 Apoptosis is a pathway of cell death in which cells activate enzymes (caspases) that degrade

the cells’ own nuclear DNA and nuclear and cytoplasmic proteins then fragments of the
apoptotic cells then break off.
 The plasma membrane of the apoptotic cell remains intact, but the membrane is altered in
such a way that the cell and its fragments become avid or ready targets for phagocytes.
 The dead cell and its fragments are rapidly cleared before cellular contents have leaked out,
so apoptotic cell death does not elicit an inflammatory reaction in the host.
 Morphologic Appearance of Apoptotic Cells
 The nuclei of apoptotic cells show various stages of chromatin condensation and
aggregation.
 The cells rapidly shrink, form cytoplasmic buds, and fragment into apoptotic bodies
composed of membrane-bound vesicles of cytosol and organelles.
Clearance/elimination of Apoptotic Cells
 Apoptotic cells attract phagocytes by producing “eat-me” signals:
1) In normal cells phosphatidylserine (an phospholipid membrane component) is present on the
inner leaflet of the plasma membrane, but in apoptotic cells this phospholipid “flips” to the
outer leaflet, where it is recognized by tissue macrophages and leads to phagocytosis of the
apoptotic cells.
2) Cells that are dying by apoptosis also secrete soluble factors that recruit phagocytes.
3) Some apoptotic bodies express adhesive glycoproteins that are recognized by phagocytes. 1
 Apoptosis occurs in many normal situations (physiologic apoptosis): 1) to eliminate cells that have
outlived their usefulness at the end of an immune response), 2) to eliminate potentially harmful self-
reactive lymphocytes, 3) to maintain a constant cells number during cells proliferation, or during
embryogenesis.
 Apoptosis also occurs as a pathologic event (pathologic apoptosis): eliminates cells that are genetically
altered or injured beyond repair (without eliciting a severe host reaction, thereby keeping the extent of
tissue damage to a minimum). Death by apoptosis is responsible for loss of cells in a variety of
pathologic states such as: DNA damage, Cell injury in certain infections, Growth factor deprivation,
Accumulation of misfolded proteins.
NOTES: These injurious stimuli cause apoptosis if the insult is mild, but larger doses of the same stimuli result
in necrotic cell death.
Inducing apoptosis of cancer cells is a desired effect of chemotherapeutic agents, many of which work by
damaging DNA. ‫ وا لتيي عملا لكثير‬،‫ت لخاليا ا لمبرمج ل لخاليا ا لسرطانية هو ا لتأثير ا لمرغوبف يه ل ع واملا لعالج ا لكيميائي‬
‫ت حفيز مو ا‬
mechanism of apoptosis‫ف لحمضا لنووي‬ ‫منها عنطريقإتال ا‬.

 Apoptosis results from the activation of enzymes called caspases (so named because
they are cysteine proteases that cleave proteins after aspartic residues).
 Active forms of these enzymes 1) cleave (and thereby activate) another series of caspases
2)which in turn cleave numerous targets, 4) culminating in activation of nucleases 5)that
degrade DNA and nucleoproteins. 6)Caspases also degrade components of the nuclear
matrix and cytoskeleton,7)leading to fragmentation of cells.
 Two distinct pathways converge on caspases activation:
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the mitochondrial pathway and the death receptor pathway.
 The Mitochondrial (Intrinsic) Pathway of Apoptosis
Mitochondria contain several proteins (cytochrome c, proteins that neutralize endogenous inhibitors of
apoptosis) that are capable of inducing/promote apoptosis when they are release in the cytoplasm.

