Inflammation Outcomes:

Healing, Sepsis
 Summary of acute inflammation
• Stimulated by physical injury, infection, foreign body
• Resident macrophages and/or damaged endothelium, mast cells—
IL-1, TNF, endothelin, histamine
• Vascular response: vasodilation, endothelial contraction,
exudation of plasma
• Neutrophils: marginate (selectin-glycoprotein), adhere (integrin-
CAM), extravasate (CD31), migrate (IL-8, chemotactic stimuli)
• Phagocytosis: recognition, engulfment, killing
 Phagocytosis receptors bind mannose, oxidized lipids,
lipopolysaccharides, lipoteichoic acids, opsonins
 Killing is O2-dependent (respiratory burst, NADPH oxidase generated
H2O2; myeloperoxidase generated HOCl; iNOS generated NO) or
independent (lysozyme, lactoferrin, defensins)
• Responding leukocytes cause pain and loss-of-function via
prostaglandins, enzymes
• Complete resolution; fibrosis, organization or scarring; abcess
formation; progression to chronic inflammation
 Outcomes of Acute Inflammation
• Resolution of tissue structure and function with elimination of
stimulus
• Tissue destruction and persistent inflammation
 Abscess
• pus-filled cavity (neutrophils, monocytes and liquefied cellular debris)
• walled off by fibrous tissue and inaccessible to circulation
• tissue destruction caused by lysosomal and other degradative enzymes
 Ulcer
• loss of epithelial surface
• acute inflammation in epithelial surfaces
 Fistula
• abnormal communication between organs or an organ and a surface
 Scar
• Causes distortion of structure and sometimes altered function
• Chronic inflammation
 Marked by replacement of neutrophils and monocytes with lymphocytes,
plasma cells and macrophages
 Accompanied by proliferation of fibroblasts and new vessels with
scarring
 Causes of chronic inflammation
• Persistent infections
 Organisms usually of low toxicity that invoke delayed
hypersensitivity reaction
 M. tuberculosis and T. pallidum causes granulomatous reaction
• Prolonged exposure to potentially toxic agents
 Exogenous agents include silica which causes silicosis
 Endogenous causes include atherosclerosis caused by toxic
plasma lipid components
• Autoimmunity
 Auto-antigens provoke self-perpetuating immune responses that
cause chronic inflammatory diseases like RA, MS
 Responses against common environmental substances cause
chronic allergic diseases, such as bronchial asthma
 Granulomatous inflammation
• Focus of chronic inflammation encountered in a limited
number of conditions
• Cellular attempt to contain a foreign body or an offending
agent that is difficult to eradicate (i.e. Tb)
• Microscopic aggregation of macrophages that are
transformed into epithelioid cells, surrounded by a collar
of lymphocytes and occasionally plasma cells
• Epithelioid cells have a pale pink granular cytoplasm with
indistinct cell boundaries, often merging as giant cells
 Foreign body epitheloids have dispersed nuclei
 Infectious body epitheloids have marginal or horse-shoe nuclei
• Enlarged granuloma with central necrosis is an abcess
• Enlarged granuloma on a surface is an ulcer
 Patterns of Inflammation
• Serous Inflammation
 Marked by outpouring of thin fluid
 From blood serum, e.g. burn blisters
 Effusion from mesothelial cells lining the pleural, peritoneal and pericardial cavity
• Fibrinous Inflammation
 A feature of pericardial and peritoneal inflammation
 Vascular permeability allows larger molecules like fibrin to pass or procoagulant
stimulus exists in the interstitium (e.g. cancer cells)
• Suppurative Inflammation
 Characterized by production of large amount of pus composed of neutrophils,
necrotic cells and edema fluid
 Involves pyogenic bacteria e.g. Streptococci and Staphylococcus aureus
 Abscesses are focal localized collections of purulent inflammatory tissue caused
by suppuration.
