessive injury, however,
causes cells to pass the threshold into
irreversible injury.

Reversible and Irreversible Cell Injury

Irreversble injury is marked by :
- severe mitochondrial vacuolization,
- extensive damage to plasma membranes,
- swelling of lysosomes and
- the appearance large, amorphous densities in
mitochondria..

Reversible and Irreversible Cell Injury

Two phenomena consistently characterize
irreversibility.
1) The inability to reverse mitochondrial
dysfunction (lack of oxidative phosphorylation
and ATP generation) even after removal of
the original injury.
2) Profound loss in membrane function

n
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Ischaemic cell injury

As

the oxygen tension within the cell

decreases, there is loss of oxidative
phosphorylation and decreased generation of
ATP followed by sodium pump failure, with
loss of potassium, influx of sodium and water,
and cell swelling.
There is progressive loss of glycogen,
decreased protein synthesis and reduced
intracellular Ph.

Ischaemic cell injury cont.

If

hypoxia continues, worsening ATP

depletion causes further morphologic
deterioration e.g. loss of ultrastructural
features such as microvilli and the formation
of "blebs" at the cell surface. "Myelin figures,"
may be seen within the cytoplasm or
extracellularly.
If oxygen is restored, all of these
disturbances are reversible.

Ischaemic cell injury cont

If ischemia persists, irreversible injury and necrosis

ensue.
Irreversible injury is associated morphologically with
severe swelling of mitochondria, extensive damage
to plasma membranes, and swelling of lysosomes.
Large, flocculent, amorphous densities develop in
the mitochondrial matrix.
The dead cell are phagocytosed by other cells.

ISCHEMIA-REPERFUSION INJURY

Restoration

of blood flow to ischemic tissues can

result in recovery of cells if they are reversibly
injured.
Ischemia-reperfusion injury is a clinically
important process in such conditions as
myocardial infarction and stroke.

ISCHEMIA-REPERFUSION INJURY

New damaging processes are set in motion during

reperfusion, causing the death of cells that might
have recovered otherwise New damage may be
initiated during reoxygenation by increased
generation of oxygen free radicals from parenchymal
and endothelial cells and from infiltrating leukocytes
Reactive oxygen species can further promote the
mitochondrial permeability transition,

ISCHEMIA-REPERFUSION INJURY

Ischemic injury is associated with inflammation as a

result of the production of cytokines and increased
expression of adhesion molecules by hypoxic
parenchymal and endothelial cells.
These agents recruit circulating polymorphonuclear
leukocytes to reperfused tissue; the ensuing
inflammation causes additional injury.
Activation of the complement pathway may
contribute to ischemia-reperfusion injury.

NECROSIS
Necrosis

refers to a spectrum of morphologic

changes that follow cell death in living tissue,
due to degradative action of enzymes on the
injured cell.
It occurs in irreversible injury.
This may elicit inflammation in the
surrounding tissue.

NECROSIS
There

is denaturation of intracellular proteins

and enzymatic digestion of the cell.
The enzymes are derived either from the
lysosomes of the dead cells themselves, in
which case the enzymatic digestion is
referred to as autolysis, or from the
lysosomes of immigrant leukocytes, during
inflammatory reactions.

Morphology of necrosis.
Necrotic cells show
increased eosinophilia with a glassy
homogeneous appearance.
The cytoplasm becomes vacuolated and
appears moth-eaten.
Finally, calcification of the dead cells may
occur.

Morphology of necrosis cont.

Nuclear changes show one of three patterns, all due to
nonspecific breakdown of DNA
1- karyolysis : basophilia of the chromatin may fade
2- Pyknosis, (also seen in apoptotic cell death) is characterized
by nuclear shrinkage and increased basophilia. Here the DNA
apparently condenses into a solid, shrunken basophilic mass.
3- Karyorrhexis: fragmentation of the nucleus.
With the passage of time (a day or two), the nucleus in the
necrotic cell totally disappears

Morphology of necrosis
By electron microscopy, necrotic cells are
characterized by :
overt discontinuities in plasma membrane,
marked dilation of mitochondria with the
appearance of large amorphous densities,
intracytoplasmic myelin figures,
amorphous osmiophilic debris, and
aggregates of fluffy material probably
representing denatured protein

Types of necrosis
There are different types of necrosis :
- Coagulative necrosis,
- Liquefactive necrosis,
- Caseous necrosis and
- Fat necrosis

Coagulative necrosis:

There is preservation of the basic outline of the

coagulated cell for a span of some days.
The affected tissues has a firm texture e.g.
myocardial infarct Ultimately, the necrotic myocardial
cells are removed by fragmentation and
phagocytosis of the cellular debris by scavenger
leukocytes and by the action of proteolytic lysosomal
enzymes brought in by the immigrant white cells.

