ROBBINS NOTES: Aging and Radiation Self Study p. 54-56, and 185 (Aging) and p.

320-323, 226, and 231

Cellular Aging
1. Age is important risk factor for many diseases
A. Alzheimer
B. Cancer
C. Ischemic heart disease
2. Contributions to cellular aging not just cells “running out of steam”
A. Genes and signaling pathways also contribute to cellular aging
3. Overall= cellular aging is result of progressive decline in life span and cell functional activity

Contributors to Cellular Aging

1. Accum
ulation
of DNA

mutations metabolic insult to mitochondrial DNA, ROS accumulation (toxins, radiation exposure), decreased efficiency of DNA repair
mechanisms over time
Consequence compromise functional activity and cell survival
2. Decreased cellular replication fixed number of divisions leading to arrested/terminally non dividing states (Replicative Senescence)
Werner Syndrome= rare disease characterized by premature aging with reduced vitro life span are cells have less replication rounds
3. Mechanism of Replicative Senescence progressive telomere shortening
Telomere= short repeated DNA sequences to ensure complete chromosome replication some cut off w/ somatic replication
Telomerase= enzyme that adds nucleotides using own RNA as template to extend telomere length
Telomerase location in low level in stem cells but absent in most somatic cells
Cancer App reactivates telomerase to allow infinite proliferation
When shortened too much sensed in cell as broken DNA which signals cell cycle arrest
4. Diseases Associated with Abnormal telomere maintenance: Telomeropathies
Aplastic anemia
Cytopenias may be related to hematopoietic stem cell failure
Premature hair greying
Skin pigment/nail abnormalities
Pulm and liver fibrosis
5. Defective protein homeostasis decreased translation of proteins/defective
chaperone and proteasome function increases levels of misfolded proteins and can
trigger apoptosis; current attempts to find signaling pathways that affect aging
mechanisms
6. Persistent inflammation
Accumulation of damaged cells may activate inflammasome pathway
Released cytokines during inflammation may induce cellular alteration to
exacerbate aging
Can lead to chronic disease diabetes 2, atherosclerosis

Calorie Restriction and Decreasing Aging

1. Reduced activation of insulin-like growth factor receptor signaling
2. Reduced IGF-1 signaling lower rate of cell growth and metabolism and maybe
decrease DNA replication errors
3. Improve immunity also inhibits aging

Amyloid of Aging
1. Senile systemic amyloidosis systemic deposition of amyloid in elderly patients and
often involves the heart
2. Symptoms Restricted cardiomyopathy and arrhythmias
3. Amyloid derived from normal TTR (transthyretin)
Injury Produced By Ionizing Radiation
1. Radiation= Energy that travels in waves or high speed particles
2. Radiation can be ionizing or non-ionizing depending on if they are strong enough to displace elections from atoms can lead to electron collision
that leads to more electron displacement
Non-ionizing: UV, infrared, microwave, sound waves
Ionizing: x-rays and gamma rays main sources; electromagnetic waves of high frequency that dissipate energy
High energy neutrons, alpha particles (2 proton + 2 neutron), beta particles (like electrons)  cause high damage in small area
3. Human exposure to ionizing radiation CT, x-ray, other medical devices: double edge sword effect b/c radiation is mutagenic, carcinogenic, and
teratogenic
Terminology For Expressing Exposure/Absorption/Dose of Ionizing Radiation
1. Curie (Ci) disintegrations per second of spontaneously disintegrating radionuclide
(radioisotope)
2. Gray (Gy) energy absorbed by target tissue (per gram of tissue)
3. Sievert (Sv) equiv dose that depends on biologic rather than physical effects of radiation; way
to see bodily damage produced by a certain absorbed dose); determined by radiation type,
type/volume of tissue exposed, exposure duration, etc
4. Example: x-ray radiation 1 mSv= 1mGy
Determinants of Biologic Effects of Ionizing Radiation
1. Rate of delivery effect overall is cumulative to extent damage repair mechanisms are unable to
repair, but giving smaller doses can give cells time to repair some of the damage
2. Field size body can tolerate relatively high levels of radiation if it’s given in small specific fields
3. Cell proliferation  Rapidly dividing cells are more vulnerable to ionizing radiation b/c damage is
done to the DNA (DNA damage is more compatible with nondividing cells) cell damage can
lead to p53 upregulation can cause cell death
4. Hypoxia Ionizing radiation works via ROS production so if there is no oxygen, effect of
radiotherapy may be reduced
5. Vascular Damage endothelium is moderately sensitive to radiation and may narrow and
occlude blood vessels ischemia damage may appear months-years after exposure
DNA Damage and Carcinogenesis
1. DNA damage not completely repaired leads to mutation that can lead to cancer later on
2. Potential damage from ionizing radiation single/double strand breaks, crosslinks between DNA
and protein: DOUBLE STRAND BREAKS MOST IMPORTANT IN CANCER
3. Repair systems are linked to cell cycle regulation that can initiate signal transduction and p53
4. Double strand breaks may persist and lead to mutation and lead to improper cell cycle
checkpoints and allow cells with unstable genomes to survive and become tumors/cancer

Radiation Induced Fibrosis= common consequence of cancer radiotherapy (weeks/months) in irradiated

field
1. Occurs with the replacement of dead parenchymal cells with connective tissue forming
scars/adhesions
2. Vascular damage contributes to fibroblast activation which contributes to radiation induced
fibrosis
Cell Level Effects of Radiation
1. Nuclear swelling and condensation, apoptosis, cells with abnormal nuclear morphology may
persist for years
2. Cytoplasmic changes swelling, mitochondrial distortion, ER degeneration
3. Histology giant cell formation, nuclei changes, changes in mitotic figures creates similarity between cancer and post-irradiation tissues
4. Light microscopy vascular
change and interstitial fibrosis
prominent in irradiated tissue
5. Later damage can appear over
time or with higher doses

Radiation Effects on Organ Systems

Lymphlymphopenia (could regenerate), shrinking lymph nodes, spleen
Bone marrow Marrow aplasia b/c hematopoietic precursor damage, neutrophil counts
rise then fall , thrombocytopenia, anemia aplastic anemia possible if death to marrow
stem cells leading to failure of blood count recovery
Cancer Risk doses of 100mSv can cause cancer/ serious damage

Important DNA Repair Mechanisms in Preventing Cancer:

Mismatch repair, nucleotide excision repair, recombination repair
**Repair mechanisms are often implicated in sponatneous cancers and inherited
Robbins: Chapter 3 Inflammation and Repair (not in Pathoma)

Overview of Diseases Associated with Underlying Inflammation

Other diseases that may be associated with inflammation suggests that anti-
inflammatory drugs could have additional benefits
1. Type 2 Diabetes
2. Alzheimer
3. Cancer

Consequences of too Little Immune response infection risk

1. Most often caused by decreased leukocyte number associated
with bone marrow damage and/or immunosuppressants (bone
marrow is major site of lymphocyte maturation)

Inflammation Termination Process

1. Terminate when offending agent eliminated
2. Mediators are broken down and displaced
3. Leukocytes have short life span in tissue
4. Initiation of anti-inflammatory machanisms
5. Marks beginning of tissue repair process  cell regeneration and
scarring
6. Scarring= filling residual defects with connective tissue

Causes of Inflammation
1. Infection most common and medically important cause of inflammation
2. Tissue necrosis always elicits inflammation via release of factors from necrotic cells
3. Foreign bodies via tissue injury or microbes they carry; includes deposits that are
made by body (EX: urate crystals in gout, cholesterol crystal in atherosclerosis)
4. Immune Reactions (hypersensitivity) allergies or autoimmune conditions

Recognition of Microbes and Damaged Cells first step in inflammatory responses

1. Cell receptors for microbes TLRs located on plasma membranes and endosomes for
PAMP recognition and trigger production/expression of cytokines, membrane proteins
to promote lymphocyte activation
2. Sensors of cell damage cytosolic receptors for DAMPs (damage associated molecular
patterns) and activate inflammasome
DAMP examples: uric acid, ATP from damaged mitochondria, reduced K, DNA
released from nuclei
Inflammasome induce IL-1 production
3. Autoinflammatory Syndromes: gain of function syndrome of DAMP receptors that
causes spontaneous inflammation
4. Circulating Proteins complment system, mannose binding lectin for microbial sugars,
collectins

Acute Inflammation: Dialation of small vessels increase permeability of microvasculatureleukocyte emigration from microcirc to injury
1. Vascular Reactions goal to maximize movement of plasma proteins and leukocytes out of circ and into site of injury
Exudate: extravascular fluid with high protein and has cellular debris
Transudate: essentially blood plasma ultrafiltrate low protein/cell material due to osmotic/hydrostatic imbalances
Edema: excess fluid in interstitial tissue/serous cavities (exudate OR transudate)
Pus: purulent exudate is inflammatory exudate rich in leukocytes (esp. neutrophils), dead cell debris, and microbes
Transcytosis: increased transport of fluid/protein via endothelium that may be increased by VEGF/other factors
2. Changes in Vascular Flow and Caliber (vasodilation increased blood flow and slower blood flow)
A. Immediate transient vasoconstriction may occur
B. Main initial vasodilation mediator= histamine on vascular smooth muscle
C. Vasodilation arterioles first then new capillary beds nearby
D. Results of increased blood flow heat and erythema (redness) at inflammation site
E. AFTER Vasodilation increased microvasculature permeability and exudation to extravascular tissue
F. Vascular Congestion: Consequences of fluid loss from blood vessels increased RBC concentration in vessel and increased blood
viscosity increased stasis of blood leads to leukocyte (esp neutrophil) accumulation along vascular endothelium allowing for
more inflammatory mediator activation
3. Mechanisms of Increasing Vascular Permeability= Endothelial cell retraction and endothelial injury
A. IMMEDIATE TRANSIENT RESPONSE Rapid + Short lived Endothelial cell retraction (most common) via Histamine, Bradykinin,
Leukotriene targeting mainly the POST-CAPILLARY VENULES
 B. DELAYED PROLONGED RESPONSE:  endothelial injury leads to endothelial cell necrosis and detachment leakage is sustained
until damaged vessels are thrombosed/repaired
4. Lymph Vessel Response: increase flow too to help drain edema fluid, vessel proliferation (blood vessels do this too)
A. Inflammation lymphangitis (lymph vessels) and lymphadenitis
(lymph nodes) may occur secondarily
B. Lymphangitis can cause red streaks near skin wound which is a
clinical sign of infection in the wound; the streaks follow course
of lymph channels
C. Lymphadenitis usually due to increased cellularity during
infection

Leukocyte Recruitment to Sites of Inflammation: Main Leukocytes= Neutrophils (rapid) and Macrophages (slow) Adhesion + cytokine mediation
1. Macrophage vs Neutrophil Methods of Action (Neutrophil: first 6-24 hours) vs Macrophage (24-48 hours and can prolif in tissue)
Macrophage rely on new gene transcription for a SLOWER + LONG LIVED response including growth factors for repair
Neutrophils use cytoskeletal rearrangements and enzyme assembly for RAPID + TRANSIENT (last 24-48 hrs) response
Exception to pattern: Pseudomonas infection response dominated by neutrophils for several days
Viral infections lymphocytes (B/T cells) may arrive before leukocytes
Hypersensitivity reaction some mainly via lymphocytes
Allergic reactions eosinophils dominate
2. LEUKOCYTE ADHESION TO ENDOTHELIUM: Mediators= Selectins (leukocytes and endothelium) and Integrins (leukocyte)
A. Normal blood flow RBC move faster and more towards center than circulating leukocytes
B. Inflammation slowing blood flow and vasodilation lead to more white cells in more peripheral position near endothelium
(MIGRATION) to be better able to detect changes in endothelium adhesion molecule expression if cytokines/mediators sensed
C. Selectins receptor on leukocytes (L-selectin) and endothelium (E and P Selectin) that mediate initial weak interaction
E-Selectin expression increased via cytokine stim
P-Selectin normally in Weibel Palade bodies until His or Thrombin stim triggering dist to endothelium/platelet surface
Leukocyte: express L-selectin and ligands for E and P Selectin (sialic acid oligosaccharides bound to glycoprotein)
Cytokines: IL-1, TNF, etc stim E-selectin and ligand for L-selectin expression on endothelium slow down leukocytes
D. Integrins transmembrane 2-chain glycoprotein that mediate firm adhesion
Normal express on leukocyte plasma membrane in low affinity form until triggered by chemokines
Chemokine chemoattractant cytokines secreted at inflammation sites for display on endothelial surface
Integrin + Chemokine Interaction triggers integrin conformation change and clustering into high-affinity form
Cytokines TNF and IL-1 activate endothelial cells to increase expression of integrin ligands:
ICAM-1: binds LFA-1 and Mac-1 integrins
VCAM: binds VLA-4 integrin
Outcome leukocytes stop rolling and their integrins interact with endothelial ligands and signal for firm attachment
3. LEUKOCYTE MIGRATION THROUGH ENDOTHELIUM (does not injure vessel wall)
A. Transmigration=leukocytes squeezing between cells at intercellular junctions after firm adhesion to endothelium occurring mainly
at POST-CAPILLARY VENULES (site of maximal retraction of endothelial cells)
B. PECAM-1 (platelet endothelial cell adhesion molecule) in Ig superfamily expressed on leukocytes and endothelial cells mediate
binding events for transmigration
C. After transmigration leukocytes pierce basement membrane (likely
via secreting collagenases) and enter extravascular space
4. CHEMOTAXIS OF LEUKOCYTES: mediated by chemoattractants (includes endogenous
and exogenous substances)
A. Chemotaxis: leukocyte movement towards site of injury by following
chemical gradient (chemoattractants)
B. Chemoattractants: bacterial products (esp peptide with N-
formylmethionine terminus), Cytokine/chemokines, C5a complement,
Leukotriene B4 (and other products of lipoxygenase path of AA
metabolism)
C. Common Chemoattractant mechanisms GPCR binding on leukocyte
surface to induce actin polymerization towards leading edge of cell and
localization of myosin filaments at back; filopodia pull back of cell
towards extension direction
5. Pharm Application: Agents blocking TNF (major cytokine in leukocyte recruitment)
 A. Major therapy method for chronic inflammatory diseases (RA, psoriasis, some IBD)
B. Other methods leukocyte integrin antagonists
C. NOTE: these types of treatment can also lead to patient’s defense against microbes (trade-off) especially Mycobacterial infection
(intracellular microbe)
D. While TNF/IL-1 plays role in Sepsis, blocking these have no effect (probs b/c other cytokines can take over)

