Cellular adaptation Cell injury and death

Cell Injury: Cells proceed in order to maintain their Intra & Extracellular environment within a
narrow range of physiological norms (homeostasis) .e.g. partial pressure of gases, Ph of arterial
blood, Blood Pressure. They are constantly adjusting structure and function to accommodate
changing demands and extracellular stresses. The principal adaptive responses are:

 Atrophy.
 Hypertrophy.
 Hyperplasia.
 Metaplasia.
 Regeneration.

If the cell’s adaptive capability is exceeded, cell injury may develop. Within certain limits, injury is
reversible and cells return to a stable baseline; however with persistent stress, irreversible injury
results and the affected cells die.

Causes of Cell Injury:

 Hypoxia due to inadequate blood oxygenation or reduction of oxygen-carrying capacity

 Chemical agents (not only toxins, but also substances normally present in our body: glucose)
 Infectious agents
 Immune reactions (Anaphylaxis, autoimmune reactions...)
 Genetic defects (inborn errors of metabolism mainly)
 Nutritional imbalance (protein energy insufficiency, vitamins deficiency)
 Physical agents (trauma, extreme temperatures, changes in atmospheric pressure)
 Aging process. (Repeated trauma can lead to tissue degradation even in the absence of cell
death)

Mechanisms of Cell Injury:

Four intracellular systems are most vulnerable:
 Cell membrane integrity.
1
  ATP generation.(via mitochrondial aerobic respiration)
 Increase in Intracellular Calcium
 Integrity of genetic apparatus.

Figure 1 Cellular and biochemical sites of damage in cell injury

Biochemical mechanisms of Cell Death:

• ATP depletion (blocks of metabolic pathways and transport mechanisms, protein synthesis)
1- failure of cell membrane pump (Na+ K+ATPase) results in increase intracellular Na and
water ………..cellular swelling, swelling of endoplasmic reticulum and swelling of
mitochondria.
2- Disaggregation of ribosomes and failure of protein synthesis.
3- Stimulation of phophofructokinase activity and accumulation of lactic acid secondary to
anaerobic glycolysis.

• Oxygen deprivation, lack of O2 this may induce formation of oxygen reactive species (free
radicals) e.g. O2-, H2-, H2O2- upon redox reaction.

To be noted that hypoxic injury becomes irreversible after :

- 3-5 minutes for neurons
- 1-2 hours for myocardial cells and hepatocytes
- Many hours for skeletal muscle cells

• Loss of calcium homeostasis.









2
 

Figure 2. Sources and consequences of increased cytosolic calcium in cell injury. ATP, adenosine
triphosphate

• Defect in plasma membrane permeability. (Bacteria toxin)

• Mitochondrial damage (defective metabolism).

Patterns of Cell Death:

 Necrosis
 Apoptosis
 Necrobiosis

A. Necrosis: occurs as a result of loss of blood supply, exposure to toxins or effects of chemical and
physical factors.
It is characterized by cellular swelling, protein’s denaturation and organelles break down. This type
of cell death may cause important tissue dysfunction.

Three irreversible nuclear changes: Pyknosis, Karyorrhexis and Karyolysis.

A. Pyknosis: is the shrinkage of the nucleus; chromatin becomes collected in few dense
fragments.
B. Karyorrhexis: is the fragmentation of the nucleus & breakdown of the chromatin.
C. Karyolysis: is the degradation and complete destruction of the nucleus & dissolution
of chromatins

At the level of the cytoplasm the following changes are observed:

 Loss of granules.
 Loss of Striations.
 Shrinking.
 Swelling of intracellular organelles.

3
 Figure 3. Schematic representation of a
normal cell and the changes in
reversible and irreversible cell injury...

-Types of Necrosis: based on the gross appearance of tissues obtained and on whether the cellular damage
is due to enzymatic catabolism or to protein denaturation three types are mainly described:

a) Coagulative necrosis
b) Liquefaction necrosis
c) Fat necrosis.
a. Coagulative Necrosis: Is the most common type of necrosis and characterized by cell swelling,
denaturation of cytoplasmic protein and breakdown of organelles.
In this typeof necrosis the necrotic tissues will have opaque appearance (like boiled meat).this
irreversible focal injury appears after sudden cessation of blood flow in organs such as heart, kidney
and spleen or as result of some chemicals(mercury, phenol). Areas with coagulative necrosis are
pale, firm, and slightly swollen. As necrosis progresses, tissues become more yellowish and softer as
result of inflammatory reaction and autolysis.

Caseous necrosis ( Caseous=cheesy): is a variant of coagulative necrosis encountered when cell

death is attributable to certain microorganisms (like in case of tuberculosis, tularemia, syphilis,
histoplasmosis), necrotic tissues are soft, granular, friable and reminiscent (like dry cheese).
Caseous necrotic tissues have affinity for salts, thus they frequently become calcified and
surrounded by fibrous capsule

b. Liquefaction Necrosis: it is a focal degradation of tissues that rapidly undergo softening and
liquefaction e.g.: brain (CNS injury).

c. Fat Necrosis: it is mainly seen in adipose tissue or near the pancreas as result of lipase leakage.
(Saponification)
Necrosis Results usually in Infarction and gangrene formation.

4
B. Apoptosis: it is a kind of internally controlled suicide. In this case dead cells are removed with minimal
damage of surrounding tissues. This process involves a specific proteolytic cascade that causes the cell to
shrink and condense, which alters the cell surface and leads to cell damage.Those cells are phagocytosed
with no leakage of their contents (Epidermis, menstruation)

C. Necrobiosis: Applied when degeneration develops gradually and necrotic parts remain attached to
healthy body parts.

Mechanisms of Free radical-induced injury:

Free Radical: Chemical Species with a single unpaired electron in its outer orbit .Molecules that react with
free radicals become free radicals in their turn
-Free radicals may be generated within cells by:
• Redox reactions during normal physiological process like respiration, intracellular oxidase
activity(xanthine oxidase), metal transition(Cupper,Iron).
They generate O2.-(superoxide radicals), OH-, and H2O2
• Nitric oxide (NO) is an important mediator that can act as a free radical by conversion into highly
reactive nitrite species.
• Absorption of radiant energy (ultraviolet light, X rays), it can result in hydrolysis of water into OH-
and H+.
• Enzymatic metabolism of exogenous chemicals like carbontetrachloride.