• Ulcers
 Local defect or excavation of the surface of an organ or tissue by sloughing of
inflammatory necrotic tissue
 Acute stage - intense polymorphonuclear infiltration and vascular dilation in
margin
 Chronic stage - margin and base develop fibroblastic proliferation, scarring and
accumulation of lymphocytes, plasma cells and macrophages
Systemic inflammatory response
• Acute Phase Response
 Fever
 Acute-phase protein secretion from liver
 Leukocytosis
 Tachycardia, increased blood pressure
 Shivering, chills
 Anorexia, somnolence, malaise
• Septic shock
 Acute Phase Proteins
• Secretion of Acute Phase proteins by the liver
• C-reactive Protein (CRP)
• Serum Amyloid A (SAA)
• Serum Amyloid P (SAP)
• Complement
• Fibrinogen
• Prothrombin
• Ferritin
• Ceruloplasmin
• α1-antitrypsin
• α2-macroglobulin
• Acute phase proteins bind:
 Microbial constituents, acting as opsonins to fix
complement
 Chromatin, aiding early clearing of necrotic cells
Autonomic and Behavioral Responses
• Autonomic
 redirection of blood flow from cutaneous to
vascular bed
 increased pulse and blood pressure
 decreased sweating
• Behavioral
 Rigors (Shivering)
 Chills
 Anorexia
 Somnolence
 Malaise
 Sepsis
• Systemic Inflammatory Response Syndrome involves
two or more of the following
• temperature >38.3ºC or <36ºC
• heart rate >90 beats/min; <32 mm Hg
• respiratory rate >20 breaths/min, PaCO2 or need for mechanical
ventilation
• WBC count >12,000/uL or <4,000/uL or >10% immature forms
(bands)
• Sepsis is defined as SIRS associated with suspected or
confirmed infection--positive blood cultures are not
necessary
• Severe sepsis is sepsis complicated by a predefined
organ dysfunction
• Septic shock is cardiovascular collapse (hypotension)
related to severe sepsis despite adequate fluid
resuscitation
 Septic stimuli
• Gram-negative bacteria
 LPS, endotoxin
 Binds to LPS binding protein (LBP)
 Binds to CD14 opsonin receptor
 TLR-4 binds LPS and LPS-LBP
 Stimulates release of TNF, IL-1, IL-6
• Gram-positive bacteria
 Exotoxins, superantigens
 Bind Vb regions of TCRs and/or to MHC-II
 TLR-2 binds cell wall components
 Stimulates release of IFN-g, TNF, IL-1, IL-6
 Progression of sepsis
• Cytokine release and amplification
 Vasular response and neutrophil migration
• Coagulation cascade
 Short arm, extrinsic pathway, activated by expression of Tissue
Factor VIIa Xa thrombin fibrin
 high plasma levels of plasminogen-activator inhibitor type-1
(PAI-1) suppress plasmin and fibrinolysis
 disseminated intravascular coagulation in 30-50% cases
• Counter-inflammatory response
 Apoptosis of Th and B-cells
• Systemic acute phase response
 increased cortisol production and release of catecholamines
 upregulation of adhesion molecules
 release of prostanoids and platelet-activating factor (PAF)
• Organ failure
 Multiple organ failure
• Neutrophils damage tissue directly by
releasing lysosomal enzymes and
superoxide-derived free radicals
• TNF-α induces nitric oxide synthase
 nitric oxide causes further vascular instability
 contributes to direct myocardial depression
• Widespread vasodilation
• Decreased production of vasopressin
(ADH) and glucocorticoids
• Circulatory collapse and tissue hypoxia
 Findings of shock at autopsy
• Congestion of lung
 may also have fibrinous casts lining alveolar
spaces
• Petechial or ecchymotic hemorrhages on
serosal and endothelial surfaces
• Necrosis
 proximal tubular epithelium in kidneys
 entrilobular hepatocytes
Restoration of Structure and Function
• Occurs if connective tissue structure relatively intact
• Surviving parenchymal cells must have the capacity to
regenerate
• Labile Cells
 Actively divide throughout life
• cells of the epidermis and gastrointestinal mucosa
• cells lining surface of the genitourinary tract
• hematopoietic cells of the bone marrow
• Stable Cells
 Undergo few divisions normally, but can be activated from G0
cells when needed
• hepatocytes
• renal tubular cells
