INFLAMMATION

Dr Ugwa

INTRODUCTION
Inflammation is a protective response designed to rid the body of both the initial cause of cell injury (e.g.
microbes, toxins, trauma) and the consequences of such injury (e.g. necrotic cells and tissues).

It is the response of living vascularized tissues to injury. Inflammation aims to destroy, dilute or wall off
the injurious agent, but it, in turn sets into motion a series of events that as far as possible, heals and
reconstitute the damaged tissue.

Repair begins during the early phases of inflammation but reaches completion usually after the injurious
influence has been neutralized. During repair, the injured tissue is replaced by regeneration of native
parenchymal cells or by filling of the defect with fibroblastic tissue (scarring), or most commonly by a
combination of these two processes (labile, stable, permanent cells).

Inflammation and repair may be harmful in some situations e.g. in hypersensitivity reactions and chronic
diseases like rheumatoid arthritis, atherosclerosis

Repairs may lead to disfiguring scars or intestinal fibrous bands causing intestinal obstruction or cancers.

CARDINAL SIGNS OF INFLAMMATION

1. Rubor (redness) – Histamine mediated vasodilation of arterioles.
2. Tumor (swelling) – Histamine mediated increase in permeability of venules.
3. Dolor (pain) – PG E2 sensation specialized nerve ending to the effects of bradykinin and other
pain mediators.
4. Calor (heat)
5. Function Laesa (function loss)

TYPES
1. Acute inflammation
2. Chronic inflammation

Acute Inflammation

- Transient and early response to injury lasting for minutes, several hours or a few days.
- It aims to deliver leucocytes and plasma proteins (e.g. antibodies) to sites of infection or injury.

Components of acute inflammation

1. Vascular changes
a. Alterations in vascular caliber that can lead to increase in blood flow.
b. Vascular structural changes in the main vasculature that permits plasma proteins and
leucocytes to leave the circulation.
 2. Cellular events- Emigration of the leucocytes from the microcirculation and their accumulation at
sites of injury.

Vascular Changes

1. Inconstant and transient vasoconstriction of arteries lasting a few seconds.

o It is a neurogenic reflex
2. Vasodilation of arterioles – Caused by histamine and other vasodilators (e.g., nitric oxide)
which relax vascular smooth muscles causing increased blood flow.
o This leads to increased hydrostatic pressure producing protein and cell poor fluid
(transudate) in the interstitial space. SG <1.912
3. Increased permeability of venules
a. Endothelial cell contraction, leading to the formation of widened intercellular junction or
intercellular gaps. This is mediated by histamine, bradykinin and leukotrienes,
substanceP.
o Venules are affected, leaving out capillaries and arterioles
o It is short-lived (15 – 30 minutes)

b. Endothelial injury leading to endothelial cell necrosis and detachment. This can be by
(i) Direct injury – Severe burns or light bacterial infection.
(ii) Leucocyte mediated injury – Adhere to endothelium and may release toxic
oxygen radicals or proteolytic enzymes.
4. Increased transcytosis – via vesicles and vacuoles across the cytoplasm of endothelial cells
e. g. in cancers. VEGF helps to produce these vesicles and vacuoles called vesiculovacuolar
organelles.

All three factors (arteriole vasodilation, increased permeability of venules and transcytosis) may come
into play at the same time. These will deliver protein and cell rich fluid in the interstitium (exudate) SG
>1.020

5. Swelling of tissue (edema) – Net outflow surpasses lymphatic ability to remove fluid.
6. Reduction in blood flow – A decrease in hydrostatic pressure is caused by outflow of fluid
into the interstitial space. This aids peripheral orientation of WBC (neutrophils) along the
vascular endothelium also known as leucocyte margination.

CELLULAR EVENTS

A critical aim of acute inflammation is to deliver WBC, especially neutrophils, to the site of injury.

