HISTOPATHOLOGY

TOPICS
I. General Pathology
II. Cellular Injury and Cell Death

Prepared by: FRITZ VON GELLA, RMT, MD

 Learning Objectives
At the end of this lecture video, the student is able to:
• Define different terms associated with pathology.
• Explain the four aspects of disease process.
• Define the division and scope of pathology.
• Discuss the causes of cell injury
• Differentiate the types of cell death.
• Explain the mechanism of the changes in cell injury
• Identify the microscopic changes in reversible
and irreversible injury.
• Differentiate the types of necrosis
• Identify microscopic tissue findings in necrosis.
I. GENERAL PATHOLOGY
 Pathology
o From Greek “pathos” (suffering) and “logos” (study)

o Study of structural, biochemical and functional changes in

cells, tissues and organs that underlie diseases.

o Uses molecular, microbiologic, immunologic, and

morphologic techniques to attempt to explain the signs
and symptoms manifested by the patient.

o Serves as the bridge between the basic sciences and

clinical medicine.

o Scientific foundation for all of medicine.

 Divisions of Pathology
o General pathology – reactions of cells and tissues to
abnormal stimuli and inherited defects.

o Special, or Systemic pathology – specific responses in

specialized organs and tissues that are responsible for
disorders that involve these organs.
 4 Aspects of Disease Process
Etiology

Clinical
Pathogenesis
manifestations

Morphologic changes
 4 Aspects of Disease Process
o Etiology – origin of disease, which may be intrinsic/genetic or
acquired (infectious, nutritional, chemical, physical)

o Pathogenesis – mechanism of its development or sequence of

events in the response of cells or tissues to the etiologic agent;
spectrum of disease.

o Morphologic changes – biochemical and structural alterations

induced in the cell/organs that are characteristic or diagnostic
of an etiologic process.

o Clinical manifestations – functional consequences and

derangements of the morphologic changes
 4 Aspects of Disease Process
Etiology: Acquired – Infectious - Bacteria

Clinical
Pathogenesis:
Manifestations
1) Edema
55/M 2) Red Hepatization
Classic Pneumonia 3) Gray Hepatization
4) Resolution
Morphologic changes
Morphologic
changes

Pathogenesis
 4 Aspects of Disease Process
Etiology: Acquired – Infectious - Bacteria

Clinical
Pathogenesis:
Manifestations:
1) Edema
• Cough
55/M 2) Red Hepatization
• Tachypnea
• Fever Classic Pneumonia 3) Gray Hepatization
4) Resolution
• Abnormal
Chest Finding Morphologic changes
4 Aspects of Disease Process
II. CELLULAR INJURY
AND CELL DEATH
OVERVIEW OF CELLULAR RESPONSES TO STRESS
AND NOXIOUS STIMULI
OVERVIEW OF CELLULAR RESPONSES TO STRESS
AND NOXIOUS STIMULI
 Causes of Cellular Injury
o Hypoxia and ischemia
Hypoxia, which refers to oxygen deficiency, and
ischemia, which means reduced blood supply, are among
the most common causes of cell injury.

o Toxins
Potentially toxic agents are encountered daily in the
environment; these include air pollutants, insecticides, CO,
asbestos, cigarette smoke, ethanol, and drugs.

o Infectious agents
All types of disease-causing pathogens, including
viruses, bacteria, fungi, and protozoans, injure cells.
 Causes of Cellular Injury
o Immunologic reactions
Autoimmune reactions against one’s own tissues,
allergic reactions against environmental substances, and
excessive or chronic immune responses to microbes.

o Genetic abnormalities
Genetic aberrations can result in pathologic changes
as conspicuous as the congenital malformations associated
with Down syndrome or as subtle as the single amino acid
substitution in hemoglobin giving rise to sickle cell anemia.
 Causes of Cellular Injury
o Nutritional imbalances
Protein–calorie insufficiency among impoverished
populations remains a major cause of cell injury, and
specific vitamin deficiencies are not uncommon even in
developed countries with high standards of living.

