Cellular Adaptations, Cell

injury & Cell death

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 Learning Objectives
 At the end of the chapter you will be able to:
1. Define hyperplasia, hypertrophy, atrophy
& metaplasia & list some of their causes.
2. Know the difference between reversible &
irreversible forms of cell injury.
3. Describe the various types of necrosis

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4. Describe apoptosis
5. Discuss the various intracellular as well as
extracellular accumulations

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 Alteration in cell function & growth
• Cells: active participants in their environment,
constantly adjusting structure & function to
accommodate changing demands &
extracellular stresses. 
• Normal cell is able to handle normal
physiologic demands, maintaining steady
state called homeostasis.
 

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• Severe physiologic stress & pathologic stimuli
tend to disrupt the structural & functional
aspects of the cell
→ Cellular adaptation occurs

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 Cellular adaptation
• Is an altered state, preserving the viability &
function of the cell as it responds to such stimuli.
• Cells adapt by undergoing changes in size,
number, & type.
• The adaptive response includes:-
Hypertrophy
 Hyperplasia
 Atrophy
 Metaplasia

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• These adaptive changes can occur singly or in
combination.
• Normal adaptive response Vs abnormal
adaptive response
• Normal – once the stimulus is removed, the
adaptive response ceases unlike in abnormal.

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 Hypertrophy
• Is an increase in the size of the cell resulting in
the enlargement of the organs
• Results from an increase functional demand
or due to a specific hormonal stimulation.
• By undergoing hypertrophy, the cell achieve
equilibrium between its demand & functional
capacity.

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• Hypertrophy commonly seen in cardiac &
skeletal muscle tissues.
• Hypertrophy can be:-
 Physiological
E.g. Muscular hypertrophy due to exercise
 Pathological
E.g. myocardial hypertrophy due to
hypertension

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 Hyperplasia
• Is an increase in the number of cells of a tissue
or an organ
• Closely related to Hypertrophy & often
develop concurrently in tissues, so that both
may contribute to an overall ↑ in organ size
(e.g., gravid Uterus)
 

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• Occurs in those cells that are capable to
undergo mitotic division
• Nerve cells, skeletal cells & cardiac cells do not
divide, hence an increase work load to skeletal
& cardiac cells respond only by hypertrophy

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• Hyperplasia can be physiologic or pathologic
1. Physiological hyperplasia: is divided in to:
- hormonal hyperplasia: e.g., proliferation of
the glandular epithelium of the female breast
at puberty & during pregnancy

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- Compensatory hyperplasia, i.e., hyperplasia
that occurs when a portion of the tissue is
removed or diseased. e.g., when liver is
partially resected.
– The stimuli for hyperplasia in this setting are
polypeptide growth factors, produced by remnant
hepatocyte cells as well as non parenchymal cells
found in the liver

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2. Pathologic hyperplasia
• Instances of excessive hormonal or growth
factor stimulation.
E.g. i. Endometrial hyperplasia
• Occurs when balance b/n estrogen and
progesterone is disturbed, a common cause of
AUB/ Abnormal Uterine Bleeding.
ii. BPH (Benign prostatic hyperplasia)

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• In these situations, the hyperplasic process
remains controlled; if hormonal or growth
factor stimulation abates, the hyperplasia
disappears
• differentiates from cancer, in w/c cells
continue to grow despite the absence of
hormonal stimuli

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• Nevertheless, pathologic hyperplasia
constitutes a fertile soil in w/c cancerous
proliferation may eventually arise.
• Thus, pts with hyperplasia of the
endometrium are at increased risk of
developing endometrial cancer.  

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 Atrophy
• Is a decrease in the size of the cell, which
might result in shrinkage of the organs.
• There is loss of cellular substance

N.B: Atrophic cells may have diminished

function, they are not dead.