Phagocytosis and Clearance of the Offending Agent: LEUKOCYTE

ACTIVATION=leukocyte responses to recognition of microbes/dead
cells
1. Most important mechanisms for microbe/offender
destruction= PHAGOCYTOSIS and INTRACELLULAR KILLING
2. PHAGOCYTOSIS= Particle recognition + attachment
engulfment and form phagocytic vacuole kill/degrade ingested material
A. Recognition/attachment: Opsonization (via IgG, C3b, MBL) overall enhances binding via leukocyte receptor recognition
Mannose Receptor: on macrophage; binds terminal mannose/fucose residue on glycoprotein/glycolipid commonly found on
microbial cell wall (mammal glycoprotein/glycolipid has N-acetylgalactosamine or sialic acid instead so won’t be ingested)
Scavenger Receptor: bind LDL particles and various microbes
B. Engulfment: after particle is bound, Pseudopods (cytoplasm extension) flows around particle and plasma membrane pinches to
form Phagosome (cytosolic vesicle) encircling particle  phagosome fuses with lysosome to form Phagolysosome
C. NOTE: Engulfment process may release some granule contents to extracellular space and damage normal bystander cells
3. Intracellular Destruction of Microbes and Debris= via ROS, RNS, and Lysosomal enzymes final step to infectious agent/necrotic cell elimination
A. Location: mainly in lysosome to separate harmful substance form rest of cell but can be released extracellularly tissue damage
ROS Respiratory Burst
B. Respiratory Burst (neutrophils)via Phagocyte Oxidase (NADPH oxidase enzyme complex) (oxidizes NADPH NADP) forming
O2- (superoxide anion) within the phagolysosome
C. Phagocyte oxidase: has cytosolic protein components that migrate to phagosomal membrane to form complex upon activation
ROS H2O2-MPO Halide System= most efficient bactericidal system of neutrophils
D. H2O2: Formed mainly spontaneously from O2- via dismutation (redox at same time) and can only kill microbes when, in presence
of Cl- gets converted to hypochoorite OCL2- (bleach) by Myeloperoxidase (in azurophilic neutrophil granules)
E. Hypochlorite: destroy microbes via halogenation (covalent binding of halide to microbe) or protein/lipid oxidation
F. H2O2 can also be converted to OH that can cause destruction via modification of cell lipid proteins/nucleic acid
G. NOTE: MPO Deficiency actually has little effect b/c leukocytes have redundant microbicidal mechanisms
Chronic Granulomatous Disease= defect in generation of ROS susceptible to bacteria that are catalase positive b/c can utilize H2O2 for resp burst
4. Body’s Antioxidants help protect from ROS that can be released by leukocytes during inflammatory process
A. Superoxide Dismutase
B. Catalase (H2O2 detox)
C. Glutathione peroxidase (strong H2O2 detox prevent OH- radical formation
RNS Formation: peroxynitrite formation
5. Nitric Oxide (NO) soluble gas made from Arg via NOS (eNOS=endothelial, nNOS (neural), iNOS (inducible) iNOS involved in microbe killing
A. eNOS and nNOS always expressed to maintain vascular tone/neurotransmitter activity
B. iNOS express upon macrophage cytokine activation in macrophage, NO is made and reacts with O2- (superoxide) making
ONOO (peroxynitrite free radical) RNS formed and attacks lipid/protein/nucleic acid of microbe
C. NO also naturally helps with vasodilation (significance in inflammation response unclear)
6. Granule Enzymes and Other Proteins from Neutrophils and Monocytes  help engulf microbe/dead tissue but can also cause tissue damage
A. Actively secretory (distinct from lysosome killing mech)  Degranulation: extracellular release of granule contents
B. Neutrophil Granule Types NOTE: granules can also fuse with phagocytic vesicles during phagolysosome formation
Secondary: Small and Specific lysozyme, collagenase, gelatinase, lactoferrin, Pla, Histaminase, alk phosphatase
Primary: Larger and Azurophil MPO, bactericidal factors (defensins), acid hydrolases (enzymes that work in acidic
environment), other neutral proteases
C. Macrophage Contents: Acid hydrolases, collagenase, elastase, phospholipase, Pla (plasminogen activator)
D. Acid Proteases: degrade bacteria and debris within phagolysosome acidified by membraine proton pumps
E. Neutral Proteases: degrade extracellular components (collagen, basement membrane, fibrin, elastin) tissue destruction
F. Neutrophil elastase degrade bacteria virulence factors
7. Anti-proteases: naturally in serum/tissue fluid to prevent destructive effects of granule enzymes
Example: a2-anti-trypsin inhibits neutrophil elastase
 A2-anti-trypsin Deficiency leads to sustained action of leukocyte proteases causing over-inflammation/tissue damage
Overview of ROS and RNS Formation
Neutrophil Extracellular Traps (NETs)= extracellular fibrillar networks to concentrate
anti-microbial substances at infection site via fibril
entrapment of microbes1. 1. Produced by neutrophil in
response to bacteria/fungi/inflamm mediators
2. Contents= viscous mesh of nuclear chromatin bound to
granule proteins
3. NET formation: kills neutrophil (NETosis) b/c uses nuclear
contents but adds a non-phagocytic method of killing
microbes
4. NET histones/chromatin may be targeted in SLE

Leukocyte Mediated Tissue Injury: via granule release to extracellular space

Causes
1. Collateral damage in infection response
2. Inappropriate inflammation response autoimmune
3. Hyperreactivity allergy, drug reaction
Ways to cause extracellular granule release to extracellular space
1. Activation of leukocytes (normal if contained)
2. Frustrated Phagocytosis: Phagocytes encountering immune
complexes they can’t digest
3. Damage to phagolysosome membrane can be done by
ingested urate, silica crystals and cause release of contents

Other Functional Responses of Activated Leukocytes (especially macrophages)

1. Cytokine production amp OR limit inflammation reaction
2. Growth Factor production stim prolif of endothelial cells, fibroblasts, synthesis of
collagen/enzymes for connective tissue remodeling
3. Macrophage key role in orchestrating chronic inflammation esp after inflammation has
subsided
4. NOTE: T-lymphocyte Role Th17 releases IL-17 which induce chemokine secretion to
recruit more leukocytes
Th17 Deficiency: susceptible to fungal/bacterial infection and develop “cold abscess” b/c
lack warmth associated with proper acute inflammation
Termination of Acute Inflammatory Response
1. Natural decline over time neutrophil has short half life (apoptosis within hours-day or
two in tissue)
2. Triggering anti-inflammatory process through inflammation process itself TGF-B and IL-
10 , lipoxins

Mediators of Inflammation=most important are vasoactive amines, lipid products (PG, LTs),
cytokines/chemokines, complement components
1. Cell-Derived: rapid release from granules and are most important in tissue rxns to agents
2. De-novo synthesis: PG, LT, cytokines
3. Plasma-derived mediators (complement): most made in liver and need cleavage/activation
and are helpful for circulating microbes but can be recruited to tissue
4. Main producers= macrophage, dendritic cells, mast cells
Others endothelial cells, neutrophils, platelets
5. Most mediators are short lived via decay, enzyme inactivation, scavenging
6. One mediator can activate other mediators: amplification or counteracting effect

Vasoactive Amines: Histamine and Serotonin Early response

1. Stored as preformed molecules allowing rapid response
2. Histamine location: mast cell in connective tissue (most), basophils, platelets in blood
A. His release Degranulation via physical response, antibody binding,
anapylatoxins (C3a, C5a) that trigger signaling pathways, IL-1,8,
Neuropeptides (substance P)
B. His Function: arteriole dilation and venule increase in permeability main
mediator in transient increase vascular permeability (interendothelial gaps)
C. Bind H1 receptor on microvascular endothelial cells target of
Antihistamine drugs
D. Contracts some smooth muscle (not as potent as LT effect)
3. Serotonin: preformed vasoactive mediator in platelets and certain neuroendocrine cells
A. Main Function= neurotransmitter in GI and vasoconstriction (importance in
inflammation not known)
Arachidonic Acid Metabolites: Prostaglandins (PG) and Leukotriene (LT) Lipid Mediators
1. Arachidonic Acid on membrane phospholipids obtained via diet/conversion
of linoleic acid; release from membrane is stim by physical stim or via
mediators (C5a) via Phospholipase A2/others to be converted to eicosanoids
(bioactive mediators) which function via GPCR binding on target
2. Enzymes of AA Metabolism: Cyclooxygenases (COX) (make PG) and
Lipoxygenases (make LT and lipoxins)

3. Prostaglandins (PG): made via COX-1 and COX-2 MOST IMPORTANT= PGE2,
PGD2, PGF2a, PGI2, TXA2
A. Made in mast cell, macrophages, endothelial cells, etc
B. Involved in pathogenesis of pain/fever
C. Cox-1 made in
response to inflammatory stim/some always expressed for
homeostasis function
D. Cox-2 induced via inflammatory stim and inflammation
specific
E. Naming based on structural features (PGD,E,F,G,H)
and subscript indicating double bond numbers
F. PGD2 and PGE2: major for mast cell
PGE2: more widely dist; for vasodilation and
increase permeability of postcapillary venules
PGD2: same as PGE2 but also is neutrophil
chemoattractant
G. TXA2 (Thromboxane): platelets have TX synthase and used
for stim platelet aggregation and vasoconstriction for
thrombosis
H. PGI2 (Prostacyclin): synthase in vascular endothelium
for vasodilation and inhibition of platelet aggregation
Coronary/Cerebral Artery Thrombosis: associated with imbalance of TXA2 and
PGI2
I. PGE2: makes skin hypersensitive to painful stim and causes
fever during infection
Leukotrienes: made in leukocytes/mast cells via Lipoxygenase IMPORTANT: LTA4
LTB4, LTC4
1. Involved in vascular/smooth muscle reaction and Leukocyte recruitment
2. Synthesis first makes LTA4 which gives rise to LTB4 or LTC4
3. LTB4 made by neutrophil/some macrophage and is potent chemotactic agent/neutrophil activator helping aggregation/adhesion, ROS
generation, release of lysosomal enzymes
4. LTC4 made mainly in mast cells, metabolites are LTD4 and LTE4 and cause
strong vasoconstriction, bronchospasm, increased venule perm.
Lipoxins: made by Lipoxygenase Pathway SUPPRESS INFLAMMATION via leukocyte
recruitment INHIBITION
1. Inhibit neutrophil chemotaxis/adhesion
2. Synthesis is 2 component process: leukocytes/esp. neutrophils make
intermediates and platelets convert to lipoxin

PG and LK: Pharm Application inhibition of PG and LK to suppress inflammation

1. Cyclooxygenase Inhibitors: Aspirin/NSAIDs (ibuprofen) inhibit COX-1 and 2 for
pain/fever relief (block PG synthesis)
A. Aspirin causes irreversible inactivation
B. New Target COX-2 only b/c COX-1 has more broad effects
(especially in protecting gastric epithelium), HOWEVER, targeted
COX-2 inhibition may be pro-thrombotic b/c it may shift balance
towards COX-1 formation of TXA2
2. Lipoxygenase Inhibitors not affected by NSAIDs, drugs targeting Lipoxygenase
for asthma treatment
3. Corticosteroids: broad spectrum anti-inflammatory agent via reduction of
transcription of COX-2, phospholipase A2, Il-1, TNF-F, and iNOS
4. Leukotriene Receptor Antagonists: asthma treatment

Cytokines and Chemokines

Cytokine=proteins secreted by mainly activated lymphocytes/macrophages/dendritic
cells; endothelial/epithelial/connective tissue cells can also secrete
NOTE: growth factors acting on epithelial/mesenchymal cells are NOTE cytokines
1. TNF and IL-1: main cytokine made by activated macrophage/dendritic cell; help
leukocyte recruitment/adhesion and migration; TLR help induce expression
 Endothelial Activation: E/P selectin expression, pro-coagulation
Leukocyte Activation: TNF augment neutrophil response/general microbicidal activity, IL-1 activates collagen synthesis via
fibroblast, and prolif of synovial/mesenchymal cells, stim Th17
Acute Phase Response: systemic response
Cachexia: from sustained TNF
Bacteria: may utilize for SIRS (systemic response syndrome), sepsis
Chemokines: small proteins acting mainly as chemoattractants for specific leukocytes Act via GPCR signaling (usually overlapping ligand specificity)
4 Major Categories: based on Cysteine residue arrangement CXC,
CC, C chemokine, CX3C
1. CXC: one AA residue separates first two of 4 conserved
cysteines
A. Mainly act on neutrophils and is induced by
IL-1 and TNF mainly
B. EXAMPLE= IL-8 (aka CXCL-8)
C. Secreted by macrophage/endothelium to
activate neutrophil chemotaxis
2. C-C: first 2 conserved Cys are adjacent mainly
chemoattractant for monocyte, eosinophil, basophil
lymphocyte
A. MCP-1, CCL2 monocyte chamoattractants
B. Eotaxin (CCL11) selective for lymphocyte
recruitment
C. MIP-1a, CCL3 macrophage inflammatory
proteins
3. C chemokine: lack first and third conserved Cys
A. Lymphocyte specific lymphotactin (XCL1)
4. CX3C: 3 AA are between first two conserved Cys
promote strong adhesion between T cell and monocytes
A. Only known member is Fractakine (CX3CL1) 
Form 1: surface bound induced in endothelial cells via inflammatory cytokines
Form 2: soluble is derived from proteolysis of Form 1 and acts as chemoattract
HIV Application: CXCR4 and CCR5 are chemokine receptors that act as coreceptors for HIV glycoprotein and helps viral entry to cells
Chemokines in Acute inflammation: inflammatory chemokines
1. Leukocyte attachment to endothelium and chemoattractant
2. Sometimes called inflammatory chemokines
Chemokines and Maintenance of Tissue Architecture: homeostatic chemokines
1. Some are constitutively expressed by stromal cells
2. Organize dif cell types (T, B cells) to specific anatomic regions like spleen, lymph node, etc
Pharm App: chemokine suppressors have been difficult to make maybe due to functional redundancy

Other Cytokines in Acute Inflammation

1. IL-6: secreted by macrophages (activate acute phase proteins) IL-6 Antagonists are used to treat Rheumatoid Arthritis
2. IL-17: promote neutrophil recruitment IL-17 antagonists are used to treat psoriasis
3. Type 1 Interferons inhibit viral replication

Complement System soluble proteins and their membrane receptors (innate AND adaptive immunity function)
C3 cleavage C3 is most abundant component and
cleavage is most imp in complement activation (3
pathways: classical, alt, lectin)  MAKE C3 convertase
PATHWAYS
Classic via IgM/IgG
Alt via microbial surface molecules (endotoxin, LPS)
Lectin plasma MBL binds carbs on microbes to directly
activate C1
C3b: covalently binds target cell/molecule or binds other
C3b to form C5 convertase forming C5a and C5b C5b
leads to C6-C9 binding forming the MAC (has multiple C9
components)
COMPLEMENT REGULATORS: C1 inhibitor, DAF, CD59
C1 Inhibitor: block C1 activation (classical path)
C1 inhibitor deficiency HAE
DAF: prevent formation of C3 convertase
link to plasma membrane via GPI
CD59: inhibit MAC formation link to plasma
membrane via GPI
GPI anchor deficiency DAP/CD59 LOF PNH
Factor H Plasma Protein: another complement regulatory protein
1. Cofactor in C3 convertase proteolysis
 2. Factor H mutation Hemolytic uremic syndrome and wet macular degeneration of eye associations
Main Roles of Complement
1. Inflammation: ANAPHYLATOXINS C5a (some C4a and C3a) stim His release from mast cells increase vasc permeability and vasodilation, C5a
also used for chemotaxis (neutrophil, monocyte, eosinophil, basophils) and activation of lipoxygenase pathway in Arachidonic acid metab
2. Opsonization/Phagocytosis C3b and iC3b are opsonins when fixed to microbial cell walls (neutrophil/macrophage have receptors for these)
3. Cell Lysis MAC deposition makes holes in membrane important in killing Neisseria Bacteria MAC deficiency leads to susceptibility to
Neisseria Mengococci and gonococci

