Cellular Responses

to Stress
and Toxic Insults:
Adaptation,
Injury, and Death
Dr. Carmel Therese B. Apao
 Study of structural and
functional causes of human
disease
 sequence of cellular,biochemical,
Cause and molecular events that follow
Genetic or acquired the exposure of cells or tissues to
an injurious agent

Etiology Pathogenesis

Pathology
Morphologic Clinical
Changes Manifestations
structural changes induced in the Functional consequences of these
cells and organs of the body changes
Normal cell function requires
a balance between
physiologic demands and the
constraints of cell structures
and metabolic capacity
HOMEOSTASIS
 • Hypertrophy
• Hyperplasia
• Atrophy
• Metaplasia

ADAPTATION NECROSIS

IRREVERSIBLE CELL
NORMAL CELL Inability
to adapt
INJURY DEATH
(homeostasis)

APOPTOSIS
CELL INJURY

REVERSIBLE
INJURY
 DEFINITION STIMULUS MECHANISM EXAMPLES
HYPERTROPHY ↑ in SIZE of cells • ↑ functional ↑ production of • PHYSIOLOGIC
demand cellular proteins • Gravid uterus
• ↑ hormonal • Muscle of body
occurs in tissues stimulation builders
incapable of cell • PATHOLOGIC
division • LVH
HYPERPLASIA ↑ in NUMBER of Hormonal or • Growth factor- • PHYSIOLOGIC
cells compensatory driven • Pubertal breast
proliferation of changes
mature cells • Liver regeneration
occurs in tissues • ↑ output of new • PATHOLOGIC
capable of cell cells from • Endometrial
division tissue stem hyperplasia
cells
ATROPHY ↓ in cell SIZE and • ↓ workload, • ↓ protein • PHYSIOLOGIC
NUMBER denervation synthesis • Embryonal atrophy
• Ischemia • ↑ protein (notochord &
• Malnutrition degradation thyroglossal duct)
• Loss of • autophagy • PATHOLOGIC
endocrine • Senile atrophy of
stimulation brain
• Pressure
METAPLASIA Differentiated Stress Reprogramming of • Columnar to
cell type replaced stem cells squamous: Vitamin A
by another cell deficiency
type • Squamous to
columnar: Barrett
esophagus
Hypertrophy
Hyperplasia
Atrophy
Metaplasia
 • Hypertrophy
• Hyperplasia
• Atrophy
• Metaplasia

ADAPTATION NECROSIS

IRREVERSIBLE CELL
NORMAL CELL Inability
to adapt
INJURY DEATH
(homeostasis)

APOPTOSIS
CELL INJURY

REVERSIBLE
INJURY
Causes of cell injury

Oxygen deprivation
(hypoxia)
Chemical agents &
• -ischemia Physical agents
-inadequate oxygenation drugs
-loss of O2-carrying
capacity of blood

Immunologic Genetic
Infectious agents
reactions derangements

Nutritional
imbalances
Morphologic Alterations in Cell
Injury
Morphologic Alterations in
Reversible Cell Injury

Cell • inability to maintain ionic and fluid homeostasis

due to failure of energy-dependent ion pumps in
the plasma membrane

swelling • Small clear vacuoles in the cytoplasm; increased

eosinophilic staining

Fatty • cytoplasmic lipid vacuoles

• Seen in cells involved in fat metabolism
change (hepatocytes and myocytes)
Morphologic Alterations in
Reversible Cell Injury

Ultrastructural Changes

• Plasma membrane alterations – blebbing,

blunting, loss of microvilli
• Mitochondrial changes – swelling, amorphous
densities
• Dilation of ER- myelin figures
• Nuclear alterations- disaggregation of granular
and fibrillar elements
Morphologic Alterations in
Reversible Cell Injury
 • Hypertrophy
• Hyperplasia
• Atrophy
• Metaplasia

ADAPTATION NECROSIS

IRREVERSIBLE CELL
NORMAL CELL Inability
to adapt
INJURY DEATH
(homeostasis)

APOPTOSIS
CELL INJURY

REVERSIBLE
INJURY
Morphologic Alterations in Cell
Injury: NECROSIS

Two processes underlying

changes

Denaturation Enzymatic
of proteins digestion
Morphologic Alterations in Cell
Injury: NECROSIS

Necrotic cells are more eosinophilic (pink) than

viable cells

Appear “glassy”, vacuolated cell membranes,

fragmented

Dead cells may be replaced by large, whorled

phospholipid masses called myelin figures
• These precipitates are either phagocytosed or degraded into
fatty acids → attract calcium salts, forming fatty soaps
Morphologic Alterations in Cell
Injury: NECROSIS

