Session 6: Cell death

KASPER MK

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 Learning tasks
At the end of this session, students are expected to be
able to:
• Define necrosis.
• Explain patterns of tissue necrosis.
• Identify cellular changes in necrotic tissue.
• Define apoptosis.
• Identify examples of apoptosis in physiological and
pathological situations.
• Identify cellular changes in apoptotic cells.

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 Introduction
• With continuing damage, the injury becomes
irreversible, at which time the cell cannot recover and
it dies.
• There are two (2) types of cell death:
i. Necrosis.
ii. Apoptosis.
 Necrosis
Definition
• Necrosis is the type of cell death that is associated
with loss of membrane integrity and leakage of
cellular contents culminating in dissolution of cells,
largely resulting from the degradative action of
enzymes on lethally injured cells.
– The enzymes responsible for digestion of the cell may
be derived from lysosomes of both the dying cells and
inflammatory leukocytes.
 Necrosis cont…
• Ischemia, infections, toxins, and immune reactions
cause necrosis type of cell death.
• When damage to membranes is severe, enzymes
leak out of lysosomes, enter the cytoplasm, and
digest the cell, resulting in necrosis.
• Cellular contents also leak through the damaged
plasma membrane into the extracellular space,
where they elicit a host reaction (inflammation).
 Patterns of tissue necrosis
• These patterns are:
1. Coagulative necrosis.
2. Liquefactive necrosis (colliquative necrosis).
3. Gangrenous necrosis (wet or dry gangrene).
4. Caseous necrosis.
5. Fat necrosis.
6. Fibrinoid necrosis.
• Most of these patterns of necrosis have distinct gross
appearance except fibrinoid necrosis.
– Fibrinoid necrosis is seen only histologically.
 Coagulative necrosis
• Coagulative necrosis is a most common type of
necrosis in which the underlying tissue architecture
is preserved for at least several days.
– Hallmark of coagulative necrosis.
• Injury denatures not only structural proteins but
also enzymes, thereby blocking the proteolysis of
the dead cells.
– It is caused by the denaturing and coagulation of
proteins within the cytoplasm.
• The affected tissues take on a firm texture.
Coagulative necrosis cont…
• Leukocytes are recruited to the site of necrosis, and
the dead cells are digested by the action of
lysosomal enzymes of the leukocytes.
• The cellular debris is then removed by
phagocytosis.
• Microscopic examination shows loss of the nucleus
but preservation of cellular shape.
• The necrosed cells are swollen and appear more
eosinophilic than the normal.
 Coagulative necrosis cont…
• Most often due to
ischemic injury(infarct).
• It is characteristic of
infarcts (areas of
ischemic necrosis) in all
of the solid organs like
heart, liver, spleen and
kidney except the
brain.
 Liquefactive necrosis
• 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.
• For unknown reasons, hypoxic death of cells
within the central nervous system often evokes
liquefactive necrosis.
 Liquefactive necrosis cont…
• Dead cells are completely digested, transforming the
tissue into a liquid viscous mass.
• Eventually, the digested tissue is removed by
phagocytes.
• If the process was initiated by acute inflammation, as
in a bacterial infection, the material is frequently
creamy yellow and is called pus.
 Liquefactive necrosis cont…
• Liquefaction necrosis results from cellular destruction
by hydrolytic enzymes, leading to autolysis and
heterolysis.
• Liquefaction necrosis occurs in:
i. Abscesses.
ii. Brain infarcts.
 Gangrenous necrosis
• It is not a distinctive pattern of cell death.
• It usually refers to the condition of a limb (lower
leg) that has lost its blood supply and undergone
coagulative necrosis involving multiple tissue
layers.
– This gives dry gangrene.
• When bacterial infection is superimposed,
coagulative necrosis is modified by the liquefactive
action of the bacteria and the attracted leukocytes
– Resulting in wet gangrene.
Gangrenous necrosis cont…
• Gangrenous necrosis is a gross term used to
describe dead tissue.
• Common sites of involvement include:
i. Lower limbs (commonest site).
ii. Gallbladder.
iii. GI tract.
iv. Testes.
• Dry gangrene has coagulative necrosis for the
microscopic pattern.
• Wet gangrene has liquefactive necrosis.
 Gangrenous necrosis cont…

dry gangrene (diabetic foot)

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 Caseous necrosis
• Caseous necrosis is
encountered most often
in foci of tuberculous
infection.
• Caseous means “cheese-
like,” referring to the
soft, friable yellow-
white appearance of the
area of necrosis.