o Physical agents
Trauma, extremes of temperature, radiation,
electric shock, and sudden changes in atmospheric
pressure all have wide-ranging effects on cells.
 Causes of Cellular Injury
o Aging
Cellular senescence results in a diminished ability of
cells to respond to stress and, eventually, the death of cells
and of the organism.
 General Principles of
Cellular Injury
o The cellular response to injurious stimuli depends on
the type of injury, its duration, and its severity.

o The consequences of an injurious stimulus also depend

on the type, status, adaptability, and genetic makeup of
the injured cell.

o Cell injury usually results from functional and

biochemical abnormalities in one or more of a limited
number of essential cellular components.
Mechanisms of Cell Injury and Death
o Hypoxia and Ischemia
Deficiency of oxygen leads to failure of many energy
dependent metabolic pathways, and ultimately to death of
cells by necrosis.
Mechanisms of Cell Injury and Death
o Hypoxia and Ischemia

Loss of this critical energy store has deleterious effects on

many cellular systems:

• Reduced activity of plasma membrane ATP-

dependent sodium pumps
• Increase in anaerobic glycolysis
• Structural disruption of the protein synthetic
apparatus
Mechanisms of Cell Injury and Death
o Hypoxia and Ischemia
Mechanisms of Cell Injury and Death
o Hypoxia and Ischemia

Loss of this critical energy store has deleterious effects on

many cellular systems:

• Reduced activity of plasma membrane ATP-dependent

sodium Pumps
• increase in anaerobic glycolysis
• Structural disruption of the protein synthetic apparatus
Mechanisms of Cell Injury and Death
o Ischemia-Reperfusion Injury

Under certain circumstances, the restoration of

blood flow to ischemic but viable tissues results,
paradoxically, in increased cell injury.

• New damage may be initiated during reoxygenation

by increased generation of ROS

• The inflammation that is induced by ischemic injury

may increase with reperfusion because it enhances
the influx of leukocytes and plasma proteins.
Mechanisms of Cell Injury and Death
o Oxidative Stress

Oxidative stress refers to cellular abnormalities that

are induced by ROS, which belong to a group of molecules
known as free radicals.

Free radicals are chemical species, extremely

unstable, and readily react with inorganic and organic
molecules; when generated in cells, they avidly attack
nucleic acids as well as a variety of cellular proteins and
lipids.
Mechanisms of Cell Injury and Death
o Oxidative Stress
Mechanisms of Cell Injury and Death
o Oxidative Stress

ROS are produced by two major pathways.

• ROS are produced normally in small amounts in all

cells during the reduction-oxidation (redox)
reactions.

• ROS are produced in phagocytic leukocytes, mainly

neutrophils and macrophages.
Mechanisms of Cell Injury and Death
o Oxidative Stress
Mechanisms of Cell Injury and Death
o Cell Injury Caused by Toxins
Toxins, including environmental chemicals and
substances produced by infectious pathogens, induce cell
injury that culminates primarily in necrotic cell death.

Two general mechanism:

• Direct-acting toxins
• Latent toxins
Mechanisms of Cell Injury and Death
o Endoplasmic Reticulum Stress
The accumulation of misfolded proteins in a cell can
stress compensatory pathways in the ER and lead to cell
death by apoptosis.

Intracellular accumulation of misfolded proteins

may be caused by abnormalities that increase the
production of misfolded proteins or reduce the ability to
eliminate them.
Mechanisms of Cell Injury and Death
o Endoplasmic Reticulum Stress
Mechanisms of Cell Injury and Death
o Endoplasmic Reticulum Stress
Mechanisms of Cell Injury and Death
o DNA Damage
Exposure of cells to radiation or chemotherapeutic
agents, intracellular generation of ROS, and acquisition of
mutations may all induce DNA damage, which if severe
may trigger apoptotic death.

o Inflammation
Inflammatory cells, including neutrophils,
macrophages, lymphocytes, and other leukocytes, secrete
products that evolved to destroy microbes but also may
damage host tissues
 Common Events in Cell Injury From
Diverse Causes
o Mitochondrial Dysfunction
 Common Events in Cell Injury From
Diverse Causes
o Defects in Membrane Permeability

