Inflammation and Repair

Acute: Of short duration or occurring suddenly.
Angiogenesis: The formation of new blood vessels.
Cardinal signs of inflammation:
• Rubor: Redness.
• Tumour: Swelling.
• Calor: Heat.
• Dolor: Pain.
• Functio laesa: Loss of function or impaired
function.
Chemical mediators: A variety of chemicals secreted
by various cells and from injured tissue involved in the
inflammatory response, e.g. histamine. Responsible
for mediating vascular and cellular responses in
inflammation.
Chemotaxis: Phenomenon that guides and attracts
WBCs to the site of injury. Chemotactic agents include
some of the chemical mediators, antibodies, products
from bacteria and dead tissue.
Chronic: Long-standing; occurring over a long period
of time.
Cicatrix: A scar; the fibrous tissue left after the
healing of a wound.
Cicatrization: The formation of a scar (by conversion
of granulation tissue to a scar).
Collagen: The protein substance of fibers of skin,
tendon, bone, cartilage and other connective tissues;
produced by fibroblasts; several different types.
Erythema: Redness of the skin due to capillary
dilatation; erythematous - relating to or marked by
erythema. Compare with rubor - redness of the skin or
mucous membranes as one of the four signs of
inflammation.
Exudate: Fluid accumulation outside of a vessel; it
has a high protein content and contains various types
of inflammatory cells.
Fibrosis: Formation of fibrous tissue usually in repair
or replacement of cellular elements.
Granulation tissue: Small, rounded masses of tissue
formed during healing; made up of newly formed
capillaries, fibroblasts elaborating connective tissue,
and macrophages.
Hyperemia: Excess of blood in a part or organ
(congestion).
Keloid: A sharply elevated, irregularly shaped scar
due to excessive collagen formation during connective
tissue repair.
Leukocyte: Or white blood cell (WBC); the cell type
that predominates in acute inflammation is the
polymorphonuclear leukocyte/WBC (PMN) or the
neutrophil.
Leukocytosis: A transient increase in the number of
leukocytes (WBCs) in the blood.
Monocyte / macrophage: Another type of white
blood cell; as inflammatory process continues these
cells finish off what the neutrophils begin and continue
to clean up the debris; macro = large; phage = eater.
Permeability: The degree of selectivity a membrane
shows in allowing substances to pass through or in
preventing passage; "leakiness".
Phagocytosis: A process in which a cell takes
particles and substances into itself for destruction;
phago = eating, cyto = cell. For example, a neutrophil
can engulf (phagocytize) foreign particles, bacteria,
dead material or other debris.
Pus: A thick, opaque, usually yellowish-white, fluid
matter that is formed as part of an inflammatory
response typically associated with an infection and is
composed of exudate chiefly containing dead white
blood cells (such as neutrophils), tissue debris, and
pathogenic microorganisms (such as bacteria).
Pyogen: A pus-producing microorganism.
Pyrogen: A fever-producing substance.
Regeneration: Renewal of a structure by
replacement of cells (same or similar cells).
Repair: Restoration of damaged tissue by the growth
of new cells (may be same as those lost or different,
simpler cells). Dependent on original cell type, i.e.
labile - continue to divide throughout life (e.g. skin
epithelial cells, blood cells); stable - low level of
division, but can divide in response to stimulus (e.g.
liver cells) or permanent - cannot divide postnatally
(e.g. nerve cells).
Scar: Cicatrix; a mark remaining after the healing of a
wound.
Transudate: In this case the fluid contains little, if
any protein or cells, and is usually due to changes in
hydrostatic pressure or osmotic pressure in the blood
vessel (also see later module on "Blood Flow and Body
Fluids").
Vasodilation: Increase in size or diameter of a blood
vessel; brought about by chemical mediators.

Overview and Definition of Inflammation

Whenever tissues are injured, e.g. cut, burned, or infected by a microorganism - a series of reactions will occur at
the site of injury. That series of reactions constitutes an inflammatory reaction (from inflammare = to excite).

The purpose of these reactions is:

1. To destroy or limit the spread of the injurious agent.

2. To allow for repair or replacement of the damaged tissue.

The definition of inflammation is very broad. It is perhaps best described as being the characteristic response of
living tissues to an injury.

1. Inflammation is a dynamic process consisting of a chain of reactions which succeed or overlap each other.
It is not a static situation; it starts with the injury and culminates with healing or repair.
 2. The injury must be non-lethal. If the injury is of such severity to destroy the tissue at the outset, no
inflammatory response can occur.
3. The inflammatory reaction is non-specific. Many diverse injuries can cause inflammation and the initial
stages of the inflammatory action are identical in almost all of the tissues, irrespective of the type of
injury.
4. The intensity, duration and outcome of the inflammatory reaction are modified by a variety of host factors
as well as the injurious insult or etiologic agent.
5. It is primarily a defense mechanism but it may be potentially harmful.

The mediators of defense include phagocytic leukocytes, antibodies, and complement proteins. Most of these
normally circulate in the blood and can be rapidly recruited to any site in the body. Some of the cells involved in
the inflammatory response also reside in tissues, where they serve as sentinels on the lookout for threats. The
process of inflammation delivers leukocytes and proteins to foreign invaders, such as microbes, and to damaged or
necrotic tissues, and it activates the recruited cells and molecules, which then function to eliminate the harmful or
unwanted substances.

Sequence of events in an inflammatory reaction. Macrophages and other cells in tissues recognize microbes and
damaged cells and liberate mediators, which trigger the vascular and cellular reactions of inflammation.

Inflammation may be of two types, acute and chronic. The initial, rapid response to infections and tissue damage is
called acute inflammation. It typically develops within minutes or hours and is of short duration, lasting for several
hours or a few days. Its main characteristics are the exudation of fluid and plasma proteins (edema) and the
emigration of leukocytes, predominantly neutrophils (also called polymorphonuclear leukocytes). When the
injurious agent is removed, the reaction subsides and residual injury is repaired. If the initial response fails to clear
the stimulus, the reaction progresses to a protracted type of inflammation that is called chronic inflammation.
Chronic inflammation may follow acute inflammation or arise de novo. It is of longer duration and is associated
with more tissue destruction, the presence of lymphocytes and macrophages, the proliferation of blood vessels,
and fibrosis.

