INFLAMMATION

Lecture 1
 INFLAMMATION
Def: Response of vascularized tissue to infection
and damaged tissue that brings the cells and
molecules of host defense from the circulation
to the sites where they are needed, in order to
eliminate the offending agents.
• Actually it’s a protective response that is
essential for survival.
 Cardinal features or signs of acute
inflammation
1.Rubor (Redness): Rapid & transitory increase in blood (due
to dilation of vessels) flow occurs. It leads to increase of blood
in microcirculation (hyperemia) causes rubor (redness) &
calor.
2.Tumor (Swelling): Increased vascular permeability (vascular
leakage) leads to marked outflow of protein rich fluid & its
accumulation into extra vascular tissue.
3.Calor - Heat
4.Dolor -Pain (chemical mediators and leukocyte mediated
damage
5.Functio laesa - loss of function.
First four sign was listed by Celsus (a Roman writer) and the 5th
sign was added by Rudolf Virchow in 19th century.
Aetiology/Causes of inflammation/Acute
inflammation
1. Infectious agents: (Bacteria, virus, fungus,
parasite)
2.Physical agents :burn ,ionizing radiation.
3.Chemical agents : corrosive acids, alkalis.
4.Tissue necrosis :myocardial infraction.
5.Immunologic reactions :allergic rhinitis, rheumatic
fever, acute glomerulonephritis.
6.Foreign bodies-sutures, splinters
7.Trauma.
 Types
• Depending on duration:
1. Acute inflammation
2. Chronic inflammation
• Morphological types:
1. Acute: Serous, Fibrinous, Suppurative, Ulcer.
2. Chronic: Specific
Nonspecific
 Morphology
Serous Suppurative

Fibrinous
Difference between acute and chronic
Traits Acute Chronic

Onset Fast, minutes or Slow, days

hours
Cellular infiltrate Mainly neutrophils Macrophage &
lymphocytes
Tissue injury Usually mild & self Often severe &
limited progressive
Local & systemic Prominent Less
signs
Duration Short duration Prolonged duration
 Effects of acute inflammatory
reaction
– Overall Beneficial
(A) Beneficial effects(protective response)
i. Dilution of toxin
ii. Protective antibodies
iii. Plasma mediator system
iv. Cell nutrition
v. Promotion of immunity
vi. Initiates repair
vii. Fibrin clot
▪ Union between severed tissue e.g. cut
▪ Barrier
▪ Aids in phagocytosis
 Effects of acute inflammatory
reaction
(B) Harmful effects:
i. Obstruction to the lumen due to swelling e.g. acute
laryngitis
ii. Hypersensitivity reactions
iii. Leucocytes induced cell injury
iv. Ischemic necrosis e.g. acute osteomyelitis
v. Disfiguring scars or fibrous bands e.g. intestine
vi. Encephalitis or meningitis  intracranial pressure,
coma & death.
 Acute Inflammation
• It is the immediate & early response of
vascularized connective tissues to an sub
lethal but injurious stimuli, leading to
accumulation of protein rich fluid (exudation)
& leukocytes predominantly neutrophils in the
extravascular tissue spaces or serous cavities.
• Acute inflammatory cells=neutrophils
• Chronic inflammation: Chronic
inflammation is an inflammation of
prolonged duration (weeks to years) in
which continuing inflammation, tissue
injury , and healing , often by fibrosis,
proceed simultaneously.
• Acute inflammation : acute appendicitis.
• Chronic inflammation: chronic gingivitis,
chronic polycystities, chronic
appendicitis.
• Time course:
• Acute inflammation: less than 48 hours.
• Chronic inflammation: more than 48
hours(weeks, months, years)
• Cell types: Acute inflammation: neutrophils
• Chronic inflammation: lymphocytes,
macrophage, plasma cells (mononuclear cells)
 Events of acute inflammation
• Vascular events:
– Changes of vascular flow & caliber
– Increase vascular permeability

• Cellular events
– Extravasations of leukocytes
• In the lumen: Margination, Rolling & Adhesion
• Diapedesis or transmigration
• Chemotaxis