Nuclear changes

Pyknosis- small dense nucleus

Karyolysis- faint, dissolved nucleus

Karyorrhexis- fragmented nucleus

Morphologic Alterations in Cell
Injury: NECROSIS
Tissue patterns of necrosis

COAGULATIVE LIQUEFACTIVE GANGRENOUS

CASEOUS FAT NECROSIS FIBRINOID

Coagulative necrosis

• Most common
• CHON denaturation with preservation of cell & tissue
framework
• Seen in hypoxic death of all tissue except the brain
• Tissue later undergoes autolysis or heterolysis
Liquefactive necrosis

• Digestion of dead
cells, resulting in
transformetion of the
tissue into a liquid
viscous mass (pus)
• Localized bacterial
infections (abscesses)
and in the brain
Gangrenous necrosis

• Not a specific pattern of cell death but a term

commonly used in clinical practice
• Usually applied to describe a limb that has lost
its blood supply  necrosis (coagulative)
• If with bacterial infection → liquefactive
necrosis
• Dry gangrene – predominantly coagulative
• Wet gangrene – more liquefactive
Caseous necrosis

• Tuberculous lesions
• Gross: soft, friable,
cheese-like
• Architecture not
preserved
• Microscopic: amorphous
eosinophilic material
with cell debris
Fat necrosis

• Lipase activation
release of fatty acids
 complex with Ca
soaps (saponification)
• Seen in pancreatitis
• Gross: white chalky
areas (fat
saponification)
• Microscopic: vague cell
outlines, Ca deposition
 Fibrinoid necrosis

• Special form of necrosis

usually seen in immune
reactions involving blood
vessels
• Ag-Ab complexes
deposited in walls of
arteries + fibrin leak out
of vessels  bright pink
amorphous appearance
on H&E
• Immune-mediated
vasculitis syndromes
Mechanisms of Cell injury

BIOCHEMICAL INTRACELLULAR
MECHANISMS MECHANISMS
Biochemical mechanisms

Responses to stimuli depend on type,

duration & severity of injury

Consequences depend on type, state

& adaptability of injured cell
Biochemical Mechanisms
Biochemical mechanisms

ATP depletion

Mitochondrial damage

Influx of intracellular calcium & loss of calcium

homeostasis

Accumulation of oxygen-derived free radicals

Defects in membrane permeability

 ATP depletion

• Fundamental cause of necrotic cell

death
• Consequence of ischemic & toxic injury
• Reduced Na pump activity  ↑ influx of
Na, H20 and Ca  cell swelling
• Hypoxia  ↑ glycolysis  glycogen
depletion, increased lactic acid,
intracellular acidosis
• Ribosomal detachment  ↓ protein
synthesis
Mitochondrial damage

• Consequence of increased
cytosolic Ca++, ROS and O2
deprivation
• Damage  formation of
mitochondrial permeability
transition pore  loss of
mitochondrial membrane
potential  ↓ ATP  necrosis
• Abnormal oxidative
phosphorylation  formation
of ROS  necrosis
• Damage  ↑ permeability of
the outer mitochondrial
membrane  leakage of
caspases  apoptosis
Ca++ influx & loss of homeostasis

• Ischemia/Toxins  Ca influx
+ release of Ca from
mitochondria and ER 
• Activates phospholipases
degrades membrane
phospholipids
• Activates proteases breaks
down membrane and
cytoskeleton proteins
• Activates ATPases ATP
depletion
• Activates endonucleases
chromatin fragmentation
Accumulation of O2-derived free
radicals (Oxidative Stress)

• Free radicals
• chemical species that have a single
unpaired electron in an outer orbit
• “attack” and modify adjacent
molecules (proteins, lipids,
carbohydrates, nucleic acids)
• Ex: ROS
• If increased  oxidative stress
Properties of the Principal Free
Radicals Involved in Cell Injury
Accumulation of O2-derived free
radicals (Oxidative Stress)
Defects in membrane permeability

• Consistent feature of most

forms of cell injury except
apoptosis
• Mechanisms
• ROS
• Decreased phospholipid
synthesis
• Increased phospholipid
breakdown
• Cytoskeletal abnormalities
• Consequences
• Mitochondrial membrane
damage
• Plasma membrane damage
• Injury to lysosomal membranes
Clinicopathologic Examples of
Cell Injury and Necrosis
 Ischemic Ischemia-
and hypoxic reperfusion
injury injury