Inflammation is induced by chemical mediators that are produced by host cells in response to injurious stimuli.
When a microbe enters a tissue or the tissue is injured, the presence of the infection or damage is sensed by cells,
including macrophages, dendritic cells, mast cells, and other cell types. These cells secrete molecules (cytokines
and other mediators) that induce and regulate the subsequent inflammatory response. Inflammatory mediators are
also produced from plasma proteins that react to the microbes or to products of necrotic cells. Some of these
mediators promote the efflux of plasma and the recruitment of circulating leukocytes to the site where the injurious
agent is located. Mediators also activate the recruited leukocytes, enhancing their ability to destroy and remove the
agent. Many anti-inflammatory drugs target specific mediators.

The first step in inflammatory responses is the recognition of microbes and necrotic cells by cellular receptors and
circulating proteins. Epithelial cells, tissue macrophages and dendritic cells, leukocytes, and other cell types
express receptors that sense the presence of microbes and necrotic cells. Circulating proteins recognize microbes
that have entered the blood.

The external manifestations of inflammation or cardinal signs of inflammation are heat (calor), redness (rubor),
swelling (tumor), pain (dolor), and loss of function (functio laesa). These manifestations occur as consequences of
the vascular changes and leukocyte recruitment and activation (will be discussed later in more detail).

Inflammation is terminated when the injurious agent is eliminated. Mediators are broken down and dissipated, and
leukocytes have short life spans in tissues. Anti-inflammatory mechanisms are activated that control the response
and prevent it from causing excessive damage to the host. After the agent has been eliminated the process of
tissue repair begins. Repair consists of a series of events that heal damaged tissue. Injured tissue is replaced
through regeneration of surviving cells and/or filling of residual defects with connective tissue (scarring).

Acute Inflammation
The complex series of events which occur in the acute inflammatory reaction include vascular and cellular events,
both of them mediated by chemical factors (mediators). In order to study the inflammatory reaction, we'll discuss
these various components separately, but remember that they are all intimately related and occur concomitantly.
Vascular Events
The vascular reactions of acute inflammation consist of changes in the flow of blood and the permeability of
vessels, both designed to maximize the movement of plasma proteins and leukocytes out of the circulation and into
the site of infection or injury.

Immediately following an injury, there is frequently a transient vasoconstriction of arterioles. This is mediated by
nerves to the smooth muscle within the arteriolar walls (i.e. it is a neurogenic response). This process is brief and
usually lasts up to five minutes.

The transient vasoconstriction is followed by the hemodynamically more important vasodilatation, first of arterioles
and then the remaining circulation (capillaries, venules).

• Opening of precapillary sphincters of arterioles.

• Opening up of new capillary beds.
• Opening of arterial venous shunts in capillary bed.

Vasodilation is induced by inflammatory mediators such as histamine. This results in increased blood flow to the
injured area and thus, on gross examination, the area appears red or erythematous.

With very mild injuries, the vascular changes may not proceed any further than this stage. With more severe
injury, the vasodilation is soon followed by slowing or stasis of the blood flow.

Vasodilatation is often accompanied by increased vascular permeability. This refers to the outpouring of fluids and
proteins from the blood vessels. This affects firstly and predominantly venules; however, capillaries and arterioles
are also involved. Increased vascular permeability is induced by histamine, kinins, and other mediators that
produce gaps between endothelial cells, by direct or leukocyte-induced endothelial injury, and by increased
passage of fluids through the endothelium.

Increased vascular permeability allows plasma proteins and leukocytes, the mediators of host defense, to enter
sites of infection or tissue damage. The process of the escape of plasma and plasma proteins along with white
blood cells from the vessel is known as exudation. This inflammatory exudate accounts for an increase in the
volume of interstitial fluid (edema) and tissue swelling at the local site of injury.

There are two events in the inflammatory response that are responsible for the increased vascular permeability:

1. Rise in hydrostatic pressure within the microcirculation: Arteriolar vasodilatation is followed by a

rise in pressure within the capillaries and venules. This results in the passive transport of a large volume
of fluid along with small molecules into the interstitium (space between tissues). Recall Starling's forces:
osmotic pressure of interstitial fluid, intravascular hydrostatic pressure moving fluid out; osmotic pressure
of plasma proteins, tissue hydrostatic pressure moving fluid in - usually balanced such that net movement
is outward and quite small - drained into the lymphatics.
2. Widening of the inter-endothelial cell junctions: These cells contain myofibrils within the cytoplasm
and these allow for contraction of the cells. This is the mechanism by which large molecules may escape,
resulting in a protein-rich exudate.

An inflammatory exudate is characterized by having:

1. A high specific gravity (> 1.020).

2. High protein levels - > 2 - 4 gms per dl.
3. Numerous cells or cell fragments.

In contrast, a transudate is due to a rise in hydrostatic pressure, reduced plasma proteins (oncotic pressure),
lymphatic obstruction or Na+ retention. It consists of fluid similar to water with a low specific gravity (<1.0120)
with little to no protein or cells (or cell fragments). Transudates are NOT associated with inflammation but with
clinical situations such as: heart failure, venous obstruction, and malnutrition, among others.

Local hemoconcentration: The viscosity of blood is increased as a result of fluid loss from the vessel. This leads
to packing or sludging of red blood cells, therefore slowing blood flow. Occasionally, the blood flow is slowed to the
point of stasis or thrombosis (clotting). Thrombosis in vessels may also occur due to a second mechanism in severe
injuries in instances in which there is direct damage to endothelial cells which, in turn, initiate the formation of
blood clots in the damaged areas.
The cellular elements in a blood vessel normally travel in a stream in the centre of the vessel. As a result of loss of
fluid because of increased vascular permeability and of slowing of blood flow in the vessel, the circulating cellular
elements, including white blood cells, become displaced to the periphery of vessels where they come in to contact
with the endothelial cells. This is referred to as margination.

Cellular Events
The most important feature of inflammation is the accumulation of leukocytes in the affected tissue. Leukocytes
will:

• Engulf, degrade bacteria, immune complexes and cell debris.

• Release lysosomal enzymes.
• Release chemical mediators.
• Release toxic radicals.

All these may help clear the inflammation but may also prolong the inflammation and/or increase tissue injury.
Migration of leukocytes (exudation) through vessel walls during inflammation into adjacent tissues is the main
cellular phase of acute inflammation and occurs in a multi-step process that is mediated by adhesion molecules and
cytokines. This process can be divided into phases, consisting first of adhesion of leukocytes to endothelium at the
site of inflammation, then transmigration of the leukocytes through the vessel wall, and movement of the cells
toward the offending agent. Different molecules play important roles in each of these steps.

