General Pathology

Cell Injury & Cell Death I

DR TEOH HOON KOON

DEPARTMENT OF PRE -CLINICAL SCIENCES, FMHS
Learning Outcome
1) Cellular response to stress and injury
2) Causes of cell injury
3) Reversible injury versus irreversible cell injury: Key morphological changes
4) Necrosis: Definition, types and mechanisms
5) Apoptosis: Definition, mechanisms, physiological role & comparison with
necrosis
Homeostasis
 Process of maintaining steady state in response to external changes
 Steady state: intracellular environment is maintained at fairly narrow range of physiologic
parameters
 Example: Regulation of body temperature to maintain internal value of around 37°C
 Other examples: acid-base balance, blood glucose concentration & fluid balance
Cellular Response
1) Physiological stress/pathologic stimuli cell adaptation

2) Adaptive capability exceeded/harmful cell injury

3) Injury is mild/brief reversible

4) Injury is severe/persistent irreversible cell death

Cellular Adaptation
 Reversible changes in number, size, phenotype, metabolic activity or function

 Physiologic adaptation: response to normal stimulation by hormone or endogenous

chemical mediators

 Example:

1) hormone – induced enlargement of the breast and uterus during pregnancy

2) Muscle getting bigger from lifting weight

 Pathologic adaptation: response to stress that allow cells to modulate
structure & function to prevent injury

 4 distinct forms:

1) Hypertrophy

2) Hyperplasia

3) Atrophy

4) Metaplasia
Hypertrophy
 Increase in size of cells enlarged organ

 Occurs in cells with limited proliferative capacity

 Cell number same but cell size bigger increased amounts of structural proteins
& organelles

 Can be physiologic or pathologic

 Example of physiologic hypertrophy: enlargement of uterus during pregnancy

Gross appearance: gravid (L) Normal uterus: small spindle-shaped smooth muscle
uterus vs normal uterus cells
(R) Gravid uterus: large, plump hypertrophied smooth
muscle cells
 Example of pathologic hypertrophy: enlargement of cardiac due to hypertension
or aortic valve disease

• Myocardial hypertrophy: thicker left

ventricular wall (> 2cm)
• Viable & functional
Hyperplasia
 Increase in cell number enlarged organ

 Occurs in cells with proliferative capacity

 Increased cell number due to proliferation of differentiated cells & replacement

by tissue stem cells

 Can be physiologic or pathologic

 Physiologic hyperplasia:
1) Hormonal hyperplasia: proliferation of glandular epithelium in breast during puberty
& pregnancy
2) Compensatory hyperplasia: restoration of resected liver

 Pathologic hyperplasia: mostly due to excessive hormone/growth factor stimulation

1) Disturbed balance between estrogen & progesterone endometrial hyperplasia
2) Proliferating fibroblasts and blood vessels during wound healing

 Hyperplastic process remains controlled & disappears if signal abates unlike cancer
 Hyperplasia can occur concurrently with hypertrophy
Atrophy
 Shrinkage in size of cells due to loss of cell substance
 Diminished function but survival is still possible
 Causes of atrophy:
1) Decreased workload e.g. limb immobilisation during fracture
2) Loss of innervation
3) Diminished blood supply
4) Nutritional deficiency
5) Loss of endocrine stimulation
6) Aging
 Mechanisms:
1) Decreased protein synthesis due to reduced metabolic activity
2) Increased protein degradation via ubiquitin-proteasome pathway
Normal brain Atrophied brain due to aging & reduced
blood supply
Metaplasia
 Replacement of one adult cell type (sensitive to the stress) by another adult cell
type (able to withstand the stress)

 Reversible change

 Reprogramming of stem cell to differentiate in new pathway

 Metaplastic change: may lead to malignant transformation

Epithelial metaplasia in respiratory epithelium
of habitual cigarette smoker
 Normal ciliated columnar epithelium
replaced by stratified squamous epithelium
 Survival advantage but lost important
protective mechanisms
Summary: Cellular adaptations to stress