-Three reactions are particularly relevant to cell injury mediated by free radicals:

1. Lipid peroxidation of membranes (destruction of double bonds of polyunsaturated lipids)

2. DNA fragmentation: free radicals react with thymine in nuclear and mitochondrial DNA. Such
interaction is mainly implicated in cell killing and malignant transformations.

3. Cross-linking of proteins: free radicals promote sulfhydryl-mediated protein cross-linking

resulting in enhanced rate of degradation or loss of enzymatic activity.

Figure 4. Functional and morphologic

consequences of decreased intracellular
ATP during cell injury.

5
Antioxidant system :
Cells have developed multiple mechanisms to remove free radicals and thereby minimize injury. Free
radicals are inherently unstable and generally decay spontaneously. Superoxide, for example, is
unstable and decays (dismutates) spontaneously into oxygen and hydrogen peroxide in the presence
of water. There are, however, several nonenzymatic and enzymatic systems that contribute to
inactivation of free radical reactions (seeFig. 5 ). These include the following:

•    Antioxidants either block the initiation of free radical formation or inactivate (e.g., scavenge) free
   radicals and terminate radical damage. Examples are the lipid-soluble vitamins E and A as well as
ascorbic acid and glutathione in the cytosol.
•    As we have seen, iron and copper can catalyze the formation of reactive oxygen species. The levels
   of these reactive forms are minimized by binding of the ions to storage and transport proteins
(e.g., transferrin, ferritin, lactoferrin, and ceruloplasmin), thereby minimizing OH formation.
•    A series of enzymes acts as free radical-scavenging systems and break down hydrogen peroxide
and superoxide anion. These enzymes are located near the sites of generation of these oxidants
and include the following:
   •    Catalase, present in peroxisomes, which decomposes H2O2 (2 H2O2 ➙ O2 + 2 H2O).
•    Superoxide dismutases are found in many cell types and convert superoxide to H2O2 (2 O2-
+ 2 H ➙ H2O2 + O2). This group includes both manganese-superoxide dismutase, which is
  
   localized in mitochondria, and copper-zinc-superoxide dismutase, which is found in the
cytosol.
•    Glutathione peroxidase also protects against injury by catalyzing free radical breakdown
(H2O2 + 2 GSH ➙ GSSG [glutathione homodimer] + 2 H2O, or 2 OH + 2 GSH ➙ GSSG + 2
   H2O). The intracellular ratio of oxidized glutathione (GSSG) to reduced glutathione (GSH) is
a reflection of the oxidative state of the cell and is an important aspect of the cell's ability
to detoxify reactive oxygen species.

In many pathologic processes, the final effects induced by free radicals depend on the net balance
between free radical formation and termination. As stated earlier, free radicals are thought to be
involved in many pathologic and physiologic processes, to be mentioned throughout this book.

6
 Fig 5. The role of
reactive oxygen
species in cell injury.

-Cellular adaptation to injury:

• Regeneration: is a process of morpho-functional restoration of organs, tissues, cells & intracellular

organelles without intensification or increase of cell and organ function e.g.: restoration of recovering
epithelial skin & mucous membrane. It can be physiological and pathological.
Pathological Regeneration: takes place when a disturbance of the process of regeneration occurs; e.g.:
insufficient regeneration or Big Callus Formation.
Three groups of cells are known according to Cells’ Capacities for Regeneration: Labile cells, Stable cells
and Permanent cells.

A. Labile cells: continue to multiply during all life e.g.: epithelial cells of skin, lymph nodes,
mucous membrane, erythrocytes.
B. Stable cells: have a decrease or loss of ability for regeneration in adolescents but retain their
ability to proliferate in adult like e.g. paranchymal cells of liver, pancreas, kidney, adrenal
and thyroid.
C. Permanent cells: they lose their ability to proliferate around time of birth e.g.: neurons of
the central nervous system. (CNS)

• Hypertrophy: it is the increase of size & mass of morphofunctional structures (organs, cells,
intracellular organelles) & intensification of their functions. This hypertrophy can be physiological or
pathological ( an increase of uterus size & mammary glands in response to pregnancy is counted
physiological)

7
 •Atrophy: wasting & diminution in size & function of the cells tissues or organs. (An organ can be
undersized due to imperfect development –hypoplasia- e.g.: birth defect). It can also be due to
physiological or pathological reactions. Physiological atrophy like thymus and atrophy of genital organs
with age…
Pathological atrophy is due to several causes:
 Defective supply of nutrients.
 Due to reduction of blood supply.
 Diminishing of functional activity.
 Damage of nerve supply. (naturopathic atrophy)
 Deficiency of endocrine glands.
 Pressure atrophy e.g.: tumors or even external pressure.

 Metaplsia is the reversible replacement of one differentiated cell type with another mature
differentiated cell type. The change from one type of cell to another is generally caused by some
sort of abnormal stimulus. In simplistic terms, it is as if the original cells are not robust enough to
withstand the new environment, and so they change into another type more suited to the new
environment. If the stimulus that caused metaplasia is removed or ceases, tissues return to their
normal pattern of differentiation. Metaplasia is not synonymous with dysplasia and is not directly
considered carcinogenic. It is also contrasted with heteroplasia, which is the abnormal growth of
cytologic and histologic elements without a stimulus.