Margination is when blood is viscous, as a result of stagnation of blood flow, there is peripheral orientation of
WBCs because of sludging of RBCs (rouleaux). WBCs are pushed to the periphery because they are smaller
particles.

At this point, the white blood cells become sticky and actually adhere to the endothelium, i.e. pavementing.
Normally up to 50% of PMNs are transiently marginating and sticking: during inflammation the percent increases
as well as the absolute numbers of PMNs. The rolling and adhesion of cells in inflammation is the result of
interaction of cell adhesion molecules (CAMs) in both endothelial cells and leukocytes. These molecules are either
expressed, induced or enhanced by chemical mediation. In inflammation the rolling of inflammatory cells in the
endothelium is the initial step on their "way out" of the vessels. This occurs due to alteration of expression and
conformation of cell-surface glycoproteins in response to chemotactic agents.

The attachment of leukocytes to endothelial cells is mediated by complementary adhesion molecules on the two
cell types whose expression is enhanced by cytokines. Cytokines are secreted by cells in response to microbes and
other injurious agents, thus ensuring that leukocytes are recruited to the tissues where these stimuli are present.
The two major families of molecules involved in leukocyte adhesion and migration are the selectins and
integrins.

The adhesion molecules most important at this stage (L-Selectin) are present on the phagocytes' surface (i.e.,
inflammatory cells capable of phagocytosis such as polymorphonucleated neutrophils, macrophages, basophils,
etc.). When absent, (e.g., leukocyte adhesion deficiency, a familial disease) there are serious infections with lack of
phagocytes at the infection site. In the endothelial cells, two main subclasses of adhesion molecules have been
described: P-Selectin and endothelial cell - leukocyte adhesion molecules (ELAM-1 or E-Selectin). Their
number increases (upregulation) with cytokines. They interact with the phagocyte adhesion molecules.

Firm adhesion of leukocytes to endothelium is mediated by a family of leukocyte surface proteins called integrins.
The adhesion of inflammatory cells is mediated by endothelial adhesion molecules of the immunoglobulin
superfamily, binding to integrins found on the leukocyte cell surfaces. These integrins only adhere to their ligands
when the leucocytes are activated by inflammatory chemotactic factors. The leukocytes stop rolling, and
engagement of integrins by their ligands delivers signals leading to cytoskeletal changes that arrest the leukocytes
and firmly attach them to the endothelium.

After being arrested on the endothelial surface, leukocytes migrate through the vessel wall primarily by squeezing
between the widened endothelial cell junctions where they are actually able to pass through that space. This
process is active and requires energy. This extravasation of leukocytes, called transmigration, occurs mainly in
postcapillary venules, the site at which there is maximal retraction of endothelial cells. This movement of
leucocytes across the basement membrane to the extravascular space is called diapedesis. Red blood cells (RBCs)
often leave the vascular lumen behind a white blood cell. This is a passive phenomenon and results from
hydrostatic pressures forcing red blood cells out of the permeable vessel.

PMNs are the first type of leukocyte to appear in the inflamed area. This is partly due to the fact that they are
faster and more numerous. Thus, the cell type in the inflammatory response varies with the age of the lesion and
type of stimulus. In most acute inflammations, PMNs (neutrophils) predominate (early - dependent on C5a
generation, in the first 6-24 hours) to be later replaced by monocytes or macrophages (days later). Exceptions:
viral infections (lymphocytes first). This is also due to the fact that the PMN is short-lived, the monocyte migration
is sustained longer and chemotactic factors for PMN and monocytes are activated at different periods. Once outside
the blood vessel, monocytes are referred to as macrophages or histiobcytes.

Once in the tissues, these cells stimulate and control subsequent inflammatory response and interact with the
immune system.

The reaction of inflammatory cells to substances in their environment determines the direction of locomotion of the
cell or organism. The unidirectional migration of cells toward an attractant or movement along a chemical gradient
is a process called chemotaxis. All WBCs respond to such stimuli but PMNs and monocytes are most reactive.
Chemotactic factors can be exogenous and endogenous.

Chemotactic factors for neutrophils include:

• Components of the complement system; complement fractions (C5a).

• Bacterial (E Coli, staph aureus) and viral products, particularly peptides with N-formylmethionine termini.
• Products of the lipoxygenase pathway of Arachidonic acid metabolism, particularly leukotriene B4 (LTB4).
• Cytokines (chemokines).

Specific receptors for chemotactic agents on cell surfaces direct the cell movement (e.g., C5a, leukotriene B4).
Once receptor-ligand interaction takes place mobilization of membrane-associated calcium ions activate the
contractile elements needed for cell locomotion.

The finding of a large number of neutrophils at a site of injury is a major histological feature of acute inflammation.
In most acute reactions, neutrophils appear first and are followed by macrophages. This is due to their greater
mobility and also because there are many more neutrophils than monocytes in the circulation.

After two or three days, macrophages begin to outnumber neutrophils in most inflammatory reaction sites (an
exception to this would be in those instances in which the injurious stimulus continues to operate). The normal life
span of macrophages is much greater (months to years) versus the life span of an average neutrophil (2-4 days).
Also, macrophages are relatively resistant to the lower pH (acidity) which is found at inflammatory sites.

Phagocytosis is the process of ingestion of particulate matter, i.e. bacteria, foreign debris, by the cell. It literally
means "cell-eating". It may be regarded as the culmination of an inflammatory reaction.

Cells with the greatest phagocytotic properties are neutrophils and macrophages. Eosinophils are also
phagocytotic; however, lymphocytes and plasma cells are not. Phagocytosis is the process whereby some of the
debris at an inflammatory site is removed (this is done primarily by macrophages), the remainder is removed by
lymphatics.