Source: basicmedicalkey.com
Cell Injury
 Cell severely stressed cell adaptive capability exceeded cell injury
 Cells exposed to harmful agents or with intrinsic abnormalities cell injury
 Causes of cell injury:
1) Oxygen deprivation
2) Chemical agents
3) Infectious agents
4) Immunologic reactions
5) Genetic factors
6) Nutritional imbalances
7) Physical agents
8) Aging
Oxygen Deprivation
 Hypoxia (O2 deficiency): very important & common cause of cell injury/death
 Interferes with aerobic respiration
 Causes of hypoxia:
1) Ischaemia e.g. stroke
2) Inadequate oxygenation of the blood e.g. pneumonia
3) Reduction in oxygen-carrying capacity of blood e.g. anaemia
 Chemical Agents
 Toxins: severe cellular damage (membrane permeability, osmotic homeostasis,
enzymes & cofactors) death
 Other examples:
1) Environmental toxins: air pollutant, pesticides
2) Alcohol
3) Misused of therapeutic drugs
4) Excessive glucose, salt or water
Genetic Factors
 Genetic aberrations: congenital malformations e.g. Down syndrome, Angelman
syndrome or Turner syndrome
 Genetic mutations: Sickle cell anaemia, haemophila, Duchenne muscular dystrophy
or neurofibromatosis

Source: www.europeanpharmaceuticalreview.com Source: diabeticsweekly.com

 Genetic defects: deficiency in functional proteins, accumulation of damaged DNA or

misfolded proteins
 Examples: glycogen storage disease, lysosomal storage disease or phenylketonuria
 Nutritional Imbalances
 Nutritional deficiencies: major cause of cell injury
 Example:
1) Protein-calorie insufficiency
2) Vitamin deficiency
 Nutritional disorder: obesity or diabetes mellitus type 2
Infectious Agents
 Diverse ways that infectious pathogens (virus, bacteria or fungi) can cause injury

Immunologic Reactions
 Immune reaction can results in cell injury e.g. autoimmune reactions

Physical Agents
 Trauma, radiation, temperatures or atmospheric pressure can also cause cell injury

Aging
 Cellular senescence altered replicative & repair abilities diminished response
to injury cell death
 Onset of injury: rapid decline of cell
function, remains viable
 Irreversible stage: cell death occurs
 Cell death precedes ultrastructural,
light microscopic and gross
morphologic changes
Reversible Injury
 Cellular derangements can be corrected
 Cell returns to normalcy when injurious stimulus abates
 Intracellular characteristics:
1) Plasma membrane alterations e.g. blebbing, microvili
distortion
2) Mitochondrial changes e.g. swelling
3) Dilation of ER
4) Detachment of ribosomes
5) Chromatin clumping
6) Myelin figure (damaged cellular membranes)
Reversible Injury: Morphology
1) Cellular swelling
 Cells incapable of maintaining ionic &
fluid homeostasis and is the result of
failure of energy-dependent ion pumps in
the plasma membrane
 Microscopic: small, clear vacuoles in
cytoplasm. Represent distended or
pinched off ER segments
 Also known as hydropic change or
vacuolar degeneration
 Apparent at whole organ level: pallor, (A) Normal kidney tubules: viable epithelial cells
increased turgor or increased organ
weight (B) Reversible ischaemic injury: surface blebbing,
eosinophilia of cytoplasm & occasional cell
swelling
Reversible Injury: Morphology
2) Fatty change
 Occurs in hypoxic injury & various forms
of toxic or metabolic injury
 Appearance of lipid vacuoles in the
cytoplasm
 Cells involved in & dependent on fat
metabolism e.g. hepatocytes &
myocardial cells