It is a benign (i.e. non-cancerous) change that occurs as a response to chronic physical or chemical
irritation, such as cigarette smoke that causes the mucus-secreting ciliated simple columnar
respiratory epithelial cells that line the airways to be replaced by stratified squamous epithelium,
or a stone in the bile duct that causes the replacement of the secretory columnar epithelium with
stratified squamous epithelium (Squamous metaplasia).
Although metaplasia is an adaptation that replaces delicate cells with hardier ones that are more
likely to be able to withstand the stresses that the epithelium is faced with, it is also accompanied
by a loss of epithelial function, and is considered undesirable; this undesirability is underscored by
the propensity for metaplastic regions to eventually turn cancerous if the irritant is not
eliminated. Specialised epithelial cells are already differentiated, and cannot simply transform
their morphologies to change from one cell type to another. Metaplasia, then, does not occur as a
result of any change in the pre-existing epithelial cells but rather as a result of reprogrammed
stem cells present in the organ's connective tissue that are nudged along a different pathway of
differentiation by cytokines, growth factors and other substances in the cell's environment. In a
nutshell, metaplasia occurs by stem cells that reprogram differentiation of cells rather than by
transdifferentiation.

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 BAU-Pathology Notes Booklet 2-Fall 2011-12/Dr. Samaha

Inflammation

Inflammation is a typical pathological process that has the following characteristics:

- Occurs in response to any factor that damages tissues.
- Includes local manifestation, involving blood cells, connective tissues & vessels.
- Aim of inflammation is elimination of harmful agent & restoration of disturbed functions.

Every organ & tissues are susceptible to inflammation; the degree and nature of inflammatory response depend
on:
- Personal reactivity.
- Nature & severity of stimulus.
- Peculiarities of organs & their circulation.
- Properties of connective tissues.

Classification of inflammation:
1. According to Etiology: inflammation can be infectious or aseptic(non-infectious)

2. according to dynamics of inflammation or time:

• Acute inflammation: less than 3 weeks.
• Sub-acute inflammation from 3-6 weeks.
• Chronic inflammation more than 6 weeks.

Cardinal signs of inflammation:

- Local heat (calor)
- Redness (rubor)
- Pain (dolor)
- Swelling & edema (tumor)
- Loss of function (functio lesiae)

Pathogenesis of Inflammation:
A) Stages of Inflammation:

1. Alteration:
- Starts with tissue injury; this injury might be primary or secondary.
- Primary tissue injury occurs under action of harmful agents as well as circulatory & metabolic disorders.
- Secondary injury develops during inflammatory process. Some mechanisms of secondary inflammation
development are known:
a) Action of leukocytes and lysosomal enzymes (proteases, phospholipases , etc.)
b) Excessive formation of free radicals.
c) Disturbance in blood supply.
d) Hypoxia and acidosis.
e) Activation of complements.
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 2. Exudation:
It is the output of fluids or part of blood from vessels into interstitial space surrounding inflammatory
area. Exudation develops due to:
1. Increase hydrostatic pressure in vessels (hyperemia).
2. Decrease osmotic pressure in vessels (acidosis).
3. Increase oncotic or colloid pressure in interstitial space (due to cells’ destruction).
4. Increase in vascular wall permeability.

Main mechanisms of increased vascular walls permeability:

a) Direct injury of vascular wall.
b) Contraction of endothelial cells & formation of pores between them.
c) Action of lysosomal enzymes and complement activation.
d) New formed capillaries have higher permeability.

3. Proliferation:
This stage is characterized by angiogenesis, collagen deposition, granular tissue formation and formation
of new cells or formation of a scar tissue.

B) Vascular Changes in inflammation

Changes in blood flow in inflamed area are crucial for development of inflammatory signs and symptoms.
These changes run in the following order:

1- Inconstant and transient vasoconstriction of arterioles, lasting for a few seconds, due to activation of
adrenergic reflex by pain irritation& due to action of serotonin & endothelin.

2-Arterial hyperemia: observed due to vasodilatation & release of blood elements into inflamed area.
Arterial hyperemia develops due to:
- Exhaustion of adrenergic reserve & release of acetylcholine
- Release of histamine, substance “P” & prostaglandins.

- The effects Histamine are provided by two kinds of receptors: H2 receptors which mediate dilation of
arterioles & H1 receptors mediate venules permeability.

- This stage is characterized by the following Manifestations:

a) Redness due to increase of blood flow into inflamed area. (Blood rich in O2)
b) Increase of temperature of inflamed area.
c) Presence of arterial pulsation.

3- Venous hyperemia: develops due to decrease of blood output from inflamed tissue. There are three
mechanisms explaining development of this stage:

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 a) Intravascular changes:
 Elevation of blood viscosity due to leukocytes’ margination and increase of globulin &
swelling of RBC’s.
 Activation of clotting system and microthrombosis.
 Slowing of blood flow.

b) Vascular changes: manifested as swelling of endothelium & disturbance in its adhesion

properties.
c) Extravascular changes: compression of blood vessels by lymphatic ones.

4- Stasis: means stopping of blood flow in inflamed areas.

C) Inflammatory mediators:
They are classified according to their Origin: we have cellular mediators & plasma mediators.
- Cell mediators: are either preformed or newly synthesized.
a) Preformed: are present in our cells before inflammation e.g.: histamine,
serotonin, lysosomal enzymes.
b) Newly synthesized: produced in case of inflammation like prostaglandins,
leukotrienes, platelet activating factors and cytokines.

- Plasma mediators: like complements C3a, C5a, & Hageman factor or factor XII.