Phagocytosis is also the main mechanism for bacterial killing and degradation and involves three steps:

• Recognition and attachment (may be mediated by opsonins):

o Opsonins are substances which coat bacteria and render them more susceptible to phagocytosis.
They are usually immunoglobulins (e.g. IgG) or complement fractions (e.g. C3b). The opsonized
particles attach to two receptors on PMNs or macrophages:
§ A receptor for Fc fragment of IgG (to react with IgG opsonin).
§ A receptor to C3b (to react with C3b opsonin).
• Engulfment (pseudopods flow around organisms/particle with complete enclosure followed by fusion with
lysosomal granules resulting in a phagolysosome; requires the presence of calcium and magnesium):
o Pseudopods flow around organisms with complete enclosure followed by fusion with lysosomal
granules resulting in a phagolysosome. While this takes place, leakage of enzymes and
metabolic products (H2O2) from the leukocyte into the extracellular space occurs, thus increasing
the tissue damage. This process of engulfment requires the presence of calcium and magnesium.
• Killing and/or degradation (lysosomes then fuse to the sack and release their enzymes directly into this
sack or vacuole):
o The killing of microbes and the destruction of ingested materials are accomplished by reactive
oxygen species (ROS, also called reactive oxygen intermediates), reactive nitrogen species,
mainly derived from nitric oxide (NO), and lysosomal enzymes. This is the final step in the
elimination of infectious agents and necrotic cells.
Mediators
Neurogenic Mediators
Neurogenic mediators operate in the very early phases of inflammatory reaction and cause fleeting arteriolar
vasoconstriction. The mechanism of neurogenic mediation was suggested by Sir Thomas Lewis in 1927 and
constitutes the first part (pallor) of Lewis' triple response.

Even without neuroconnections (denervation), the major aspects of acute inflammation occur. The reason for this
is that the main mediators of the vascular changes are chemical. Neurogenic mediators have probably a secondary
and less important role in mammals.

Chemical Mediators
The mediators of inflammation are the substances that initiate and regulate inflammatory reactions. A large
number of anti-inflammatory agents that are used every day by many people (e.g., aspirin and acetaminophen)
block the production of these chemical mediators. The most important mediators of acute inflammation are
vasoactive amines (especially histamine), lipid products (prostaglandins and leukotrienes), cytokines (including
chemokines), and products of complement activation.

Cell-Derived Vasoactive Mediators

Vasoactive amines:

• Histamine is the major mediator in the early phases of the acute inflammatory reaction. Histamine acts
via H-1 type receptors present in vascular endothelium. The effect is short-lived (< 60 minutes).
o Major source is mast cells - these are ubiquitous throughout the body and occur in connective
tissue often adjacent to blood vessels. Histamine is contained within granules of the mast cell
(and also found in granules of basophils and platelets). When mast cells are injured or
appropriately activated, they degranulate, i.e. contents of the granules are released. Serotonin
(5-hydroxytryptamine) is present in platelets and certain neuroendocrine cells. It also is a
vasoconstrictor, but the importance of this action in inflammation is unclear. In humans,
serotonin probably has little role.
o Mast cells degranulate in response to:
1. Physical injury - trauma, cold, heat, irradiation.
2. Immunological process - immune complexes, via receptors for IgE
3. Fragments of the complement system - C3a and C5a (anaphylatoxins)
4. Histamine releasing factors from PMNs, monocytes and platelets.
5. Interleukin-1.
• Has two major functions:
1. Dilatation of arterioles (vasodilatation).
2. Increased vascular permeability in
venules.

Arachidonic acid metabolites:

• The lipid mediators prostaglandins and

leukotrienes are produced from arachidonic
acid present in membrane phospholipids,
and they stimulate vascular and cellular
reactions in acute inflammation. Release of
arachidonic acid by phospholipases
(lysosomes) is induced by mechanical,
chemical and physical stimuli. Once freed
from the membrane, arachidonic acid is
rapidly converted to bioactive mediators.
The end products are prostaglandins and
leukotrienes. These mediators, also called
eicosanoids are synthesized by two major
classes of enzymes: cyclooxygenases (which
generate prostaglandins) and lipoxygenases (which produce leukotrienes and lipoxins). Eicosanoids bind to
G protein-coupled receptors on many cell types and can mediate virtually every step of inflammation.
 Prostaglandins produce vasodilatation and increased permeability. Leukotrienes increase permeability and
have chemotactic activity.

Cytokines:

• Proteins secreted by many cell types (principally activated lymphocytes, macrophages, and dendritic cells,
but also endothelial, epithelial, and connective tissue cells) that mediate and regulate immune and
inflammatory reactions (recruitment of leukocytes, activation of endothelial adhesion molecules, systemic
effects - fever).

Platelet activating factor (PAF):

• Generated by stimulation of practically all inflammatory cells, endothelial cells and damaged tissue cells.
In addition to being a powerful vasodilator, it also increases permeability. Other functions include:
stimulation of platelets, inflammatory cells and endothelial cells. It is best known for its ability to produce
aggregation of platelets at the site of injury. It also has chemotactic functions.

Endothelins:

• A peptide produced by endothelial cells. It has a powerful vasoconstrictive effect.

Plasma-Derived Vasoactive Mediators

1. Plasma protease systems are three different but interrelated systems. They are the complement
system, the clotting system, and the kinin system. They have several characteristics in common and are a
series of inactive enzymes (proenzymes) which when the first proenzyme is activated initiates a cascade
in which the substrate of the activated enzyme is the next component of the system:
• Kinin system is activated by stimulation of the plasma kinin cascade from precursor (high
molecular weight kininogen). The ultimate result is bradykinin, which is the active kinin. When
bradykinin when released:
• Increases vascular permeability
• Produces contraction of smooth muscle.
• Vasodilatation.
• Produces pain.
• It acts on endothelial cells to increase gaps and it is inactivated by kininases (in plasma and
tissues). Like histamine, the effects of bradykinin are transitory and are most important during
the early phases of inflammation.
2. Complement system consists of at least 20 different proteins (including their cleavage products, some of
which are numbered C1 through C9) circulating in the blood. Upon activation of the system - for example,
by contact with antigen-antibody complexes (classic pathway) or by-products released by bacteria or by
components of other plasma protein systems (alternative pathway) various by-products of complement
are released. The complement system is a non-specific self defense mechanism. In the process of
complement activation, several cleavage products of complement proteins are elaborated that cause
increased vascular permeability, chemotaxis, and opsonisation.
• The complement system is the most important of the plasma protein systems of inflammation; its
components participate in practically every aspect of the inflammatory response. Activation of
components C1 à C5 produces subunits that enhance inflammation by
• Opsonizing bacteria (C3b).
• Attracting leukocytes (chemotaxis) - C5b, 6, 7 complex, C5a.
• By acting as mast cell activators causing degranulation and histamine release (C3a,
C5a).
• Components C6 à C9 (form the membrane attack complex) create pores in the bacterial
walls producing an influx of ions and fluid into bacteria which subsequently bursts.
3. Clotting (coagulation) system forms a fibrinous exudate or meshwork at the inflamed site to trap cells,
microorganisms and foreign bodies. This prevents the spread of infection and inflammation into the
surrounding tissues; keeps cell debris, bacteria and foreign bodies at the site of greatest phagocytic
activity; and forms a clot that stops the bleeding and provides a framework for repair and healing. The
main substance of this mesh is an insoluble protein called fibrin which is the end product of the
coagulation cascade.