The sequence of events is:

1. Margination – WBC aggregate into rouleaux in venules.

o Neutrophils are pushed from the central axial column to the periphery
o This is due to stasis
2. Rolling – Due to activation of selectin molecules on the surface of neutrophils and
endothelial cells.
 o The neutrophils loosely bind to selectins and roll along the endothelium.
E-selectin – endothelium
P-selectin – platelets and endothelium
L-selectin – leucocytes
3. Adhesion – Adhesion molecules firmly bind neutrophils to endothelial cells. Adhesion
molecules include:
a. Neutrophil adhesion molecules
o These are present on neutrophils and through them the neutrophils bind to the
endothelium.
o They are the β2 integrins (CD11a, CD18)
o The CD11a and CD18 activation is mediated by C5a and leukotriene B4.
o Catecholamines, corticosteroids (steroid escon) and lithium inhibit the activation of
adhesion molecules causing an increase in neutrophil count
o Endotoxins enhance activation of adhesion molecules leading to neutropenia

b. Endothelial cell adhesion molecules

o These are Intercellular adhesion molecules (ICAM) and vascular cell adhesion molecule
(VCAM) which bind to the β2 integrins on the surface of the neutrophils.
o ICAM and VCAM activation is mediated by interleukin1 and TNF

Leukocyte adhesion molecule deficiency (LAD)

o Autosomal recessive
o LAD type1- deficiency of CD11a : CD18
o LAD type2- deficiency of selectins
o Causes: delayed separation of the umbilical cord (>1 month), gingivitis, poor wound
healing, leukocytosis

4. Transmigration (diapedesis)
o Neutrophils dissolve the basement membrane
o Fluid rich in proteins and cells (exudate) accumulate in the interstitial tissue
o The exudate dilutes bacterial toxins and provide opsonins (assists in phagocytosis),
antibodies and complement
5. Chemotaxis
o Following extravasation, WBCs emigrate in tissue towards the site of injury following a
chemical gradient
o Chemo attractants can be endo or exogenous
o Exogenous e.g., bacterial products
o Endogenous- components of complements e.g., C5a, products of lipoxygenase pathway
e.g., leukotriene B4 and cytokines e.g., IL8
o Chemotactic mediators (C5a, LTB4 and IL8) bind to neutrophilic receptors causing the
release of calcium which increases neutrophilic motility
o Calcium binds on actin regulated proteins leading to the extension of pseudopods in the
neutrophil that pulls the remainder of the cell in the direction of the extension.
 6. Phagocytosis

(a)Opsonization

(b)Ingestion

(c) Killing

(a) Opsonization

▪ To make the microbe tasty for the neutrophil

▪ Opsonins bind to the bacteria
▪ Examples of opsonins: IgG, C3b,
▪ Neutrophils have membrane receptors for IgG and C3b
▪ Opsonization enhances neutrophil recognition and attachment to bacteria.
▪ Bruton’s agammaglobulinemia is an opsonization defect (antibody deficiency)
(b) Ingestion
▪ Neutrophils engulf (phagocytose) and then trap bacteria in phagocytic vacuoles
▪ During engulfment, extensions of the cytoplasm (pseudopods) flow around the
object to be engulfed, eventually resulting in complete enclosure of the particle
within a phagosome.
▪ The phagosome fuses with a lysosome forming a phagolysosome, resulting in
discharge of the granules of the lysosome into the phagolysosome
▪ In Chediak-Higashi syndrome, a defect in membrane fusion prevents the
formation of the phagolysosome.

(c) Bacterial killing

(i) O2 dependent myeloperoxidase (MPO) system

- Only present in neutrophils and monocytes (not macrophages)
- Produces super oxide free radicals
- NADPH converts molecular O2 to superoxide
- Superoxide dismutase converts superoxide to hydrogen peroxide
- Myeloperoxidase combines hydrogen peroxide with chloride ion to form hypochlorite free
radical (HOCl⁻) which kill bacteria
- Chronic granulomatous disease results from inherited defects encoding NADPH oxidase
(leading to NADPH oxidase deficiency). It is X-linked and causes defect in microbe killing
leading to numerous granuloma formation.

