Cell Injury

Accumulations

Dr. Roy
Intracellular accumulations
Introduction
- metabolic derangements may produce intracellular accumulation
- of abnormal amounts of various substances that may be harmless
- the substance may be seen within the cytoplasm, within lysosomes, or in the
nucleus
Mechanism
- there are 4 pathways of abnormal intracellular accumulation
1) inadequate removal of a normal substance (fatty change)
2) accumulation of endogenous abnormal substance (defect in protein folding)
3) failure to degrade a substance (storage disorder)
4) Deposition/accumulation of abnormal exogenous substance (silica, carbon)

2
Pathways of abnormal Intracellular Accumulations
Intracellular accumulations: Lipids
Introduction
- any form of lipids can accumulate within cells
- triglycerides (fatty change), cholesterol/cholesterol esters (atherosclerosis,
xanthoma), phospholipids (as component of myelin figures: necrotic cells)
Fatty change
- abnormal accumulation of triglycerides within parenchymal cells
- most common: fatty change liver
Causes
- alcoholism
- non alcoholic fatty liver (NAFLD)
- malnutrition/starvation

4
 Fatty Liver: Pathogenesis
1) increased NADH
- when alcohol is metabolized, there is an increase in NADH/NAD+ ratio
- NAD+ is used for ethanol metabolism, also, NAD+ is needed for fatty acid oxidation
- so, when NAD+ is depleted, fat accumulates in liver
Remember: fatty change is reversible*
- excess NADH leads to anion gap metabolic acidosis (lactic acidosis)
2) Fasting hypoglycemia
- impaired gluconeogenesis, inhibition of TCA cycle
3) Hepatosteatosis
- increased NADH/NAD+ ratio in Glycolysis pathway leads to increase conversion of DHAP to
Glycerol-3-phosphate
4) Direct Hepatocyte injury
- ethanol and acetaldehyde are toxic to the hepatocytes
Ethanol Metabolism
Intracellular accumulations: Lipids
Non-alcoholic fatty liver disease (NAFLD)
Pathogenesis
Metabolic Syndrome:
- criteria: 3 or more need to be present
1) Insulin resistance (inability of cells to respond adequately to Insulin)
2) Elevated BP
3) Elevated Triglycerides
4) Low HDL-C
5) Abdominal obesity

7
Insulin Resistance
Natural history of NAFLD
NAFLD: Non Alcoholic Fatty Liver Disease
NASH: Non Alcoholic Steatohepatitis
HCC: Hepatocellular Carcinoma
 Intracellular accumulations: Lipids
Fatty change
Morphology
- on gross, liver is enlarged, yellow and greasy
- on histology, microvesicular, macrovesicular fatty change
- to demonstrate fat in tissues, require special technique:
liver biopsy is never transported in formalin fixative.
Fresh tissue is immediately prepared using frozen section
(cryostat, -20℃)
- special stain: Oil Red O stain

11
Intracellular accumulations: Lipids

Fatty change
Labs:
- liver function tests (abnormal enzyme levels)
- when compared to other chronic liver diseases, in which serum ALT tends to be
higher than serum AST, in alcoholic liver disease. Reversal of AST/ALT ratio.
- serum AST tend to be higher than serum ALT levels by a ratio of 2 : 1 or greater
- gamma glutamyl transferase (GCT): gives a rough correlation between amount of
alcohol intake and GCT activity

12
 Freezing microtome for frozen section
- fresh tissue (without fixative)
- temperature set at -24℃
- tissue section stained with modified H&E
- whole process takes 15 to 20 minutes
- routine tissue processing takes approx. 12 hrs
Fatty liver:
routine stain
Normal liver histology

Fatty liver histology

 Fatty liver:
Oil Red O positive

Fatty liver: gross morphology

Intracellular accumulations: Lipids
Cholesterol and cholesterol esters
Atherosclerosis
- seen within intima of blood vessels
- atheroma consists of a raised lesion with a soft, yellow, grumous core of lipids
- lipids, mostly are cholesterol, and cholesterol esters
- the lesion is capped by a fibrous lining
Xanthomas
- acquired and hereditary hyperlipidemias
- yellow to orange plaque-like lesions. On biopsy show lipid-laden macrophages.
(eyelids, elbows, Achilles tendon)
 Atherosclerosis
Xanthoma

Atherosclerotic plaque
(atheroma)
- note: cholesterol clefts

Xanthoma Striatum Palmare

Intracellular accumulations: Proteins
- accumulation of proteins within cells occur in various diseases
Causes
- Massive proteinuria: nephrotic syndrome. Protein droplets are seen within
tubular epithelial cells of PCT. Referred to as: reabsorption droplets
- Plasma cells: with chronic antigenic stimulation (fungal/parasitic), plasma cells
accumulate large amounts of immunoglobulins: Russell bodies
- Defective intracellular transport: ⍺1-antitrypsin deficiency
- Accumulation of cytoskeletal proteins: Mallory bodies
- Aggregation of abnormal proteins: Amyloid
Resorption droplets:
- note: bright pink droplets seen in
glomerulus
- renal biopsy in Nephrotic syndrome
Russell bodies:
- note: plasma cells with Russell
bodies
⍺1-antitrypsin deficiency
- note: pink droplets within hepatocytes
- PAS with diastase reaction
Plasma cells:
- note: plasma cells with eccentric
nuclei.
- small bowel biopsy
Mallory bodies
- note: pink smudgy material within
hepatocytes
- liver biopsy in Alcoholic hepatitis
(steatohepatitis)
Intracellular accumulations: Hyaline Change
- alteration within cells, or in extracellular space
- appears as glassy pink on routine H & E stain