Cardinal Signs of Inflammation

• Redness or rubor:
 o Vasodilatation and congestion of blood vessels by chemical mediators (PGs).
• Swelling or tumor:
o Exudation of fluid/edema (increased vascular permeability) and cells. Mediated by vasoactive
amines: C3a and C5a, bradykinin, leukotriene C, D, E.
• Heat or calor:
o Mechanisms for this are poorly understood; however, greater blood flow to the region may be a
contributing factor.
• Pain or dolor:
o Direct pressure upon nerves by the edema fluid. Also signalling of the neural system by chemical
mediators (bradykinins, histamine, serotonin, and prostaglandins).
• Loss of function (functio laesa):
o Secondary to reflex inhibition of muscular movements associated with pain. Also, mechanical
disability may be produced by the swelling and pain.

Case Study
A 13-year-old female complained of periumbilical pain. One day later the pain intensified and was more prominent
at palpation of the right lower quadrant. Abdominal palpation revealed tenderness and guarding with rebound
tenderness. She had not had a bowel movement for 48 hours. Her axillary temperature was 38ºC. Her rectal
temperature was 39.5ºC.

Her white cell differential count showed 95% polymorphonuclear neutrophils (PMNs). An appendectomy was
performed through a right lower quadrant incision.

This case of acute appendicitis illustrates many of the features of acute inflammation. The most important
pathological and morphological feature of inflammation is the accumulation of leukocytes/neutrophils in the
affected tissue.

In this example:

• There is an increase in neutrophils (PMNs) in the white cell differential count.

• A collection of neutrophils (PMNs) in the lumen of the appendix (pus).
• Neutrophils (PMNs) in the clear spaces between smooth muscle fibres in the muscularis propria.
• Inflammatory cell infiltrates in the blood vessels.

This patient presents with several of the cardinal signs of inflammation and the presence of fever, a systemic
manifestation of inflammation.

Classifications of Inflammation
The basic pathophysiologic and morphologic changes follow a fairly regular progression and occur in a predictable
sequence in inflammation; the ultimate character, extent, severity and duration of the tissue changes are
dependent upon many factors relating to the host, the injurious agent and the clinical intervention. Accordingly,
certain inflammations are short-lived or protracted, they may be characterized by an exudate reflecting the
etiological agent or they may be of a certain special form because of the location. Inflammation may be classified
according to:

Inflammation based on duration:

• Can be acute or chronic. No sharp line of division exists between these forms. An acute inflammation may
subside or may persist and become chronic. Not all chronic inflammation begins as an acute inflammation.
A low-grade stimulus or organisms of low toxicity may incite a chronic reaction without ever arousing a full
blown acute response. Clinically the difference between acute and chronic inflammation is purely one of
duration; chronic inflammation lasts two weeks or longer, regardless of the etiology.
• Acute inflammation:
o In a clinical sense, acute inflammation is usually of sudden onset and accompanied by one or
more of the cardinal signs. It also generally lasts a matter of hours or days. Acute reactions occur
when the injury is transient, e.g. physical trauma, burn, or an infection in which the organism is
rapidly eradicated by the body's defence mechanisms.
o In a pathological sense, acute inflammation has, as its dominant morphological changes, the
vascular and exudative changes described, i.e. exudation of fluid and accumulation of cells. The
cellular infiltrate contains numerous neutrophils, resulting in exudative inflammation.
• Chronic inflammation:
 o This results from an injurious agent which persists in the tissues and continues to cause damage
often for weeks or months, e.g. foreign body (wood splinter) which remains in the tissue;
organisms which are not eradicated.
o Chronic inflammation can arise basically under two different sets of circumstances:
§ Evolution of acute to chronic inflammation: This occurs characteristically in certain
infections. An acute inflammation becomes chronic when it cannot be resolved (etiologic
agent persists, impairment in normal healing, etc.) So, there are chronic inflammations
with persisting acute disease (peptic ulcer disease). The inflammatory reaction with
chronicity takes on two new facets:
1. A proliferation of connective tissue (predominantly fibroblasts) and vessels
(angiogenesis).
2. Local increase in macrophages, lymphocytes and plasma cells.
§ Chronic inflammation without any recognizable acute phase: This occurs with low grade
injuries, such as with organisms of relatively low virulence. An example of this is the
inflammatory reaction to the tubercle bacillus which rapidly passes through an acute
pattern; exposure to non-degradable material (dusts); autoimmune reactions
(rheumatoid arthritis).
• While the acute inflammation was characterized by vascular and exudative features (microscopic) and
cardinal signs grossly, in chronic inflammation there is great amount of proliferation of cells and
connective tissue, while exudation is less conspicuous (lymphocytes, plasma cells).
• The chronic inflammatory pattern described above (mononuclear cell infiltrate, connective tissue
response) is described as being of a non-specific pattern. A special form of chronic inflammation is
granulomatous inflammation. This is a characteristic response seen in some infections such as
tuberculosis, syphilis, and some fungi, as well as in foreign body inflammatory reactions. This form of
chronic inflammation is characterized by the presence of granulomas (a nodule, a grain-like body, or a
tiny 'tumor'). A granuloma may perhaps be best described as a well-circumscribed collection of epithelioid
macrophages. They are termed epithelioid because they resemble epithelial cells, i.e. they have abundant
eosinophilic cytoplasm. In addition to the collection of these cells, other elements are usually present in a
granuloma. There may or may not be a central focus of necrotic debris (this feature is especially
prominent in tuberculosis). Often multinucleated giant cells are present and these are very helpful in
recognizing a granuloma. The giant cells represent epithelioid macrophages which have fused their cell
borders resulting in one large multinucleated cell. Often, giant cells form around foreign bodies when the
foreign particles are too large to be engulfed (phagocytosis) by a single macrophage. An outer rim of
lymphocytes and plasma cells is also frequently seen around many granulomas.
• Granulomatous inflammations are characteristic tissue reactions in some infections (tuberculosis;
syphilis; cat-scratch disease; fungal; protozoan); in persistent foreign body inflammations (foreign body
granuloma; pneumoconioses), in rheumatic fever (Aschoff body); in rheumatoid arthritis (subcutaneous
nodules), and in some diseases of unknown etiology (sarcoidosis, granuloma annular of skin). Some
granulomatous inflammations are sufficiently characteristic for a consideration of a given disease, but the
demonstration of the specific agent is necessary for the ultimate diagnosis.