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• Atrophy can be:-
 Physiological
E.g. During embriogenesis
 Pathological
E.g. Denervation

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 Causes of atrophy
 Disuse
 Denervation
 Decreased blood supply
 Inadequate nutrition
 Loss of endocrine stimulation
 Aging
 Pressure

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 Disuse atrophy
• When there is decreased work load
• As in prolonged bed rest→ skeletal muscle
• Occurs in the muscle of the extremities
 Denervation atrophy
• Is a form of Disuse atrophy
• Occurs in paralyzed extremities due to lack of
innervations

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 Lack of endocrine stimulation
• Occurs when there is a lack of a hormone
stimulating a tissue
• As in atrophy of the reproductive structures
after menopause
 Inadequate nutrition
• The body undergoes a general wasting of
tissue mass
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 Senile atrophy
• Atrophy due to aging
• The aging process is associate with cell loss
• This is typically seen in tissue containing
permanent cells

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 Atrophy due to decreased blood supply
• A decrease in blood supply cause a decrease
in the delivery of oxygen & nutrients
• In ischemic tissue, where the blood supply is
inadequate even to maintain the atrophic cell;
cell injury or cell death may ensue.

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 Pressure atrophy
• Occur as a result of tissue compression for
some time like in benign tumor
• It is probably the result of ischemic change
caused by compressed blood vessel.

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 Metaplasia
• Is a reversible change of one adult cell type in
to another that is able to tolerate the stress.
• It is a reversible condition
• An example is the conversion of columnar
epithelium of the respiratory tract into
squamous type in habitual cigarette smokers.

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• Has survival advantages, but, protective
mechanisms are lost, (mucus secretion &
ciliary clearance of particulate matter)
• The influences that induce metaplastic
transformation, if persistent, may induce
cancer transformation in the metaplastic
epithelium.

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 Dysplasia
• Disordered cell growth which result in altered
cell structure
• Changes may vary in size, shape & appearance
• Smokers often have dysplastic changes in their
respiratory tract
• Is an abnormal condition but can be reversible
if stimulus is withdrawn
• Has potential to undergo neoplastic change
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 Cell injury & cell death

Normal cells
(homeostasis)
stress ↓ ↓injurious agent
↓ ↓
Adaptation → → Cell injury
unable to
adapt

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• The cell may acquire a reversible injury or may
obtain an irreversible injury & may die.
• The factor influencing cell injury & cell death
depends on:
Intensity of stimulus
Duration of the injury
Type of injury
Type of cell involved

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 Causes of cell injury
• Oxygen deprivation
• Physical agents
• Chemical agents & drugs
• Infectious agents
• Immunologic reactions
• Genetic derangements
• Nutritional imbalance

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 Mechanisms of cell injury
• Cell injury results from functional &
biochemical abnormalities in one or more of
several essential cellular components.
• The most important targets of injurious
stimuli are:
 Aerobic respiration involving mitochondrial
oxidative phosphorylation & production of
ATP

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The integrity of cell membranes
Protein synthesis
The cytoskeleton
The integrity of the genetic apparatus of the
cell

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• Biochemical mechanisms that are responsible
for cell injury induced by different stimuli are:
- Depletion of ATP
- Mitochondrial damage
- Influx of intracellular calcium & loss of
calcium homeostasis
-Accumulation of oxygen-derived free
radicals (oxidative stress)
- Defects in membrane permeability
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 Cell injury
Two types of cell injury

1. Reversible cell injury

2. Irreversible cell injury

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 A. Reversible cell injury
• Back to normal after removal of the injurious
agent
• Two patterns can be recognized under the light
microscopy
1. Cellular swelling
• First manifestation of injury
• Appears whenever the cells are incapable of
maintaining ionic & fluid homeostasis.
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• is result of loss of function of plasma membrane
energy dependant ion pumps
2. Fatty change
• Manifested by the appearance of small & large
lipid vacuoles in the cytoplasm & occurs in
hypoxic & various toxic injury
• Principally seen in cells involved in & dependant
on fat metabolism such as hepatocytes &
myocardial cells
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 B. Irreversible cell injury
• With persistent stimuli ---- cell can not recover
so irreversible cell injury.
• Irreversibly injured cells undergo changes that
are recognized as cell death.
Cell death
 is the ultimate result of cell injury
 Is one of the crucial event in the development
of disease
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 Reversible vs irreversible
cell injury
Reversible injury Irreversible injury
* Decreased ATP levels * Amorphous densities in
* Ion imbalance mitochondria
* Swelling * Severe membrane
• Decreased pH damage
• Fatty change (liver) * Lysosomal rupture
• Extensive DNA damage
Irreversibly Apoptosis
Injured cell
Dead cell