– Phagocytosis
 Vascular events
• Changes of vascular flow & caliber
– Inconstant & transient vasoconstriction, followed
by vasodilatation of arteriolar part & increase
vascular flow & transudation of fluid
– Vasodilatation is quickly followed by increased
permeability of microvasculatures leading to
exudation
 Vascular events
– Stasis: Dilated blood vessels packed with red
blood cells in sluggish circulation

– Margination of leukocytes, mainly neutrophils

along the vascular endothelium & ultimately
pavementing the inner surface of the endothelium

– leukocytes then migrate across the vascular

endothelium into the interstitium and move
toward the chemoattractant in the interstitial
tissues
 Increase vascular permeability
• Hallmark of acute inflammation
• Lead to escape of protein rich fluid into extravascular tissue
• Loss of protein from plasma reduce the intravascular
osmotic pressure & increased the osmotic pressure in
interstitium
• Combination of increased hydrostatic pressure, increased
vascular permeability, decreased osmotic pressure in
plasma & increased osmotic pressure in interstitium lead to
marked outflow of fluid in extravascular tissue spaces
• Result in inflammatory edema
 Cellular events
• Extravasation
– In the lumen
• Margination
• Rolling
• Adhesion
– Diapedesis or transmigration
– Chemotaxis
• Phagocytosis
– Recognition & attachment
– Engulfment
– Killing & or degradation
 Extravasation of leukocytes

– Extravasation is defined as the sequence of events

in the Journey of leukocytes from the vascular

lumen to the interstitial tissue spaces across the

interendothelial gap.
 Adhesion & Transmigration
• Adhesion occurs due to presence of complementary adhesion
molecules both on the leukocyte & endothelial surfaces.

– Normally adhesion molecules lies in an inactivated form

which are activated by chemo attractant & cytokines

– During inflammation certain chemo attractants or

cytokines influences the adhesion molecules by:

❖Activation of adhesion molecules

❖Modulating surface expression of adhesion molecules
❖Increase avidity of adhesion molecules
 Phagocytosis
• It is the process of recognition & attachment,
engulfment, killing & or degradation of the offending
agents (microbes, immune complex & tissue debris)
by phagocytic cells
• Steps of phagocytosis-
– Recognition & attachment
• Needs
– Complimentary adhesion molecules on leukocytes &
endothelial cell surfaces
– Opsonins
– Engulfment with subsequent formation of a phagocytic
vacuole
– Killing & or degradation ingested materials
 Recognition & attachment
• Phagocytic cells (neutrophil & macrophage) recognize
most of the micro-organisms by the help of mannose &
scavenger receptors
• Macrophage mannose receptors recognizes microbes
& not host cells
• Scavenger receptors binds a variety of microbes &
modified LDL particles
• The efficiency of phagocytosis is greatly enhanced
when microbes are coated or opsonized by specific
opsonins for which the phagocytes expresses high
affinity receptors.
 OPSONIN
– These are the naturally occurring protein substances,
present in serum which encoat the offending agents &
help the process of phagocytosis

– Type of opsonins are-

• Immunoglobulin family:
– IgG1 & IgG3
• Complement components
– C3b & C3bi
• Collectin: Bind to microbial cell walls & are involved in
innate immunity
 Engulfment
– Phagocytic cells form pseudopods from the cell membrane
& gradually enclose the offending agents & ultimately
engulf it within a phagosome created by the plasma
membrane of the phagocytes

– Phagosome then fuses with lysosomal membrane & form

phagolysosome

– Lysosome discharge its granules content into

phagolysosome which become activated & kill the
offending agents

– Neutrophils & macrophages become progressively

degranulated.
 Killing & degradation
• Ultimate step in the elimination of offending agents &
necrotic cells, is their killing & degradation within
leukocytes which occur most efficiently after activation of
phagocytes