Inflammation based on exudate:

• Serous: Usually due to mild injuries. The fluid contains only albumin (no fibrinogen). It is
characteristically derived from secretions of serosal mesothelial cells (pleural, peritoneal, pericardial and
synovial). Examples include blister from burns of skin; pulmonary TB (effusion into pleural space =
pleuritis, serous); in early phase of bacterial infections. In tissues, it is identified with difficulty
(abnormally dilated spaces; fine precipitate of protein).
• Fibrinous: Characterized by the presence of fibrin (derived from leakage of fibrinogen from blood
vessels). It is seen in more severe inflammations in which the greater degree of increased vascular
permeability allows the escape of larger plasma proteins such as fibrinogen. For example, in rheumatic
fever ("bread and butter" pericarditis) in pneumococcal pneumonias. In tissues, it is easily identifiable
because the precipitated fibrin is deeply acidophilic; in strands and bands, in part fibrillar. Observed in
acute inflammatory but also in active zones of chronic inflammatory process. Fibrin can be removed
(fibrinolysis) or may get replaced by fibrous tissue scar.
• Suppurative or purulent: A type of liquefactive necrosis caused by pyogens (pus-producing bacteria);
large amount of pus, i.e. fluid containing neutrophils and liquefied tissue debris and bacteria is seen. Pus
is protein-rich fluid containing viable and necrotic neutrophils and tissue debris partially liquefied by
proteolytic enzymes. This is characteristically seen in certain infections, e.g. staphylococcus,
pneumococcus, meningococcus, gonococcus, E coli, some non-hemolytic streptococcus. For example,
acute appendicitis. In tissue, it is recognized by pools of numerous PMNs (viable and dead).
 • Catarrhal: Outpouring of a large amount of mucous secretion. It is seen in the course of inflammation of
mucous-secreting membranes, e.g. common cold - viral infection of the respiratory epithelium of nose.
• Sanguineous: The exudate contains a large number of red blood cells. It is indicative of serious damage
to the blood vessels (RBCs enter the perivascular tissue). It is almost never "pure" but in a mixed form
with other type of exudate (usually purulent or fibrinous or both). For example, it is often seen in TB
(sanguineous pleuritis); in inflammations as reactions to tumor invasion (sanguineous pericarditis).
Exudates are very infrequently pure. Usually one sees a combination of several types, e.g. fibrinopurulent,
serosanguineous, etc.

Location and special forms of inflammation (or outcome):

• Abscess: A localized collection of pus caused by suppuration (=formation of visible pus) in a tissue or
organ. It is caused by an irritant of great intensity (staphylococcus; turpentine) that characteristically
remains localized and leads to outpouring of great numbers or polys (polymorphonuclear leukocytes); the
locally liberated large amounts of trypsin overcome the tryptic inhibitor of the serum (difficulty in
permeating solid tissues); the trypsin digests damaged and dead tissues and converts it into a semisolid
mass.
• Empyema: Localized collection of pus in a pre-formed cavity. This most frequently refers to the pleural
cavity.
• Ulcer: A local defect or excavation of the surface of an organ or surface covered by an epithelium
(mucous membrane, skin), produced by sloughing of inflammatory necrotic tissue on or near the surface.
• Pseudomembranous: Occurs on mucosal surfaces, e.g. pharynx, larynx or respiratory passages
(diphtheria), the GI tract. It is produced by a powerful necrotizing toxin (such as diphtheria) characterized
by the formation of a pseudomembrane overlying the affected area. The false membrane consists of
precipitated fibrin, necrotic epithelium and WBCs. It is characterized by the accumulation of fibrin, necrotic
debris, and acute inflammatory cells on the surface.
• Fistula: Abnormal communication between two hollow organs, both lined by epithelium (e.g. vesico-
uterine between urinary bladder and uterus) or endothelium (e.g. arteriovenous). This may also be
congenital in nature or may result from a neoplasm or trauma.
• Sinus: Abnormal tract (communication) between a solid organ (or tissue) and an epithelial-covered
surface, usually skin (e.g. a pulmonary abscess which drains to the skin's surface).

All three categories are descriptive of every inflammatory reaction, since all have in common: duration, some type
of exudation and location. Therefore, inflammations do not fall into only one of these categories, but rather can be
described fairly specifically in all three terms.

Systemic Effects of Inflammation

To this point, only the local changes at the site of an injury have been discussed. In severe inflammatory reactions,
however, there may be changes that involve the entire body.

• Fever: This is probably the result of release of factors from white blood cells or from microorganisms
(pyrogens) that act directly on the temperature regulating centre in the hypothalamus. For example,
bacterial, chemical, endogenous (from PMN and other phagocytes). Now there is evidence that
prostaglandins are mediators of fever. Fever increases the metabolic rate and theoretically has a
beneficial effect. Extreme high temperatures are lethal (denature proteins).
• Leukocytosis: An increase in the white blood cell count above normal levels (i.e. greater than 10,000 per
mm). Increased production and release of WBC from and by the bone marrow. In acute inflammatory
responses, the leukocytosis is the result generally of an increase in the number of neutrophils. In addition,
one will see increased numbers of immature neutrophils in the circulating blood. In a chronic inflammatory
reaction, one is more likely to have a lymphocytosis (i.e. absolute increase in numbers of lymphocytes). In
allergic conditions, an eosinophilia is frequently seen.
• Acute-phase proteins: Plasma proteins, mostly synthesized in the liver (stimulated by cytokines), whose
plasma concentrations may increase several hundred-fold as part of the response to inflammatory stimuli.
Three of the best-known of these proteins are C-reactive protein (CRP), fibrinogen, and serum amyloid A
(SAA) protein. Many acute-phase proteins, such as CRP and SAA, bind to microbial cell walls, and they
may act as opsonins and fix complement. Fibrinogen binds to red cells and causes them to form stacks
(rouleaux) that sediment more rapidly at unit gravity than do individual red cells. This is the basis for
measuring the erythrocyte sedimentation rate as a simple test for an inflammatory response caused by
any stimulus. Acute-phase proteins have beneficial effects during acute inflammation, but prolonged
production of these proteins (especially SAA) in states of chronic inflammation can, in some cases, cause
secondary amyloidosis. Elevated serum levels of CRP serve as a marker for increased risk of myocardial
 infarction in patients with coronary artery disease. It is postulated that inflammation involving
atherosclerotic plaques in the coronary arteries predisposes to thrombosis and subsequent infarction.
• Other: Malaise, anorexia, sleepiness, increased heart rate and blood pressure, chills, etc.