(ii) O2 independent system

- Refers to killing by substance located in the granules of leukocytes. Example:

o Lactoferrin binds iron necessary for bacterial production. This is why fesolate
is withheld in sepsis.
o Major basic protein-eosinophil product that kills helminths
o Bactericidal permeability increasing protein (BPI)
o Lysozymes
o Defensins
Mediators of inflammation

Characteristics

1. Mediators are generated either from cells or from plasma proteins.

a. Examples of such cells are platelets, neutrophils, monocytes/macrophages, and mast cells,
most parenchymal and mesenchymal cells. The mediators can be stored intracellularly (eg
histamine) or are synthesized de novo (e.g., prostaglandins, cytokines).
b. Plasma-derived mediators (e.g., complement proteins, kinins) are produced mainly in the
liver
2. Active mediators are produced in response to various stimuli ensuring that inflammation is
normally triggered only when it is needed
3. One mediator can stimulate the release of other mediators. Such cascades provide mechanisms
for amplifying—or, in certain instances, counteracting—the initial action of a mediator
4. They can act on one or a few target cell types, can have diverse targets, or may even have
differing effects on different types of cells. Eg histamine may produce local signs of itching or
systemic signs of anaphylaxis
5. Activated mediators have short half lives

Cell derived Mediators

1. Vasoactive Amines: Histamine and Serotonin- They are stored as preformed molecules in cells and
are therefore among the first mediators to be released during inflammation. Histamines are
produced by mast cells (mainly), basophils and platelets. Histamine by binding to H1 receptors
causes dilation of arterioles and increases the permeability of venules. It is the principal
mediator of the immediate transient phase of increased vascular permeability, producing
interendothelial gaps in venule.

Serotonin (5-hydroxytryptamine) is a preformed vasoactive mediator with actions similar to

those of histamine. It is present in platelets and some neuroendocrine cells.

2. Arachidonic Acid (AA) Metabolites: Prostaglandins, Leukotrienes, and Lipoxins- Diverse stimuli
act on cells causing the membrane AA to be rapidly converted to produce prostaglandins and
leukotrienes. These biologically active lipid mediators bind to G protein–coupled receptors on
many cell types and can mediate virtually every step of inflammation. AA-derived mediators,
also called eicosanoids, are synthesized by two major classes of enzymes: cyclooxygenases
(which generate prostaglandins) and lipoxygenases (which produce leukotrienes and lipoxins).
Eicosanoids.

Prostaglandins (PGs), synthesized from many other cell types, are produced by the actions of
two cyclooxgenases, the constitutively expressed COX-1 and the inducible enzyme COX-2. The
most important ones in inflammation are PGE2, PGD2, PGF2α, PGI2 (prostacyclin), and TxA2
(thromboxane). TxA2 is a potent platelet-aggregating agent and vasoconstrictor. Prostacyclin
(PGI2) is a vasodilator and a potent inhibitor of platelet aggregation. PGD2 causes vasodilation
and increases the permeability of post-capillary venules, thus potentiating edema formation.
PGF2α stimulates the contraction of uterine and bronchial smooth muscle and small arterioles,
 and PGD2 is a chemoattractant for neutrophils.
In addition to their local effects, the prostaglandins are involved in the pathogenesis of pain and
fever in inflammation. PGE2 is hyperalgesic and makes the skin hypersensitive to painful stimuli.

Leukotrienes are produced by the actions of lipoxygenase enzymes which are secreted mainly by
leukocytes. There are three different lipoxygenases, 5-lipoxygenase being the predominant one
in neutrophils. LTB4 is a potent chemotactic agent and activator of neutrophils. The cysteinyl
containing leukotrienes C4, D4, and E4 (LTC4, LTD4, LTE4) cause intense vasoconstriction,
bronchospasm (important in asthma), and increased vascular permeability. Leukotrienes are
much more potent than is histamine in increasing vascular permeability and causing
bronchospasm