1) When cells are deprived/‫ ت حرم‬of growth factors and other

survival signals, or are exposed to agents that damage DNA, or
accumulate unacceptable amounts of misfolded proteins, a
number of sensors called “BH3 proteins” are activated.
2) “BH3 proteins” in turn activate two pro-apoptotic proteins
called Bax and Bak.
3) which dimerize/weak, insert into the mitochondrial
membrane, and form channels through which cytochrome c and
other mitochondrial proteins escape into the cytosol.
4) These sensors also inhibit the anti-apoptotic molecules Bcl-2
or Bcl-xL enhancing the leakage of mitochondrial proteins (e.g.,
cytochrome c).
Cytochrome c, together with some cofactors, activates caspase-
9.
5) The net result is the activation of the caspase cascade,
ultimately leading to nuclear fragmentation.
6) Conversely, if cells are exposed to growth factors and other
survival signals, they synthesize anti-apoptotic members of the
Bcl-2 family, the two main ones of which are Bcl-2 itself and Bcl-
xL. These proteins antagonize Bax and Bak, and thus limit the
escape of the mitochondrial pro-apoptotic proteins.
Many cells express surface molecules, called death receptors, that trigger apoptosis.
The death receptor pathways lead to the activation of caspase-8 (initially).
The death receptor pathway is for example involved in elimination of self-reactive
lymphocytes and in killing of target cells by some cytotoxic T lymphocytes.
The two pathways of apoptosis differ in their induction and regulation, and both culminate in the activation of caspases..
In the death receptor pathway, signals from plasma membrane receptors (Fas /TNF receptor) lead to the assembly of
adaptor proteins into a “death-inducing signaling complex,” which activates caspases, and the end result is the same (5).
 Necrosis = a type of cell death resulting in a premature‫ ا لمبكر‬cell death in living tissue. It is
caused by factors external to the cell or tissue (e.g. infection, toxins, or trauma).
Necrosis is associated with loss of membrane integrity and uncontrolled leakage of cellular
contents into the extracellular space.
The leaked cellular contents often initiates in the surrounding tissue an inflammatory response. If
a large number of cells have died, inflammation can be extensive, causing the destruction of
additional cells. For this reason, it is often necessary to remove necrotic tissue surgically, a
procedure known as debridement.
Necrosis is characterized by changes in the cytoplasm and nuclei of the injured cells:
• Cytoplasmic changes. Necrotic cells are characterized by discontinuities in plasma and
organelle membranes, marked dilation of mitochondria, disruption of lysosomes, and
intracytoplasmic myelin figures (more prominent‫ ب روزا‬in necrotic cells than during reversible
injury).
• Nuclear changes due to breakdown of DNA and chromatin.

Morphologic changes in reversible and irreversible cell injury (necrosis).

Early (reversible) ischemic injury showing surface blebs, increased eosinophilia of cytoplasm,
swelling of occasional cells.
Necrotic (irreversible) injury of epithelial cells,loss of nuclei and fragmentation of cells and
leakage of contents. 5
The major mechanisms and sites of
damage in cell injury in necrosis:
Depletion of ATP, Influx of Calcium,
Mitochondrial Damage and
Dysfunction, Accumulation of
Oxygen-Derived Free Radicals
(Oxidative Stress), Defects in
Membrane Permeability, Damage to
DNA and Proteins.
Note: Multiple biochemical
alterations may be triggered by any
one injurious insult. It is therefore
difficult to assign any one
mechanism to a particular insult or causes: Ischemia and certain toxins Note: Cytosolic free
clinical situation in which cell injury calcium is normally maintained by ATP-dependent calcium
is prominent. For this reason, transporters at concentrations as much as 10,000 times
therapies that target individual lower than the concentration of extracellular calcium or
mechanisms of cell injury may not be of sequestered intracellular mitochondrial and ER
effective. calcium.
Figure. Sources and consequences of increased cytosolic calcium in cell injury.
Depletion of ATP

The major causes of ATP depletion are:

• reduced supply of oxygen and nutrients
• Mitochondrial damage
• the actions of some toxins (e.g., cyanide), etc.