Other Mediators of Inflammation

1. Platelet Activating Factor (PAF): causes platelet aggregation, vasoconstriction,
bronchoconstriction, at low levels can cause some vasodilation and increased vascular
permeability Anti-PAF therapy has not been established
2. Products of Coagulation: Protease Activated Receptors (PARs) activated by thrombin
(fibrin clot formation protease) and expressed in leukocytes and can trigger platelet
aggregation during clot formation LINK BETWEEN CLOTTING AND INFLAMMATION
3. Kinins: vasoactive peptides made from kininogens that have been cleaved by kallikrein
implication in anaphylaxis
Bradykinin increase vascular permeability and contract smooth muscle,
dilate blood vessels and causes pain
Bradykinin inactivation quick via kininase enzyme
4. Neuropeptides: secrete by sensory nerve/leukocytes: Main= Substance P/ Neurokinin
Substance P: in nerve fibers of lungs and GI pain transmission, BP regulation, stim
hormone secretion, increase vasc permeability

Morphologic Patterns of Acute Inflammation

Hallmark: small blood vessel dilation and
extravascular leukocyte/fluid accumulation
Special Morphologic Patterns: depends on cause/severity of inflammation

1. Serous Inflammation: marked via exudation of cell-poor fluid to areas lined

by peritoneum, pleura, pericardium generally not via infection so leukocyte
poor fluid; fluid may be from plasma or irritated mesothelial cell secretions:
EFFUSION=fluid accumulation in body cavities consisting of transudates (Serous
Effusion)
Example: blistering from burn/viral infection

2. Fibrinous Inflammation: seen in inflammation of body cavity lining

(meninges, pericardium, pleura) via large vascular leaks or local
procoagulant stimulus producing a fibrinous exudate vascular leaks
cause leak of fibrinogen leading to fibrin formation in extracellular
space that may be cleared via fibrinolysis and macrophages but if not
removed in time leads to fibroblast ingrowth which causes scarring

Histo Fibrin is eosinophilic mesh

3. Purulent (Suppurative) Inflammation/Abscess: pus

production, high neutrophil in exudate along with edema and
necrotic cells mainly caused by Pyogenic (pus producing)
bacteria Example: Acute Appendicitis

Abscess: localized pus collection caused by suppuration or

tissue/organ/confined space from bacteria seeding; abscess
will have central region of necrotic leukocytes/tissue cells that
may become walled off from fibrosis/connective tissue
formation
 4. Ulcers: local defect/excavatinon of organ/tissue surface
via inflamed necrotic tissue shedding (only occurs near
skin/mucosa surface (mouth, GI mucosa or often in
lower extremity of people with circulation issues)
acute and chronic inflammation often occurs within

Examples: Peptic ulcers, diabetic ulcers in legs

Acute stage: intense PMN infiltration and vascular
dilation at defect margin
Chronic: fibroblast prolif at margins, scarring,
lymphocyte/macrophage/plasma cell accumulation
Outcomes of Acute Inflammation: 3 Typical outcomes (Complete resolution, Scarring/Fibrosis, Chronic Inflammation)
1. Complete Resolution: best case scenariorestoration of
site to normal that is more likely in short/limited injury with
little damage in first place in tissue that can regenerate;
process involves removal of cell debris/microbe via
macrophage and lymph reabs or edema fluid
2. Scar/Fibrosis: connective tissue replacement after
substantial tissue destruction/tissue that can’t regenerate
or serous cavity with too much fluid to clear creates mass
of fibrous tissue
3. Chronic Inflammation when acute response can’t be
resolved either via interference to healing process of
persistence of injurious agent

Chronic Inflammation: Response of prolonged duration of inflammation, tissue injury, and repair mechanisms all are happening at the same time that may
or may not occur after/with acute inflammation

Causes of Chronic Inflammation: Persistent infection, hypersensitivity, prolonged toxic exposure,

1. Persistent Infection: mycobacteria and certain virus/fungi/parasite may cause acute inflammation that evolves to chronic or evoke delayed-type
hypersensitivity that can cause granulomatous inflammation
2. Hypersensitivity: autoimmune diseases (Rheumatoid arthritis and MS), allergies these responses may have mix of acute and chronic
inflammation mechanisms and fibrosis may occur at later stages
3. Toxic exposures (endogenous or exogenous): Exogenous example particulate silica leads to silicosis (inflammatory lung disease) endogenous
example cholesterol/lipid deposition leading to Atherosclerosis

Morphologic Features of Chronic Inflammation            

1. Infiltration with mononuclear cells: macrophage, lymphocyte, plasma cells
2. Tissue Destruction: via persistence of offending agent OR inflammatory agent
3. Attempts at Healing: via connective tissue replacement via angiogenesis and fibrosis

Cell Mediators of Chronic Inflammation  Macrophage, Lymphocytes

1. Macrophages: dominant in most chronic inflammation via cytokine/growth factor secretion,
phagocytosis, activation of T-lymphocytes become dominant cell population in inflammation
rxn within 48 hrs
Development: via hematopoietic stem cells in bone marrow and from
embryonic yolk sac and fetal liver in early dev
Yolk Sac/Fetal Liver derivatives: give rise to tissue specific macrophages (Kupffer,
microglial, etc) that reside w/o inflammation needed and replenish via resident cell
proliferation
Monocytes (in circulation) release from bone marrow and differentiate
to macrophage (macrophage has much longer half life than monocyte)
Mononuclear phagocyte system
Kupffer cells (liver)
Sinus histiocytes (spleen/lymph nodes)
Microglial cells (CNS)
 Alveolar Macrophage (lungs)

2. Mechanisms of Macrophage Activation: Classical

and Alternative Pathways
Classical: induce w/ microbial/toxin engagement with TLR/sensors or T-cell signal (most
imp= IFN-y)  Classical system activates “M1 macrophages” that make NO and ROS,
upregulate lysosomal enzymes, and secrete cytokines to stim inflammation

Alternative: not induced by IFN-y; instead induced by Il-4, 13 and does not produce
macrophages that are specifically microbicidal activates “M2 macrophages” important
for tissue repair via growth factor secretion for angiogenesis, fibroblast activation, collagen
synthesis

Macrophage Propagation of Inflammatory Response

1. Secretion of mediators of inflammation (TNF, IL-1, chemokines) and eicosanoids
2. Display antigens to T-cells and response to T-cell signals (feedback loop)

NOTE: Macrophages also produce tissue destruction and are the reason why tissue destruction is
one of the hallmarks of chronic inflammation

Role of Lymphocytes

1.
CD4 T-Cells: promote inflammation via
secretion of cytokines
TH1 IFN-y to activate
macrophages via classical pathway
TH2 secrete IL4,5,13 to
recruit/activate eosinophils for
alternative pathway of macrophage
activation
TH17 secrete IL-17 to induce
secretion of chemokines that recruit
neutrophils
2. General Interactions
A. Lymphocytes and macrophages interact bidirectionally propagate chronic inflammation
(see image)
B. Common to see activated B lymphocytes and antibody producing plasma cells at sites of
chronic inflammation
C. Tertiary Lymphoid Organs: forms in some reactions where accumulation of lymphocytes, APCs, and plasma cells form lymphoid structure
that resembles follicles found in lymph nodes; exact role of this structure is unknown
Seen in Rheumatoid Arthritis synovium, Thyroid of Hashimoto thyroiditis, and Gastric mucosa of H. pylori infection
Other Cells in Chronic Inflammation
1. Eosinophils IgE mediated reactions; recruitment driven by adhesion molecules and chemokines from leukocytes and epithelial cells; contains
major basic protein that is highly cationic and toxic to parasites (also injures host epithelial cells)
2. Mast cells in acute and chronic inflammation; tissue residents; express FceRI receptor that binds Fc of IgE to trigger mediator release; role in
chronic inflammation via release of cytokines
3. Neutrophils presence can last months even though more associated with acute inflammation Acute on chronic inflammation (Osteomyelitis
is example; also associated with chronic damage induced by smoking)

Granulomatous Inflammation: form of chronic inflammation with collections of activated macrophages and often T-cells (which activate macrophages)
 1. Epithelioid cells: activated macrophages with abundant cytoplasm that resemble epithelial cells
2. Giant cells: multinucleate cells that are made from activated macrophages that fused
3. Purpose of granuloma formation: effort to contain offending agent that is hard to eradicate
4. Types of Granulomas= Immune and Foreign Body
A. Immune: stim by inciting agent that
is hard to eradicate and activate T
cells and perpetuate (IL-12 and IFN-y)
B. Foreign Body: doesn’t involve T-cell
mediated immune response;
epithelioid cells and giant cells
appose to surface of foreign body
5. Associated Diseases
A. Associated Microbes M.
tuberculosis, Treponema pallidum, or
fungi
B. Crohn’s disease chronic granuloma
formation due to T cell derived
cytokines
C. Sarcoidosis
D. TB commonly associated and need to exclude TB first when you see granulomas in patient

Systemic Effects of Inflammation

1. Acute phase response: cytokine induced systemic reactions associated with inflammation important mediators= TNF, IL-1, 6, some type 1 INF
2. Fever: prominent in acute phase response induced by pyrogens
Common mech: prostaglandin mediation influencing hypothalamus setting of temp (via arachidonic acid mechanisms)
3. Acute Phase proteins: plasma proteins mainly made in liver; production stim via cytokines
A. CRP: bind microbial cell walls; opsonin; elevated CRP is used as marker of MI risk (thought to have inflammatory connection)
B. Fibrinogen: binds RBCs and cause them to form stacks (rouleaux) that sediment more rapidly  sedimentation rate increase
C. Serum Amyloid A: bind microbial cell walls; opsonin; SAA can also form amyloids (secondary amyloidosis)
D. Hepcidin: iron regulating peptide reduces iron levels that can cause anemia in chronic inflammation
4. Leukocytosis: very common in bacterial infections: initially occurs via accelerated release from bone marrow pool (more immature neutrophil
LEFT shift) and if infection is prolonged, stim of precursors via colony stimulating factors
A. Leukemoid Reaction: extreme elevation of leukocyte levels
B. Neutrophilia: increase in blood neutrophil count
C. Eosionphilia: seen in allergies/parasitic infections
D. NOTE: some diseases are associated with Leukopenia (decrease in leukocytes) Rickettsiae and certain protozoa
5. Other Features: tachycardia, hypertension, decreased sweating, shivering and chills, anorexia, malaise

Sepsis: can occur when there is large amount of bacteria in blood that
stimulates large quantities of cytokines
Septic shock Triad of symptoms: DIC, hypotensive shock, and metabolic
disturbances (insulin resistance, hyperglycemia)

SIRS: “systemic inflammatory response syndrome” similar to septic

shock and can occur as complication of noninfectious disorders
(burns, trauma, pancreatitis)

Tissue Repair
1. General Reactions= regeneration via prolif eration or deposition of connective tissue
to form scar

Regeneration: prolif of cells that survive injury (need stem cells)

Scar Formation: connective tissue deposition for tissue unable to regenerate

formation of fibrotic scar; organization refers to fibrous development in tissue space
occupied by an inflammatory exudate
Regeneration
1. Cell proliferation remnants of injured tissue, vascular endothelial cells (bring
in more nutrients), and fibroblasts (use fibrous scar to fill in anything that can’t
regenerate)
2. Dependent on type of tissue damaged: labile (best at regenerating) stable
permanent (can’t regenerate)
3. ECM Role: binds growth factors needed to signal cell prolif/growth
4. Growth factors: made by cells near damage usually, esp activated
macrophages, epithelial cells, and stromal cells  stim expression of genes
that help drive cells through cell cycle and support biosynthesis of
organelles/molecules for division

Specific Regeneration Mechanisms

1. Epithelial of GI and Skin: rapid prolif of residual cells stim by tissue stem cells as
long as basement membrane intact; residual cells can produce growth factors
for process
2. Parenchymal organs: generally limited except for the liver that can regenerate;
other organs with some regenerative capacity= pancreas, adrenal, thyroid, lung
3. Liver Regeneration: proliferation of remaining hepatocytes and repopulation from progenitor cells can correct up to a 90% liver resection
A. Hepatocyte proliferation: Process is driven by IL-6 (and other cytokines) made by Kupffer cells and hepatocyte growth factor (HGF)
B. Progenitor cell regeneration: if prolif capacity of hepatocyte impaired; some reside in Canals of Herring unclear what signals
stimulate this process

Repair By Scarring: General Steps

1. Homeostatic plug formation: provide scaffold for inflammation
2. Inflammation: M2 macrophages produce growth factors to stim prolif of cells
3. Cell proliferation: up to 10 day process Epithelial cells to cover wound, Angiogenesis, Fibroblast to lay down collagen fibers
4. Granulation tissue formed tissue type unique to wound healing
5. Remodeling: produce stable scar (2-3 weeks after injury)

Scarring
1. Healing by first intention (primary union): epithelial regeneration with minimal scarring
2. Healing by second intention (secondary union): larger wounds that heal via combo of regeneration and scarring

Angiogenesis: Steps
1. Vasodilation (NO) and increased permeability (VEGF)
2. Separation of pericytes and breakdown of basement membrane space for vessel sprout
3. Migration of endothelial cells towards injury and proliferation behind the “tip” of migrating cells
4. Remodeling into capillary tubes
5. Recruitment of periendothelial cells (pericytes for small capillaries and smooth muscle cells for larger vessels) to form mature vessel
6. Suppression of endothelial proliferation and migration and deposition of basement membrane to prevent overgrowth
Morphology: Granulation Tissue and Scarring

Angiogenesis: Growth factors/Signaling Proteins

1. Growth Factors
A. VEGF (VEGF-A) stim endothelial cell migration/prolif, NO production
B. FGF (FGF-2) stim endothelial cell prolif and migration
C. PDGF  recruit smooth muscle cell
D. TGF B suppress endothelial prolif/migration and enhance ECM protein
production
2. Signaling
A. NOTCH: cross talk with VEGF to regulate new vessel sprouting
B. ECM proteins: interaction with integrin receptors; scaffold for vessel growth
C. Matrix Metalloproteinases (MMP): degrade ECM to make space for
remodeling