Lipoxins generated from AA by the lipoxygenase pathway are inhibitors of inflammation and
thus play a role in the resolution of inflammation

3. Platelet-Activating Factor (PAF) – Produced by a variety of cell types, including platelets,

basophils, mast cells, neutrophils, macrophages, and endothelial cells. In addition to platelet
aggregation, PAF causes vasoconstriction and bronchoconstriction. However, at extremely low
concentrations it induces vasodilation and increased permeability of venules with a potency 100
to 10,000 times greater than that of histamine. PAF also causes increased leukocyte adhesion to
endothelium, chemotaxis, degranulation, and the oxidative burst. Thus, PAF can elicit most of
the vascular and cellular reactions of inflammation.

4. Reactive Oxygen Species- Oxygen-derived free radicals may be released extracellularly from
leukocytes after exposure to microbes, chemokines, and immune complexes, or following a
phagocytic challenge. Their production is dependent on the activation of the NADPH oxidase
system. Superoxide anion, hydrogen peroxide (H2O2), and hydroxyl radical (•OH) are the major
species produced within cells. The function in inflammation includes;

a. Increase in the expression of chemokines (e.g., IL-8), cytokines, and endothelial

leukocyte adhesion molecules, amplifying the inflammatory response.
b. Phagocytosis
c. Endothelial cell damage, with resultant increased vascular permeability.
d. Leads to inactivation of antiproteases, such as α1-antitrypsin. This leads to unopposed
protease activity, with increased destruction of extracellular matrix

Antioxidants that protect the body against these reactive oxygen species include superoxide
dismutase, catalase (which detoxifies H2O2), glutathione peroxidase another (H2O2 detoxifier).
ceruloplasmin and the iron-free fraction of serum transferrin

5. Nitric Oxide- is released from endothelial cells and causes vasodilation and is therefore called
endothelium-derived relaxing factor. It also reduces platelet aggregation and adhesion, inhibits
several features of mast cell–induced inflammation, and inhibits leukocyte recruitment.
 6. Cytokines and Chemokines
a. Cytokines are proteins produced by many cell types (principally activated lymphocytes and
macrophages, but also endothelial, epithelial, and connective tissue cells) that modulate the
functions of other cell types. Tumor Necrosis Factor (TNF) and Interleukin-1 (IL-1), produced
mainly by activated macrophages, are two major cytokines that mediate inflammation. They
induce the expression of endothelial adhesion molecules, synthesis of chemical mediators,
production of enzymes associated with matrix remodelling, and increases in the surface
thrombogenicity of the endothelium.

The production of IL-1 is controlled by a multi-protein cellular complex, called the

“inflammasome”. Mutations in genes encoding members of this protein complex could lead to
inherited autoinflammatory syndromes like Mediterranean fever. The mutation here either
constitutively activate the inflammatory enzyme complex or interfere with the negative
regulation of this enzymatic process. Affected patients present with fever and other systemic
manifestations of inflammation without overt provocation.

IL-1 and TNF (as well as IL-6) induce the systemic acute-phase responses associated with
infection or injury. TNF also regulates energy balance by promoting lipid and protein
mobilization and by suppressing appetite. Therefore, sustained production of TNF contributes to
cachexia, a pathologic state characterized by weight loss and anorexia that accompanies some
chronic infections and neoplastic diseases.

b. Chemokines- are a family of small molecular weight proteins that act primarily as
chemoattractants for specific types of leukocytes. Chemokines have two main functions: they
stimulate leukocyte recruitment in inflammation and control the normal migration of cells
through various tissues.

7. Other Cytokines in Acute Inflammation- IL-6 is made by macrophages and other cells andis
involved in local and systemic reactions. IL-17, produced mainly by T lymphocytes, which
promotes neutrophil recruitment

PLASMA DERIVED PROTEINS

These are derived from the complement, kinin, and clotting systems.