Source: www.niehs.nih.gov
Irreversible Injury
 Persistent or excessive injury point of no return
 Culminate in cell death: necrosis or apoptosis
 Necrosis: lose of membrane integrity leakage of cellular contents
dissolution of cells
 Elicit inflammatory response to eliminate dead cells & start repair process
Necrosis: Morphology
 Increased eosinophilia in H & E stains
 Glassy, homogenous appearance due to loss
of glycogen particles
 Vacuolated cytoplasm
 Pyknosis karyorrhexis karyolysis
 More myelin figures: phagocytosed or form
fatty acids
 Calcification of such fatty acid residues
results: calcium soaps

Necrosis of epithelial cells: loss of

nuclei, cell fragmentation & leakage of
contents
 Necrosis: Ultrastructural Features

Normal kidney rabbit: abundant Early injury: microvilli lost; blebs Necrosis: markedly swollen
microvili (mv) lining the luminal have formed. Mitochondria mitochondria containing
(L) space. would have been swollen. electron-dense deposits,
expected to contain precipitated
calcium and proteins.
(A) Source: Dr. Brigitte Kaisslin, Institute of Anatomy, University of Zurich, Switzerland.
(B, C) Courtesy of Dr. M.A. Venkatachalam, University of Texas Health Sciences Center,
San Antonio, TX.
Patterns of Tissue Necrosis
 Necrotic tissue or organ: when large numbers of cells die
 Several morphologically distinct patterns,
 Important to recognise because they may provide clues about the underlying
cause
Coagulative Necrosis
 Underlying tissue architecture is preserved for several days
 Denatures structural proteins & enzymes blocking the proteolysis of dead cells
 Eosinophilic and anucleate cells up to days or weeks
 Leucocytes recruited to site to digest dead cells (lysosomal enzyme)
 Phagocytosis to remove cellular debris
 Example: infarcts in solid organs (except brain)
(A) Wedge-shaped kidney infarct (yellow)
(B) Normal kidney (N) and necrotic cells in the infarct (I) showing preserved
cellular outlines with loss of nuclei and an inflammatory infiltrate (which is
difficult to discern at this magnification)
Liquefactive Necrosis
 Seen in focal bacterial or occasionally fungal infections
 Accumulation of inflammatory cells enzymes from leucocytes digest
(liquefy) tissue
 Complete digestion liquid viscous mass phagocytosis
 If bacterial mediated: creamy yellow material - pus
Brain infarct with tissue dissolution
Necrotic area shows cystic space
with cell debris. Surrounding zone
shows granulation tissue.
Gangrenous Necrosis
 Not a specific pattern of cell death, more commonly used in clinical practice
 Limb (usually lower) lost blood supply necrosis (typically coagulative)
involving multiple layers of tissues
 Presence of bacterial infection modified to liquefactive (wet gangrene)
Caseous Necrosis
 Most often seen in foci of tuberculous (TB) infection
 Caseous (cheese like): friable white appearance of the area of necrosis
 Microscopically, necrotic area appears as:
1) Collection of fragmented or lysed cells
2) Amorphous granular debris enclosed within a distinctive inflammatory
border; characteristic of a focus of inflammation known as granuloma
Tuberculosis of the lung: large Eosinophilic, amorphous, granular
area of caseous necrosis material. Periphery shows
(yellow-white and cheesy granulomatous inflammation.
debris).
Fat Necrosis
 Focal areas of fat destruction typically from release of activated pancreatic lipases
into the substance of the pancreas and the peritoneal cavity
 Acute pancreatitis: pancreatic enzymes leak out of acinar cells and liquefy the
membranes of fat cells in the peritoneum
 The released lipases split the triglyceride esters contained within fat cells
Fatty acids combine with calcium to Foci of shadowy outlines of necrotic fat
produce grossly visible chalky-white cells, with basophilic calcium deposits,
areas (fat saponification). surrounded by an inflammatory reaction.