Chemical
injury
Ischemic and hypoxic injury

• Most common type of injury

• Hypoxia  reduced O2 delivery
• Mechanical obstruction in arteries 
Ischemia  Reduced venous
drainage, compromised delivery of
substrates for glycolysis
Mechanisms of ischemic cell
injury

Sequence of events:
• Decreased O2 tension
• Loss of oxidative phosphorylation
• Decreased production of ATP
• Failure of sodium pump  loss of K  influx of
Na and water  cell swelling
• Influx of Ca
• Progressive loss of glycogen, decreased CHON
synthesis
Mechanisms of ischemic cell
injury

• More ATP depletion  further deterioration

• Cytoskeleton disperses  blebs
• Myelin figures from membrane destruction
• Mitochondrial swelling, ER dilation
• If O2 is restored, these changes are reversible
Mechanisms of ischemic cell
injury

• Persistent ischemia  irreversible injury and

necrosis
• Severe swelling, plasma membrane damage,
swelling of lysosomes
• Massive Ca influx
• Cell components degraded  intracellular
enzymes leak out
• Dead cells replaced by amorphous phospholipid
masses
Ischemia-reperfusion injury

Death of cells after blood flow resumes

Associated with neutrophilic infiltration

Ischemia-reperfusion injury

Mechanisms:
• Increased generation of O2-derived
free radicals
• Resulting inflammation and
recruitment of PMNs
• Activation of complement
Chemical injury

DIRECT
binding to critical molecular component

INDIRECT
conversion to reactive toxic metabolites
 • Hypertrophy
• Hyperplasia
• Atrophy
• Metaplasia

ADAPTATION NECROSIS

IRREVERSIBLE CELL
NORMAL CELL Inability
to adapt
INJURY DEATH
(homeostasis)

APOPTOSIS
CELL INJURY

REVERSIBLE
INJURY
Apoptosis

• “Programmed Cell Death”

• induced by a tightly regulated suicide program in
which cells destined to die activate intrinsic
enzymes that degrade the cells’ own nuclear DNA
and nuclear and cytoplasmic proteins
• Apoptotic cells break up into fragments, called
apoptotic bodies, which contain portions of the
cytoplasm and nucleus
Apoptosis: Causes

PHYSIOLOGIC PATHOLOGIC
• Programmed destruction of cells in
embryogenesis
• Death due to injurious
• Hormone-dependent involution of stimuli
tissues
• Cell deletion in proliferating cell • Viral infections (e.g.
populations hepatitis)
• Death of cells that have served their
purpose • Pathologic atrophy in
• Deletion of potentially harmful self- parenchymal organs
reactive lymphocytes
• Cell death induced by cytotoxic T- after duct obstruction
cells to eliminate virally infected or
neoplastic cells
• Cell death in tumors
Apoptosis: Morphologic features

Cell shrinkage

Chromatin condensation &

fragmentation

Cellular blebbing and fragmentation

into apoptotic bodies
Phagocytosis of apoptotic bodies by
adjacent healthy cells or
macrophages

Lack of inflammation
Mechanisms of apoptosis

INITIATION PHASE
• Intrinsic (mitochondrial) pathway
• Extrinsic (death receptor) pathway

EXECUTION PHASE- enzymes cause cell death

(activation of cascade of caspases)

REMOVAL OF DEAD CELLS – by phagocytes

Intrinsic (Mitochondrial) Pathway

• due to increased mitochondrial

permeability
• Proapoptotic > antiapoptotic
proteins
• Activates caspase 9
• Anti-apoptotic: BCL2, BCL-XL, and
MCL1
• Pro-apoptotic: BAX and BAK
• Sensors: BAD, BIM, BID, Puma,
and Noxa
Extrinsic (Death receptor) Pathway

• activation of death receptors on

the cell membrane (TNFR1 and
Fas)

Fas + FasL =
attracts ≥3 Fas

Forms a binding
site for FADD

Activates
caspases 8 and 10
Execution Phase

Initiator caspases Executioner Nuclear

• Intrinsic: Caspase 9 caspases fragmentation;
• Extrinsic Caspase 10 • Caspase 3 and 6 Endonuclease
activation;
Breakdown of
cytoskeleton
Examples of apoptosis

Growth factor deprivation

DNA damage

Protein misfolding

TNF family receptors

Cytotoxic T lymphocytes
Necroptosis
Necroptosis

• shares aspects of both necrosis and apoptosis

• resembles necrosis morphologically and apoptosis
mechanistically
• “programmed necrosis”
• Causes: TNF and viral proteins
• Caspase-independent; activates RIP1 and RIP3
complexes → ↑ ROS and ↓ mitochondrial ATP
production → necrosis
Intracellular Accumulations
Intracellular accumulations