D) Cellular mediators: include vasoactive Amines, arachidonic acid metabolites and cytokines

- Vasoactive amines:
1) Histamine mediates the increase in capillary permeability associated with contraction of endothelial cells
in post-capillary venulae that occurs with mild injuries. It is liberated from basophiles, mast cells, and
platelets. Histamine is liberated by degranulation triggered by the following stimuli:
- Binding of specific antigen to basophiles and mast cell membrane-bound IgE (complement is not
involved)
- Binding of complement fragments C3a and C5a, anaphylatoxins, to specific cell-surface receptors on
basophiles and mast cells (specific antigen and IgE antibodies are not involved)
- Physical stimuli such as heat and cold

2) Serotonin (5-hydroxytryptamine): derives from platelets and liberated alongside with histamine and acts
similarly to it.

- Arachidonic acid metabolites

Arachidonic acid, a 20-carbon fatty acid, is the primary precursor of inflammatory mediators. It is present as
a component of phospholipids of cell membranes (primarily phosphatidil inositol and other complex lipids).
Free arachidonic acid is released from tissues by the action of phospholipase A2 and other acyl hydrolases.
There are two pathways in the synthesis of eiconosoids from arachidonid acid:

11
a) Cyclooxygenase pathway: all eiconosoids with ring structures. The prostaglandins, thromboxanes and
prostacyclins, are synthesized via this pathway. Two cyclooxygenases have been identified: COX-1 and
COX-2. COX-1 is constitutive, whereas COX-2 is induced in response to inflammatory stimuli.
COX-1: regulates angiogenesis in endothelial cells, it is also involved in cell signaling, promotes the
production of natural mucus lining that protects the inner stomach and contribute to reduced acid
secretion and reduced pepsin content. It is normally present in a variety of areas in the body, including
not only the stomach but any other site of inflammation.
COX-2: is expressed in a limited number of cell types and regulated by specific stimulatory events,
suggesting it is responsible for the prostanoid biosynthesis involved in inflammation and mitogenesis.

b) Lipoxygenase pathway: several lipoxygenases act on arachidonic acid to form 5-

HPETE( hydroperoxyeicosatetraenoic acid) and HETE (hydroxyeicosatetraenoic acid) that are unstable
and converted to leukotriens and lipoxins.

 Thromboxanes A2 and PGF2α are pro-inflammatory because they induce platelet aggregation &
stimulate mediators’ formation.

 PGE2 is thought to sensitize the nerve endings to the action of bradykinin, histamine and other chemicals
which leads to pain sensation’s development. Also it modifies the set point of thermoregulatory center
and has an important function in fever development.

 PGE2 and PGF2α stimulate synthesis of protective mucus in both stomach and small intestine
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  Endothelial PGI2 is a powerful vasodilator and inhibitor of platelet aggregation.

 LTB4, a chemotactic factor for neutrophils

 LTC4, LTD4, and LTE4, potent vasoconstrictors, bronchoconstrictors, and mediators of increased
capillary permeability, which are sometimes jointly referred to as the slow-reacting substance of
anaphylaxis (SRS-A)

 Lipoxins: are anti-inflammatory mediators

Inflammatory Actions of Eiconosoids

Action Metabolite
Vasoconstriction Thromboxane A2, leukotrienes C4, D4, E4
Vasodilation PGI2, PGE1, PGE2, PGD2
Increased vascular permeability Leukotrienes C4, D4, E4, Histamine,Serotonin, Bradykinin, Nitric Oxide
Chemotaxis, leukocyte adhesion Leukotriene B4, HETE, lipoxins

c) Cytokines:
- Are soluble proteins secreted by several types of cells.
- Can act as effector molecules influencing the behavior of other cells.
- Are mediators of immunologic response; e.g., interferon-gamma (produced by T cells and NK cells)
activates monocytes.
- Are also important mediators of inflammation. The cytokines IL-1 and TNF are secreted by monocytes-
macrophages and other cells and have several effects on inflammation:
▪ They induce acute phase responses, such as:
- Systemic effects of inflammation, including fever and leukocytosis
- Hepatic synthesis of acute phase proteins, such as C-reactive protein, serum amyloid-associated
protein, complements components, fibrinogen, prothrombin, ferritin, and ceruloplasmin
- Synthesis of adhesion molecules
- Neutrophil degranulation

▪ They reduce the thrombo-resistant properties of endothelium, thus promoting thrombosis.

E- Humoral mediators: Three systems are mainly involved:

- Kinin-Kalikrenin system: mediates vascular permeability, arteriolar dilation and pain.
- Coagulative system: participate in activation of both coagulative and anti-coagulative systems.
- Complement system: consists of a group of plasma proteins that participate in immune lysis of cells:

13
 1) C3a and C5a (anaphylatoxins) mediate degranulation of basophils and mast cells with the release of
histamine. C5a is chemotactic, mediates the release of histamine from platelet dense granules, induces
expression of leukocyte adhesion molecules, and activates the lipoxygenase pathway of arachidonic acid
metabolism.
2) C3b is an opsonin.
3) C5b-9, the membrane attack complex, is a lytic agent for bacteria and other cells.

F-Cellular Reactions in Inflammation:

1) Neutrophils: are the most prominent inflammatory cells in foci of acute inflammation during the first 24
hours. Important causes of neutrophilia (increased neutrophils in the peripheral blood) include bacterial
infections and other causes of acute inflammation, such as infarction.

2) After 2-3 days, neutrophils are replaced mainly by monocytes and macrophages, which are longer-lived,
capable of engulfing larger particles and dividing and proliferating within the inflamed tissue. Important causes
of monocytosis (i.e., increased number of monocytes in the peripheral blood) include tuberculosis, brucellosis,
and salmonella infection.

3) Lymphocytes are the most prominent inflammatory cells in many viral infections and, along with
monocytes-macrophages and plasma cells, are the most prominent cells in chronic inflammation.
Lymphocytosis (i.e., an increased number of lymphocytes in the peripheral blood) is most often caused by viral
infections such as influenza, mumps, rubella, and infectious mononucleosis and certain bacterial infections such
as whooping cough and tuberculosis.