Fibrinoid Necrosis
 Special form of necrosis usually seen in immune reactions involving blood
vessels
 Typically occurs when complexes of antigens and antibodies are deposited in
the walls of arteries
 Deposits of these “immune complexes,” together with fibrin that has leaked
out of vessels, result in a bright pink and amorphous appearance in H&E
stains, called “fibrinoid” (fibrin-like)
The wall of the artery shows a circumferential bright pink
area of necrosis with inflammation (neutrophils with dark
nuclei).
Mechanism of Cell Injury
1) ATP depletion
2) Mitochondrial damage & dysfunction
3) Calcium influx
4) Oxidative stress
5) Membrane permeability defects
6) Damage to DNA & proteins
ATP Depletion
 With O2: oxidative phosphorylation of ADP
 Without O2: glycolytic pathway uses glucose from circulation or hydrolysis of
intracellular glycogen
 Required for all synthetic & degradative processes in cells
 Major cause of ATP depletion:
1) Reduced O2 and nutrients
2) Mitochondrial damage
3) Toxin e.g. cyanide
 Tissues with greater glycolytic capacity (liver) survive better than tissues with
limited glycolytic capacity (brain)
Mitochondrial damage & dysfunction
Calcium Influx
Oxidative Stress
Membrane Permeability Defects
Apoptosis
 Regulated mechanism of cell death
 Eliminate unwanted/irreparably damaged cells
with least possible host reaction
 Morphology:
1) Chromatin condensation & aggregation
2) Fragmentation to nucleosome-sized pieces
3) Cytoplasmic vacuolation
4) Apoptotic bodies
 Phagocytosed immediately without inflammatory
response
 Maybe histologically undetectable
Apoptosis in Physiologic Situations
 Normal phenomenon to remove unwanted cells & maintain constant cell number
 Example:
1) Embryogenesis: specific cell death at defined times during development
2) Involution of hormone-dependent tissue upon hormone ablation: endometrial cell
breakdown during menstruation, regression of lactating breasts post weaning
3) Cell loss in proliferating population: intestinal crypt cells to maintain cell number
4) Elimination of cells that have served their purpose: neutrophils & lymphocytes at the
end of immunologic response
5) Elimination of potentially harmful self-reactive lymphocytes before their maturation
6) Cell death by CTL: defence against virus-infected or neoplastic cells
Source: https://embryology.med.unsw.edu.au
Apoptosis in Pathologic Situations
 Eliminate genetically altered cells or cells injured beyond repair
 Without severe host reaction to keep tissue damage to minimum
 Example:
1) DNA damage due chemical/physical agents: Cells acquired mutations, eliminated to
avoid malignant transformation
2) Accumulation of misfolded proteins: Excessive amount will lead to ER stress
3) Cell injury in certain infections: virus infection e.g. HPV virus, EB virus
4) Atrophy in parenchymal organ due to duct obstruction e.g. pancreas, kidney
Mechanism of Apoptosis
 Feature Necrosis Apoptosis
Cell size Enlarged (swelling) Reduced (shrinkage)

Nucleus Pyknosis ➙ karyorrhexis ➙ Fragmentation into nucleosome-

karyolysis size fragments

Plasma membrane Disrupted Intact; altered structure,

especially orientation of lipids

Cellular contents Enzymatic digestion; may leak out Intact; may be released in
of cell apoptotic bodies

Adjacent inflammation Frequent No

Physiologic or pathologic role Invariably pathologic (culmination Often physiologic, means of

of irreversible cell injury) eliminating unwanted cells; may
be pathologic after some forms of
cell injury, especially DNA damage
Recap Learning Outcome
1) Cellular response to stress and injury
2) Causes of cell injury
3) Reversible injury versus irreversible cell injury: Key morphological changes
4) Necrosis: Definition, types and mechanisms
5) Apoptosis: Definition, mechanisms, physiological role & comparison with
necrosis
Reference
 Robbins Basic Pathology, Ninth Edition