Laying Down of Fibroblasts/Connective Tissue Deposition

1. General Steps= migration/prolif of fibroblasts and deposition of ECM proteins made by
fibroblasts
2. Cytokines/growth factors= PDGF, FGF2, TGFB from M2 macrophages mainly TGF-B is
most important
NOTE: TGF-B levels is mainly regulated by rate of secretion of active molecule not by transcription rate
Microfibrils in fibrillin can regulate TGF-B bioavilability
Glucocortocoids can decrease TGF-B levels and impair healing process
3. Fibroblast action
A. Enter cells via edge and migrate towards center
B. Can differentiate to myofibroblasts that contain actin to contract wound
4. Over time, scar becomes avascular during maturation process
Remodeling of Connective Tissue: increase strength and contract scar
1. Cross link collagen and increase size of collagen fibers and switch from type 3 to 1 to increase
strength
2. Myofibroblasts cause wound contraction initially
3. Scar shrinking: degrade connective tissue, degrade collagen/ECM components via matrix
metalloproteases
4. Balance between MMP and TIMP (tissue inhibitor of metalloproteinases)
Abnormal Wound Healing
1. Chronic Wounds= Venous leg ulcers (in elderly, hemosiderin common, venous hypertension
esp in legs), Arterial ulcers (atherosclerosis), Pressure sores, Diabetic ulcers (mainly lower
extremities appear as epithelial ulceration on histo with extensive granulation tissue under
dermis
2. Wound rupture after surger not common but seen more in abdominal surgery
3. Excessive Scarring hypertrophic scars and keloids
Hypertrophic scar: excessive collagen leading to raised scar but generally regresses over time
Keloid: scar beyond original wound and does not regress (may have genetic link)
4. Exuberant granulation: formation of excessive granulation tissue that may need to be removed via cautera/surgery
5. Desmoids/aggressive fibromatoses: excessive prolif of fibriblast/connective tissue elements (grey zone between benign and malignant tumor)
6. Contracture= excessive contraction seen more in burn, palms, soles, anterior thorax
Fibrosis of Parenchymal Organs
1. Abnormal deposition of collagen in internal organs in chronic disease
2. Can be due to chronic infectious/immune response and is associated with loss of tissue
3. Major cytokine= TGF-B increase in activity (may be triggered by cell death and ROS)
4. Main source of collagen=myofibroblasts (stellate cells mainly in liver cirrhosis)
More Inflammation Robbins Readings: 121-134, 134-145, 168-182

Ch. 5: Diseases of the Immune System

General Aspects of Normal Immunity

1. Immune system and immune response generally refer to adaptive immunity

Innate Immunity: signals are recognized via pattern recognition receptors on plasma
(external pathogen)/endosomal membranes (intracellular, often viral) and cause either
Inflammation or Anti-viral defense and work with adaptive immunity mechanisms
A. Signals associated with damaged tissue= DAMPs
B. Signals associated with pathogen= PAMPs
C. Other recognized bacterial signals= N-formylmethionyl residues, mannose
Innate Immunity Receptor Types: TLR, NOD, CLR, RIG-I
D. NOD-like receptors (NLRs) recognize diverse variety of substances and
some signal via inflammasome complex to activate caspase-1 to cleave IL-
1 to active form
Autoinflammatory Syndromes: periodic fever syndromes associated with overactive NOD
respond well to IL-1 antagonists signifying IL-1 associated mechanism of NOD
Gout Association: NLRs recognize urate crystals and stim inflammation
E. CLRs= C-type lectin receptors on macrophage plasma membrane and
DCs to detect fungal glycans
F. RIG-I and Cytosolic DNA sensors: sensors of microbial RNA/DNA
Adaptive Immunity
1. Humoral Antibody mediated via B cell production
2. Cell-mediated T-cell action (cytotoxic or phagocyte activation)

Cells and Tissues of Immune System

Lymphocytes
1. Each T or B lymphocyte expresses a single antigen receptor;
diversity via lymphocyte maturation
2. Antibodies=antigen receptors expressed on B-cells
3. T-cell receptors are the counterpart to the antibodies
4. Clonal selection: when foreign antigens bind to and activate
lymphocytes
5. Naïve lymphocytes: express antigen receptors but haven’t
reacted to an antigen yet
6. Effector Lymphocytes: induced via lymphocyte activation
and function to eliminate microbes
7. Memory lymphocytes: also induced via activation but are
functionally silent to respond rapidly in the future

T-Lymphocytes
1. Help B-cells make antibodies
2. Location: splenic periarteriolar sheath and lymph node interfollicular zone, circulation
 3. Receptor complex: TCR, CD3 complex (y, d, e proteins) and 2 ζ Chains TCR binds antigens, CD3 help with signal activation
4. Other molecules expressed on T-cells
CD4: bind invariant portion of MHC 2 molecules Helper T cells which secrete cytokines to help B cells produce Abs and macrophages
CD8: binding to invariant portion of MHC 1 molecules cytotoxic T lymphocyte (CTL) which function more for directly killing virus
infected cell
Co-stimulators: other invariant proteins on T-cells
CD28: receptor for costimulatory molecules
Costimulators are induced on APCs by microbes and adhesion molecules to strengthen bond between T-cell and APCs
Treg: suppresses the immune response
5. Most T cells have TCRs composed of a and b chains, and a minority have yd chains
The yd TCR T-cells are mainly in mucosal surfaces and don’t express CD4 or 8 and recognize non-protein molecules (don’t need MHC)
6. NKT Cells: small population of T cells that express marker for T and NK cells recognize microbial glycolipids (Don’t need MHC)

MHC Molecules: Major Histocompatibility Complex Molecules

1. MHC restriction: in each person, a person’s T-cells only recognize peptides displayed by their own MHC molecules
2. HLA= human leukocyte antigen (human MHC) on a cluster of genes on chromosome 6
3. Class 1 MHC: express on loci HLA-A, B, C
Composition: polymorphic a chain noncovalently associated with invariant B2 microglobulin peptide
Antigen binding on extracellular portion of alpha chain with polymorphic residues and a conserved region to bind CD8+ T cells
4. Class 2 MHC: express on loci HLA-DP, DQ, DR
Composition: heterodimer of non-covalently linked a and b subunits
Expressed on APCs (dendritic, macrophage, B cells)
Antigen binding: extracellular portion has cleft for antigen and CD4 binding
5. Other proteins encoded on MHC locus: C2, C3 and Factor B for complement system and TNF and lymphotoxin cytokines
6. Each person expresses only one set of HLA genes polymorphism for great diversity
7. HLA haplotype: refers to each set of maternal and paternal HLA genes (inheritance “en bloc” that act like single locus)
Important to match when doing transplantation
Only identical twins can accept grafts without fear of transplantation rejection
Minor histocompatibility loci lead to risk of matched sibling donors still causing transplant rejection
B-Lymphocytes (Bone-marrow derived lymphocytes)
1. B-cell= mediator of humoral immunity and cells that produce antibodies
2. Recognize antigen via membrane-bound antibody of IgM class expressed on surface with signal molecules to form BCR complex
3. Can respond to soluble and cell associated proteins, lipids, polysaccharides, etc
4. Associated Molecules
CD21: complement receptor (AKA CR2) to recognize complement breakdown products which promotes B-cell activation
EBV: utilizes CD21 for infecting B cells
5. B cells can differentiate to plasma cells to release antibodies IgG, M, A (more than 95% circulating antibodies), IgE, D

NK Cells and Innate Lymphoid Cells

1. NK cells: arise from same lymphoid progenitor that gives rise to T and B cells but work for innate immunity don’t need activation
2. NK cells only have 2 receptor types: inhibitory and activating (basal inhibitory state)
Inhibitory recognize self MHC 1
Activating recognize molecules expresses/upregulated during stress (infection related to downreg of MHC 1)
Secretes: IFN-y to activate macrophages
3. Innate Lymphoid Cells lymphocytes that lack TCR but make cytokines similar to T-cells
Th1 IFN-y, TH2 IL-5, TH17 IL-17
Antigen Presenting Cells
1. Dendritic Cells capture antigens; called Langerhans cells in the epidermis, express many receptor to capture microbes (TLR, C lectin)
Express high levels of MHC/other molecules needed for antigen presentation/activation of T cells
2. Plasmacytoid DCs subset of DCs that resemble plasma cells major sources of anti-viral cytokine Type 1 interferon
3. Follicular dendritic cells: in germinal center contain Fc receptors for IgG and receptors for C3b to trap antigen/complement and promote
antibody responses (don’t display antigen to T-cells)
4. Other APCs: macrophages, B-cells present to helper T
Lymphoid Tissues: Generative (primary/central) lymphoid or Peripheral (secondary) lymphoid organs
1. Generative Lymph Organs: Thymus and bone marrow
2. Peripheral Lymph Organs:
A. Lymph node: located along lymph channels with resident APC to sample antigen and receive antigens being transported  B cells
concentrate in follicles and T cells in parafollicular cortex activated T and B cells can migrate and meet
Folliclehas FDC to activate B cells
Paracortex has DCs to present antigen to T-cells
B. Spleen: blood enters via sinusoids to allow trapping of bloodborne antigens via resident DCs/macrophages T cells concentrate in
periarteriolar lymph sheaths around small arterioles and B cells in follicles
C. Cutaneous/mucosal lymph system: pharyngeal tonsils, Peyers patch, other systems scattered in skin/GI and contain large number
of lymphocytes
Cytokines
1. Interleukins= molecularly defined cytokines (most have local effects; IL-1 has systemic effect)
2. Innate response TNF, IL-1, 12, IFNs, IFN-Y, chemokines
3. Adaptive response IL-2, 4,5,17, IFN-y
 4. Termination of immune response TGF-B, IL-10
5. Colony stimulating factors (stim hematopoiesis in bone marrow) made by marrow stromal cells  GM-CSF and IL-17

Overview of Lymphocyte Activation and Adaptive Immune Responses

Steps:
1. Antigen recognition utilized in vaccine dev where adjuvant (microbial mimic) stimulates innate immune is added to antigen
T-cell co-stimulator= B7 (CD80 and 86) on APC binding to CD28 on T cell
NOTE: necrotic cells can express substances (DAMPs) that act as co-stimulatory signals and trigger immune response
2. Activation and proliferation
A. T-cell: CD4+ T to release of IL-2 cytokine and receptors to increase T cell proliferation is early response and express CD40L to stim
macrophages/B cells; other T cells= TH1, TH2, TH17(neutrophil recruitment)
B. Macrophage activation: Classical via TH1 (IFN-y and CD40 role) and alternative via TH2 (IL-13 also induce mucus secretion)
C. CD8 Cytotoxic Mechanism: perforin-granzyme system stored in granules to stim apoptosis
D. B-cell activation= T-cell independent and dependent mechanisms; in general heavy chain determines class and antibody function
3. Differentiation of specific lymphocytes to effector and memory cells
4. Antigen elimination and decline of immune response apoptosis of effector lymphocytes, memory cells can last years for next infection
response
Overview of Immune Components and Activation Mechanisms

Hypersensitivity: Immunologically Mediated Tissue Injury

Causes of Hypersensitivity Reactions: common mediators= antibodies, effector T-cells improperly triggered
1. Autoimmunity reactions against self antigens failure of self tolerance
2. Excessive reactions against microbes immune complex formation/deposition can trigger inflammation, persistent T-cell response, cross
reactivity between microbe and host tissue, harm in process of getting rid of pathogen
3. Reactions against environmental antigens
4. NOTE: inflammation is commonly seen in these types of diseases, so sometimes called immune mediated inflammatory diseases

Classification of Hypersensitivity Reactions: classify via mechanism of immune injury

Type 1 Allergy (rapid response) = immediate and late phase reactions

1. Injury caused by TH2, IgE, mast cells
 2. General process= TH2 interaction with allergen and induction of IL-4,5,13 (esp IL-4 which increases IgE), with the IgE made on first exposure, IgE
on mast cells can trigger immediate reaction via IgE crosslinking when interacting with the allergen again (repeated exposure); Th2 also secretes
eotaxin chemokine to recruit eosinophils to area
3. Mast cell sensitization: FceRI receptor has high affinity for IgE heavy chain allow for rapid response on repeat exposures (basophils and
eosinophils also express these receptors but play lesser role in this response)
4. Mast cell general mediators
A. Vasoactive amines: Histamine (main), chemotactic factors, neutral proteases, kinins, acidic proteoglycans
B. Lipid Mediators: PGs, LTs (arachidonic acid pathways) PGD2 mainly and causes bronchospasm, increase mucus; LTC4 and LTD4
are vasoactive and spasmogenic agents (very active), LTB4 is chemotactic
C. Cytokines: for late-phase rxn (TNF, IL4,5)
5. Development of Allergies (mainly genetic)
A. Atopy= propensity to develop immediate hypersensitivity reaction  usually have higher IgE and Th2 cells that make IL-4
B. Environmental exposures during life
C. Infection may trigger other allergic responses
D. NOTE: hypersensitivity may not be Th2/IgE mediated people may have sensitive mast cells to random stimuli
6. Immediate and Late Phase Responses could be anaphylactic if effect is systemic
A. Immediate: mast granule and vasodilation/leakage, and smooth muscle spasm within 5-30 minutes
B. Late phase: 2-8 hours and can last days; neutrophil, eosinophil, Th2
Overview of Type 1 Hypersensitivity

Type 2 Antibody Mediated

1. I
g
G

and IgM bind tissue/cell surface antigens

2. Antibodies cause disease when they target cells that ends up having a negative effect on body
3. Mechanism: generally Abs are high affinity that activate complement and bind Fc receptors of phagocytes
4. Phagocytes have receptors for Fc tails of IgG and C3b (opsonins); most opsonized cells are destroyed at spleen (splenectomy is possible tx for
certain Type 2 mediated diseases)
5. Common situations associated: Transfusion reaction, hemolytic disease (erythroblastosis fetalis) where anti-RBC IgG from mom passes,
autoimmune hemolytic anemia, agranulocytosis, thrombocytopenia, certain drug reactions
6. Inflammation
A. Complement activation can recruit neutrophils/monocytes to trigger inflammation
B. Leukocytes can be activated by Fc
 C. Antibody mediated inflammation causes tissue injury  glomerulonephritis, organ rejection, etc
7. Antibody mediated cellular dysfunction
A. Ab may impair host protein/function without directly causing cell injury/inflammation  Myasthenia gravis impairs receptor, G
raves disease (over stim of receptor)
Type 3 Immune complex mediated
1. IgG and IgM form antigen-antibody complexes that deposit in vascular beds and cause inflammation causing tissue damage
2. In-situ immune complex: less common but occur when immune complex forms in areas where antigen previous was
3. Tend to cause systematic disease  common organ targets are kidney (glomerulonephritis), joints (arthritis), small blood vessels (vasculitis)
4. Acute Serum Sickness: systemic; less common now because way antibodies are donated to people is refined; seen more in people that receive
antibodies from different species; chronic form can occur from prolonged exposure (SLE is example)
5. Stages: Formation of immune complex deposition of immune complex (Tend to go to areas where high amonuts of blood is filtered)
6. Inflammation and Tissue injury deposition can trigger inflammation rxn via complement activation and Fc engagement
A. Symptoms= fever, urticaria, joint pain, lymph node enlargement, proteinuria about 10 days after antigen administration
B. Histologic Feature: Acute vasculitis and firbrinoid necrosis with intense neutrophilic infiltration  may appear as granular deposits
of immunoglobulin/complement on immunofluorescence or electron dense regions on electron microscopy
7. Arthus Reaction= local immune complex that appears as area of tissue necrosis from acute immune complex vasculitis  can trigger by injecting
antigen from animal with preformed antibody