4) Eosinophils are the predominant inflammatory cells in allergic reactions and parasitic infestations. The most
important causes of eosinophilia include allergies such as asthma, hay fever, and hives and also parasitic
infections. Other causes include polyarteritis nodosa and Hodgkin lymphoma.

5) Mast cells and basophils are sources of histamine. Important causes of basophilia include chronic
myelogenous leukemia and other myeloproliferative diseases.

Cellular response of leukocytes

1. Emigration: is the passage of inflammatory leukocytes between the endothelial cells into the adjacent
interstitial tissue. Before emigration, circulating leukocytes from the central blood flow move toward the
endothelial surface.
a. Margination: occurs as leukocytes localize to the outer margin of the blood flow adjacent to the
vascular endothelium.
b. Pavementing: occurs as leukocytes line the endothehal surface.
c. Rolling (or tumbling): is mediated by the action of endothehal selectins loosely binding to leukocytes
and producing a characteristic "rolling" movement of the leukocytes along the endothelial surface.
d. Adhesion: occurs as leukocytes adhere to the endothelial surface. it is mediated by the interaction of
integrins on leukocytes binding to immunoglobulin-family adhesion proteins on endothelium.
e. Transmigration: is the movement of leukocytes across the endothelium. it is mediated by platelet
endothelial cell adhesion molecule-1 (PECAM-1) on both leukocytes and endothelium.
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2. Chemotaxis:
- is the process by which leukocytes are attracted to and move toward an injury.
- is mediated by diffusible chemical agents (Table 2-1); movement of leukocytes occurs along a
chemical gradient.
- Chemotactic factors for neutrophiis, produced at the site of injury, include:
a. Products from bacteria
b. Complement components, especially C5a
c.Arachidonic acid metabolites, especially leukotriene B4 (LTB4),
hydroxyeieosatetraenoic acid (HETE), and kallikrein

3. Phagocytosis: is the ingestion of particulate material (e.g., tissue debris, living or dead bacteria, other foreign
cells) by phagocytic cells. Neutrophils and monocytes-macrophages are the most important phagocytic cells.
a. Opsonization: facilitates phagocytosis by coating of particulate material by substances referred to as
opsonins, which immobilize the particles on the surface of the phagocyte. The most important opsonins
are immunoglobulin G (IgG) subtypes and C3b, a complement component.

b. Anatomic changes: Phagocytosis is characterized morphologically by internalization of the attached

opsonized particle by pseudopodial extensions from the surface of the leukocyte, which enclose the
foreign particle, forming an internalized vesicle, the phagosome; Phagosomes fuse with cytoplasmic
lysosomes and form phagolysosomes (associated with leukocytic degranulation).

4. Intracellular microbial killing: is mediated within phagocytic cells by oxygen-dependent and oxygen
independent mechanisms.

15
Outcome of acute inflammation

1. Resolution of tissue structure and function: often occurs if the injurious agent is eliminated.
2. Tissue destruction and persistent acute inflammation
a. Abscess:
o Is a cavity filled with pus (neutrophils, monocytes, and liquefied cellular debris).
o Is often walled off by fibrous tissue and is relatively inaccessible to the circulation,
o Results from tissue destruction by lysosomal products and other degradative enzymes.
o Is usually caused by bacterial infections, often by staphylococci.

b. Ulcer
o Is the loss of surface epithelium.
o Can be caused by acute inflammation of epithelial surfaces (e.g., peptic ulcer, ulcers of the skin).

c. Fistula
o is an abnormal communication between two organs or between an organ and a surface

d. Scar
o Is the final result of tissue destruction, with resultant distortion of structure and, in some cases,
altered function.

3. Conversion to chronic inflammation: is marked by the replacement of neutrophils and monocytes with
lymphocytes, plasma cells, and macrophages. often includes proliferation of fibroblasts and new vessels, with
resultant scarring and distortion of architecture.
o Cells involved in chronic inflammation are mainly Macrophages, lymphocytes and Monocytes
but there is no Neutrophils.
o Accumulation of mononuclear cells in inflamed areas called “granuloma”.
o Microbes engulfed by Macrophages are not destroyed so they can live inside them, which
stimulate continuous secretion of inflammatory mediators. Macrophages secrete hemopoeitin
which stimulate formation of monocyte in bone marrow.

Systemic Manifestation in Inflammation:

▪ Activation of endocrine system and arising of inductive syndrome characterized by release of hormones
affecting inflammatory process; two groups of hormones are distinguished:
- Pro-inflammatory hormones: reinforce inflammation development like growth hormone, aldosterone &
thyroxin.
- Anti-inflammatory hormones like glucocorticosteroids & cortisol acting by:
• Inhibiting phospholipase A2 and inactivation of eiconozoids.
• Activation of histaminases.
• decrease immune response.
▪ Fever.
16
▪ Changes in blood functional state:
 Leukocytosis.
 Increase acute phase proteins.
 Increase of ESR.

Acute Phase Protein:

The following proteins are known to be elevated in acute phase protein:
1) Protease inhibitors like alpha-1 antitrypsin that inactivate proteases in extracellular
fluid (collagenase & elastase).
2) C-reactive proteins: indicator of inflammation, participate in complement activation &
stimulate phagocytosis.
3) Haptoglobin: reacts with hemoglobin & induce Peroxidase activity.
4) Fibrinogen responsible for blood clotting and promotes wond healing.

Advantages of Inflammation:
 Localization & isolation of injury.
 Neutralization & inactivation of toxic substances.
 Destruction of microbes.
 Preparation for wound healing.
Disadvantages of inflammation:
 Pain & swelling, leading to some disabilities.
 Inflammation may lead to rupture of visceral organs and sometimes severe
hemorrhage.
 Formation of scar tissue.
 Prolonged inflammation may cause destruction of surrounding healthy tissues.