Necrosis
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 With cell death, there are marked changes

with in the cell.
 There are two types of cell death:-
1. Necrosis
2. Apoptosis

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 1.Necrosis
• Spectrum of morphologic changes that follow
cell death in living tissue
• Death of a cell or tissue-Only in living
organisms
• Resulting from the progressive degradative
action of enzymes in lethally injured cells
• Occurs after abnormal stress like ischemia or
other injuries
• It is always pathological
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Nuclear changes due to non specific breakdown of
DNA
Karyolysis- Fading of the basophilia of chromatin
Pyknosis- Nuclear shrinkage and increased basophilia, chromatin
condenses in to a solid mass
Karyorrhexis- Pyknotic nucleus undergoes fragmentation. With
the passage of time (a day or two) the nucleus in necrotic cell
totally disappears.

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 Types of necrosis
1. Coagulative necrosis 
• Most often results from sudden interruption
of blood supply to an organ.
• It is , in early stage, characterized by general
preservation of tissue architecture.
• Affected tissues exhibit a firm texture.

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2. Liquefactive necrosis 
• It is characterized by digestion of tissue.
• It shows softening & liquefaction of tissue.
• It characteristically results from ischemic
injury to the CNS.
• It also occurs in suppurative infections
characterized by formation of pus.

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3. Gangrenous necrosis
• It is due to vascular occlusion & most affects the lower
extremities & the bowel.
• Two types gangrene
1. Dry
2. Wet

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i. Dry gangrene
• Associated with obstruction of the arterial
blood supply with out interference of the
venous return
• Is confined to the extremities
• The involved part become dry, skin wrinkle
• The color change to dark brown or black
• The spread is slow
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• There is a line of demarcation
• Can be changed to wet gangrene, if bacterial
infection

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ii. Wet gangrene
• Is primarily due to interference of the venous
return
• There is bacterial invasion
• Can affect the extremities or even the internal
organs
• The involved part is cold, swollen & pulse less
• The skin is moist, foul smelling & black
• No line of demarcation
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• Spread of tissue is rapid
• Can be fatal

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4. Caseous necrosis
• It is type of necrosis most often seen in foci of
tuberculosis infection
• The term caseous is derived from the cheesy
white gross appearance of the area of
necrosis.
• On microscopic examination, the necrotic
focus appears as amorphous granular debris.
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5. Fat necrosis 
• Focal areas of fat destruction
• Typically occurring as a result of release of
activated pancreatic lipases in to the
substance of the pancreas & the peritoneal
cavity.
• This occurs in acute pancreatitis.

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• The activated enzymes liquefy fat cell
membranes & the lipases split the triglyceride
contained with in fat cells.
• The released fatty acids combine with calcium
to produce grossly visible chalky white areas
(fat saponification)

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• Necrosis can be followed by release of
intracellular enzymes into the blood,
inflammation or dystrophic calcification.

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 2. Apoptosis
• Is an internally programmed cell death
• Is designed to eliminate unwanted cells
• Can be physiologic or pathologic
• Serves in many normal function
• Is not necessarily associated with cell injury

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Morphology
• The following morphologic features characterize
cells undergoing apoptosis:
- Cell shrinkage
- Chromatin condensation
- Formation of cytoplasmic blebs & apoptotic
bodies
- Phagocytosis of apoptotic cells or cell bodies
usually by macrophages
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Mechanisms of Apoptosis
• Apoptosis is an active enzymatic process in
which nucleoproteins are broken down and
then the cell is fragmented.
• The fundamental event in apoptosis is the
activation of enzymes called caspases.

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1. The Mitochondrial (Intrinsic) Pathway of

Apoptosis
2. The Death Receptor (Extrinsic) Pathway of
Apoptosis
 

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Clearance of Apoptotic Cells
• Apoptotic cells undergo several changes in
their membranes that promote their
phagocytosis.
In normal cells phosphatidylserine is present
on the inner leaflet of the plasma membrane.

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But in apoptotic cells this phospholipid "flips"
out and is expressed on the outer layer of the
membrane, where it is recognized by
macrophages.
Cells that are dying by apoptosis also secrete
soluble factors that recruit phagocyte.