• Pathway killing-
– Oxygen-dependent pathway
• Myeloperoxidase-Halide system dependent pathway
• Myeloperoxidase-Halide system independent pathway
– Oxygen independent pathway:
– Lysosome, Lactoferin, Major basic protein, Defensin
How does oxygen dependent intracellular
killing occurs?
• Production of super oxide, which is an
oxygen rich barrier bacteria killing
substance . The superoxide is converted
to hydrogen peroxide by an enzyme
called superoxide dismutase. Superoxide
also react with the hydrogen peroxide to
produce hydroxyl radicals , which assist in
killing the invading microbe.
 Degradation of offending agents
• After killing, acid hydrolases which are
normally stored in lysosomes of leukocytes
become activated in acid environment (pH 4
to 5) & degrade the microbes within the
phagolysosomes.
 Why different leukocytes appear
at different phase of inflammation
– In acute inflammation neutrophils predominate during the
first 6-24 hours, then are replaced by monocytes in 24-48
hours & the causes are-
• Neutrophils are more numerous in blood
• Neutrophils respond more quickly to chemo attractant
• Different chemo attractant induced at different phase
of inflammation & neutrophils may attach more firmly
to adhesion molecules that are rapidly induced on
endothelial cells
• After entering in tissue ,neutrophils are short lived &
they under go apoptic cell death & disappear after 24
to 48 hours
Fate/Outcome of acute inflammation

– Complete resolution

– Healing by connective tissue replacement

(Fibrosis)

– Progress to chronic inflammation

Outcome of acute inflammation
 Systemic effects of inflammation
• Acute phase reaction
– Fever – IL-1, IL-6, TNF-
– ↓Appetite
– ↑ In sleep
– ↑ Acute phase protein
• C reactive protein
• Serum amyloid – A
• Complement component
• Coagulation protein
– Hemodynamic alteration – shock
– Neutrophilia
– Fibroblast effect
• Morphology
• Serous inflammation is characterized by the
outpouring of a watery, relatively protein-poor
fluid that, depending on the site of injury, derives
either from the serum or from the secretions of
mesothelial cells lining the peritoneal, pleural,
and pericardial cavities. The skin blister resulting
from a burn or viral infection is a good example of
a serous effusion accumulated either within or
immediately beneath the epidermis of the skin
Fluid in a serous cavity is called an effusion.
• Fibrinous inflammation occurs as a consequence of more
severe injuries, resulting in greater vascular permeability
that allows large molecules (such as fibrinogen) to pass the
endothelial barrier. Histologically, the accumulated
extravascular fibrin appears as an eosinophilic meshwork of
threads or sometimes as an amorphous coagulum . A
fibrinous exudate is characteristic of inflammation in the
lining of body cavities, such as the meninges, pericardium,
and pleura. Such exudates may be degraded by fibrinolysis,
and the accumulated debris may be removed by
macrophages, resulting in restoration of the normal tissue
structure (resolution).