Treatment of Inflammation:
two lines of treatments:
- Symptomatic treatments.
- Etiologic treatments.

1. Etiological therapy directed toward elimination of cause of disease (antibiotics, injury repair).

2. Pathogenic treatment or symptomatic: directed on the main mechanism of pathological process.

a. Inactivation & inhibition of formation & release of inflammatory mediators.
b. Block of release of lysosomal enzymes by stabilization of lysosomal membranes.
c. Prevention of excessive free radicals formation.
d. Proinflammatory therapy: in case of chronic inflammation.

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 FEVER

Fever is a typical pathological process having the following characteristics:

- It has been developed in evolution as a general reaction in warm blooded animals and humans.
- It arises as consequence of the action of special substances called “pyrogenes”.
- It arises as a result of disturbances of the thermoregulatory center of the hypothalamus.

-Classification of Fever: Based on the degree of body temperature:

 Sub-febrile fever: 37-38◦ C
 Febrile fever: 38-39 ◦C
 Highgrade fever: 39-40◦ C
 Hyperpyeritic fever: 40◦ C

-Pathogenesis of fever:
→When exogenous pyrogens are present in tissues or blood they are engulfed by leukocytes (large killer
lymphocytes or Macrophages)
→Activated Macrophages produce IL-1 & TNF-α, Activated T cells produce TNF- and other phagocytes
produce IL-1 & IL-2 (endogenous pyrogenes).
→Il-1 produces fever immediately that reaches the hypothalamus (preoptic area) which may lead to an
increase in temperature in 10 minutes.
→Endogenous pyrogenes act on preoptic area to change its thermostat & stimulate production of
prostaglandins by hypothalamic neurons. Also pyrogenes activate phospholipase and cyclooxygenase
activity and prostaglandins are further produced.
→PGE2 activates adenylate cyclase in cells & cause the accumulation of AMP in neuron as well as
activation of protein kinase. All of these will provide change in neuron metabolism & excitability.
In the thermoregulatory center two types of neurons are present: cold sensitive neurons and warm
sensitive neurons.
→ Prostaglandin E2 action results in increasing sensitivity of cold sensitive neurons & decreasing
sensitivity to warm sensitive neurons.
→Cold sensitive neurons begin to analyze our normal blood temperature as cold and as a result it will
stimulate a group of reactions that increase heat production & decrease heat loss.
a) Mechanisms of decreasing of heat loss:
- Peripheral vasoconstriction; decrease of sweating & piloerection: mainly by stimulation of adrenergic
nervous system.
b) Mechanisms of increasing of heat production:
- Increase of metabolism, disturbances of oxidative phosphorylation (by adrenergic output) and an
increase of thyroid function.
- Shivering: How does shivering occur?
•The posterior hypothalamus initiates shivering via mid-brain& extra pyramidal nuclei.
•The impulses descend to motor neurons of spinal cord and then to the somatic motor neurons in an
asynchronous manner”on and off fashion”.
•This excitation will lead to synchronous muscular contractions & generation of heat (chills).

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 → After stopping of endogenous pyrogenes production and Normalization of cold sensitive neurons
sympathetic output is suppressed. But blood temperature stays high and will stimulate warm sensitive
neurons of hypothalamus.
→ Stimulation of warm sensitive neurons leads to prevalence of parasympathetic nervous activity which may
cause heat loss (This prevalence has negative chronotropic, bathomotropic effects).

-Stages of fever development: Three stages of fever development are known:

a) Increase of body temperature (prevalence of heat production over heat loss).
b) High constant temperature (balance between heat loss & production).
c) Decrease of body temperature (prevalence of heat loss).
- In the second stage, attention should be made for duration and level of fever.
•Duration of fever is affected by properties of causative agent & by endopyrogenes synthesis in the
organism.
•Level of temperature is connected with the endogenous pyrogens amount and with organisms’
reactivity.
- In the third stage of fever two patterns of body temperature’s decrease are known:
Rapid (critical) and Slow (lytic).

-Fever Auto prevention:

There are special systems of endogenous antipyresis for prevention of excessive hyperpyrexia. That is
the hypothalamic Arginin-Vasopressin mechanism. The decrease of body temperature in arginin-vasopressin
action is provided by the neuromodulative mechanism of action on the thermoregulatory centers. Arginin-
vasopressin decreases the excitability of cold-sensitive neurons of the hypothalamus.
Also Brain cortex has inhibitory influences on thermoregulatory centers too.

-Biological meanings of fever: fever has positive and negative effects on the general state of the human
organism.
a) Positive effects:
- Bacteriostatic effect of high temperature.
- Activation of non specific mechanisms of resistance to infection (phagocytosis, production of
INF …).
b) Negative effects:
- Disorders of brain function in case of excessive fever that may lead to convulsions,
unconsciousness & sometimes death.
-Hyperthermia:
- Hyperthermia is defined as an increase of body temperature due to disorder of the thermoregulatory
center. This center looses its capacity to support temperature balance.
- Etiology of hyperthermia: an increase of environmental temperature leads to difficulties in heat loss
(worst conditions, high temperature & high humidity).
- Stages of hyperthermia development:
 Compensating stage; normal body temperature (increase heat loss, decrease heat
production).
 Decomposition stage; develops due to exhaustion of thermoregulatory centers (body
temperature becomes dependent on environmental one).
 Development of “Coma” & death may occur due to respiratory center paralysis.

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20
 School of Arts and Sciences
Pathophysiology
Allergy

DEFINITIONS

A. Immunogen
A substance that induces a specific immune response.

B. Antigen (Ag)
A substance that reacts with the products of a specific immune response.

C. Hapten
A substance that is non-immunogenic but which can react with the products of a specific immune
response. Haptens are small molecules which could never induce an immune response when
administered by themselves but which can when coupled to a carrier molecule. Free haptens,
however, can react with products of the immune response after such products have been elicited.
Haptens have the property of antigenicity but not immunogenicity.