• Normal endogenous substance produced at a

normal rate but the metabolic rate is
inadequate to remove it
• Normal or abnormal endogenous substance
accumulation due to genetic or acquired
defects in metabolism, packaging, transport
or secretion
• Abnormal exogenous substance accumulation
due to lack in machinery to degrade them
Lipids Proteins

Hyaline
Glycogen
Change

Pigments
Lipids

• Triglycerides- most common

• Cholesterol
• Cholesterol esters
• phospholipids
Lipids: Steatosis

• Fatty change
• Occurs when a normal
constituent
(triglycerides)
accumulates, leading
to increase in
intracellular lipids
• Most common in liver
• Reversible may lead
to cirrhosis if in
excess
Lipids: Steatosis

Caused by:
• Excessive entry of free fatty acids into the
liver
• Enhanced fatty acid synthesis
• Increased esterification of fatty acids into
the liver to TG
• Decreased fatty acid oxidation
• Decreased apoprotein synthesis
• Impaired liporotein secretion from liver
Lipids: Cholesterol & cholesterol
esters

• Atherosclerosis
• Xanthomas
• Inflammation &
necrosis
• Cholesterolosis
• Niemann-Pick disease
type C
Proteins

• Defective intracellular
transport and
secretion of
intracellular proteins
and secretion of
critical proteins
• Toxicity of
aggregated,
abnormally folded
proteins
(neurodegenerative
disorders)
Proteins

Reabsorption droplets in proximal Nephrotic syndrome

renal tubules
Excess of normally-secreted Plasma cells actively producing Igs
proteins (Russell bodies)

Defective intracellular transport α1-antitrypsin deficiency

and secretion
Accumulation of cytoskeletal Alzheimer disease (neurofibrillary
proteins tangles)
Aggregation of abnormal proteins Amyloidosis
Hyaline change

• Alteration that imparts a homogenous glassy pink

appearance in H&E-stained sections; not specific
• Intracellular Hyaline
• α1-antitrypsin deficiency
• Extracellular Hyaline
• Hyaline arteriosclerosis in HPN and DM
Glycogen

• Abnormalities in glucose and glycogen

metabolism
• Excessive deposits seen as vacuoles
• Glycogen storage disease
• Glycogen granules in cells due to inherited defects in
glycogen metabolism
• Diabetes mellitus
• Glycogen granules in hepatocytes, renal tubular
epithelium and cardiac myocytes
Pigments

Exogenous
• Carbon or coal dust
(anthracosis)
• Tattooing
Endogenous
• Lipofuschin
• Lipids + phospholipids in
complex with protein
• Sign of lipid perodixation
• “wear and tear” pigment
• Melanin
• Homogentisic acid; in
alkaptonuria (ochronosis)
• Hemosiderin
Calcification
 PARAMETER DYSTROPHIC METASTATIC

Type of Tissue Necrotic Viable

Serum calcium Normal Increased

Causes:
• PTH excess
• Bone resorption
• Vitamin D disorders
• Renal failure
Histology • Basophilic, amorphous granular, clumped
appearance; either intra or extra cellular
• Heterotopic bone may be formed
Clinical importance Psamomma bodies – sand- • Lung involvement
like lamellated • Nephrocalcinosis
concretions
• Papillary thyroid CA
• Serous cystadenoCA of
ovaries
• Meningioma
• Mesothelioma
Psammoma bodies
Dystrophic calcification
Cellular Aging
Cellular Aging

Result of a progressive decline in cellular

function and viability caused by genetic
abnormalities and the accumulation of
cellular and molecular damage due to the
effects of exposure to exogenous influences
Cellular Aging

Diminished metabolic functions

• Reduced ATP generation
• Diminished synthesis of structural, enzymatic
and regulatory proteins
• Decreased capacity for nutrient uptake
• Increase DNA damage and decreased repair
• Accumulation of oxidative damage in
proteins and lipids
• Accumulation of advanced glycation end
products causing protein cross-linking
CELLULAR AGING

Morphologic alterations
• Irregular, abnormally lobed nuclei
• Pleomorphic & vacuolated mitochondria
• Decreased cytoplasmic endoplasmic reticulum
• Distorted Golgi apparatus
Mechanisms that Counteract
Aging

• Decreased IGF-1 signaling

• Insulin-like effect (anabolic: increased cell growth)
• If decreased, there is also decreased chance of cell
damage
• Increased sirtuins
• Proteins that function in response to food deprivation
and DNA damage
• If increased, produced substances that promote
longevity
Red wine activates sirtuins

Thank You!