• However, failure to completely remove the fibrin results in

the ingrowth of fibroblasts and blood vessels
(organization), leading ultimately to scarring that may have
significant clinical consequences. For example, organization
of a fibrinous pericardial exudate forms dense fibrous scar
tissue that bridges or obliterates the pericardial space and
restricts myocardial function.
 Ulcer
• An ulcer is a local defect, or excavation, of the
surface of an organ or tissue that is produced by
the sloughing (shedding) of inflammatory
necrotic tissue.
– Site of ulcer formation
• Mucosa of mouth, stomach, intestine
• Genitourinary tract
• Cornea
• Lower extremity (older person)
• Suppurative (purulent) inflammation is
manifested by the presence of large amounts of
purulent exudate (pus) consisting of neutrophils,
necrotic cells, and edema fluid. Certain organisms
(e.g., staphylococci) are more likely to induce
such localized suppuration and are therefore
referred to as pyogenic.
• Abscesses are focal collections of pus that may be
caused by seeding of pyogenic organisms into a
tissue or by secondary infections of necrotic foci.
Abscesses typically have a central, largely necrotic
region rimmed by a layer of preserved
neutrophils , with a surrounding zone of dilated
vessels and fibroblastic proliferation indicative of
early repair. As time passes the abscess may
become completely walled off and eventually be
replaced by connective tissue.
 Abscess
• Abscess may be defined localized collection of purulent
inflammatory tissue cause by suppuration buried in a tissue,
an organ or a confined space.
• Or Focal collection of pus that may be caused by seeding of
pyogenic organisms into a tissue or by secondary infections of
necrotic foci.
Suppurative
• Site of abscess formation
– Dermis of skin
– Lung
– Liver
– Breast
– Brain
– Bone
– Kidney
• Structure of an abscess
– Central zone of liquefactive necrosis
– Intermediate zone – preserved neutrophils
– Peripheral zone – Pyogenic membrane
(inflammatory granulation tissue).
• Pus : Pus is a purulent & inflammatory
exudates rich in leucocytes (mostly
neutrophils), the debris of dead cells and
microbes.
• Chemotactic agents for leucocytes:
• -Bacterial products
• Cytokines
• C5a
• Leukotriene B4
 Exudate and Transudate
• Exudate: An exudate is an inflammatory
extravascular fluid that has high protein
concentration, less cellular debris and has a
high specific gravity(> 1.020)
• Transudate: It is an ultra filtrate of plasma
resulting from osmotic or hydrostatic
imbalance across the vessel wall.
It has low protein content, little or no cellular
material and low specific gravity(<1.015)
INFLAMMATION
Lecture 2
 Mediators of inflammation
• Mediators originate either from plasma or from
cells
• The production of active mediators are triggered
by microbial products or by host proteins, such
as proteins of the complements, kinin or
coagulation system
• Most of the mediators perform their biologic
activity by initially binding to specific receptor
on target cells. Some however have direct
enzymatic activity or mediate oxidative damage
• One mediator can stimulate the release of other
mediators by target cells themselves & these
secondary mediators may be identical to initial
mediator but also may have opposing activities
 Mediators of inflammation
• Mediators may act on one or few target cell
type, have diverse targets or may even have
differing effects on different cell types
• Once activated & released from the cell, most of
these mediators are short-lived, they quickly
decay or are inactivated by enzymes, they are
scavenged or inhibited
• Thus a system of check & balance in the
regulation of mediators action
• Most mediators have the potential to cause
harmful effects on host
 Chemical mediators of acute
inflammation
• Derived from cells
– Preformed
• Histamine: Most cell, Basophils, Platelets
• Serotonin: Platelet
• Lysosomal enzyme: Neutrophils, macrophages
– Newly synthesized
• PAF
• Prostaglandin—mast cells, leucocytes
• Leukotriene
• Cytokines: TNF(Tissue necrosis factor), IL_1(Interleukin-1)
• Nitric oxide
• Derived from plasma
– Complement activation with production of
• C3a, C5a, C5b-9
– Hageman factor activation lead to activation of-
• Kinin system (Bradykinin)
• Coagulation/Fibrinolytic system
 Histamine
• Histamine: It is an important vasoactive amines
– Source
• Mast cell, the richest source
• Basophils
• Platelets
• Preformed histamine present in the mast cell granules & is released
by mast cell degranulation in presence of variety stimuli such as-
– Physical injury reaction (Heat & cold)
– Immunologic reaction as binding of antibody to mast cell
– Complement component (C5a, C3a)
– Histamine releasing protein derived from leukocytes
– Neuropeptides (Substance – P)
– Cytokines (IL-1, IL-8)
 Function of Histamine
• Small arteriolar dilation
• Increase vascular permeability
• Smooth muscle constriction
• Large vessel constriction
• Constrict smooth muscles
• Increase glandular (Mucus) secretion
Histamine acts on the microcirculation mainly via
H1 receptor on endothelium
 Complement system
• Complement system consists of 20
component of protein (together with their
cleavage products) which are found in
greatest concentration in plasma