→ irreversible damage to mitochondrial and

lysosomal membranes → necrosis

Figure. The functional and morphologic

consequences of depletion of
and decreased
activity of many intracellular adenosine triphosphate
cellular enzymes (ATP). ER, endoplasmic reticulum.
There are six distinctive morphological patterns of (tissue) necrosis that may provide clue about
the cause of damage:
• Coagulative necrosis, Liquefactive necrosis, Caseous necrosis, Fat necrosis, Gangrenous
necrosis, Fibrinoid necrosis.
Coagulative necrosis: a form of tissue necrosis in which the underlying tissue architecture is
preserved for several days, and the affected tissues take on a firm gelatinous (gel-like) texture
(as a result of enzymes and proteins denaturation, thereby blocking the proteolysis of the dead
cells).
 This pattern of necrosis is typically seen in hypoxic (low-oxygen) environments, such as in
infarcts (area of ischemic necrosis), severe ischemia, etc.
 It occurs primarily in the solid organs or tissues such as the kidney, heart and adrenal glands
except the brain.
Liquefactive necrosis: is a form of tissue necrosis where dead cells are completely digested
by enzymes, transforming the tissue into a liquid viscous mass.
 Liquefactive necrosis is seen in focal bacterial or fungal infections (because microbes
stimulate the accumulation of inflammatory cells and the enzymes of leukocytes digest
(‘liquefy’) the tissue).
Caseous necrosis is considered a combination of coagulative and liquefactive necrosis, typically
caused by mycobacteria=Mycobacterium tuberculosis, fungi and some foreign substances.
 The necrotic tissue appears as a thick, yellowish, “cheesy” substance. Dead cells disintegrate
but are not completely digested, leaving granular particles.
 Unlike with coagulative necrosis, the tissue architecture is completely obliterated and cellular
outlines cannot be discerned. 8
Fat necrosis: A form of tissue necrosis resulting from fat destruction (because of the action of
activated lipases on fatty tissues such as the pancreas). Calcium, magnesium or sodium may
bind to these lesions to produce a chalky-white substance.
Gangrenous necrosis refers to an area of necrotic tissue that has been invaded by bacteria.
Such an infection frequently occurs after an infarction in the intestines or in a limb where blood
supply is deficient and bacteria are normally present.
Fibrinoid necrosis is a form of necrosis visible only by microscopy.
It is caused by an immune reaction in which complexes of antigens and antibodies are deposited
in walls of arteries.
NOTE:
 Leakage of intracellular proteins through the damaged cell membrane and ultimately into
the circulation provides a means of detecting tissue-specific necrosis using blood or serum
samples.
Cardiac muscle, for example, contains a unique isoform of the enzyme creatine kinase and of
the contractile protein troponin, whereas hepatic bile duct epithelium contains a temperature-
resistant isoform of the enzyme alkaline phosphatase, and hepatocytes contain transaminases.
Irreversible injury and cell death in these tissues result in increased serum levels of such
proteins, and measurement of serum levels is used clinically to assess damage to these tissues.

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Autophagy (“self-eating”) refers to lysosomal digestion of the cell’s own components.
It is a survival mechanism in times of nutrient deprivation‫حرمان‬, such that the starved cell
subsists by eating its own contents and recycling these contents to provide nutrients and energy.
With time, the starved cell eventually can no longer cope by devouring itself; at this stage,
autophagy may also signal cell death by apoptosis (by mechanisms that are not well defined).
Note: Autophagy is also involved in the clearance of misfolded proteins in neurons and
hepatocytes. Therefore, defective autophagy may be a cause of neuronal death induced by
accumulation of these proteins and, subsequently‫ وبا لتا لي‬neurodegenerative diseases.
Mechanism:
1) In the autophagy process, intracellular organelles and portions of cytosol are first
sequestered within an autophagic vacuole.
2) The vacuole fuses with lysosomes to form an autophagolysosome, 3) in which lysosomal
enzymes digest the cellular components.
4) The products are used to provide nutrients for the cell.

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