Coagulative necrosis:
Coagulative

necrosis, with preservation

of the general tissue architecture, is
characteristic of hypoxic death of
cells in all tissues except the brain.

Liquefactive necrosis
Is

characteristic of focal bacterial or,

occasionally, fungal infections.
It is also seen in hypoxic death of cells within
the central nervous system.
Liquefaction completely digests the dead
cells.
The end result is transformation of the tissue
into a liquid viscous mass..

Liquefactive necrosis

If

the process was initiated by acute

inflammation, the material is frequently
creamy yellow because of the presence of
dead white cells and is called pus

Gangrenous necrosis
Is

a term used by surgeons.

It is usually applied to a limb, generally the
lower leg, that has lost its blood supply and
has undergone coagulation necrosis.
When bacterial infection is superimposed,
coagulative necrosis is modified by the
liquefactive action of the bacteria and the
attracted leukocytes (so-called wet
gangrene).

Caseous necrosis
Is

a type of coagulative necrosis, seen in

tuberculous infection.
The term caseous is derived from the cheesy
white gross appearance of the area of
necrosis.
On microscopic examination, the necrotic
area appears as amorphous pink granular
debris surrounded by granuloma.

Fat necrosis
Is

focal areas of fat destruction, due to

release of activated pancreatic lipases into
the substance of the pancreas and the
peritoneal cavity.
This occurs in acute pancreatitis.
The released fatty acids combine with
calcium to produce grossly visible chalky
white areas (fat saponification)..

Fat necrosis
On

histologic examination:
The necrosis takes the form of foci of shadowy
outlines of necrotic fat cells, with basophilic
calcium deposits, surrounded by an
inflammatory reaction

APOPTOSIS

Apoptosis is programmed cell death.

It is a pathway of cell death that is induced by a
tightly regulated intracellular program in which cells
destined to die activate their own enzymes to
degrade their own nuclear DNA, nuclear proteins
and cytoplasmic proteins.
The cell's plasma membrane remains intact, but its
structure is altered in such a way that the apoptotic
cell sends signal to macrophages to phagocytose it.

APOPTOSIS cont.

The dead cell is rapidly phagocytosed and cleared,

before its contents have leaked out, and therefore
cell death by this pathway does not elicit an
inflammatory reaction in the host.
Thus, apoptosis is fundamentally different from
necrosis, which is characterized by loss of
membrane integrity, enzymatic digestion of cells, and
frequently a host reaction.
Apoptosis and necrosis sometimes coexist.

CAUSES OF APOPTOSIS

Apoptosis means "falling off."

It occurs normally in many situations, and serves to
eliminate unwanted or potentially harmful cells and
cells that have outlived their usefulness.
It is also a pathologic event when cells are damaged
beyond repair, especially when the damage affects
the cell's DNA; in these situations, the irreparably
damaged cell is eliminated.
Apoptosis can be physiologic, adaptive, and
pathologic.

Apoptosis in Physiologic Situations

The

programmed destruction of cells during

embryogenesis.
Hormone-dependent involution in the adult,
such as endometrial cell breakdown during
the menstrual cycle, the regression of the
lactating breast after weaning, and prostatic
atrophy after castration.
Cell deletion in proliferating cell
populations,eg. intestinal epithelia.