• Complement components present as

inactive form in plasma & they are
numbered C1 through C9 & become active
with proteolytic cleavage.
• The complement system consists of plasma
proteins that play an important role in host
defense (immunity) and inflammation. Upon
activation, different complement proteins coat
(opsonize) particles, such as microbes, for
phagocytosis and destruction, and contribute
to the inflammatory response by increasing
vascular permeability and leukocyte
chemotaxis. Complement activation ultimately
generates a porelike membrane attack
complex (MAC) that punches holes in the
membranes of invading microbes.
 Pathway of activation
• Classical pathway is activated by
– Circulating antigen-antibody complex
• Alternate pathway is activated by
– Bacterial endotoxins
– Complex polysaccharide
– Aggregated Ig-A
– Cobra venom & other substances
• Lectin pathway:
– Collectin a Plasma mannose-binding lectin bind to
carbohydrates on microbes & activate early components of
complements C1( CIs, Clr)
• Direct pathway: Clevage occur by enzymes
Pathway of activation
• Complement components (numbered C1 to C9) are present
in plasma in inactive forms, and many of them are activated
by proteolysis to themselves acquire proteolytic activity, thus
setting up an enzymatic cascade. The critical step in the
generation of biologically active complement products is the
activation of the third component, C3 . C3 cleavage occurs (1)
via the classical pathway, triggered by fixation of the first
complement component C1 to antigen-antibody complexes;
(2) through the alternative pathway, triggered by bacterial
polysaccharides (e.g., endotoxin) and other microbial cell-
wall components, and involving a distinct set of plasma
proteins including properdin and factors B and D; and (3) by
the lectin pathway, in which a plasma lectin binds to
mannose residues on microbes and activates an early
component of the classical pathway (but in the absence of
antibodies).
• All three pathways lead to the formation of a C3
convertase that cleaves C3 to C3a and C3b. C3b
deposits on the cell or microbial surface where
complement was activated and then binds to the
C3 convertase complex to form C5 convertase;
this complex cleaves C5 to generate C5a and C5b
and initiate the final stages of assembly of C6 to
C9. The complement-derived factors that are
produced along the way affect a variety of
phenomena in acute inflammation:
• Coagulation and Kinin Systems
 Function of complement system
• Vascular phenomenon
– C3a, C5a & C4a (anaphylatoxins) stimulate histamine
release from mast cell thus causes vasodilatation &
increase vascular permeability
– C5a activate the lipooxygenase pathway of arachidonic
acid metabolism in leukocytes, causing further release
of inflammatory mediators
• Leukocyte adhesion, chemotaxis (C5a) & activation
• Phagocytosis (C3b & C3bi act as opsonin)
• Formation of membrane attack complex
 Disorders of complement
• Deficiency of C3 results in increased susceptibility to
bacterial infection
• Deficiency of the alternate pathway proteins associated
with defective resistance to infection
• Deficiency of complement C2 & C4 is associated with
autoimmune disease
• Deficiency of late components of complements results
in defective formation of MAC
• Deficiency of DAF: Chronic hemolytic anemia
• Deficiency of C1 inhibitor is associated with hereditary
angioneurotic edema
 Arachidonic acid metabolites (Eicosanoids)
• Arachidonic acid is a 20-carbon
polyunsaturated fatty acid (5,8,11,14
eicosatetraenoic acid) which are rapidly
remodeled to generate biologically active lipid
mediators that serve as intracellular and
extracellular signals to affect a variety of
biologic process including inflammation &
hemostasis
• Source of AA
– Dietary source
– Denovo synthesis – from linoleic acid (essential FA)
Generation of arachidonic acid metabolites & their roles in
inflammation
 Pathway of AA metabolism
• Cyclooxygenase pathway
– PGH2
– PGI2
– TAX2
– PGD2, PGE2, PGF2

• Lipoxygenase pathway
– 5-lipoxygenase pathway derived mediators-
• 5-HETE, LTA4, LTB4, LTC4, LTD4, LTE4
– 12-lipoxygenase pathway derived mediators-
• LXA4, AXB4
 Functions
• TXA2 • PGD2
– Platelet aggregation – Powerful vasodilators and
– Vasoconstriction potentiate oedema
• PGI2 (prostacycline) – Bronchoconstriction
– Vasodilatation – Increase glandular secretion
– Inhibit platelet aggregation • PGE2
– Potentiates permeability – Fever & pain production,
increasing and chemotactic vasodilators and potentiate
effects of other mediators edema