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 Subcellular Responses to Injury
• Certain agents and stresses induce distinctive
alterations involving only subcellular
organelles.
• Some of these alterations occur in acute lethal
injury, others are seen in chronic forms of cell
injury, and still others are adaptive responses.

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 i. Lysosomal Catabolism
• Autophagy - Refers to lysosomal digestion of
the cell's own components. 
• Autophagy is thought to be a survival
mechanism in times of nutrient deprivation,
such that the starved cell lives by eating its
own contents.

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• Intracellular organelles and portions of cytosol
are first sequestered from the cytoplasm in an
autophagic vacuole formed from ribosome-
free regions of the rough ER (RER).
• The vacuole fuses with lysosomes to form an
autophagolysosome, and the cellular
components are digested by lysosomal
enzymes.

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• Heterophagy, in which a cell (usually a
macrophage) ingests substances from the
outside for intracellular destruction

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ii. Induction (Hypertrophy) of Smooth
Endoplasmic reticulum/SER
• The smooth ER (SER) is involved in the
metabolism of various chemicals.
• Cells exposed to these chemicals show
hypertrophy of the ER as an adaptive
response that may have important functional
consequences.

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• For instance, barbiturates are metabolized in
the liver by the cytochrome P-450 mixed-
function oxidase system found in the SER.
• In addition, the products formed by this
oxidative metabolism include reactive oxygen
species (ROS), which can injure the cell.

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 iii. Mitochondrial Alterations
• Mitochondrial dysfunction plays an important
role in acute cell injury and death.
• In some non lethal pathologic conditions,
there may be alterations in the number, size,
shape, and presumably function of
mitochondria.

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• Mitochondria may assume extremely large
and abnormal shapes (megamitochondria), as
seen in hepatocytes in various nutritional
deficiencies and alcoholic liver disease. 
• Inherited metabolic diseases of skeletal
muscle, the mitochondrial myopathies→ large
& increase in number of the mitochondria

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 iv. Cytoskeletal Abnormalities
• Abnormalities of the cytoskeleton occur in a
variety of pathologic states.
• These abnormalities may be manifested as an
abnormal appearance and function of cells.
• Perturbations in the organization of
microtubules can cause sterility by inhibiting
sperm motility

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• It may result also in defective mobility of cilia
in the respiratory epithelium, resulting in
chronic infections due to impaired clearance
of inhaled bacteria.

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 A. Intracellular accumulations
• Under some circumstances cells may
accumulate abnormal amounts of various
substances
• may be harmless or associated with varying
degrees of injury.
• The substance may be located in the
cytoplasm, within organelles (typically
lysosomes), or in the nucleus.

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• it may be synthesized by the affected cells or
may be produced elsewhere.
• There are three main pathways of abnormal
intracellular accumulations
I. A normal substance is produced at a normal
or an increased rate, but the metabolic rate is
inadequate to remove it.

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II. A normal or an abnormal endogenous substance
accumulates because of genetic or acquired
defects in its folding, packaging, transport, or
secretion/ Defect in Golgi apparatus.
III. An abnormal exogenous substance is deposited
and accumulates because the cell has neither
the enzymatic machinery to degrade the
substance nor the ability to transport it to
other sites.

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 1. Fatty Change (Steatosis)
• Fatty change refers to any abnormal
accumulation of triglycerides within
parenchymal cells.
• It is most often seen in the liver but it may
also occur in heart, skeletal muscle, kidney,
and other organs.

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 Morphology
Liver
• Grossly - fatty liver appears enlarged, yellow &
greasy.
• Microscopically – intracytoplasmic large vacuoles.

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• Steatosis may be caused by:
- Toxins
- Protein malnutrition
- Diabetes mellitus
-Obesity
- Anoxia

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• The significance of fatty change depends on
the cause and severity of the accumulation.
• When mild it may have no effect on cellular
function.