Apoptosis in Physiologic Situations

Death of host cells that have served their useful

purpose, such as neutrophils in an acute
inflammatory response, and lymphocytes at the end
of an immune response.
Elimination of potentially harmful self-reactive
lymphocytes..
Cell death induced by cytotoxic T cells, a defense
mechanism against viruses and tumors that serves
to eliminate virus-infected and neoplastic cells

Apoptosis in Pathologic Conditions

Cell

death produced by a variety of injurious

stimuli eg. radiation and cytotoxic anticancer
drugs damage DNA.
Cell injury in certain viral diseases, such as
viral hepatitis.
Pathologic atrophy in parenchymal organs
after duct obstruction, such as occurs in the
pancreas, parotid gland, and kidney.
Cell death in tumors.

Morphology of Apoptosis
Cell

shrinkage.
Chromatin condensation. This is the most
characteristic feature of apoptosis. The
chromatin aggregates peripherally, under the
nuclear membrane.
The nucleus itself may break up into
fragments.

Morphology of Apoptosis
Formation

of cytoplasmic blebs and

apoptotic bodies. The apoptotic cell first
shows extensive surface blebbing, then
undergoes fragmentation into membranebound apoptotic bodies composed of
cytoplasm and tightly packed organelles, with
or without nuclear fragments.
Phagocytosis of apoptotic cells or cell
bodies, usually by macrophages.

Morphology of Apoptosis
On

histologic examination, in tissues stained

with hematoxylin and eosin, apoptosis
involves single cells or small clusters of cells.
The apoptotic cell appears as a round or oval
mass of intensely eosinophilic cytoplasm with
dense nuclear chromatin fragments.
There is no inflammation.

Figure 1-9 The sequential ultrastructural changes seen in necrosis (left) and apoptosis (right). In apoptosis, the initial changes consist of nuclear chromatin condensation
and fragmentation, followed by cytoplasmic budding and phagocytosis of the extruded apoptotic bodies. Signs of cytoplasmic blebs, and digestion and leakage of cellular
components. (Adapted from Walker NI, et al: Patterns of cell death. Methods Archiv Exp Pathol 13:18-32, 1988. Reproduced with permission of S. Karger AG, Basel.)

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Feature

Necrosis

Apoptosis

Cell size

Enlarged (swelling)

Reduced (shrinkage)

Nucleus

Pyknosis karyorrhexis
karyolysis

Fragmentation into nucleosome size fragments

Plasma
membrane

Disrupted

Intact; altered structure, especially orientation of

lipids

Cellular
contents

Enzymatic digestion; may leak

out of cell

Intact; may be released in apoptotic bodies

Adjacent
inflammation

Frequent

No

Physiologic or Invariably pathologic

pathologic role (culmination of irreversible cell
injury)

Often physiologic, means of eliminating

unwanted cells; may be pathologic after some
forms of cell injury, especially DNA damage

Cell Injury ,
3&4

Intracellular Accumulations
Intracellular accumulation of abnormal amounts of
various substances.
(1) a normal cellular constituent accumulated in excess,
such as water, lipids, proteins, and carbohydrates
(2) an abnormal substance, either exogenous, such as
a mineral or products of infectious agents, or
endogenous, such as a product of abnormal
synthesis or metabolism
(3) a pigment.

Intracellular Accumulations
-The substance may be either the cytoplasm or
the nucleus.
- In some instances, the cell may be producing
the abnormal substance, and
- In others it may be merely storing products of
pathologic processes occurring elsewhere in
the body

COMMON CAUSES OF INTRACELLULAR

ACCUMULATION

1- A normal endogenous substance is produced at a

normal or increased rate, but the rate of metabolism
is inadequate to remove it. Eg.fatty change in the
liver.
2- A normal or abnormal endogenous substance
accumulates because of genetic or acquired defects
in the metabolism, packaging, transport, or secretion
of these substances. Eg. lysosomal storage
diseases.

COMMON CAUSES OF INTRACELLULAR

ACCUMULATION

3- An abnormal exogenous substance is

deposited and accumulates because the cell
has neither the enzymatic machinery to
degrade the substance nor the ability to
transport it to other sites. Eg.accumulations
of carbon particles.

LIPIDS
All major classes of lipids can accumulate in
cells:
triglycerides,
cholesterol/cholesterol esters, and
phospholipids.
In addition, abnormal complexes of lipids and
carbohydrates accumulate in the lysosomal
storage diseases.

Steatosis (Fatty Change)

The

terms steatosis and fatty change is

abnormal accumulations of triglycerides
within parenchymal cells.
Often seen in liver, but it also in heart,
muscle, and kidney.