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 Caseous necrosis cont…
• The area of caseous necrosis is often enclosed with
characteristic of a focus of inflammation known as
a granuloma.
• On microscopic examination, the necrotic focus
appears as a collection of fragmented or lysed cells
with an amorphous granular pink appearance in the
Haematoxylin & Eosin stained tissue.
 Fat necrosis
• Fat necrosis can be caused by trauma to tissue with
high fat content forming focal areas of fat
destruction.
• It commonly seen in:
i. Pancreas.
ii. Breast.
• In acute pancreatitis, activated pancreatic lipases
that have leaked out of and liquefy the membranes
of fat cells in the peritoneum
• These lipases split the triglyceride esters contained
within fat cells.
 Fat necrosis cont…
• The released fatty acids combine with calcium to
produce grossly visible chalky white areas (fat
saponification).

• Histologically, the foci of necrosis contain shadowy

outlines of necrotic fat cells, basophilic calcium and
an inflammatory reaction.
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 Fibrinoid necrosis
• It is a special form of necrosis in which complexes
of antigens and antibodies are deposited in the
walls of arteries.
– Seen in polyarteritis nodosa, vasculitis.
• The deposited immune complexes, together with
fibrin produce a bright pink and amorphous
appearance on Haematoxylin & Eosin stains called
fibrinoid (fibrin-like).
 Fibrinoid necrosis cont…
• Deposition of fibrin-like
material which has the
staining properties of
fibrin.
• It is encountered in
various examples of
immunologic tissue injury.
• Fibrinoid necrosis is
detected only by
histologic examination.