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 2. Cholesterol and Cholesterol Esters
• Cellular cholesterol metabolism is tightly
regulated to ensure normal cell membrane
synthesis without significant intracellular
accumulation 
• Cholesterol & cholesterol esters accumulate
inside:
- Phagocytic cells (macrophages) &
- Arterial smooth muscle walls

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• Macrophages may be filled with minute,
membrane-bound vacuoles of lipid, imparting
a foamy appearance to their cytoplasm (foam
cells).
• In hereditary and acquired hyperlipidemic
syndromes, macrophages accumulate
intracellular cholesterol;

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• when present in the sub epithelial connective
tissue of skin or in tendons, clusters of these
foamy macrophages form masses called
xanthomas.

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 3. Proteins
• Morphologically visible protein accumulations
are much less common than lipid
accumulations. 
• Example:- The marked accumulation of newly
synthesized immunoglobulin's that may occur
in the RER of some plasma cells, forming
rounded, eosinophilic Russell bodies.

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• Mallory body, or "alcoholic hyaline," is an
eosinophilic cytoplasmic inclusion in liver
cells that is highly characteristic of alcoholic
liver disease.
 

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 4. Glycogen
• Excessive intracellular deposits of glycogen are
associated with abnormalities in the metabolism
of either glucose or glycogen.  
• Morphologically appear as clear vacuoles within
the cytoplasm.
• Glycogen accumulates within cells in a group of
closely related genetic disorders collectively
referred to as glycogen storage diseases, or
glycogenoses.
 
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 5. Pigments
• Pigments are colored substances that are
either exogenous, coming from outside the
body, or endogenous, synthesized within
the body itself.
 
• The most common exogenous pigment is
carbon (an example is coal dust).

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• When inhaled, it is phagocytosed by alveolar
macrophages and transported through
lymphatic channels to the regional
tracheobronchial lymph nodes - anthracosis.
• coal workers' pneumoconiosis - Heavy
accumulations may induce emphysema or a
fibroblastic reaction that can result in a serious
lung disease.

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• Endogenous pigments include lipofuscin,
melanin, and certain derivatives of
haemoglobin (bilirubin).
Lipofuscin or "wear-and-tear pigment"
• Is an insoluble brownish-yellow granular
intracellular material that accumulates in a
variety of tissues (particularly the heart, liver,
and brain) as a function of age or atrophy.

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•It is not injurious to the cell but is important
as a marker of past free radical injury.

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 Melanin
• Is a brown-black pigment synthesized exclusively
by melanocytes located in the epidermis.
• Acts as a screen against harmful ultraviolet
radiation
• Although melanocytes are the only source of
melanin, adjacent basal keratinocytes in the skin
can accumulate the pigment (e.g., in freckles), as
can dermal macrophages. Vitiligo and albinism
occurs due to decrease in melanin pigment.
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 Hemosiderin
• Is a haemoglobin-derived granular pigment
that is golden-yellow to brown.
• Accumulates in tissues when there is a local or
systemic excess of iron.

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 EXTRACELLULAR CHANGES
PATHOLOGIC CALCIFICATION
• It implies the abnormal deposition of calcium
salts, together with smaller amounts of iron,
magnesium, and other minerals. 
• Two types
1. - Dystrophic calcification
2. - Metastatic calcification

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 I. Dystrophic calcification
• When the deposition occurs in dead or dying
tissues, it is called dystrophic calcification.
• it occurs in the absence of calcium metabolic
derangements (i.e., with normal serum levels
of calcium). 
• Dystrophic calcification is encountered in
areas of necrosis of any type.

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• Although dystrophic calcification may be an
incidental finding indicating insignificant past
cell injury, it may also be a cause of organ
dysfunction.
• For example, calcification can develop in aging
or damaged heart valves, resulting in severely
compromised valve motion.

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 II. Metastatic Calcification
• Metastatic calcification can occur in normal
tissues whenever there is hypercalcemia.
• The four major causes of hypercalcemia are:
1. Increased secretion of parathyroid hormone
2. Destruction of bone due to the effects of
accelerated turnover (e.g., Paget disease),
immobilization, or tumors

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3. Vitamin D-related disorders including
vitamin D intoxication and sarcoidosis  
4. Renal failure, in which phosphate retention
leads to secondary hyperparathyroidism. The
elevated serum phosphate levels directly
depress serum calcium levels and thereby
stimulate parathyroid gland activity.

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