Steatosis (Fatty Change)

The
-

causes of steatosis include :

toxins,
protein malnutrition,
diabetes mellitus,
obesity,
anoxia and
alcohol abuse

Steatosis (Fatty Change)

Free fatty acids from adipose tissue or ingested food

are normally transported into hepatocytes. In the
liver, they are esterified to triglycerides, converted
into cholesterol or phospholipids, or oxidized to
ketone bodies.
Release of triglycerides from the hepatocytes
requires apoproteins to form lipoproteins.
Excess accumulation of triglycerides within the liver
may result from defects in any one of the events in
the sequence from fatty acid entry to lipoprotein exit.

Morphology of Steatosis
Clear

vacuoles within parenchymal cells. The

sections may then be stained with Sudan IV
or Oil Red-O, both of which impart an
orange-red color to the contained lipids.
Liver. In mild fatty change gross appearance
is normal. With progressive accumulation,
the organ enlarges and becomes
increasingly yellow and greasy.

Morphology of Steatosis
Light

microscopy: vacuoles in the cytoplasm

displacing the nucleus to the periphery of the
cell
Occasionally, contiguous cells rupture, and
the enclosed fat globules coalesce,
producing so-called fatty cysts

Cholesterol and Cholesterol Esters

- Cells use cholesterol for the synthesis of cell

membranes.
-Accumulations in the form of intracellular
vacuoles, are seen in several pathologic
processes eg. Atherosclerosis

Cholesterol and Cholesterol Esters

Atherosclerosis. In atherosclerotic plaques, smooth

muscle cells and macrophages within the intimal
layer of arteries are filled with lipid vacuoles, most of
which are made up of cholesterol and cholesterol
esters.
Some of these fat-laden cells rupture, releasing lipids
into the extracellular space.
The extracellular cholesterol esters may crystallize in
the shape of long needles, producing clefts in tissue
sections.

Cholesterol and Cholesterol Esters

Xanthomas. Intracellular accumulation of cholesterol

within macrophages is also characteristic of acquired
and hereditary hyperlipidemic states seen in
connective tissue of the skin and in tendons.
Inflammation and necrosis. Foamy macrophages are
frequently found at sites of cell injury and
inflammation, owing to phagocytosis of cholesterol
from the membranes of injured cells.

Cholesterol and Cholesterol Esters

Cholesterolosis.

Accumulations of
cholesterol-laden macrophages in the lamina
propria of the gallbladder.
Niemann-Pick disease, type C. In this
lysosomal storage disease, an enzyme
involved in cholesterol trafficking is mutated,
and hence cholesterol accumulates in
multiple organs.

GLYCOGEN

Glycogen is a readily available energy store that is

present in the cytoplasm.
Excessive intracellular deposits of glycogen are seen
in patients with an abnormality in either glucose or
glycogen metabolism.
They appear as clear vacuoles within the cytoplasm.
Staining with mucicarmine or the periodic acid schiff
(PAS) reaction imparts a rose-to-violet color to the
glycogen.

GLYCOGEN cont.
Diabetes

mellitus is the prime example of a

disorder of glucose metabolism. In this
disease, glycogen is found in the epithelial
cells of the distal portions of the proximal
convoluted tubules, as well as within liver
cells, cells of the islets of Langerhans, and
heart muscle cells

GLYCOGEN cont.
Glycogen

also accumulates within the cells in

a group of closely related disorders, all
genetic, collectively referred to as the
glycogen storage diseases, or
glycogenoses. In these diseases, enzymatic
defects in the synthesis or breakdown of
glycogen result in massive accumulation,
and cell death.

PIGMENTS
Pigments

are colored substances, some of

which are normal constituents of cells (e.g.,
melanin), whereas others are abnormal and
collect in cells only under special
circumstances.
Pigments can be exogenous, coming from
outside the body, or endogenous, synthesized
within the body itself

Exogenous Pigments
.The most common exogenous pigment is carbon or
coal dust, which is an air pollutant.
. When inhaled, it is picked up by macrophages within
the alveoli and is then transported through lymphatic
channels to the regional lymph nodes.
. Accumulations of this pigment blacken the tissues of
the lungs (anthracosis) and the involved lymph
nodes.
. In coal miners, the aggregates of carbon dust may
induce a fibroblastic reaction or even emphysema
and thus cause a serious lung disease known as coal
worker's pneumoconiosis .