D.Allergen

Strictly speaking ,allergens are antigens that induce the production of specific IGE in humans,but the
has extended to antigens that produce other types of hypersensitivity.

Allergens include;plant pollen,house dust,animal hair and feathers,food such as milk and egg,foreign
serum and hormones.insect venoms,drugs and chemicals

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E.HYPERSENSITIVITY or allergy

It is an exaggerated or inappropriate reaction of the normal immune system that is harmful to the host.

The first contact of the person with the antigen sensitizes =induces the antibody and then the
subsequent contacts elicit the allergic response

Hypersensitivity reactions can be divided into four types: type I, type II, type III which are antibody
mediated and type IV which is cell mediated

So this classification is based on the mechanisms involved and time taken for the reaction. Frequently,
a particular clinical condition (disease) may involve more than one type of reaction.

TYPE I HYPERSENSITIVITY

Type I hypersensitivity is also known as immediate or anaphylactic hypersensitivity. The reaction may
involve skin (urticaria and eczema), eyes (conjunctivitis), nasopharynx (rhinorrhea, rhinitis),
bronchopulmonary tissues (asthma) and gastrointestinal tract (gastroenteritis). The reaction may cause
a range of symptoms from minor inconvenience to death. The reaction usually takes 15 - 30 minutes
from the time of exposure to the antigen, although sometimes it may have a delayed onset (10 - 12
hours).

Immediate hypersensitivity is mediated by IgE. The primary cellular component in this hypersensitivity
is the mast cell or basophil. The reaction is amplified and/or modified by platelets, neutrophils and
eosinophils. A biopsy of the reaction site demonstrates mainly mast cells and eosinophils.

The mechanism of reaction involves preferential production of IgE, in response to certain antigens
(allergens). IgE has very high affinity for its receptor on mast cells and basophils. A subsequent
exposure to the same allergen cross links the cell-bound IgE and triggers the release of various
pharmacologically active substances

Cross-linking of IgE Fc-receptor is important in mast cell triggering. Mast cell degranulation is preceded
by increased Ca++ influx, which is a crucial process; ionophores which increase cytoplasmic Ca++ also
promote degranulation, whereas, agents which deplete cytoplasmic Ca ++ suppress degranulation

NOTE : Mast cells may be triggered by other stimuli such as exercise, emotional stress, chemicals (e.g.,
photographic developing medium, calcium ionophores, codeine, etc.), anaphylotoxins (e.g., C4a, C3a,
C5a, etc.). These reactions, mediated by agents without IgE-allergen interaction, are not
hypersensitivity reactions although they produce the same symptoms.

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 Table 1- Pharmacologic Mediators of Immediate Hypersensitivity

MEDIATOR

Preformed mediators in granules

bronchoconstriction, mucus secretion, vasodilatation,

histamine
vascular permeability

tryptase Proteolysis

kininogenase kinins and vasodilatation, vascular permeability, edema

attract eosinophil and neutrophils

ECF-A
(tetrapeptides)
 

Newly formed mediators

leukotriene B4 basophil attractant

leukotriene C4,
same as histamine but 1000x more potent
D4

prostaglandins
edema and pain
D2

PAF platelet aggregation and heparin release: microthrombi

The reaction is amplified by PAF (platelet activation factor) which causes platelet aggregation and
release of histamine, heparin and vasoactive amines. Eosinophil chemotactic factor of anaphylaxis
(ECF-A) and neutrophil chemotactic factors attract eosinophils and neutrophils, respectively, which
release various hydrolytic enzymes that cause necrosis. Eosinophils may also control the local reaction
by releasing arylsulphatase, histaminase, phospholipase-D and prostaglandin-E, although this role of
eosinophils is now in question.
 

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Substances that increase intracellular cAMP seem to relieve allergic symptoms, particularly broncho-
pulmonary ones, and are used therapeutically Conversely, agents which decrease cAMP or stimulate
cGMP aggravate these allergic conditions.

Diagnostic tests for immediate hypersensitivity include skin (prick and intradermal) tests ,
measurement of total IgE and specific IgE antibodies against the suspected allergens. Total IgE and
specific IgE antibodies are measured by a modification of enzyme immunoassay (ELISA). Increased IgE
levels are indicative of an  atopic condition, although IgE may be elevated in some non-atopic diseases
(e.g., myelomas, helminthic infection, etc.).

There appears to be a genetic predisposition for atopic diseases and there is evidence for HLA (A2)
association.

Symptomatic treatment is achieved with antihistamines which block histamine receptors. Chromolyn
sodium inhibits mast cell degranulation, probably, by inhibiting Ca++ influx. Late onset allergic
symptoms, particularly bronchoconstriction which is mediated by leukotrienes, are treated with
leukotriene receptor blockers (Singulair, Accolate) or inhibitors of the Lipooxygenase pathway
(Zileutoin). Symptomatic, although short term, relief from bronchoconstriction is provided by
bronchodilators (inhalants) such as isoproterenol derivatives (Terbutaline, Albuterol). Thophylline
elevates cAMP by inhibiting cAMP-phosphodiesterase and inhibits intracellular Ca ++ release is also used
to relieve bronchopulmonary symptoms.

The use of IgG antibodies against the Fc portions of IgE that binds to mast cells has been approved for
treatment of certain allergies, as it can block mast cell sensitization.

Hyposensitization (immunotherapy or desensitization) could be acute or chronic,involves the

administration of small amount of the allergen.

It is another treatment modality which is successful in a number of allergies, particularly to insect

venoms and, to some extent, pollens. The mechanism is not clear, but there is a correlation between
appearance of IgG (blocking) antibodies and relief from symptoms. Suppressor T cells that specifically
inhibit IgE antibodies may play a role.