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 Morphology of Necrosis
Cytoplasmic changes.
– Necrotic cells show increased eosinophilia.
– Cell may have a more glassy, homogeneous appearance.
– Myelin figures are seen.
– Cytoplasm becomes vacuolated and appears “moth-
eaten.”
– Discontinuities in plasma and organelle membranes.
– Marked dilation of mitochondria with large amorphous
densities.
– Disruption of lysosomes.
– Intracytoplasmic myelin figures.
 Morphology of Necrosis cont…
Nuclear changes.
• Assume one of three patterns due to breakdown of
DNA and chromatin giving basophilic staining.
1. Pyknosis
– Shrinkage of the nucleus.
2. Karyorrhexis
– Pyknotic nucleus undergoes fragmentation.
3. Karyolysis
– Fading of chromatin
• Electron microscopy reveals profound nuclear
changes culminating in nuclear dissolution.
 Apoptosis
Definitions
• A form of cell death in which programmed
sequence of events lead to the elimination of cells
without releasing harmful substances into the
surrounding area.
• Apoptosis is a pathway of cell death in which cells
activate enzymes (caspases enzymes) that degrade
the cells’ own nuclear DNA and nuclear and
cytoplasmic proteins.
 Apoptosis cont…
• Apoptosis plays a crucial role in developing and
maintaining health by eliminating old cells,
unnecessary cells, and unhealthy cells.
• Fragments of the apoptotic cells then break off,
giving the appearance that is responsible for the
name (apoptosis, “falling off”).
• In apoptosis, there is nuclear dissolution without
complete loss of cell membrane integrity.
 Apoptosis cont…
• Thus plasma membrane of the apoptotic cell
remains intact.
– Though the membrane is altered in such a way that the
cell and its fragments become avid targets for
phagocytes.
• The dead cell and its fragments are rapidly cleared
before cellular contents have leaked out.
– Therefore apoptosis does not elicit an inflammatory
response.
 Causes of Apoptosis
• Apoptosis occurs in many normal physiological
situations and serves to eliminate potentially
harmful cells and cells that have outlived their
usefulness.
• It also occurs as a pathologic event when cells are
damaged beyond repair, especially when the
damage affects the cell’s DNA or proteins.
 Examples of apoptosis in
physiologic situations
1. The programmed destruction of cells during
embryogenesis.
– Formation of interdigital space of fingers and toes.
2. Involution of hormone-dependent tissues upon
hormone deprivation.
– Endometrial cell breakdown during the menstrual cycle.
– Regression of the lactating breast after weaning.
 Examples of apoptosis in
physiologic situations cont…
3. Cell loss in proliferating cell populations, such as
intestinal crypt epithelia, in order to maintain a
constant number.
4. Elimination of cells that have served their useful
purpose.
– Neutrophils after acute inflammatory response.
 Examples of apoptosis in
physiologic situations cont…
5. Elimination of potentially harmful self-reactive
lymphocytes.
– To prevent reactions against the body’s own tissues.
6. Cell death induced by cytotoxic T lymphocytes.
– A defense mechanism against viruses and tumors that
serves to kill virus-infected and neoplastic cells.
Examples of apoptosis in pathologic
conditions
1. DNA damage.
– Cell with damage DNA triggers intrinsic mechanisms that
induce apoptosis.
2. Accumulation of misfolded proteins.
– Excessive accumulation of these proteins cause
endoplasmic reticulum stress, which culminates in
apoptotic death of cells.
Examples of apoptosis in pathologic
conditions cont…
3. Cell injury in certain infections, particularly viral
infections.
– Apoptotic death that may be induced by the virus.
4. Pathologic atrophy in parenchymal organs after duct
obstruction
– e.g. pancreas, parotid gland, and kidney.
5. Cell death in tumours exposed to chemotherapeutic
agents.
Clearance of Apoptotic Cells
• Apoptotic cells entice phagocytes by producing
“eat-me” signals.
– Phosphatidylserine molecules, appear on the outer
surface of the cells, which facilitate their identification.
• Cells that are dying by apoptosis also secrete
soluble factors that recruit phagocytes.
• Some apoptotic bodies express adhesive
glycoproteins that are recognized by phagocytes.
 Morphology of Apoptosis
• The stages of pyknosis, karyorrhexis and
karyolysis can be seen.
• The cells rapidly shrink, form cytoplasmic buds,
and fragment into apoptotic bodies.
• Apoptosis may be histologically undetectable.
– Because these fragments are quickly extruded and
phagocytosed without eliciting an inflammatory
response.
Necrosis vs Apoptosis

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 Key points
• Necrosis elicits an inflammatory reaction.
• In coagulative necrosis, tissue architecture is
preserved for at least several days.
• Brain tissue after to ischemic injury(infarct) elicits
liquefactive necrosis.
• Caseous necrosis is associated with granuloma
formation in TB infection.
• Chalky white necrotic areas is seen in fat necrosis.
• Fibrinoid necrosis is detected only by histologic
examination.
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 Key points cont…
• Apoptosis is a form of coordinated and internally
programmed cell death.
• Caspases enzymes are crucial in apoptosis.
• Apoptosis can occur in both physiological by serves
to eliminate potentially harmful cells and cells that
have outlived their usefulness.
• Apoptosis occurs to cells which undergo DNA
damage.

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 Evaluation
1. Define necrosis.
2. Differentiate between dry gangrene from wet
gangrene.
3. How does fat necrosis occur?
4. List five differences between necrosis and apoptosis.
5. Explain how apoptotic bodies are cleared.

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 References
• Bezabeh M.; Tesfaye A.; Ergicho B. et al (2004):
General pathology lecture notes for Health Sciences
students. Ethiopia Public Health Training Initiative.
Pg. 20-22.
• Mohan H.;(2010): Text book of Pathology (6th Ed.)
Jaypee Brothers Medical Publishers, India . Pg. 47-
49.
• Kumar V.; Abbas A. K.; Aster J. C.;(2013): Robbins
and Contran Pathologic Basis of Disease (9th Ed.)
Elsevier Saunders, China. Pg. 18-21.
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