Exogenous Pigments
Tattooing is a form of localized, exogenous
pigmentation of the skin. The pigments
inoculated are phagocytosed by dermal
macrophages.

Endogenous Pigments

Lipofuscin is an insoluble pigment, also known as

wear-and-tear or aging pigment.
Lipofuscin is not injurious to the cell or its functions.
Its importance lies in its being the telltale sign of free
radical injury and lipid peroxidation.
In tissue sections, it appears as a yellow-brown,
finely granular intracytoplasmic, often perinuclear
pigment It is prominent in the liver and heart of
aging patients or patients with severe malnutrition
and cancer cachexia.

Figure 1-40 Lipofuscin granules in a cardiac myocyte as shown by A, light microscopy (deposits indicated by arrows), and B, electron microscopy (note the perinuclear,
intralysosomal location).

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Endogenous Pigments cont.

Melanin, is an endogenous, non-hemoglobinderived, brown-black pigment formed when the

enzyme tyrosinase catalyzes the oxidation of
tyrosine to dihydroxyphenylalanine in melanocytes.
The other black pigment in this category is
homogentisic acid, a black pigment that occurs in
patients with alkaptonuria, a rare metabolic disease.
Here the pigment is deposited in the skin, connective
tissue, and cartilage, and the pigmentation is known
as ochronosis

Endogenous Pigments cont.

Hemosiderin is a hemoglobin-derived, golden yellowto-brown, iron containing pigment in cells. Iron is

normally stored in the form of ferritin micelles. When
there is a local or systemic excess of iron, ferritin
forms hemosiderin granules, which are easily seen
with the light microscope. Excesses of iron cause
hemosiderin to accumulate within cells, either as a
localized process or as a systemic derangement.

Endogenous Pigments cont.

Local

excesses of iron and hemosiderin

result from hemorrhages or vascular
congestion, eg hemosiderosis is the
common bruise.
With lysis of the erythrocytes, the hemoglobin
eventually undergoes transformation to
hemosiderin.

Endogenous Pigments cont.

Systemic

overload of iron, hemosiderin is

deposited in many organs and tissues, a
condition called hemosiderosis.
It is seen with: (1) increased absorption of
dietary iron, (2) impaired use of iron, (3)
hemolytic anemias, and (4) transfusions
because the transfused red cells constitute
an exogenous load of iron

Endogenous Pigments cont.

Morphology. Iron pigment appears as a coarse,

golden, granular pigment lying within the cell's
cytoplasm usually in the macrophages.In severe
systemic hemosiderosis the pigment may
accumulate in the parenchymal cells throughout the
body (liver, pancreas, heart, and endocrine organs).
Iron can be visualized in tissues by the Prussian blue
histochemical reaction, in which it appears blueblack.

Endogenous Pigments cont

In

most cases of systemic hemosiderosis,

the pigment does not damage the
parenchymal cells or impair organ function.
The more severe cases eg. a disease called
hemochromatosis, it resulting in liver
fibrosis, heart failure, and diabetes mellitus

Pathologic Calcification
Pathologic

calcification is the abnormal

tissue deposition of calcium salts.
There are two forms of pathologic
calcification. When the deposition occurs
locally in dying tissues, it is known as
dystrophic calcification; it occurs despite
normal serum levels of calcium and in the
absence of derangements in calcium
metabolism.

Pathologic Calcification cont.

In

contrast, the deposition of calcium salts in

otherwise normal tissues is known as
metastatic calcification, and it almost always
results from hypercalcemia secondary to
some disturbance in calcium metabolism.

Dystrophic calcification
Seen

in areas of necrosis and/or damage

eg.in the atheromas of advanced
atherosclerosis or in aging or damaged heart
valves. Whatever the site of deposition, the
calcium salts appear macroscopically as fine,
white granules or clumps, often felt as gritty
deposits. Sometimes a tuberculous lymph
node is virtually converted to stone

Morphology.
Histologically,

calcium salts are basophilic,

amorphous granular. They can be
intracellular, extracellular, or both. In the
course of time, heterotopic bone may be
formed in the focus of calcification.
Progressive deposition on outer layers may
create lamellated configurations, called
psammoma bodies (papillary cancers).