1. Complement System

Complement proteins are present in inactive forms in the plasma, and many of them are activated to
become proteolytic enzymes that degrade other complement proteins, thus forming an enzymatic
cascade capable of tremendous amplification. The critical step in complement activation is the
proteolysis of the third (and most abundant) component, C3. Cleavage of C3 can occur by one of three
pathways:

The classical pathway, which is triggered by fixation of C1 to antibody (IgM or IgG) that has combined
with antigen

The alternative pathway, which can be triggered by microbial surface molecules (e.g., endotoxin, or
LPS), complex polysaccharides, cobra venom, and other substances, in the absence of antibody

The lectin pathway, in which plasma mannose-binding lectin binds to carbohydrates on microbes and
directly activates C1.

Whichever pathway is involved in the early steps of complement activation, they all lead to the
formation of an active enzyme called the C3 convertase, which splits C3 into two functionally distinct
fragments, C3a and C3b. C3a is released, and C3b becomes covalently attached to the cell or molecule
where complement is being activated. More C3b then binds to the previously generated fragments to
form C5 convertase, which cleaves C5 to release C5a and leave C5b attached to the cell surface. C5b
binds the late components (C6–C9), culminating in the formation of the membrane attack complex
(MAC, composed of multiple C9 molecules).

The biologic functions of the complement system fall into three general categories (see Fig. 2-14 ):

• Inflammation. C3a, C5a, and C4a stimulate histamine release from mast cells and thereby
increase vascular permeability and cause vasodilation. They are called anaphylatoxins. C5a is also
a powerful chemotactic agent for neutrophils, monocytes, eosinophils, and basophils..
• Phagocytosis. C3b and its cleavage product iC3b (inactive C3b), when fixed to a microbial cell
wall, act as opsonins and promote phagocytosis by neutrophils and macrophages.
• Cell lysis. The deposition of the MAC on cells makes these cells permeable to water and ions and
results in death (lysis) of the cells.

2. Coagulation Systems

Inflammation and blood clotting are often intertwined, with each promoting the other. The clotting
system is divided into two pathways that converge, culminating in the activation of thrombin and the
formation of fibrin. The intrinsic clotting pathway is a series of plasma proteins that can be activated by
Hageman factor (factor XII). Inflammation increases the production of several coagulation factors,
makes the endothelial surface pro-thrombogenic, and inhibits anticoagulation mechanisms, thus
promoting clotting. Conversely, thrombin, a product of clotting, promotes mobilization of P-selectin,
production of chemokines and other cytokines, expression of endothelial adhesion molecules, induction
of cyclooxygenase-2 and production of prostaglandins, production of PAF and NO; and changes in
endothelial shape. As we have seen, these responses promote the recruitment of leukocytes and many
other reactions of inflammation.]

3. Kinin system- Kinins are vasoactive peptides derived from plasma proteins, called kininogens, by
the action of specific proteases called kallikreins. The kinin and coagulation systems are also
intimately connected and they combine to produce bradykinin.] Bradykinin increases vascular
 permeability and causes contraction of smooth muscle, dilation of blood vessels, and pain when
injected into the skin. These effects are similar to those of histamine. The action of bradykinin is
short-lived, because it is quickly inactivated by an enzyme called kininase.

Summary of chemical mediators functions

a. Vasodilation
▪ Examples-histamine, nitric oxide , PGI2
b. Vasoconstriction
▪ Example-thromboxane A2 (TXA2)
c. Increase vessel permeability
▪ Examples-histamine, bradykinin, LTC4-D4-E4, C3a and C5a (anaphylatoxins)
d. Produce pain
▪ Examples-PGE2, bradykinin
e. Produce fever
▪ Examples-PGE2, IL-1, TNF
f. Chemotactic
▪ Examples-C5a, LTB4, IL-8

Outcomes of Acute Inflammation

1. Complete resolution
a. Occurs with mild injury to cells that have the capacity to enter the cell cycle (e.g., labile
and stable cells)
b. Examples-first-degree burn, bee sting
2. Tissue destruction and scar formation
a. Occurs with extensive injury or damage to permanent cells
b. Example-third-degree burns
3. Progression to chronic inflammation