• parenchymal cells of glands
• mesenchymal cells (smooth muscle, cartilage, connective tissue,
endothelium, osteoblasts)
 Regeneration
• Proliferation of cells and tissues to replace
lost structures
• Whole organs and complex tissues rarely
regenerate after injury
• Compensatory growth rather than true
regeneration
 Liver hypoplasia and kidney hypertrophy
• Continuously renewing tissues regenerate
after injury if tissue stem cells are not
destroyed
 Stem Cells
• Characterized by self-renewal properties and
capacity to generate differentiated cell lineages
 obligatory asymmetric replication
• one daughter cell retains its self-renewing capacity
• the other enters a differentiation pathway
 stochastic differentiation
• stem cell divisions generate either two self-renewing stem cells
or two cells that differentiate
• Stimulation for either outcome is conjecture—seemingly random
• embryonic stem cells (ES cells) are pluripotent
• adult (somatic) stem cells are restricted by niche
 skin, gut lining, cornea, hematopoietic tissue
ES cells and KO/transgenic mice
• KO mice have specific gene deletion or
inactivation
 Transform cultured ES cells
 Transformants injected into blastocysts
 Blastocyst transplanted to surrogate dam
 Mouse develops in utero
• Transgenic mice have specific human
gene insertion or replacement
 Transformed ES cells injected into blastocysts
 Continued development in surrogate dam
 Somatic cell cloning
• Reproductive
 Transfer of adult nucleus into enucleated
oocyte restores pluripotency
 Transfer of resulting embryo to surrogate dam
 Production of cloned individual
• Therapeutic
 Transfer of adult nucleus into enucleated
oocyte restores pluripotency
 Induced to differentiate into various cell types
in vitro
 Injected into damaged organ
 Induced Pluripotent Stem Cells
• Mouse ES cell pluripotency depends on
the expression of Oct3/4, Sox2, c-myc,
Klf4, Nanog
• Human fibroblasts from adults and
newborns have been reprogrammed
 Oct3/4, Sox2, c-myc and Kfl4
 Oct3/4, Sox2, Nanog, and Lin28
• Generated cells from endodermal,
mesodermal, and ectodermal origin
• c-myc and Kfl4 are oncogenes
Stem Cells in Homeostasis and Healing
• Bone marrow
 Hematopoietic Stem Cells generate all of the blood cell lineages
 Marrow Stromal Cells generate precursors of tissue to which migrated
• Liver
 Oval cells are bipotential progenitors of hepatocytes and biliary cells
• Brain
 Neural precursor cells generate neurons, astrocytes, and
oligodendrocytes in the subventricular zone and the dentate gyrus of the
hippocampus
• Skin
 Hair follicle bulge, interfollicular areas of the surface epidermis, and
sebaceous glands
• Intestinal epithelium
 crypts are monoclonal structures derived from single stem cells
 villus contains cells from multiple crypts
• Skeletal and cardiac muscle
 satellite cells beneath the myocyte basal lamina generate differentiated
myocytes after injury
• Cornea
 limbal stem cells maintain corneal transparency
Proliferative capacity of tissues
• Labile tissues
 Continuously dividing tissues containing stem
cells
• Stable tissues
 Parenchymal cells of solid organs in G0
 Endothelial cells, fibroblasts, smooth muscle
 Limited regeneration after wounding
• Permanent tissues
 Absolutely nonproliferative
 Cardiac muscle, neurons
 Growth factors
• Polypeptides that promote survival and
proliferation by signal transduction
 Increase in cell size
• true growth factors
 Increase in cell number
• mitogens
 Protection from apoptosis
• survival factors
 Signaling mechanisms
• Receptors with intrinsic tyrosine kinase activity
 Dimeric transmembrane molecules
 Ligand binding induces stable dimerization and
phosphorylation
• 7tm GPCRs
 Seven transmembrane proteins
 Ligand binding induces association with GTP-binding
protein, which swaps GDP for GTP
 Gi or Gs protein inactivates or stimulates another
effector
• Gs activates membrane adenylyl cyclase; GTPGDP
• cAMP activates PKA, etc.