Metastatic calcification
Occur in normal tissues whenever there is
hypercalcemia. There are four principal
causes of hypercalcemia:
1)increased secretion of parathyroid hormone
(PTH) with subsequent bone resorption, as in
hyperparathyroidism

Metastatic calcification cont.

2) destruction of bone tissue: Bone tumors
(e.g., multiple myeloma, leukemia) or
metastatic bone cancers, or immobilization;
3) vitamin D-related disorders, including
vitamin D intoxication.
4) renal failure, which causes retention of
phosphate, leading to secondary
hyperparathyroidism.

Amyloidosis

AMYLOIDOSIS
Amyloid

is a pathologic proteinaceous
substance, deposited between cells in
various tissues and organs of the body in a
wide variety of clinical settings.
Light microscope: amyloid appears as
amorphous, eosinophilic, hyaline,
extracellular substance that gradually
encroaches on and produces pressure
atrophy of adjacent cells.

AMYLOIDOSIS cont.
On

congo red stain: amyloid gives a pink or

red color under ordinary light and an apple
green birefringence under polarizing light.
There are three major and several minor
biochemical forms of amyloid.
Amyloidosis is not a single disease; rather it
is a group of diseases having in common the
deposition of similar-appearing proteins.

Physical Nature of Amyloid

By

electron microscopy, amyloid is seen to

be made up largely of nonbranching fibrils of
indefinite length This structure is identical in
all types of amyloidosis.
The fibers have characteristic cross-pleated sheets and are responsible for the
distinctive staining and birefringence of
Congo red-stained amyloid

Figure 6-53 Structure of an amyloid fibril, depicting the β-pleated sheet structure and binding sites for the Congo red dye, which is used for diagnosis of
amyloidosis. (Modified from Glenner GG: Amyloid deposit and amyloidosis. The β-fibrilloses. N Engl J Med 52:148, 1980. By permission of The New England
Journal of Medicine.)

Downloaded from: Robbins & Cotran Pathologic Basis of Disease (on 4 September 2005 02:13 PM)
2005 Elsevier

Chemical Nature of Amyloid

- Approximately 95% of the amyloid material
consists of fibril proteins, the remaining
- 5% is P component and other glycoproteins.
- 15 biochemically distinct forms of amyloid
proteins that have been identified.

Amyloidosis,
Most common Forms:
(1)

(2)

(3)

AL (amyloid light chain) is derived from

plasma cells and contains immunoglobulin
light chains
AA (amyloid-associated) is a unique
nonimmunoglobulin protein synthesized by
the liver
A amyloid is found in the cerebral lesion of
Alzheimer disease and is discussed in
greater detail in

Other biochemical forms of Amyloid

Transthyretin (TTR): is deposited familial amyloid

polyneuropathies and in the heart of aged individuals
(senile systemic amyloidosis).
2-microglobulin: seen in amyloidosis that occurs in
patients on long-term hemodialysis.
-amyloid protein (A), found in Alzheimer
disease.The A protein is derived from a
glycoprotein, called amyloid precursor protein.

Classification of Amyloidosis.

Amyloid may be classified based on its constituent

chemical fibrils into categories such as AL, AA, and
ATTR.
Amyloid may be systemic (generalized), or localized.
The systemic, or generalized, pattern is subclassified
into primary amyloidosis, when associated with B- cell
dyscrasias, or secondary amyloidosis, when it occurs
as a complication of an underlying chronic
inflammatory or tissue destructive process.
Hereditary or familial amyloidosis constitutes a
separate group.