TYPE II HYPERSENSITIVITY

Type II hypersensitivity is also known as cytotoxic hypersensitivity and may affect a variety of organs
and tissues. The antigens are normally endogenous, although exogenous chemicals (haptens) which
can attach to cell membranes can also lead to type II hypersensitivity. Drug-induced hemolytic anemia,

24
granulocytopenia and thrombocytopenia are such examples. The reaction time is minutes to hours.
Type II hypersensitivity is primarily mediated by antibodies of the IgM or IgG classes and complement.
Phagocytes and K cells may also play a role (ADCC).

The lesion contains antibody, complement and neutrophils. Diagnostic tests include detection of
circulating antibody against the tissues involved and the presence of antibody and complement in the
lesion (biopsy) by immunofluorescence. The staining pattern is normally smooth and linear, such as
that seen in Goodpasture's nephritis (renal and lung basement membrane)

Treatment involves anti-inflammatory and immunosuppressive agents.

TYPE III HYPERSENSITIVITY

Type III hypersensitivity is also known as immune complex hypersensitivity. The reaction may be
general (e.g., serum sickness) or may involve individual organs including skin (e.g., systemic lupus
erythematosus, Arthus reaction), kidneys (e.g., lupus nephritis), lungs (e.g., aspergillosis), blood vessels
(e.g., polyarteritis), joints (e.g., rheumatoid arthritis) or other organs. This reaction may be the
pathogenic mechanism of diseases caused by many microorganisms.

The reaction may take 3 - 10 hours after exposure to the antigen (as in Arthus reaction). It is mediated
by soluble immune complexes. They are mostly of the IgG class, although IgM may also be involved.
The antigen may be exogenous (chronic bacterial, viral or parasitic infections), or endogenous (non-
organ specific autoimmunity: e.g., systemic lupus erythematosus, SLE). The antigen is soluble and not
attached to the organ involved. Primary components are soluble immune complexes and complement
(C3a, 4a and 5a). The
damage is caused by
platelets and
neutrophils. The
lesion contains
primarily
neutrophils and
deposits of immune
complexes and
complement.
Macrophages
infiltrating in later
stages may be involved
in the healing process.

The affinity of antibody

and size of immune
complexes are

25
important in production of disease and determining the tissue involved. Diagnosis involves
examination of tissue biopsies for deposits of Ig and complement by immunofluorescence. The
immunofluorescent staining in type III hypersensitivity is granular (as opposed to linear in type II such
as seen in  Goodpasture's syndrome). The presence of immune complexes in serum and depletion in
the level of complement are also diagnostic.

Treatment includes anti-inflammatory agents.

A
TYPE IV HYPERSENSITIVITY
B
Type IV hypersensitivity is also known as cell mediated or delayed type hypersensitivity. The classical
example of this hypersensitivity is tuberculin (Montoux) reaction which peaks 48 hours after the
injection of antigen (PPD or old tuberculin). The lesion is characterized by induration and erythema

Table 2  -   Delayed hypersensitivity reactions

Clinical
Reactio
Type appearanc Histology Antigen and site
n time
e

lymphocytes,
epidermal ( organic
followed by
chemicals, poison
contact 48-72 hr eczema macrophages;
ivy, heavy metals,
edema of
etc.)
epidermis

lymphocytes, intradermal
local
tuberculin 48-72 hr monocytes, (tuberculin,
induration
macrophages lepromin, etc.)

persistent antigen
macrophages, or foreign body
21-28
granuloma hardening epitheloid and presence
days
giant cells, fibrosis (tuberculosis,
leprosy, etc.)

26
Type IV hypersensitivity is involved in the pathogenesis of many autoimmune and infectious diseases
(tuberculosis, leprosy, blastomycosis, histoplasmosis, toxoplasmosis, leishmaniasis, etc.) and
granulomas due to infections and foreign antigens. Another form of delayed hypersensitivity is contact
dermatitis (poison ivy , chemicals, heavy metals, etc.) in which the lesions are more papular. Type IV
hypersensitivity can be classified into three categories depending on the time of onset and clinical and
histological presentation.
 

Mechanisms of damage in delayed hypersensitivity include T lymphocytes and monocytes and/or

macrophages. Cytotoxic T cells (Tc) cause direct damage whereas helper T (TH1) cells secrete cytokines
which activate cytotoxic T cells and recruit and activate monocytes and macrophages, which cause the
bulk of the damage . The delayed hypersensitivity lesions mainly contain monocytes and a few T cells.

Major lymphokines involved in delayed hypersensitivity reaction include monocyte chemotactic factor,
interleukin-2, interferon-gamma, TNF alpha/beta, etc.

Diagnostic tests in vivo include delayed cutaneous reaction (e.g. Montoux test ) and patch test (for
contact dermatitis). In vitro tests for delayed hypersensitivity include mitogenic response, lympho-
cytotoxicity and IL-2 production.

Corticosteroids and other immunosuppressive agents are used in treatment.

Table 3  -  Comparison of Different Types of hypersensitivity

type-I type-III type-IV

characteristic type-II
(anaphylactic (immune (delayed
s (cytotoxic)
) complex) type)

antibody IgE IgG, IgM IgG, IgM None

tissues &
antigen exogenous cell surface soluble
organs

15-30
response time minutes-hours 3-8 hours 48-72 hours
minutes

erythema erythema
lysis and
appearance weal & flare and edema, and
necrosis
necrosis induration

complemen monocytes
basophils and antibody and
histology t and and
eosinophil complement
neutrophils lymphocytes

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 transferred
antibody antibody antibody T-cells
with

erythroblastosi
SLE,
s tuberculin
allergic farmer's
test, poison
examples asthma, hay lung disease
fetalis, ivy,
fever
Goodpasture's granuloma
 
nephritis

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