Causes:
Extracellular hyaline: hypertension, and diabetes associated changes in vascular
wall
- in hypertension (benign), vessel wall undergoes injury due to hemodynamic
process
- in diabetes, vessel wall damage by AGE bind to basement membrane

Intracellular hyaline: Russell bodies, Mallory bodies, reabsorption droplets

Hyaline Change: Diabetes
Formation of advanced glycation end products (AGE):
- there is excess AGE formation in Hyperglycemia
- AGE binds a receptor: RAGE expressed by endothelial cells, inflammatory cells,
vascular smooth muscle cells
- AGE-RAGE signalling results in
1) release of cytokines and growth factors
2) generation of Free Radicals
3) increased procoagulant activity
4) increased proliferation of vascular smooth muscle cells and ECM
 Hyaline change blood vessel:
renal biopsy

*This change is similar in both: Benign hypertension,

and in Diabetes Mellitus
Intracellular accumulations: Glycogen
Causes
- accumulation of glycogen is seen in patients with with abnormality in either
glucose (diabetes), or glycogen metabolism (storage disorder)
- in diabetes: renal tubular epithelial cells, and in liver
- in glycogen storage disorders: liver, skeletal muscle
- example of glycogen storage disorder- Von Grierke’s (deficiency of glucose 6
phosphatase)
Morphology
- glycogen dissolves in aqueous fixatives (routine preparation)
- special stain: Best carmine, or PAS reaction produces rose to violet color
Glycogen
- note: pale appearing cytoplasm with
routine H & E stain
- PAS stain highlights glycogen
- von Gierke’s disease
Intracellular accumulations: Pigments

Exogenous
- Carbon (coal dust)

Endogenous
- Lipofuscin
- Melanin
- Hemosiderin
Intracellular accumulations: Pigments

Exogenous
Carbon
- cigarette smoking, urban pollution
- coal worker’s lung (pneumoconiosis)
- carbon is inert, and is trapped by alveolar
macrophages
Carbon laden macrophages
- note: brown and black pigment
within macrophages
- lung at autopsy in a drug addict.
Note alveolar h’age
 Intracellular accumulations: Pigments
Endogenous
Lipofuscin
- wear and tear, aging pigment
- composed of polymers of lipids and
phospholipids complexed with protein
- importance lies in its being a telltale sign
of
- free radical injury and lipid peroxidation
- no pathologic implications
- appears as a yellow-brown, finely
granular cytoplasmic, often perinuclear,
pigment
*must be differentiated from hemosiderin
Intracellular accumulations: Pigments
Endogenous
Hemosiderin
- hemoglobin derived, golden yellow to brown
- when there is a local or systemic excess of iron, ferritin forms hemosiderin granules
local excess: hemorrhages in tissues (bruise/hematoma)
systemic excess: iron overload (hemosiderosis)
- hemosiderin pigment represents aggregates of ferritin micelles
Special stain: Prussian blue stain
Hemosiderin laden macrophages
- note: golden brown material within macrophages
- Prussian blue stain
Hemochromatosis:
- Adult form of hemochromatosis is almost always caused
by mutations of HFE
- HFE gene is located on the short arm of chromosome 6 at
6p21.3, close to the HLA gene locus
- it encodes an HLA class I-like molecule that governs
intestinal absorption of dietary iron by regulating
hepcidin synthesis
- the most common HFE mutation is a cysteine-to-tyrosine
substitution at amino acid 282 (called C282Y)
- this mutation, which causes inactivation of the protein, is
present in 70% to 100% of the patients diagnosed with
hereditary hemochromatosis
- C282Y mutation of the HFE gene is largely con­fined to
white populations of European origin
Raccoon eye

36
Pathologic Calcification
Introduction
- pathologic s the abnormal tissue deposition of calcium salts, together with
smaller amounts of iron, magnesium, and other mineral salts
Types
1) Dystrophic calcification: occurs locally in dying tissues
- coagulative, caseous, or liquefactive type, and in foci of enzymatic necrosis of fat
- present in the atheromas of advanced atherosclerosis
- commonly develops in aging or damaged heart valves
- normal serum levels of calcium

37
Pathologic Calcification
2) Metastatic calcification: deposition of calcium salts in otherwise normal tissues
- always results from hypercalcemia secondary to some disturbance in calcium
metabolism
1.Increased secretion of parathyroid hormone (PTH) with subsequent bone
resorption, due to
- hyperparathyroidism: parathyroid tumors, and ectopic secretion of PTH-related
protein by malignant tumors
2. Resorption of bone tissue: secondary to primary tumors of bone marrow
(example: multiple myeloma)
3. Vitamin D related: vitamin D intoxication, sarcoidosis
4. Renal failure: which causes retention of phosphate, leading to secondary
hyperparathyroidism
38
Psammoma bodies
- note laminated pattern
 Dystrophic calcification: demaged heart
valve in Rheumatic valvular disease

Dystrophic calcification:
Psammoma bodies:
- meningioma
- papillary carcinoma thyroid
- Serous (papillary) carcinoma ovary

40
“blaming others is nothing more than excusing yourself”
Robin Sharma

41