Clinicopathologic
Category

Associated
Diseases

Major
Fibril
Protei
n

Chemically
Related
Precursor
Protein

Systemic (Generalized)
Amyloidosis
Immunocyte
dyscrasias with
amyloidosis (primary
amyloidosis)

Multiple myeloma
and other
monoclonal B-cell
proliferations

AL

Immunoglob
ulin light
chains,
chiefly type

Reactive systemic
amyloidosis
(secondary
amyloidosis)

Chronic
inflammatory
conditions

AA

SAA

Hemodialysisassociated
amyloidosis
Hereditary
amyloidosis

Chronic renal
failure

A2 m 2microglobuli
n

Familial
Mediterranean fever

AA

SAA

Familial amyloidotic
neuropathies
(several types)

ATTR

Transthyretin

Systemic senile
amyloidosis

ATTR

Transthyretin

Localized Amyloidosis
Senile cerebral

Alzheimer disease

APP

Medullary carcinoma
of thyroid

A Cal

Calcitonin

Islet of Langerhans

Type II diabetes

AIAPP

Islet amyloid
peptide

Isolated atrial
amyloidosis

AANF

Atrial natriuretic
factor

Prion diseases

Various prion diseases of

the CNS

Misfolded prion
protein (PrPsc)

Normal prion
protein PrP

Endocrine

Immunocyte Dyscrasias with Amyloidosis

(Primary Amyloidosis).

Usually systemic and is of AL type.

Is the most common form of amyloidosis. In most
cases, the patients have some form of plasma cell
dyscrasia eg. multiple myeloma or a plasma-cell
tumor.
The malignant B cells characteristically synthesize
abnormal amounts of a single specific
immunoglobulin (monoclonal gammopathy).
In addition the light chains (Bence Jones protein)
may be elevated.

Reactive/ Secondary Systemic

Amyloidosis.
The

amyloid deposition is systemic and is

composed of AA protein.
It is secondary to an associated inflammatory
condition like rheumatoid arthritis, ankylosing
spondylitis, and inflammatory bowel disease,
particularly Crohn disease and ulcerative
colitis. It may also occur in association with
tumors, like renal cell carcinoma and
Hodgkin disease.

Hemodialysis-Associated Amyloidosis
Patients

on long-term hemodialysis for renal

failure develop amyloidosis owing to
deposition of 2-microglobulin in the
synovium, joints, and tendon sheaths.

Heredofamilial Amyloidosis

Most of them are rare .

The most common is familial Mediterranean fever.
This is a febrile disorder of unknown cause
characterized by attacks of fever accompanied by
inflammation of serosal surfaces, including
peritoneum, pleura, and synovial membrane. The
amyloid fibril proteins are made up of AA.
Familial amyloidotic polyneuropathies: a familial
disorders characterized by deposition of amyloid in
peripheral and autonomic.The fibrils are made up of
mutant transthyretins (ATTR).

Localized Amyloidosis.

Sometimes, amyloid deposits are limited to a single

organ or tissue without involvement of any other site
in the body.
The deposits may produce grossly detectable
nodular masses or be evident only on microscopic
examination.
Nodular (tumor-forming) deposits of amyloid are
most often encountered in the lung, larynx, skin,
urinary bladder, tongue, and the region about the
eye.

Endocrine Amyloid
Microscopic

deposits of localized amyloid

may be found in certain endocrine tumors,
such as medullary carcinoma of the thyroid
gland, islet tumors of the pancreas,
pheochromocytomas, and undifferentiated
carcinomas of the stomach, and in the islets
of Langerhans in patients with type II
diabetes mellitus.

Amyloid of Aging

Several well-documented forms of amyloid

deposition occur with aging.
Senile systemic amyloidosis: systemic deposition of
amyloid in elderly patients(heart) was previously
called senile cardiac amyloidosis.
Those who are symptomatic present with a
restrictive cardiomyopathy and arrhythmias.
The amyloid in this form is composed of the normal
TTR molecule.

Pathogenesis
Amyloidosis

results from abnormal folding of

proteins, which are deposited as fibrils in
extracellular tissues and disrupt normal
function. Misfolded proteins are often
unstable and self-associate, ultimately
leading to the formation of fibrils that are
deposited in tissues.

Pathogenesis cont.
The

proteins that form amyloid fall into two

general categories:
(1) normal proteins that have an inherent
tendency to fold improperly and form fibrils,
and do so when they are produced in
increased amounts, and
(2) mutant proteins that are structurally unstable
and prone to misfolding and then form fibrils.