Summary of Type2/3 Hypersensitivity

Type 4 T cell-mediated “delayed-type hypersensitivity”

1. Th1 and Th17 mainly making cytokines that induce
inflammation/neutrophils/macrophages T-cell mediated response
2. Reaction generally within 24-48 hours (not immediate)
3. Th1 are the main effector cells in the reaction secrete IFN-y which activates M1
macrophages; Th17 aids in cytokine secretion and neutrophil recruitment
4. Clinical Example Tuberculin Reaction (PPD test): inject purified protein tuberculin (in
TB)
5. Morphological sign: accumulation of CD4+ T cell and macrophages around venule s
causing perivascular “cuffing”
6. Granulomatous inflammation: can occur if rxn prolonged with macrophages replacing
CD4 T cell infiltrate areas leading to epithelioid cell formation
7. Contact Dermatitis: common associated tissue injury seen in poison ivy contact, poison
oak; thought to be due to environmental factors modifying self proteins that become
recognized by T-cells as foreign and elicit reaction; also seen in drug reactions

Graft Rejection CD8 T-Cell Cytotoxicity

1. CTL against cell surfact histocompatibility
antigens play important role in Graft Rejection
2. Can cause reaction similar to type 4
hypersensitivity Reactions
Ch. 5 Immunodeficiency Syndromes (p. 168-182)

Primary (Inherited) Immunodeficiencies: SCID, X-linked agammaglobulinemia, DiGeroge, Hyper IgM, Common variable, IgA deficiency

1. Usually detected between 6 months-2 years of age

2. General sign= infection susceptibility

SCID= severe combined immunodeficiency

1. Many diseases that lead to impaired development of mature T lymphocytes
and/or B causing defect in BOTH humoral + cell-mediated immunity (generally a
T cell issue that secondarily impairs B cells)
2. Signs= diaper rash, oral thrush, fail to thrive
3. Common pathoges of susceptibility= Candida albicans, Pneumocystis jiroveci,
Pseudomonas, CMV, varicella, etc
4. NEED HSCT or else death within a year especially for X-Linked SCID
5. Gene therapy giving normal yc gene has been successful  BUT risk of T cell
acute lymphoblastic leukemia b/c triggers uncontrolled T-cell proliferation that
can cause oncogene activation
6. X-linked SCID: about ½ SCID cases mutation in gene for y chain on IL-
2,4,7,9,15 (IL-7 issue most important because important for stim of survival and expansion of mature B and T cell precursors in
primary/generative lymph organs
7. Autosomal recessive SCID 40-50% SCID cases: most from mutation inf ADA (adenosine deaminase) involve in purine metabolism which leads to
adenosine and deozyadenosine triphosphate accumulation that is toxic to lymphocytes; other possibilities are issues with MHC, recombination
tools  may be able to treat with enzyme replacement therapy

X-Linked Agammaglobulinemia (Bruton Disease)  BTK issue so impaired B-cell development

1. MUTATION= BTK (Bruton tyrosine kinase)
2. Failure of pre-B cells to differentiate to mature B cells causing absence of antibodies in blood
3. B-cell maturation stops after initial heavy chain gene rearrangement b/c BTK nonfunctional which inhibits progression of maturation pathway
4. Consequence: Ig light chains are not produced so can’t make antibody will only see free heavy chains
5. BTK gene on X chromosome so disorder is only seen in males or in sporatic cases in females
6. T-cell response may be normal, lack germinal centers and plasma cells
7. Clinical signs:
A. Not apparent until 6 months when IgG from mom is gone
 B. Frequent infection of respiratory tract common sign
C. Common organisms of infection: H. influenzae, Strep pneumo, Staph aureus which are normally opsonized via antibodies and cleared via
phagocytosis; also susceptible to enterovirus and other viruses that are normally cleared via antibodies
8. NOTE: don’t vaccinate these patients with live poliovirus due to risk of paralytic poliomyelitis
9. Other infectious agent risk
A. Echovirus can cause fatal encephalitis
B. Giardia lamblia can persist due to lack of IgA mediated clearance
C. Also associated with increase risk of developing rheumatoid arthritis and dermatomyositis
10. Treatment= replacement therapy with IVIG from pooled human serum

DiGeroge Syndrome (Thymic Hypoplasia): lack thymus

1. Chromosomal Component: 90% have deletion in chromosome region 22q11
2. Congenital defect in thymic dev leading to deficient T-cell maturation due to malformation of 3 rd and 4th pharyngeal pouch which leads to lack of
thymus development (site of T-cell development)
3. 3rd and 4th pharyngeal pouch also give rise to parathyroid and part of face and aortic arch so may have issues with these too
4. Clinical Consequences
Prone to: viral, fungal, protozoal infection, intracellular bacteria
Generally normal B cell and serum immunoglobulin function
5. Treatment: transplant of thymic tissue
6. NOTE: in some patients, immunity may improve spontaneously

Hyper-IgM Syndrome: lack T-cell activation of B-cell lack class switch

1. Defect: inability of T cells to activate B cells which prevents class switching to IgG, A, E so you get a lot of IgM
2. Genetics: 70% develop X-linked form issue in gene for CD40L on Xq26 chromosome which prevents CD40 and CD40L interaction between B
and T cells needed for T cell activation of B cells
3. Genetics: 30% via autosomal recessive form Loss of function of CD40 OR AID (activation induced cytidine deaminase) enzyme which is a DNA
editing enzyme needed for Ig class switching
4. NOTE: CD40L-macrophage activation is compromised
5. Clinical Consequences
Recurrent pyogenic infection
CD40L mutation increases susceptibility to Pneumocystis jiroveci pneumonia
High IgM may react with blood cells and cause autoimmune hemolytic anemia, thrombocytopenia, and neutropenia

Common Variable Immunodeficiency group of many disorders involving hypogammaglobulinemia

1. Can affect any antibody class, but could involve ONLY IgG
2. Effect on both sexes EQUALLY
3. Onset during childhood or adolescence
4. Diagnose via exclusion of other conditions that could cause decreased antibody production
5. Suspected Mechanism= block in B-cell differentiation
A. Patient generally has normal numbers of mature B cells but LACK plasma cells
B. Tend to have HYPERplastic B cells areas of lymph tissue (spleen, lymph follicles, etc)
C. Many things can cause this B-cell defect, T-cell aid deficiency, excessive T-cell suppressive activity
6. Clinical Consequences
A. Prone to many autoimmune disorders
B. Prone to lymphoid tumors
C. Prone to G. lamblia diarrhea
D. Often present with recurrent sinopulmonary bacterial infections, recurrent herpesvirus infection, and serious enterovirus
infections causing meningoencephalitis
7. Many genetic causes have been identified
A. Mutation in receptor of BAFF cytokine (promotes survival/differentiation of B cells)
B. Mutation in ICOS (inducible costimulatory) CD28 homolog that aids T follicular helper cells
C. UNKNOWN origin in most cases

Isolated IgA Deficiency IgA deficiency (impair mucosal immunity)

1. MOST COMMON primary immune deficiency disease
2. IgA deficiency weakened mucosal defenses
3. Clinical consequences
A. Predisposition to sinopulmonary infection and diarrhea
B. Prone to autoimmune disease (reason is unknown still)
C. IgM and IgG levels are usually normal or high
4. Pathogenesis
A. Block in terminal differentiation of IgA secreting B cells to plasma cell

Other Potential Lymphocyte Activation Defects

1. Th1 response deficiency  prone to mycobacteria
2. Th17 response deficiency prone to chronic mucocutaneous candidiasis and bacterial infections of the skin

Wiskott Aldrich Syndrome WASP gene mutation leading to progressive loss of T-lymphocytes and early death
 1. X-linked
2. Clinical Consequences
A. Thrombocytopenia, eczema, recurrent infection risk
B. Early death in most cases
C. Progressive loss of T lymphocytes
D. Don’t make antibodies to polysaccharide antigens
E. Poor response to protein antigens
3. Immunoglobulin levels
A. IgA and E are HIGH
B. IgG is NORMAL
C. IgM is LOW
4. Genetics: Mutation in gene encoding WASP protein which is a signaling protein that links membrane receptors (including antigen receptors) to
cytoskeletal elements
5. Exact mechanism of disease is unknown

Ataxia Telangiectasia
1. Autosomal recessive
2. Characteristics
A. Abnormal gait (Ataxia), vascular malformation (telangiestases), neuro defects
B. Increased tumor and cancer risk (especially lymphoid tumors)
C. Immunodeficiency
D. Autoimmune phenomena
3. Immune defects vary
4. Most common humoral immune abnormality defect in isotype switch to IgA and IgG2
5. T-cell defects usually less prominent; usually associated with thymic hypoplasia
6. Common infections
A. Upper/lower respiratory tract bacterial infections
7. Genetics: ATM (ataxia telangiectasia gene) mutation
A. ATM normally is a sensor of DNA damage to activate cell cycle checkpoints
B. ATM mutation leads to abnormal antigen gene recombination process used to produce antibodies

Defects in Innate Immunity

NOTE: inherited defect in early innate immunity usually affects leukocyte
function or complement system

Defect in Leukocyte Function: LAD, CGD, Chediak Higashi, TLR Defects

Leukocyte Adhesion Deficiency (LAD1 and LAD2)
1. Adhesion molecule defects impairing leukocyte recruitment
2. Prone to bacterial infections
3. LAD1 defect in B2 chain in integrine LFA-1 and Mac-1
4. LAD2 can’t make sialyl Lewix X b/c defect in focosyl transferase
Chronic Granulomatous Disease
1. Inherited defect in genes for phagocyte oxidase needed by phagolysosomes to generate ROS for killing bacteria
2. Prone to bacterial infections and high granuloma formation

Chediak Higashi mutation in gene for LYST protein

1. Defective fusion of phagosome and lysosome
2. Neutropenia, defective degranulation, delayed microbial killing
3. Diagnosis: Giant granules in peripheral blood smear
4. Melanocyte abnormality leads to albinism
5. Other defects: CNS defects, bleeding disorders
TLR Defect
1. TLR3 recurrent herpes simplex encephalitis
2. MYD88 (needed for downstream signaling) destructive bacterial pneumonias

Deficiencies in the Complement System

Complement Component Deficiencies
1. C2= most common
2. Early component deficiency (C2, C4) no symptom or increased bacterial/viral infections, some develop SLE-like autoimmune disease
3. C3= rare deficiency; causes severe pyogenic infection and immune complex mediated glomerulonephritis
4. Late complement deficiency (C5-C9)= prone to Neisseria infection
Complement Regulation Defect
1. C1 INH (C1 inhibitor) deficiency hereditary angioedema (HAE) due to over-production of bradykinin

Secondary (Acquired Immunodeficiencies)

AIDS: Acquired Immunodeficiency Syndrome

1. Caused by HIV and characterized by profound immunosuppression, opportunistic infections, secondary neoplasms, neuro manifestations
2. Risk groups= homosexual and bisexual men, IV drug users, hemophiliacs/recipients of HIV-infected blood (generally all occurred before 1985
before safety measures made), transmission to newborn
3. Transmission: Sexual, Parenteral, mother to child via transplacental, birth canal, or breast milk

Properties of HIV
1. In lentivirus family
2. Forms= HIV-1 (more common in US, Europe, Central Africa), HIV-2 (more common in West Africa and India)
3. Structure= spherical with electron dense, cone-shaped core that is surrounded by lipid envelope derived from host cell membrane
A. Virus core= capsid protein p24, nucleocapsid protein p7/p9, two copies of viral genomic RNA, viral enzymes
B. P24= most abundant viral antigen and is often used for detection
C. P17=matrix protein surrounding viral core
D. Virion envelope: surrounds p17
E. Gp120 and gp41= glycoproteins on viral envelope Critical to infection by HIV
4. Genome: has gag, pol, env genes typical of RETROVIRUSES
A. Has accessory genes tat, rev, vif, nef, vpr, vpu to regulate synthesis and assembly of infectious viral particles/pathogenicity
B. Glycoprotein genes have been found to be highly variable
5. Vaccine hard due to genetic variability of glycoprotein on envelope
 6. HIV-1 Subgroups= M (major), O (outlier), N (neither M nor O)  based on prevalence
7. Subgroup M further divided to subtypes A through K

Pathogenesis of HIV Infection and AIDS

1. Major tissue targets= CNS and immune
system
2. Immune infection and impairment/
loss of CD4 T cells
3. CCR5 polymorphism may protect against
HIV

Life cycle of HIV

A. Infection of cell HIV’s
gp120 will bind
chemokine receptor CCR5
or CXCR4 mainly on T-cells
(T-trophic) or
macrophage/monocytes
(M-Trophic) which
triggers conformation
change to expose fusion
peptide hydrophobic
region to allow virus to
fuse with host insert core
B. Integration of provirus
into host cell genome
Inserted viral RNA undergoes reverse transcription
forming cDNA that enter nucleus in T-cell and
integrate to host genome (can only infect memory
cells and activated T cells, NOT naïve T cells)
C. Activation of Viral
Replication
Viral genome contains NFKB binding sites that flank genome so when transcription factor expression in T-cells are stim, viral transcription is stimulated too
which ultimately leads to death of the T-cell as more viral transcription occurs stimulates a vicious cycle b/c when patient gets infection, T-cells are
activation which leads to more HIV viral replication too
D. Production and Release of Infectious Virus

Mechanism of T-cell Depletion in HIV Infections

1. Main cause= cytopathic effects of replicating virus
2. Immune system can replace the T-cells to a certain point but ultimately can’t
keep up
3. Chronic infection by HIV also exhausts cells being used to fight off the HIV
infection itself
4. Progressive destruction of architecture/cell composition of lymphoid tissues
5. Synctia Formation: Infected cells can fuse with uninfected cells
6. NOTE: low-level/latent infection of T-cells is an important feature of HIV
Infection latent period can last months to years

HIV Infection of Non-T Immune Cells

Macrophages
1. HIV-1 can infect and multiply in terminally differentiated nondividing
macrophages (despite the fact that most retroviruses require cell division to
be actively occurring for infection)
2. Macrophages are pretty resistant to the cytopathic effects of HIV compared to
CD4 T cells
3. May act as reservoir of infection
Dendritic Cells
1. May become infected and transport virus to regional lymph nodes,
transmitting virus to CD4 T cells
2. Follicular DCs may act as viral reservoir
B-Cells
1. Can’t be infected by HIV
2. HIV is associated with abnormal B cell activity spontaneous activation, hypergammaglobulinemia, defective antibody response in general
CNS Involvement
1. Macrophages and microglia cells are the predominant CNS infected cells
2. HIV is thought to reach brain via infected monocytes
3. Neuro defect mechanism not completely known may be from viral products or soluble factors produced by infected microglia