Replacement of Cells and Tissues

The discussion on inflammation revolved around the components of the reaction that tend to neutralize, destroy
and eliminate the injurious agent. The inflammatory response to microbes and injured tissues not only serves to
eliminate these dangers but also sets into motion the process of repair. Repair of damaged tissues occurs by two
types of reactions: regeneration by proliferation of residual (uninjured) cells and maturation of tissue stem cells,
and the deposition of connective tissue to form a scar.

Replacement of Cells and Tissues

Regeneration is a term used if the cells (or tissue) replacing those lost in inflammation are identical or very
similar; this process is called regeneration. Regeneration occurs by proliferation of cells that survive the injury and
retain the capacity to proliferate, for example, in the rapidly dividing epithelia of the skin and intestines, and in
some parenchymal organs, e.g., in the liver. In other cases, tissue stem cells may contribute to the restoration of
damaged tissues. Mammals have a limited capacity to regenerate damaged tissues and organs, and only some
components of most tissues are able to fully restore themselves.

Repair is a broader term; it includes the process of replacement by cells and tissues, either of the same kind as
those lost, or of a different and often simpler type. If the injured tissues are incapable of complete restitution, or if
the supporting structures of the tissue are severely damaged, repair occurs by the laying down of connective
(fibrous) tissue, a process that may result in formation of a scar. Although the fibrous scar is not normal, it
provides enough structural stability that the injured tissue is usually able to function.

The cells of the body are divided into three groups on the basis of their regenerative capacity:

• Labile: Continue to proliferate throughout life (e.g. epithelium, blood cells). Follow cell cycle from one
mitosis to the next.
• Stable: Low normal level of replication but able to divide in response to stimuli (e.g. parenchymal cells of
glandular organs, mesenchymal cells, etc.). Considered to be on G0 but recruited to G1.
• Permanent: Cannot divide in postnatal life (e.g. neurons of CNS). Have left the cell cycle.

Regeneration is much better developed in lower animals, and in protozoa and metazoa represents the major
feature of reaction to injury. Physiological regeneration (replacement) in humans include the epidermis, blood,
uterine mucosa, and glandular epithelium.

There is great variation in the ability of different kinds of cells and tissues to regenerate. Supporting tissue
regenerates best (connective tissue - fibrous, osseous, cartilage, blood vessels; epithelium - epidermis, renal
tubular, glandular, intestinal, uterine). Other cells lose their ability to regenerate in postnatal life (muscle, nerve
require replacement by simpler tissue).

Atypical regeneration of an organ: In an organ, restoration depends not only upon the parenchymal tissue's ability
to regenerate, but also whether or not the framework was destroyed (e.g. in the skin: no sweat and sebaceous
glands or hair; in liver: when architectural skeleton destroyed regeneration is irregular producing afunctional tissue
- cirrhosis).

Regeneration of organs in mammals: Liver and lung are the best, as well as kidney and spleen (accessory splenic
tissue). Repair (by connective tissue and granulation tissue) may begin shortly after injury and overlap the
vascular and cellular phenomena of inflammation.

Mechanisms Involved in Regeneration and Repair

Control of Cell Proliferation
The regeneration of injured cells and tissues involves cell proliferation, which is driven by growth factors and is
critically dependent on the integrity of the extracellular matrix, and by the development of mature cells from stem
cells. Labile cells follow the cell cycle from one mitosis to the next. Permanent cells have left the cell cycle and are
destined to senesce and die. Stable cells are best considered to be in the G0 but are able to be stimulated to G1.

Growth is best accomplished by recruitment of G0 cells into the cell cycle. This takes place by the action of:
 • Growth or stimulatory factors (well-known hormones: estrogens, progesterone, somatotropin, insulin;
circulating growth factors such as epidermal growth factor, vascular endothelial growth factor, TNF)
• Loss of a growth inhibitor normally present (negative feedback or contact inhibition).
• Cell-cell or cell-matrix interactions: Cells have receptors that recognize extracellular matrix components
(fibronectin, collagen, glycoproteins).

All three are probably in effect at any given time. Fibronectins are seen in cell surfaces, basement membranes and
pericellular matrices, and they are produced by fibroblasts, endothelial cells and monocytes. In wound healing they
facilitate migration of epithelium (glue-like), are chemotactic for monocytes, are chemotactic for fibroblasts,
stimulate endothelial migration and organization, and release bFGF from monocytes.

Collagenization and Wound Strength

It involves the proliferation of endothelial cells, fibroblasts and deposition of collagen in wounds. When the injury is
severe or persistent and there is damage of parenchymal cells and stromal framework, healing cannot occur by
regeneration alone. Non-regenerated parenchymal cells are initially replaced by proliferating fibroblasts and
endothelial cells. By 3-5 days, granulation tissue is established. Granulation tissue is pink, soft, granular and
painless. Histologically, it is a mesh of capillaries, fibroblasts, inflammatory cells and extracellular matrix (ECM).
This tissue acts like a scaffold on which the final scar will form. With time, the cells will diminish, the capillaries will
disappear and an increasing amount of connective tissue (scar) will be laid down.

The steps involved in the process of repair are:

• Angiogenesis: New vessels form by budding from pre-existing vessels. These newly formed vessels are
immature and therefore leaky (incompletely formed intercellular junctions), thus the edematous
appearance. Chemical mediators responsible for angiogenesis include: VEGF and bFGF. They bind to the
proteoglycans of the basement membranes and are released when they are damaged.
• Fibrosis: By proliferation of site fibroblasts and deposition of ECM by these cells. Again, this process is
dependent on various growth factors released by inflammatory cells.
• Maturation and organization of the scar (remodelling): Collagen and other ECM are degraded by a
family of metalloproteinases (zinc-dependent). They cleave fibrillar collagen types I, II and III as well as
collagen IV and fibronectin. They are produced by inflammatory cells as well as by some epithelial cells.
They aid in the debridement of the injured site and the remodelling of the connective tissue.