Morphology
Primary

amyloidosis cannot reliably be

distinguished from the secondary
amyloidosis but more often it involves the
heart, kidney, gastrointestinal tract,
peripheral nerves, skin, and tongue.
Secondary amyloidosis usually involves
kidneys, liver, spleen, lymph nodes, adrenals,
and thyroid as well as many other tissues

Morphology cont.
Macroscopically

the affected organs are

often enlarged and firm and have a waxy
appearance. If the deposits are sufficiently
large, painting the cut surface with iodine
imparts a yellow color that is transformed to
blue violet after application of sulfuric acid.

Morphology cont.
Histologic

diagnosis of amyloid is based on

its characteristic staining with dye Congo
red, which under ordinary light imparts a pink
or red color to amyloid deposits. Under
polarized light, the Congo red-stained
amyloid shows a green birefringence

Morphology in Kidney

1)

2)
3)

Most common organ involved. Histologically the

amyloid is deposited in the
Glomeruli: in the mesangial matrix, and basement
membranes of the glomerular capillaries. With
progression there is hyalinization of the glomeruli.
Peritubular region extending into interstitium.
Blood vessels: hyaline thickening of the arteriolar
wall and narrowing of lumen, eventually causing
ischemia with tubular atrophy and interstitial
fibrosis.

Morphology in Spleen

1)

2)

May cause splenomegaly. There are two

patterns of deposition.
Deposit is in the splenic follicles, producing
tapioca-like granules on gross inspection,
called sago spleen.
Deposit in splenic sinuses and connective
tissue of the red pulp. Fusion of deposits
gives rise to large, areas of amyloidosis,
designated the lardaceous spleen.

Morphology in Liver

May cause hepatomegaly.

The amyloid appears first in the space of Disse and
then progressively encroaches on adjacent hepatic
parenchymal cells and sinusoids.
In time due to pressure atrophy, there disappearance
of hepatocytes, causing replacement of large areas
of liver by amyloid. Vascular involvement and
deposits in Kupffer cell are frequent.

Morphology in Heart
May

be enlarged and firm. Histologically the

deposits are subendocardial and within the
myocardium between the muscle fibers.
Expansion of these myocardial deposits
eventually causes pressure atrophy of
myocardial fibers.
When they are subendocardial, the
conduction system may be damaged, causing
electrocardiographic abnormalities.

Clinical Correlation
. Amyloidosis may be found incidently with no
clinical manifestations, or it may cause death.
.The symptoms depend on the magnitude of the
deposits and on the organs affected.
. At first nonspecific symptoms such as
weakness, weight loss, light-headedness, or
syncope. Specific findings appear later and
most often relate to renal, cardiac, and
gastrointestinal involvement.

Clinical Correlation
Renal involvement: proteinuria, can cause of the
nephrotic syndrome. Progressive obliteration of
glomeruli in advanced cases leads to renal failure
and uremia
2) Cardiac amyloidosis: insidious congestive heart
failure. The most serious complications are
conduction disturbances and arrhythmias, which
may prove fatal.

1)

Clinical Correlation
3) Gastrointestinal amyloidosis: may be
asymptomatic. Amyloidosis of the tongue
may cause enlargement and hamper speech
and swallowing. Depositions in the stomach
and intestine may lead to malabsorption,
diarrhea, and disturbances in digestion.

Diagnosis

The diagnosis of amyloidosis depends on demonstration

of amyloid deposits in tissues.
The most common sites biopsied are the kidney or rectal
or gingival tissues in patients suspected of having
systemic amyloidosis.
In suspected cases of immunocyte-associated
amyloidosis, serum and urine protein electrophoresis and
immunoelectrophoresis should be performed. Bone
marrow aspirates often show plasmacytosis.
Scintigraphy with radiolabeled serum amyloid P
component is a rapid and specific test. It also gives a
measure of the extent of amyloidosis, and can be used to
follow patients undergoing treatment

Prognosis

The prognosis for patients with generalized amyloidosis

is poor especially those with immunocyte-derived
amyloidosis or with myeloma-associated amyloidosis.
Patients with reactive systemic amyloidosis have a
better prognosis and it depends to some extent on the
control of the underlying condition.
Resorption of amyloid after treatment of the associated
condition is a rare.
New therapeutic strategies aimed at correcting protein
misfolding and inhibiting fibrillogenesis are being
developed.