Natural History and Course of HIV Infection: Acute Chronic

Acute Phase
MUCOSAL
1. Characterize by infection of memory CD4 T cells in mucosal lymphoid tissue
and death of many of the infected cells (mucosal membranes have lots of
memory T-cells)
2. Few infected cells are detected in blood/other tissues
VIRAL DISSEMINATION
3. Mucosal infection is followed by viral dissemination and development of host
response can detect viral replication in lymph nodes within days of exposure
4. Can detect HIV particles in blood
ACUTE HIV SYNDROME: 3-6 weeks
1. Self limited illness with nonspecific symptoms myalgia, fever, etc
2. Spontaneously resolves usually in 2-4 weeks
3. Seroconversion and appearance of virus specific cytotoxic T cells 3-7 weeks
after exposure which can be detected in blood which are thought to aid in
initial containment of HIV infection
VIRAL SET POINT
1. After 12-weeks post-exposure, there is drop in viremia reaches equilibrium
level between infection and host defense
2. Viral set point is a predictor of rate of decline of CD4 T cells/ HIV progression
groups are “rapid progressor,” long-term non-progressor” and “elite
controllers”

Chronic Phase: “clinical latency period” can last years

1. Lymph nodes and spleen are sites of continuous HIV replication and cell
destruction
2. Few/no clinical manifestation of disease
3. Steady decline in CD4 T cells circulating

AIDS Final phase (occurs 7-10 years after infection if not treated)
1. Breakdown of host defense
2. Dramatic increase in plasma virus
3. Severe, life-threatening clinical disease  opportunistic infection, secondary
neoplasms, neuro disease

Clinical Features of AIDS: Opportunistic Infection, Tumor, CNS

Disease
Opportunistic Infections
1. Pneumocystis jiroveci fungus: pneumonia in 15-30%
untreated HIV patients
2. Candidiasis: most common fungal infection in patients with AIDS (generally in oral cavity) and rarely becomes invasive
3. CMV: mainly affects eye (chorioretinitis) and GI (esophagitis and colitis)
4. Nontuberculosis or atypical mycobacteria: occurs in late stage TB is associated with almost 1/3 deaths in AIDS patients
5. Cryptococcosis: mainly causes meningitis
6. Toxoplasma gondii: associated with encephalitis and mass lesions in CNS
 7. JC Virus: causes progressive multifocal leukoencephalopathy
8. HSV: mucocutaneous ulceration in mouth, esophagus, external genitalia, perianal region

Tumors: Kaposi sarcoma (main), B cell lymphoma, Cervical Cancer, Anal cancer
1. Most are caused by oncogenic DNA viruses that establish latent infection that healthy immune system usually controls B/c AIDS patients are
immunosuppressed, patients becomes at risk of cancers associated with viruses that are normally controlled by healthy immune systems

Kaposi Sarcoma:
1. associated with KS herpesvirus (KSHV) and Human Herpesvirus 8
2. vascular tumor characterized by spindle shaped cells expressing markers for endothelial cells and smooth muscle cells; lesions contain chronic
inflammatory cell infiltrates
3. Tumor in AIDS patients becomes widespread affecting skin, mucous membranes, GI, lymph

Lymphomas
1. Tumors induced by oncogenic viruses EBV, KSHV effects are unchecked due to T
cell depletion and lead to uncontrolled B cell proliferation and development of B
cell lymphomas containing tumor cells infected by oncogenic viruses (especially
EBV)
2. AIDS patients are prone to rare lymphomas that present as malignant effusions
3. Germinal Center B-cell hyperplasia lymphomas can occur in patients with
relatively higher CD4 T-cells counts and is thought to be linked to the B cell
hyperplasia seen in HIV infection can lead to Burkett Lymphoma and large B cell
lymphoma
4. Hodgkin Lymphoma B cell tumor associated with pronounced tissue
inflammatory response; associated with EBV infection

Uterine Cervix Carcinoma and Anal Cancer

1. Associated with human papilloma virus (HPV)

CNS Disease
1. Self limited viral meningoencephalitis
2. Aseptic meningitis
3. Vacuolar myelopathy
4. Peripheral neuropathies
5. HIV-associated neurocognitive disorder progressive encephalopathy

Effect of Anti-Retroviral Therapy on Course of HIV Infection

1. Patient can remain below threshold of detection if they adhere to current therapy
2. Transmission and many complications have been decreased since introduction of
medication
3. Complications
Immune reconstitution inflammatory syndrome: rare complication where
patient with advanced disease gets worse with therapy
Adverse sides effects to the drugs: lipoatrophy, lipoaccumulation, elevated
lipids, insulin resistance, peripheral neuropathy, early CV, kidney, liver
disease
Robbins Chapter 2 Mechanisms of Cell Injury and Death p. 31-56

Overview of Cellular Responses to Stress and Noxious Stimuli

1. Cell injury when the adaptive capability of a cell is exceeded by a stress; can be reversible
or irreversible
2. Irreversible injury leads to death of the affected cells
3. Cell death can occur in response to a variety of stresses or normal processes in the
maintenance of tissue homeostasis

Causes of Cell Injury

1. Hypoxia: O2 deficiency Most common cause= ischemia from arterial obstruction
2. Ischemia: reduced blood supply
3. Toxins: environmental agents, drugs, etc can cause cell/tissue injury
4. Infectious Agents: bacteria, virus, fungi, protozoans
5. Immunologic Reactions: Autoimmune, excessive/chronic immune response can elicit
inflammatory reactions
6. Genetic Abnormalities: deficiency in functional proteins such as enzymes needed for
metabolism, accumulation of damaged DNA or misfolded protein which can trigger cell death
7. Nutritional Imbalances
8. Physical Agents: trauma, extreme temperature, radiation, electric shock, sudden changes in
atmospheric pressure
9. Aging: cellular senescence occurs due to decreasing ability of cells to respond to stress and
eventually leads to cell death

Sequence of Events in Cell Injury and Cell Death

1. Reversible Cell Injury
a. stage of cell injury where deranged function/morphology of injury cell is able to
return to normal is the damaging
stimulus is removed
b. Features: swelling of cells/intracellular
organelles with H2O intake due to failing
energy dependent ion pumps leading to
inability to maintain fluid/ion
homeostasis
c. Some injury forms may also have injured
cells with accumulated lipids and
degenerated organelles
2. Irreversible Cell Injury: 3 main signs
a. Inability to restore mitochondrial
function
b. Loss of structure and functions of the
plasma membrane and intracellular
membranes
c. Loss of DNA and chromatin structural
integrity
3. Cell Death
a. Necrosis: traditionally considered to be
end result of severe damage beyond
 salvage through a process that is not regulated by specific signals/biochemical mechanisms occurs in setting of severe disturbances
such as loss of O2 and nutrient supply
b. Apoptosis: regulated cell death; occurs in less severe injury and some normal processes (EX: apoptosis to get rid of cells in webbed
digits during development); does not elicit inflammatory reaction
c. Necroptosis: form of regulated cell death that shows features of apoptosis and necrosis

Necrosis
1. Necrosis: form of cell death where cell membranes fall apart and cellular enzymes leak out and digest
the cell ELICITS INFLAMMATION
2. Enzymes that digest the cell come from lysosomes, the cell itself, or recruited leukocytes
3. Necrosis is often the culmination of reversible cell injury that can’t be corrected
4. Morphologic Patterns of Tissue Necrosis
a. Coagulative necrosis
b. Liquefactive necrosis
c. Gangrenous Necrosis
d. Caseous Necrosis
e. Fat Necrosis
f. Fibrinoid Necrosis

Coagulative Necrosis

Liquefactive Necrosis and Gangrenous Necrosis

Caseous Necrosis
 Fat Necrosis

Fibrinoid Necrosis

Apoptosis
1. Apoptosis: pathway of cell death where cells activate enzymes that degrade cell’s own nuclear DNA+
cytoplasmic proteins
2. Plasma membrane of apoptotic cells remain intact and are consumed by phagocytes
3. Does not elicit inflammatory response
4. Has physiologic and pathologic causes
5. Physiologic Apoptosis:
a. Normal development
b. Eliminate excess leukocytes at the end of an immune response
c. Elimination of lymphocytes that recognize self-antigens and could cause autoimmune
disease
6. Pathologic Apoptosis
a. Elimination of cells that are damaged beyond repair
Mechanisms of Apoptosis: Intrinsic and Extrinsic Pathways
1. Caspases= cysteine proteases that cleave after aspartic acid residues and are activated in apoptosis
2. Intrinsic (Mitochondrial) Pathway: pathway in most physiologic and pathologic situations
a. Cytochrome c: protein in mitochondria that can induce apoptosis
b. Proapoptotic: Bax and Bak dimerize and insert to mitochondrial membrane to form channels that allow for cytochrome c escape into
cytosol
c. BH3: sensors that shift balance between survival/apoptosis towards apoptosis via Bak/Bax
d. Caspase-9: activated by cytochrome c to activate the caspase cascade and lead to cell death
3. Extrinsic (Death Receptor) Pathway
a. Death receptor: surface molecule on many cells that trigger
apoptosis
b. Most death receptors are part of the TNF receptor family
c. Prototypic Death Receptors Type 1 TNF and Fas (CD95)
d. Fas Ligand: Membrane protein expressed on T lymphocytes
 when T lymphocytes reach Fas expressing targets, the T-
cell activates caspase 8 to trigger activation of downstream
caspases
i. This process is important in elimination of self
reactive lymphocytes and killing of target cells by
cytotoxic T lymphocytes
4. Clearance of Apoptotic Cells
a. Apoptotic cells and fragments produce “eat me” signals
b. Cells undergoing apoptosis also secrete proteins that recruit
phagocytes
c. Dead cells are cleared BEFORE the membrane is damaged
allowing for inflammation to be avoided

Other Pathways of Cell Death

1. Necroptosis:
a. Initiated by engagement of TNF receptors
b. Difference to Extrinsic Pathway Necroptosis involves activation of RIP
Kinases leading to cell dissolution
c. Has features of necrosis + apoptosis
d. May play role in ischemic injury but exact role is not well understood
2. Pyroptosis
a. Activation of inflammasome
b. Inflammasome= cytosolic danger sensing protein complex
c. Net Result= caspase activation and cytokine production that induces inflammation
d. Apoptosis and inflammation coesist

Autophagy “ Self Eating”

1. Lysosomal digestion of cell’s own components
2. Survival mechanism for starving cell use its own contents to provide extra nutrient/energy
3. First step intracellular organelles and portions of cytosol are sequestered within ER-derived
autophagic vacuole that then fuses with lysosomes to form autophagolysosome
4. Extensivy autophagy is seen in ischemic injury and some myopathies
Mechanisms of Cell Injury and Cell Death

General Principles
1. Cell response to injury depends on injury type, duration, and
severity
2. Consequence of injury depends on cell type, adaptability and
genetic makeup of the injured cell
3. Cell injury usually results from functional and biochemical
abnormalities in 1+ essential cellular components

Hypoxia and Ischemia

1. ATP production most produced via oxidative phosphorylation during reduction of O2 in
ETC
2. O2 deprivation of one of the most common causes of cell injury and necrosis
3. Compensatory Mechanisms s during hypoxia
a. Induced by HIF-1 transcription factors
b. HIF aids in synthesis of proteins that help cell survival in low O2 states EX: VEGF
and other proteins that stimulate glucose uptake and glycolysis
c. Anaerobic glycolysis can generate ATP in absence of O2
4. Persistent/severe hypoxia/ischemia ultimately leads to failed ATP generation and ATP
depletion leading to many consequences
a. Reduced activity of membrane ATP-dependent Na pumps leads to Na
accumulation and K efflux leads to cell swelling
b. Increased glycolysis leads to lactic acid accumulation decreased intracellular
pH decreased enzyme activity
c. Structural disruption of protein synthetic apparatus ribosome detachment from
rER
d. Increase in ROS accumulation
e. Irreversible damage to mitochondrial and lysosomal membranes necrosis
5. Warburg Effect counterintuitive concept where
rapidly proliferative normal cells and cancer cells rely
on glycolysis to produce much of their energy; this
occurs because metabolites generated by glycolysis
serve as precursors for synthesis of cellular
constituents needed for cell growth/division

Ischemia-Reperfusion Injury
1. When restoration of blood flow to ischemic tissue
leads to INCREASED cell injury
2. Causes ROS generation with reoxygenation;
increased inflammation due to increased influx of
leukocytes and plama proteins with the reintroduction of blood flow to ischemic area
3. Complement activation may also contribute

Oxidative Stress
1. Oxidative Stress: cellular abnormalities that are induced by ROS  free radical mediated cell injury
2. Occurs in chemical and radiation injury, hypoxia, cell aging, tissue injury via inflammation, ischemia-reperfusion injury
3. Can lead to cell death via apoptosis or necrosis or mix of both
4. Free Radical: chemical species with single unpaired electron in outer orbit making them unstable and ready to react with other molecules  in
cells, they attack nucleic acids and other proteins/lipids and can propogate formation of more free radicals
5. ROS Generation
a. Normally made in redox rxn during mitochondrial respiration and energy generation
b. Made in phagocytic leukocytes (mainly neutrophils and macrophages) to help digest microbes/other ingested substances via
respiratory burst (oxidative burst)  H2O2 in this process is converted to hypochlorite (in bleach)
c. Nitric oxide can react with O2- (superoxide) to form peroxynitrite
6. Situations that increase ROS generation
a. X-ray exposure
 b. Enzymatic metabolism of
exogenous chemicals
c. Inflammation
d. Reperfusion of ischemic
tissues
7. Free Radical Removal Mechanisms
a. SOD (superoxide dismutase)
b. GSH (glutathione)
peroxidases GSH
peroxidase 1 catalyzes
breakdown of H2O2
c. Catalase catalyzes
decomposition of H2O2
d. Endogenous/exogenous anti-oxidants= vitamin E, A, C, B-
carotene
8. Cell injuries caused by ROS
a. Lipid Peroxidation of Membranes
b. Crosslinking proteins that lead to enhanced degradation or loss
of enzymatic activity
c. DNA damage rxn with thymine residues produce single
stranded breaks

Cell Injury Caused by Toxins

1. Direct acting toxins combine with critical molecular component or
organelle
a. Many anti-neoplastic chemo agents induce cell damage via direct
cytotoxic
2. Latent Toxins must be converted to reactive
metabolite to cause damafe
a. EX: CYP450 in smooth ER of liver/other organs
activate many substances
b. Most important mechanism of cell injury=
free radical formation
c. EX: CCL4, acetaminophen