Collagen is the most common protein in animal world. It is a family of molecules (18 types) and there are five
major types of collagen according to biochemical composition: types I, II & III are fibrillary, while types IV & V are
amorphous. Types IV and V collagen, along with laminin, fibronectin and heparin sulfate proteoglycan are
components of the basement membranes.

Wound strength: Most wounds involving skin, fascia or tendon never regain initial strength of tissue derived." (70-
80% of tensile strength achieved at 3 months). This is probably related to the type of collagen laid down and its
organization. Adult skin has collagen type I, granulation tissue has collagen type III, cicatrization is a replacement
of type III by type I.

Skin Wound Healing

Repair of Skin Wounds
Repair of dermal wounds is a good example of a repair process; similar events take place in the healing of ulcers;
repair in tuberculous cavities of lung; repair of abscesses in liver and kidneys; following trauma, etc.:

Crust formation: Provides a quick provisional closure to the wound. After hemorrhage has ceased, the wound is
covered by coagulated blood which dries and hardens to form crust or scab. It is useful in two ways:

1. It stops further leaking of blood.

2. It is a barrier to infection.

Thus, the crust effects a provisional closure of the wound; it forms only if:

1. Blood is available (i.e. if vessels present and damaged).

2. Conditions permit drying.
There is no crust formation in the cornea and uterine mucosa.

Removal of dead tissue, other debris and exudate: Following injury, a large mass of dead tissue remains in
contact with living parts; the dead tissue may be removed by sloughing (falling-off). The inflammatory response of
the surrounding living tissue initiates the process of repair. A zone of demarcation is being formed. Slough loses
continuity with living tissue. Small amounts of dead tissue, debris and exudate are removed by liquefaction and
phagocytosis and by lymphatics.

Replacement of lost cells and tissues:

• Takes place largely by two processes:

• Cell migration.
• Cell division (proliferation).
• The cells swell and reassume embryonal properties.
• In skin wounds, three kinds of cells proliferate and migrate. The direction of fibres formed is determined
by tissue tension:
1. Fibroblasts (migrate at 8 µm/hour).
2. Endothelium (migrates in arcs and after a lag period; angiogenesis).
3. Epithelium (migrates in sheets).
• New tissue containing proliferating cellular and extracellular components is thus formed to replace the
loss; it is termed granulation tissue (N.B.: quite different from granuloma). To the naked eye, it appears
as an aggregation of tiny pink granules; these consist of:
• Newly-formed capillaries.
• Fibroblasts elaborating connective tissue (extracellular).
• Many macrophages.
• The granulation tissue has the following properties:
• It bleeds freely (if slightly touched).
• It is insensitive to pain (no nerves are present).
• It is quite resistant to infections.

Epithelium: In order to migrate (in sheets), it requires a substratum (granulation tissue/fibronectin). When there
is no defect in the underlying mesenchyme, migration is immediate (in cornea, completion in 6 hrs). In larger skin
wounds, it passes between the scab (crust) and the granulation tissue the scab then drops off.

Cicatrization: The conversion of granulation tissue to scar (via gradual closing of small vessels). The connective
tissue that has been deposited by fibroblasts is reorganized to produce the stable fibrous scar. This process begins
2 to 3 weeks after injury and may continue for months or years.

Complications include:

• Adhesions may form in repair following injury and inflammation of serous membranes (fibrous
"connections" between two serosal surfaces), i.e. after abdominal surgery.
• Keloid represents a post-traumatic repair/connective tissue proliferation in the dermis that exceeds
"above and beyond" the amounts necessary. Grossly, it is a red (or pigmented), raised and firm lesion
with sharp, often irregular outline and a smooth, shiny surface. Microscopically, the epidermis and the
subjacent dermis are normal but there are no skin appendages. The actual lesion consists of irregularly-
arranged, broad, homogenous, hyalinised and, at times, basophilic collagen fibres. There is a moderate
increase in the number of fibroblasts and capillaries; both "disappear" in an "aging" lesion. About 10% of
normal people develop keloid scars.

Primary Repair/Primary Union/First Intention

The "type" of repair that follows when the edges of the wound are in apposition. The wound is superficial, involving
only the epidermis and the dermis remaining intact. There will be no bleeding. The repair takes place actually via
regeneration of the epithelium. The epithelial cells migrate across the cut (wound) and may replace it in one day.

When cut deeper into the dermis with a few capillaries cut, there are a few drops of blood which "cement" the
edges of the wound, thus, no wound retraction. A few fibroblasts and endothelial cells migrate leaving practically
no scar. In deeper cuts when retraction present, a surgeon may approximate the edges with sutures.
Secondary Repair/Second Intention
This occurs when there is a considerable loss of tissue and the edges of wound cannot be approximated. This kind
of healing proceeds through replacement of the lost tissue by granulation tissue leading to a scar. We distinguish
several stages of wound closure (rate of wound closure):

• Latent period: The size of wound does not change. This lasts one to several days.
• Period of contraction: Likely resulting from the shrinkage of the granulation tissue. The edges are
pulled together.
• Epidermization: Occurs later in the process than contraction.

When wound edges are apart more than 20-25 mm, migration of epithelial cells ceases and skin grafting is
required.

Factors Influencing the Rate of Healing

Factors that influence that rate of healing include age, the size of the wound, secondary infections, presence of
diabetes, presence of foreign bodies in the wound, and dietary status (Vit C, Vit D, protein intake).

Rate of healing may also be influenced by:

• Protect the wound. • Control of bleeding and removal of

• Prompt irrigation.
• Immobilize the injured area (rest +
immobilization).
• Avoid manipulation.
• Drainage of exudate and pus.
• Administration of antibiotics in infections.
• Noxious materials removed (excision of
devitalized tissues; debridement).
excessively clotted blood.
• Judicious use of suture material.
• Preserve blood supply; no tight dressing.
• Elevate affected parts to help drain.
• Apply appropriate thermal modification (be
certain when cold and when heat application).
• Maintain optimal nutritional status for a given
age.