• Receptors without intrinsic enzymatic activity
 Monomeric transmembrane molecules
 Ligand binding stimulates interaction with JAKs
Growth Factor-mediated Proliferation
• Platelet Derived Growth Factor (PDGF)
 promotes the chemotactic migration of fibroblasts and smooth muscles
 chemotactic for monocytes
 competence factor that promotes the proliferative response of fibroblasts and
smooth muscles upon concurrent stimulation with progression factors
• Epidermal Growth Factor (EGF)
 promotes growth for fibroblasts, endothelial and epithelial cells
 is a progession factor - promotes cell-cycle progression.
• Fibroblast Growth Factor (FGF)
 promote synthesis of fibronectin and other extracellular matrix proteins
 chemotactic for fibroblast and endothelial cells
 promotes angiogenesis
 links extracellular matrix components (collagen, proteoglycans) and
macromulocules (fibrin, heparin) to cell-surface integrins.
• Transforming Growth Factors (TGFs)
 TGF-α - similar to EGF
 TGF-β - mitosis inhibitor that aids in modulating the repair process. May be
responsible for hypertrophy by preventing cell division. Chemotactic for
macropahges and fibroblasts
• Macrophage-derived cytokines (IL-1 and TNF)
 promote proliferation of fibroblasts, smooth muscle and endothelial cells
 Repair Process
• Removal of Debris
 begins early and initiated by liquefaction and
removal of dead cells and other debris
• Formation of Granulation Tissues
 connective tissue consisting of capillaries and
fibroblasts that fills the tissue defect created
by removal of debris
• Scarring
 fibroblasts produce collagen until granulation
tissue becomes less vascular and less cellular
 progessive contraction of the wound occurs,
resulting in deformity of original structure
 Factors that Impede Repair
• Retention of debris or foreign body
• Impaired circulation
• Persistent infection
• Metabolic disorders
 diabetes
• Dietary deficiency
 ascorbic acid
 protein
 Healing and granulation
• Fibroplasia is a response to
 Damaged connective tissue
 Parenchymal damage exceeds regenerative capacity
• Hyperplasia of connective tissue
• Neovascularization
• Granulation
 coordinated proliferation of fibroblasts with a rich bed
of capillaries
 intensely hyperemic with a roughened or granular,
glistening surface
 healthy granulation tissue resists secondary infections
 Healing by First Intention
• Clean, surgical incision or other clean narrow cut
• Focal disruption of epithelial basement
membrane with little cell damage
• Regeneration dominates fibrosis
• Scabbing with fibrin-clotted blood
• Neutrophils migrate to edges
• Epidermis becomes mitotic and deposits ECM
• Macrophages replace neutrophils
• Vascularization and collagen deposition fills gap
• Contraction of collagen minimizes epidermal
regeneration
 Healing by Second Intention
• Larger area of tissue injury such as abcess,
ulcer, infarction that destroys ECM
• Large clot or scab with fibrin and fibronectin fills
gap
• Larger volume of necrotic debris must be
removed by more neutrophils and macrophages
 Opportunity for collateral damage by phagocytes
• Scar tissue formed from vascular cells,
fibroblasts, and myofibroblasts
• Contraction of myofibroblasts distorts tissue
• More prone to infection
Keloid—excessive cutaneous fibrosis
Granulation at tracheotomy