Endoplasmic Reticulum Stress

1. Accumulation of misfolded proteins in cell can stress
compensatory pathways in ER and lead to cell death via
apoptosis
2. Normal process for eliminating misfolded proteins
a. Ubiquination to target for proteolysis
3. States of too much misfolded protein
a. Unfolded protein response activation of signaling pathways that increase chaperone production and decrease protein translocation
to reduce misfolded protein levels
b. Too much unfolded protein for cell to handle signals to BH3 family + direct caspase activation to trigger apoptosis via intrinsic
pathway
4. Protein misfolding and disease creates a deficiency in essential proteins or induces apoptosis
a. Ex: Protein misfolding Cystic Fibrosis
b. EX: Cell death due to protein misfolding Alzheimer, Huntington, Parkinson
c. Misfolded proteins can also accumulate in extracellular tissues and cause disease Amyloidosis

DNA Damage
1. Sources of DNA damage radiation, chemo agents
2. DNA damage is sensed by intracellular sentinel proteins that transmit signal that leads to p53 protein accumulation
3. P53: arrests cell cycle to allow time for DNA to be repaired before replication; if damage is too great for repair, p53 with trigger apoptosis instead
via BH3 sensor proteins
4. Mutations in p53 are associated with many neoplastic transformations

Common Events in Cell Injury From Diverse Causes

1. Mitochondrial Dysfunction plays role in necrosis and apoptosis
a. Failure of oxidative phosphorylation leads to progressive ATP depletion and ROS formation
b. Mitochondrial permeability transition pore forms during mitochondrial damage and leads to loss of mitochondrial membrane
potential and pH changes which further damages oxidative phosphorylation
 c. Cytochrome C stored in mitochondria so damage to mitochondria can
release cytochrome c and activate apoptosis
2. Defects in Membrane Permeability  common feature in necrosis (esp cell
membrane, mitochondrial membrane, and lysosomal membrane)
a. Plasma membrane leads to damaged osmotic balance and fluid influx
b. Lysosomal membrane cause leak of enzymes and activation of acid
hydrolases into cytoplasm that leads to degradation of cell components

Cellular Adaptations to Stress

1. Adaptation= reversible change in number, size, phenotype,
metabolic activity, or functions of cells in response to
environmental changes
2. Physiologic Adaption= responses of cells to normal stimulation
via hormones or endogenous chem mediators or demands of
mechanical stress
3. Pathologic Adaptation= responses to stress that allow cells to
modulate their structure and function to escape injury at the
expense of normal function

Hypertrophy
1. Hypertrophy= increase in cell size (not cell number) which
causes increase in organ size (unlike Hyperplasia increase in
cell number)
2. Occurs when cells have limited capacity to divide (EX: heart)
3. Causes= increased functional demand or growth
factor/hormonal stimulation
4. Examples
a. Physiologic: uterus enlargement during pregnancy,
skeletal muscle building
b. Pathologic: cardiac enlargement during
hypertension or aortic valve disease (EX: left
ventricular hypertrophy)
5. Mechanisms driving cardiac hypertrophy
a. Involves mechanical triggers and soluble mediators
such as growth factors which trigger synthesis of
cellular proteins
b. Leads to more proteins and myofilaments per cell
which increase force generated with each
contraction
6. Adaptations to stress can lead to cell injury if the cell is not
removed  EX: cardiac hypertrophy can ultimately lead to
cardiac failure

Hyperplasia
1. Hyperplasia= increase in number of cells in an organ
2. Takes place in tissues with cell populations that are capable of
replication
3. Often occurs in response to the same/similar to stimuli
that cause hypertrophy
4. Examples
a. Physiologic: hormonal hyperplasia
hyperplasia of glandular epithelium in breast
during pregnancy; compensatory hyperplasia
after removal/loss of a part of an organ
b. Pathologic: endometrial hyperplasia, benign
prostatic hyperplasia many cases involve
disturbance in balance of hormone signaling

Atrophy
1. Atrophy= shrinkage in cell size via loss of cell substance
 2. Causes of atrophy
a. Decreased workload
b. Diminished blood supply, innervation, nutrition, endocrine stimulation, aging, etc
3. Mechanism combo of decreased protein synthesis and increased protein degradation
a. Decreased protein synthesis via decreased metabolic activity
b. Cell protein degradation ubiquitin proteasome pathway
c. Autophagy

Metaplasia
1. Metaplasia: change where one adult cell type is replaced by another adult cell type that is better able to withstand the stress
2. Mechanism reprogramming of stem cells
3. Example= Cigarette smoke leads to normal ciliated columnar epithelial cells of trachea + bronchi to be replaced by stratified squamous epithelial
cells
4. Example in chronic gastric reflux, the normal stratified squamous epithelium of the lower esophagus may transform to intestinal type columnar
epithelium
5. Metaplastic changes may predispose to malignant transformation
Intracellular Accumulations
1. Main mechanisms= inadequate removal/degradation or excessive production of an endogenous
substance/abnormal exogenous material
2. SteatosisFatty Change
a. Accumulation of triglycerides
b. Often seen in liver most commonly caused by toxins, protein malnutrition, diabetes
mellitus, obesity, or anoxia
3. Cholesterol and Cholesterol Esters
a. Phagocytic cells may become overloaded with lipid important role in atherosclerosis
4. Proteins
a. Less common than lipid accumulations
b. EX: Nephrotic syndrome lots of protein leakage across glomerular filter that can
lead to hyaline cytoplasmic droplets
5. Glycogen
a. Associated with abnormalities in either glycogen or glucose metabolism
b. EX: glycogen accumulation in renal tubular epithelium, cardiac myocytes, B cells in
poorly controlled diabetes
6. Pigments
a. Carbon= most common exogenous pigment; ubiquitous air pollutant of urban life;
phagocytosed by alveolar macrophages and blacken draining lymph nodes and
pulmonary parenchyma
b. Lipofucin= “wear-and-tear pigment” insoluble brown/yellow granular intracellular
material during aging/atrophy; complex of lipid and protein that is not injurious to cell
but marker of past free radical injury
c. Melanin= endogenous brown/black pigment located in epidermis
d. Hemosiderin: Hemoglobin derived granular pigment; golden yellow/brown that
accumulates in tissue/cells with excess iron; iron can be visualized by Prussian blue

Pathologic Calcification
1. Caused by abnormal deposition of calcium salts
2. Dystrophic Calcification: calcium metabolism is normal but is depositing in dead/injured tissue;
may cause organ dysfunction  EX: calcification in heart valves can compromise valve motion
a. Initiated by extracellular deposition of crystalline calcium phosphate in membrane
bound vesicles
b. Crystals propagate and form larger deposits
3. Metastatic Calcification: associated with hypercalcemia and can occur in normal tissue
a. Major causes= increased parathyroid hormone, destruction of bone, vitamin D related
disorders, renal failure causing phosphate retention
Cellular Aging
1. Cellular aging is result of progressive decline in life span and
functional ability of cells
2. Abnormalities contributing to cell aging
a. Accumulation of mutations in DNA
b. Decreased cellular replication ability
3. Replicative Senescence: occurs due to shortening of
telomeres
4. Telomere= short replicated DNA sequences present at ends
of chromosomes that ensure complete replication of
chromosome ends small amount of not duplicated with
each replication
5. Telomerase= specialized RNA- protein complex that uses own RNA as template for adding nucleotides to ends of chromosomes; expressed in
germ cells and low levels in stem cells; absent in most somatic cells
6. Immortalized cancer cells have telomerase that is usually reactivated which allows the cancer cells to replicate indefinitely
7. NOTE: exact relationship between telomeres and aging is still not clear
8. Defective protein homeostasis cells are unable to maintain normal protein homeostasis over time leading to decreased synthesis
9. Calorie restriction has been found to slow down aging via reduced activation of insulin-like growth factor receptor signaling which lowers rates
of cell growth and metabolism and possibly reduces errors in DNA replication

Robbins Ch. 4 Hemodynamic Disorders, Thromboembolism, and Shock p. 97-119

1. Hemostasis: process of blood clotting that prevents excessive bleeding after blood vessel
damage

Hyperemia and Congestion

1. Hyperemia and congestion both refer to increase in blood volume within tissue
2. Hyperemia= active process due to arteriolar dilation and increased blood inflow occurs in
inflammation sites or exercising skeletal muscle
a. Hyperemic tissues appear redder
3. Congestion= passive process caused by impaired outflow of venous blood from tissue
a. Occurs in cardiac failure
b. Congested tissues have cyanosis (blue-red color) due to accumulation of
deoxygenated hemoglobin
4. Inadequate perfusion can lead to parenchymal cell death and secondary tissue fibrosis
Edema
1. Edema= accumulation of interstitial fluid within tissues
2. Hydrothorax= effusions in pleural cavity
3. Hydropericardium= pericardial effusion
4. Ascites: effusion to peritoneal cavity
5. Anascara: severe, generalized edema marked by profound swelling of subcutaneous tissue
and accumulation of fluid to body cavities
6. General Mechanisms of Edema
a. Increased vascular permeability (inflammatory related)
b. Osmotic pressure: pressure driving fluid into blood vessel
c. Hydrostatic pressure: pressure driving fluid out of blood vessel
d. Decreased osmotic pressure or increased hydrostatic pressure causes increased
movement of water into interstitium
e. Excess edema fluid is removed by lymphatic drainage

Increased Hydrostatic Pressure

1. Main cause= disorders that impair
venous return EX: DVT, congestive
heart failure

Reduced Plasma Oncotic Pressure

1. Cause= reduction of plasma albumin
concentration
2. Albumin= accounts for almost half of
total plasma protein
3. Nephrotic Syndrome: most important
cause of albumin loss from blood
when glomerular capillaries become
“leaky” leading to loss of albumin and
other plasma protein through urine

Lymphatic Obstruction
1. Often caused by localized obstruction
caused by inflammation or neoplastic
condition
2. EX: obstruction of lymphatics in breast
cancer

Sodium and Water Retention

1. Leads to edema by increasing
hydrostatic pressure via expansion of
intravascular volume and reducing
plasma osmotic pressure
2. Seen in diseases that compromise renal
function

General Clinical Features of Edema

1. Pulmonary edema often seen in
setting of left ventricular failure
2. Pulmonary edema can cause death by interfering with normal ventilation
3. Brain edema can cause beain to herniate through foramen magnem

Hemorrhage
1. Hemorrhage= extravasation of blood from vessels often the result of damage to blood
vessels of defective clot formation
2. Hematoma: hemorrhage accumulation within a tissue
3. Large bleeds into body cavities are described based on location Hemothorax,
hemopericardium, etc
4. Extensive hemorrhage can lead to jaundice due to massive breakdown of RBCs and
Hemoglobin
5. Petichiae= 1-2mm hemorrhages into skin, mucous membranes, or serosal surfaces
6. Purpura: 3-5mm hemorrhages; can be caused by same conditions associated with petechiae
7. Ecchymoses (bruise): 1-2cm subcutaneous hematomas; characteristic color changes in bruise
results from enzymatic conversion of hemoglobin (red-blue color) to bilirubin (blue-green)
and eventually hemosiderin (golden brown)
8. Clinical significance depends on volume of blood lost and rate of blood loss great losses can
lead to hemorrhagic/hypovolemic shock
Hemostasis and Thrombosis
Normal Hemostasis
1. Hemostasis= process involving platelets, clotting factors, and endothelium that occurs at site
of vascular injury and culminates in formation of blood clot to serve the purpose of
preventing/limiting the extent of bleeding
2. General Pattern: endothelial cells are key regulators in the hemostasis balance between clot
formation and clot dissolution imbalance leads to either too many clots or too much
bleeding

General Process of Hemostasis

1. Arteriolar vasoconstriction= immediate reaction to reduce blood flow to injured area
mediated by reflex neurogenic mechanisms via factors such as endothelin; transient response
2. Primary Hemostasis= formation of platelet plug vWF (von Willebrand factor) and collagen
are exposed when endothelium is disrupted leading to platelet activation (via shape change
of platelets) and release of secretory granules that result in platelet aggregation
3. Secondary Hemostasis: deposition of fibrin tissue factor (membrane-bound procoagulant
glycoperotein) is exposed during vascular injury and activates a cascade of reactions
ultimately leading to thrombin generation thrombin then cleaves fibrinogen into fibrin
which creates a meshwork that stabilizes the platelet plug
4. Clot Stabilization and Resorption: polymerized fibrin and platelet aggregates undergo
contraction and form a solid “permanent plug” that prevents further hemorrhage clot
resorption occurs via counterregulatory mechanisms that lead to clot resorption and tissue
repair

Platelets
1. Role in hemostasis= primary plug formation
2. Platelet= disc shaped anucleate cell fragments shed from megakaryocytes in bone marrow
into bloodstream
3. Granule types
a. Alpha-granules contain P-selectin adhesion molecule, fibrinogen, coagulation
factor V, and vWF, and factors involved in wound healing such as fibronectin,
platelet factor 4, platelet derived growth factor (PDGF) and TGF-B
b. Dense granules contain ADP and ATP, ionized calcium, serotonin, and
epinephrine
4. Platelet Adhesion: mediated by interaction between vWF and GpIb (platelet surface receptor
glycoprotein) and exposed collagen
a. Diseases associated with this step= Bernard Soulier syndrome (GpIb issue) and vWF
disease
 5. Platelet Shape Change: change from a smooth to spiky shape after adhesion; adhesion is also followed by alterations in the GPIIb/IIIa
glycoprotein that allows for increased affinity for fibrinogen; adhesion is also followed by translocation of phospholipids to platelet surface to
bind calcium and form nucleation sites for coagulation factor complexes
6. Granule content secretion occurs with the platelet shape change; activated platelets also
produce TXA2, a potent inducer of platelet aggregation
a. Clinical Application: aspirin inhibits TXA2 synthesis to prevent blood clots
7. Platelet Aggregation
a. Conformation change of GPIIb/IIIa allows fibrinogen binding which leads to platelet
aggregation
b. Associated disease Glanzmann thromasthenia (GpIIb/IIIa issue)

Coagulation Cascade
1. Series of amplifying enzymatic rxns that lead to deposition of insoluble fibrin clot
2. Calcium role binds y-carboxylated glutamic acid residues on factors II, VII, IX, and X
3. Vitamin K role cofactor role in enzymatic reactions that produce y-carboxylated glutamic
acids
4. Prothrombin Time (PT): assesses function of proteins in extrinsic pathway (factors VII, X, V, II,
fibrinogen) test is done by adding calcium, tissue factor, and phospholipids to plasma and timing the amount of time it takes for fibrin clot to
form
5. Partial thromboplastin time (PTT): assesses the function of proteins in the extrinsic pathway (XII, XI, IX, VIII, X, V, II, and fibrinogen) test via
adding negative charged particles that activate factor XII (AKA Hageman factor) with phospholipids and calcium and measuring the time it takes
for the fibrin clot to form
 1.