Increased membrane permeability leading

ultimately to overt membrane damage is a feature of most
forms of cell injury that culminate in necrosis.
SEQUENCE OF EVENTS IN CELL
INJURY AND CELL DEATH
 Reversible Injury
Reversible injury is the stage of cell injury at which
the deranged function and morphology of the injured cells
can return to normal if the damaging stimulus is removed
 Reversible Injury
Morphologic characteristics:
 Cellular swelling
 Fatty change

Cellular Swelling
o First manifestation of cell injury; not clearly seen in
microscope; but apparent at the level of the whole
organ
o Result of failure of energy-dependent ion pumps in
the plasma membrane, leading to the inability of
maintaining ionic and fluid homeostasis.
o Causes pallor(paleness), increased turgor (degree of
elasticity of skin), and an increase in organ weight
 Reversible Injury
Morphologic characteristics:
 Cellular swelling
 Fatty change

Fatty Change
o Occurs in hypoxic injury and various forms of toxic or
metabolic injury
o Manifested by the appearance of small or large lipid
vacuoles in the cytoplasm
o Occurs mainly in cells involved in and dependent on
fat metabolism: hepatocytes and myocardial cells
Appearance of triglyceride containing lipid vacuoles in
the cytoplasm
 Reversible Injury
Other intracellular changes associated with cell injury
include:
o Plasma membrane alterations such as blebbing,
blunting, or distortion of microvilli and loosing of
intercellular attachments.
o Mitochondrial changes such as swelling and the
appearance of phospholipid-rich amorphous densities
o Dilation of the ER with detachment of ribosomes and
dissociation of polysomes
o Nuclear alterations such as clumping of chromatin;
“Myelin figures” which are simply collections of
phospholipids resembling myelin sheaths
 Reversible Injury

Normal Reversible Irreversible

 Irreversible Injury
Irreversible injury invariably leads to cell death, which goes as
either apoptosis or necrosis.
o Necrosis
• Major pathway of cell death in many commonly encountered injuries
• Ischemia, exposure to toxins, infections, trauma
• Always due to pathologic process
o Apoptosis
• Cell kills itself; Caused by
 Deprivation of growth factors in cells
 DNA is beyond repair
• Nuclear dissolution without complete loss of membrane
integrity
• Active, energy-dependent, tightly regulated cell death
Irreversible Injury
 Irreversible Injury
Necrosis is a form of cell death in which cellular
membranes fall apart, and cellular enzymes leak out and ultimately
digest the cell.

The biochemical mechanisms of necrosis:

• Failure of energy generation in the form of ATP because of
reduced oxygen supply or mitochondrial damage
• Damage to cellular membranes, including the plasma
membrane and lysosomal membranes, which results in leakage
of cellular contents including enzymes
• Irreversible damage to cellular lipids, proteins, and nucleic
acids, which may be caused by reactive oxygen species (ROS)
 Irreversible Injury
Types of Necrosis

Coagulative necrosis

• characterized by the preservation of the architecture/outline of

the coagulated cells.
• the denaturation of proteins is the primary mechanism, which
create a delineation of the necrotic tissue in gross examination
• coagulative necrosis is characteristic of hypoxic death of cells in
all tissues except the brain.
 Irreversible Injury
Types of Necrosis

Coagulative necrosis
 Irreversible Injury
Types of Necrosis

Liquefactive necrosis

• characteristic of focal bacterial, or occasional fungal infections

• complete digestion of cells
• transformation of cells into liquid viscous mass due to the
inflammatory response elicited by the microbes.
• necrotic material becomes creamy yellow (pus) due to presence
of dead leukocytes
• seen in the hypoxic death of cells in the nervous system.
 Irreversible Injury
Types of Necrosis

Liquefactive necrosis
 Irreversible Injury
Types of Necrosis

Liquefactive necrosis
 Irreversible Injury
Types of Necrosis

Gangrenous necrosis

• not specific pattern of cell death, but usually applied to

a limb that lost its blood supply that has undergone
coagulative necrosis (dry gangrene)
• particularly in limb and extremities
• patient with a diabetic foot infection can develop into
gangrenous necrosis
• Wet gangrene – coagulative necrosis plus
superimposed bacterial infection (liquefactive necrosis)
because of actions of degradative enzymes in the
bacteria.
 Irreversible Injury
Types of Necrosis