• PGD2, PGE2, PGF2 • HETE

– Vasodilatation – Acts as chemoattractant
– Potentiate edema
• LTB4
– Powerful chemoattractant
– Neutrophil activation &
adhesion
 Functions
• LTB4
– Most powerful chemoattractants
– Activator of neutrophils aggregation & adhesion to venular
endothelium
– Generates oxygen derived free radicals
– Release of lysosomal enzymes
• 5-HETE
– Chemoattractant
• LTC4, LTD4, LTE4
– Increase vascular permeability
– Vasoconstriction
– Bronchoconstriction
 Functions
• Lipoxins (LTA4, LTB4)
– Anti-inflammatory effects-
• Inhibit leukocyte recruitment by inhibiting the neutrophils
chemotaxis and adhesion to endothelium
• Inhibit cellular components of inflammation

– Pro-inflammatory effects
• Stimulate monocytes/macrophage activation & adhesion
• LXA4-stimulate vasodilatation & attenuates the action of
LTC4-stimulated vasoconstriction

– There is an inverse relationship between the amount of

lipoxins & leukotrienes formed, and thus lipoxins acts as
endogenous negative regulators of leukotriene action
 Cytokines
– These are the proteins produced by many cells
principally of activated lymphocytes & macrophages,
but also by endothelium, epithelium, connective tissue
cells that modulate the functions of other cells.
– Monocytes derived cytokines are called monokines
• Colony stimulating factors: derived from monocyte and
macrophage, acts on immature haematopoietic stem cell
– Lymphocytes derived cytokines are lymphokines
• Perforing, lymphotoxin
• Functions –
– It is concerned with immune responses
– It is concerned with inflammatory responses
Effects of IL-1 & TNF in inflammation
 Chemokines
• Chemokines: chemokines are small family of proteins
that act primarily a chemoattractant for specific types
of leukocytes
• About 40 different chemokines & 20 different
receptors have been identified
• Classified into four major group, according to the
arrangement of the conserved cysteine © residues in
mature proteins
• Cytokines share the ability to stimulate the other
cytokines
 Chemokines
• Chemokines stimulate leukocytes recruitment
in inflammation & control the normal
migration of cells through various tissues
• Some chemokines are produced transiently in
response to inflammatory stimuli & promote
recruitment of leukocytes to the sites of
inflammation
• Other chemokines are produced constitutively
in the tissues & function in organogenesis to
organize different cell types in different
anatomic regions of tissues
• Chemokines are classified into four groups based
on the arrangement of highly conserved cysteine
residues. The two major groups are the CXC and
CC chemokines: CXC chemokines have one amino
acid separating the conserved cysteines and act
primarily on neutrophils. IL-8 is typical of this
group; it is produced by activated macrophages,
endothelial cells, mast cells, and fibroblasts,
mainly in response to microbial products and
other cytokines such as IL-1 and TNF.CC
chemokines have adjacent cysteine residues and
include monocyte chemoattractant protein 1
(MCP-1) and macrophage inflammatory protein
1α (MIP-1α) (both chemotactic predominantly for
monocytes), RANTES (regulated on activation
normal T expressed and secreted) (chemotactic
for memory CD4+ T cells and monocytes), and
eotaxin (chemotactic for eosinophils).
 Reactive Oxygen Species
• ROS are synthesized via the NADPH oxidase (phagocyte
oxidase) pathway and are released from neutrophils and
macrophages that are activated by microbes, immune
complexes, cytokines, and a variety of other inflammatory
stimuli. When the ROS are produced within lysosomes they
function to destroy phagocytosed microbes and necrotic cells,
much like NO. At higher levels, these mediators are
responsible for tissue injury by several mechanisms, including
(1) endothelial damage, with thrombosis and increased
permeability; (2) protease activation and antiprotease
inactivation, with a net increase in breakdown of the ECM;
and (3) direct injury to other cell types (e.g., tumor cells,
erythrocytes, parenchymal cells). Fortunately, various
antioxidant protective mechanisms (e.g., catalase, superoxide
dismutase, and glutathione) are present in tissues and blood
to minimize the toxicity of the oxygen metabolites
• Nitric Oxide
• NO is a short-lived, soluble, free-radical gas
produced by many cell types and capable of
mediating a variety of functions . In the
central nervous system it regulates
neurotransmitter release as well as blood
flow. Macrophages use it as a cytotoxic
metabolite for killing microbes and tumor
cells. When produced by endothelial cells
(where it was originally named endothelium-
derived relaxation factor), it causes smooth
muscle relaxation and vasodilation.