1. Thrombin: most important coagulation

2. Roles of Thrombin
a. Conversion of fibrinogen into crosslinked fibrin
b. Platelet activation via activation of PARs
c. Proimflammatory effect
d. Anti-coagulation effect can be switched from a pro-coagulation to an anti-coagulation factor

Factors that Limit Coagulation

1. Important to limit coagulation to prevent excessive clot formation
2. Blood flowing past site of injury washes out activated coagulation factors which are
then removed by the liver
3. Overall negative charge is needed for proper coagulation loss of exposed negatively
charged particles decreases coagulation
4. Most important counter-regulatory mechanism involves factors expressed by INTACT
endothelium adjacent to injury sites
5. Negative feedback coagulation cascade activation also activates a fibrinolytic
cascade that leads to the dissolution of the clots formed
6. D-dimer: one of the fibrin split products that is measured to determine the
thrombolytic state high D-dimer indicates lots of clots/large clot that the body is
trying to break down
7. Plasminogen: plasmin precursor plasmin is the main protein in breaking down clots
8. T pa most important plasminogen activator leads to clot breakdown
a. made by endothelium
b. also used as a therapeutic agent for people with clot EX: stroke
9. Alpha-2-anti-plasmin (A2AP): inhibitor of free plasmin to prevent over-activation of
plasmin; pro-coagulation role
Endothelium
1. Normal endothelial cells= express factors that
inhibit procoagulant activities
2. Injury to endothelium triggers procoagulant
activities
3. Antithrombotic properties of endothelium
a. Platelet inhibitory effects: physical barrier between platelets and subendothelial vWF and collagen, release of GFI2, NI and ADP which
inhibit platelet activation and aggregation
b. Anticoagulant Effects normal endothelium shields coagulation factors from tissue factor in vessel walls and express factors like
thrombomodulin, Protein C, heparin like molecules, and tissue factor pathway inhibitor which oppose coagulation
4. Protein C form complex with thrombomodulin and endothelial protein C receptor to cause thrombin to convert to an anti-coagulation function
5. Heparin like molefules activate antithrombin III which inhibits thrombin and coagulation factors IX, X, XI, and XII
6. T-PA fibrinolytic agent; released by normal endothelial cells

Thrombosis
Primary Abnormalities that lead to Intravascular Thrombosis= Virchow Triad”
1. Endothelial injury
2. Stasis or turbulent blood flow
3. Hypercoagulability of blood

Endothelial Injury
1. Underlies thrombus formation in heart and arterial circulation which are rich in platelets
2. Platelet adherence and activation are through to be necessary prereqs for thrombus
formation under high shear stress
3. Inflammation and other noxious stimuli can also promote thrombosis via shift in patterns
of gene expression in endothelium towards pro-thrombotic agents
4. Major Prothrombotic alterations
a. Procoagulant changes downregulation of thrombomodulin expression and
other anti-coagulants such as protein C and tissue factor protein inhibitor
b. Anti-fibrinolytic changes PAI (plasminogen activator inhibitors) downregulate
t-PA to limit fibrinolysis

Abnormal Blood Flow

1. Turbulence= chaotic blood flow contributes to thrombosis by causing endothelial
injury/dysfunction and forms countercurrents and local pockets of stasis
2. Stasis normal blood flow allows platelets to flow in the middle of the vessel lumen away
from the endothelium, when there’s stasis, platelets are more likely to “bump” into the
endothelium and trigger thrombosis and clotting factors wash out more slowly

Hypercoagulability
1. Hypercoagulability= abnormally high tendency of blood to clot
2. Cause= often via an alteration in one/multiple coagulation factors
3. Primary (genetic) disorders
a. Factor V Leiden: mutation in factor 5 found in 2-15% of whites that makes factor
5 resistant to proteolysis by protein C; heterozygotes have a 5x increase in risk
for venous thrombosis and homozygotes have 50x increase in risk
 b. Prothrombin Mutation: GA substitution in 3’ untranslated region leads to increased prothrombin transcription
c. Homocysteine Elevation: high levels are associated with increased risk of thrombosis
4. Secondary (acquired) hypercoagulability states
a. Oral contraceptive use
b. Disseminated cancers
c. Smoking
d. Obesity
e. Heparin Induced Thrombocytopenia (HIT): occurs in 5% of those treated with
unfractionated heparin via development of autoantibodies that bind complexes of
heparin and platelet membrane protein leading to a prothrombotic state and low
platelet counts (tons of clots being made that are “using up” the platelets)
f. Anti Phospholipid Antibody Syndrome: associated with multiple miscarriages,
cardiac valve vegetations, and thrombocytopenia; named via detection of
circulating antibodies that bind phospholipids, but the exact mechanism behind
the pro-coagulation state is still unclear

Fate of the Thrombus

1. Propagation: when thrombus enlarges
from more platelet and fibrin
accumulation
2. Embolization: part/all of thrombus
dislodges somewhere else in
vasculature
3. Dissolution: breakdown via fibrinolytic
factors; more likely the newer the
thrombus
4. Organization and recanalization:
endothelial cell, smooth muscle cells,
and fibroblast ingrowth and sometimes
capillary channel formation to
reestablish some continuity of the original lumen; thrombus may end up incorporated into
wall of remodeled vessel
5. Clinical application venous thrombi can cause congestion and edema and have potential
to embolize to lungs and cause death

Venous Thrombosis (Phlebothrombosis)

1. Most are in superficial or deep veins of legs
2. Superficial thrombi usually arise in saphenous system and rarely embolize but can be
painful
3. Deep DVE= deep venous thrombosis; often located in larger leg veins at/above knee
joint ; more serious than superficial b/c are prone to embolize while also being less likely to
cause pain due to collateral channels
4. Lower extremity DVTs are associated with stasis and hypercoagulable states heart failure,
bed rest, immobilization, etc

Arterial and Cardiac Thrombosis

1. Major cause= atherosclerosis
2. Myocardial infarctions can predispose to cardiac mural thrombi
3. Cardiac and aortic mural thrombi are prone to embolize most often embolize to brain,
kidney, spleen due to their rich blood supply

DIC (Disseminated Intravascular Coagulation)

1. DIC= widespread thrombosis within microcirculation
2. Seen in obstetric complications, malignancies, certain infections
3. Platelet levels widespread microvascular thrombosis consumes platelets and coagulation proteins  “consumptive coagulopathy”
4. Activates strong fibrinolytic mechanisms to control microthombi leading to possible net result of being in a state of excessive clotting and
excessive bleeding at the same time
Embolism
1. Embolus= detached intravascular solid, liquid, or gaseous mass carried by the blood from its
point of origin to a distant site often causes tissue dysfunction or infarction
2. Most are caused by a dislodged thrombus
3. Other forms fat, nitrogen bubbles, atherosclerotic debris, tumor fragments, bone marrow bits,
amniotic fluid
4. Primary consequences= ischemic necrosis (infarction) of downstream tissues; if embolus reaches
pulm circulation, can lead to hypoxia, hypotension and right sided heart failure

Pulmonary Thromboembolism
1. Origin= DVT usually
2. Saddle Embolus when a PE (pulmonary embolus) lodges at the bifurcation of the right and left
pulmonary arteries and can cause sudden death
3. Paradoxical Embolus when an embolus passes through an arterial or ventricular defect and
enters systemic circulation
4. General patterns
a. Most PEs are small and clinically silent end up incorporated into vascular wall
b. Embolic obstruction of medium sized arteries can lead to rupture of downstream
capillaries and cause pulmonary hemorrhage
c. Bronchial circulation dual circulation so circulation is often maintained despite
blockage of some vessels via emboli
d. Emboli to small end arteriolar pulmonary branches causes infarction
e. Multiple emboli over time can lead to pulmonary hypertension and right ventricular
failure (cor pulmonale)

Systemic Thromboembolism
1. Most arise from intracardiac mural thrombi 2/3 from left ventricular infarcts and most others
are from dilated left atria
2. Less common origins aortic aneurysms, thrombi overlying ulcerated atherosclerotic plaques,
fragmented valvular vegetations, or venous system (paradoxical emboli)
3. Can dislodge anywhere common sites= lower extremities (75%), CNS (10%), intestines,
kidneys, spleen
4. Arterial emboli often lodge in end arteries and cause infarction

Fat Embolism
1. Causes= soft tissue crush injury, rupture of marrow vascular sinusoids
2. Common incidental findings after vigorous CPR
3. Usually are not symptomatic
4. Could cause pulmonary insufficiency, neuro symptoms, anemia, thrombocytopenia, petechial
rash
5. Clinical Picture sudden onset of tachypnea, dyspnea, tachycardia, irritability, and restlessness
1-3 days after an injury
6. Pathogenesis mechanical obstruction and biochemical injury
a. Occlusion of pulmonary and cerebral microvasculature
b. Local toxic endothelial injury

Amniotic Fluid Embolism

1. Uncommon but grave complication of labor and immediate postpartum period
2. 80% mortality rate 5th most common cause of maternal death in US
3. 85% of survivors have permanent neurologic deficit
4. Onset severe dyspnea, cyanosis, and hypotensive shock followed by seizures and coma
a. If pt survives initial crisis, pulmonary edema usually occur and DIC
b. Death is thought to be associated with activation of thrombogenic substances from the
amniotic fluid and not the embolus itself
5. Underlying cause= entry of amniotic fluid into maternal circulation via tears in placental membranes and/or uterine vein rupture
6. Histology= squamous cells shed from fetus seen

Air Embolism
1. Cause= coalesced gas bubbles that obstruct vascular flow and cause distal ischemic injury
2. Decompression sickness: caused by sudden changes in atmospheric pressure can occur in scuba divers; in high pressures, there is increased
amount of gas dissolved in blood/tissues; if the diver ascends (depressurizes) too quickly, nitrogen expands in tissues and bubbles out to form gas
emboli
3. Bends: caused by gas bubbles within skeletal muscles and tissues in/around joints; very painful
4. Chokes: Gas bubbles in pulm vasculature can cause edema, hemorrhage, and focal atelectasis or emphysema and lead to respiratory distress
5. Caisson Disease: more chronic form of decompression sickness when recurrent or persistent gas emboli in bones lead to multifocal ischemic
necrosis; often affects the femur, tibia, and humerus
 6. Treatment: place pt in high pressure chamber to force gas back into solution to treat acute decompression sickness followed by slow
decompression to allow for gradual gas resorption x$
Infarction
1. Infarct= area of ischemic necrosis caused by occlusion of vascular supply to affected tissue
2. 40% of all deaths in US are a consequence of cardiovascular disease (often via MI or stroke)
3. Common cause= arterial thrombosis or arterial embolism
4. Less common causes of arterial obstruction= vasospasm, expansion of an atheroma, extrinsic
compression of a vessel, dissecting aortic aneurysm, or edema in a confined space
5. Venous thrombosis less likely to cause infarction and more likely to cause congestion b/c
bypass channels usually allow enough outflow to restore arterial inflow
a. Infarcts caused by venous thrombosis generally occur in organs with a single efferent
vein such as testis or ovary

Factors that Influence Infarct Development

1. Anatomy of vascular supply most important factor in prognosis is presence or absence of
alternative blood supply
a. EX: dual blood supply of lung via pulmonary and bronchial arteries decreases risk of
lung infarction
b. EX: liver receives blood from hepatic artery and portal vein
c. EX: hand and forearms have radial and ulnar supply
d. EX: kidney and spleen both have end arterial circulation making them more likely to
become infarcted
2. Rate of occlusion slowly developing occlusions give the body more time to develop collateral
blood supply to decrease chance of infarction; rapid occlusion is more likely to cause infarction
since body doesn’t have time to develop collateral supply
3. Tissue vulnerability to hypoxia
a. Neurons irreversible damage within 3-4 minutes of deprived blood supply
b. Myocardial cells 20-30 minutes until cell death from deprived blood supply
c. Fibroblasts within myocardium can remain viable for hours

Shock
1. Shock= state in which diminished cardiac output or reduced effective circulating blood volume
impairs tissue perfusion and leads to cellular hypoxia
2. Cardiogenic Shock: caused by low cardiac output via myocardial pump failure, MI, arrhythmia,
compression, outflow obstruction
3. Hypovolemic Shock: low cardiac output due to blood or plasma volume loss
4. Septic Shock: can be triggered by infection, burns, trauma, pancreatitis; massive inflammatory
mediator outpouring causes vasodilation and vascular leak leading to venous blood pooling and
tissue hypoperfusion

Pathogenesis of Septic Shock

1. Common trigger= gram positive bacterial infections (most common), gram negative bacteria,
fungi
2. Trigger will activate many immune factors that lead to inflammatory response
3. Superantigen polyclonal T-lymphocyte activators that induce release of cytokines that can lead to septic shock (EX: toxic shock syndrome)
4. Inflammatory Factors
a. Activation of TLRs (toll-like receptors) via recognition of PAMPs (pathogen associated molecular patterns)
b. GPCRs that detect bacterial peptides
c. Cytokine production TNF, IL-1, IFN-y, IL-12, IL-18 have been implicated
d. C-reactive protein marker of acute inflammation that is often used as an indicator of septic shock
e. Complement cascade activation
5. Hyperinflammatory state can also trigger counterregulatory immunosuppressive mechanisms leading to an oscillation of hyperinflammatory and
hypoinflammatory states
6. Proinflammatory states causes endothelial cell activation widestpread vascular leakage and tissue edema leading to systemic hypotension
 7. Induction of procoagulant state DIC occurs in 50% of septic patients via cytokine release and endothelial cell dysfunction
8. Metabolic Abnormalities
a. Septic patients exhibit insulin resistance and
hyperglycemia triggered by cytokines such as
TNF and IL-1
b. Many proinflammatory cytokines suppress or
stimulate insulin release depending on the
tissue lead to an ultimate state of
hyperglycemia
c. Hyperglycemia decreases neutrophil
function making it harder for body to fight the
initiating infection
d. Lactic acidosis via decreased oxidative
phosphorylation
9. Clinical Outcomes
a. Depends on immune status of host and
comorbidities
b. Standard of care= antibiotics to treat
underlying infection and IV fluids, pressors, and
supplemental O2 to maintain blood pressure
and limit tissue hypoxia

Stages of Shock
1. Initial nonprogressive stage when reflex compensatory
mechanisms are activated and organ perfusion is
maintained
a. Compensatory mechanisms= baroreceptor
reflexes, catecholamine release, ADH (anti-
diuretic hormone), renin-angiotensin
aldosterone axis, general sympathetic stim
b. Net effect= tachycardia, peripheral
vasoconstriction, renal fluid conservation, cool skin and pallor
c. Blood is shunted from skin to vital organs like heart and brain
2. Progressive stage tissue hypoperfusion and onset of worsening circulatory and metabolic
derangement including acidosis
a. Widespread tissue hypoxia
b. Excessive lactid acid production due to increased need for anaerobic glycolysis
c. Blood pooling in microcirculation
3. Irreversible Stage when cell and tissue injury are so severe that even if hemodynaic
defects are corrected, survival is not possible
a. Widespread cell injury reflected by lysosomal enzyme leakage
b. Worsening myocardial contractile function
c. Ischemic bowel may lead to leakage of intestinal flora which leads to a
superimposed bacteremic shock
d. Progression to renal failure
4. Clinical Features
a. Hypovolemic and Cardiogenic Shock hypotension, weak and rapid pulse,
tachypnea, cool + clammy skin, cyanotic skin
b. Septic shock warm and flushed skin
c. Prognosis depends on origin and duration