Gangrenous necrosis
 Irreversible Injury
Types of Necrosis

Gangrenous necrosis
 Irreversible Injury
Types of Necrosis

Caseous necrosis
• distinctive form of coagulative necrosis often seen in TB
infection.
• characterized by cheesy white gross appearance of necrotic
area (hence “caseous”)
• On microscopic examination, caseous necrosis exhibit a
granulomatous reaction:
a. Amorphous granular debris composed of fragmented
coagulated cells
b. The granular debris is enclosed within a distinct
inflammatory border.
• Unlike in coagulative necrosis, the tissue architecture is
obliterated.
 Irreversible Injury
Types of Necrosis

Caseous necrosis
 Irreversible Injury
Types of Necrosis

Fat necrosis

• not specific pattern but denoting descriptive focal areas

of fat destruction due to release of pancreatic lipases.
• Release fatty acids combine with calcium visible chalky
white areas - shadowy outlines of necrotic fat cells with
basophilic calcium deposits plus surrounding
inflammatory cells
 Irreversible Injury
Types of Necrosis

Fat necrosis
 Irreversible Injury
Types of Necrosis

Fat necrosis

• not specific pattern but denoting descriptive focal areas

of fat destruction due to release of pancreatic lipases.
• Release fatty acids combine with calcium visible chalky
white areas - shadowy outlines of necrotic fat cells with
basophilic calcium deposits plus surrounding
inflammatory cells
 Irreversible Injury
Types of Necrosis

Fibrinoid necrosis

• special form of necrosis usually seen in immune

reactions involving blood vessels.
• occurs when complexes of antigens and antibodies are
deposited in the wall of arteries
• The immune complexes along with leaked fibrin forms
fibrinoid (fibrin-like), amorphous and bright-pink
structures.
 Irreversible Injury
Types of Necrosis

Fibrinoid necrosis
 Irreversible Injury
Apoptosis is a pathway of cell death in which cells
activate enzymes that degrade the cells’ own nuclear DNA
and nuclear and cytoplasmic proteins.

• Process that eliminates cells with a variety of intrinsic

abnormalities and promotes clearance of the fragments of the
dead cells without eliciting inflammation.

• Little leakage of cellular contents hence no inflammatory

reaction
 Irreversible Injury
Physiologic Apoptosis vs Pathologic Apoptosis

Physiologic Apoptosis

Death of cells that are no longer needed; to maintain a

steady number of various cell populations in tissues.

Pathologic Apoptosis

Eliminates cells that are genetically altered or injured

beyond repair without eliciting severe host reaction, keeping the
damage as contained as possible.
 Irreversible Injury
Physiologic Apoptosis vs Pathologic Apoptosis
 Irreversible Injury
Mechanisms of Apoptosis

Apoptosis is regulated by biochemical pathways that control

the balance of death and survival-inducing signals and ultimately
the activation of enzymes called caspases (cysteine proteases that
cleave proteins after aspartic acid residues)

Two distinct pathways converge on caspase activation:

→ Mitochondrial Pathway
→ Death Receptor Pathway
 Irreversible Injury
Mitochondrial Pathway (Intrinsic)

• Responsible in most physiologic and pathologic situations

• Cytochrome c

o Protein in mitochondria that is capable of inducing

apoptosis; leaks out into the cytoplasm when
mitochondrial membrane becomes permeable; activate
caspase, triggers apoptotic death
 Irreversible Injury

Mitochondrial Pathway
 Irreversible Injury
Death Receptor Pathway (Extrinsic)

• Many cells express surface molecules called death receptors

that trigger apoptosis.
• Most are members of the tumor necrosis factor family which
contain in their cytoplasmic regions a conserved “death
domain”.
• It mediates interaction with other proteins involved in cell
death
• Involved in the elimination of self-reactive lymphocytes and in
the killing of target cells by some cytotoxic T lymphocytes (CTLs)
that express FasL.
 Irreversible Injury

Death Receptor Pathway

Irreversible Injury