Inflammation

Dr.Mahmoud Mohammed
Assistant Professor
Consultant pathologist
FICPath
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© 2005 Elsevier(on 8 September 2010 02:58 PM)
Free Radical-Induced Cell Injury
As mentioned in the discussion of ischemic reperfusion, free radical-
induced injury, particularly that induced by activated oxygen species,
is an important mechanism of cell damage. Free radical damage also
underlies chemical and radiation injury, toxicity from oxygen and
other gases, cellular aging, microbial killing by phagocytic cells
inflammatory cell damage, tumor destruction by macrophages, and
other injurious processes.
Free radicals are chemical species with a single unpaired electron in
an outer orbital. Such chemical states are extremely unstable and
readily react with inorganic or organic chemicals; when generated in
cells, they avidly attack and degrade nucleic acids as well as a variety
of membrane molecules. In addition, free radicals initiate
autocatalytic reactions; molecules that react with free radicals are in
turn converted into free radicals, further propagating the chain of
damage.
Free radicals may be generated within cells by
The reduction-oxidation (redox) reactions that occur during normal
physiologic processes .During normal respiration, for example,
molecular oxygen is sequentially reduced in mitochondria by the
addition of four electrons to generate water. In the process, small
amounts of toxic intermediate species are generated; these include
superoxide radicals
,
hydrogen peroxide (H2O2), and OH·. Further, some intracellular
oxidases (such as xanthine oxidase) generate superoxide radicals as a
direct consequence of their activity. Transition metals such as copper
and iron also accept or donate free electrons during certain
intracellular reactions and thereby catalyze free radical formation, as
in the Fenton reaction (Fe++ + H2O2 → Fe+++ + OH· + OH-). Since
most intracellular free iron is in the ferric (Fe+++) state, it must first
be reduced to the ferrous (Fe++) form to participate in the Fenton
reaction. That reduction step is catalyzed by superoxide ion, and thus
iron and superoxide synergize to elicit maximal oxidative cell injury.
Nitric oxide (NO), an important chemical mediator normally
synthesized by a variety of cell types .that can act as a free
radical or can be converted into highly reactive nitrite species.
The absorption of radiant energy (e.g., ultraviolet light, x-
rays). Ionizing radiation can hydrolyze water into hydroxyl
(OH·) and hydrogen (H·) free radicals.
Three reactions are particularly relevant to cell injury
mediated by free radicals:
Lipid peroxidation of membranes: Double bonds in membrane
polyunsaturated lipids are vulnerable to attack by oxygen-derived free
radicals. The lipid-radical interactions yield peroxides, which are
themselves unstable and reactive, and an autocatalytic chain reaction
ensues.
DNA fragmentation: Free radical reactions with thymine in nuclear
and mitochondrial DNA produce single-strand breaks. Such DNA
damage has been implicated in both cell killing and the malignant
transformation of cells.
Cross-linking of proteins: Free radicals promote sulfhydryl-mediated
protein cross-linking, resulting in enhanced rates of degradation or
loss of enzymatic activity. Free radical reactions may also directly
cause polypeptide fragmentation.
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© 2005 Elsevier(on 8 September 2010 02:58 PM)
Inflammation
is a protective response intended to eliminate
the initial cause of cell injury as well as the
necrotic cells and tissues resulting from the
original insult.
is the response of living tissue to injurious
agent.
A double edge sword?
Although inflammation helps clear infections
and other noxious stimuli and initiates repair,
the inflammatory reaction and the subsequent
repair process can cause considerable harm.
Injurious stimuli cause a protective
vascular connective tissue reaction
called “inflammation”
-Dilute
-Destroy
-Isolate
-Initiate repair
Etiology:

1- Physical Agents: Mechanical trauma,

extremes of temperature, radiation.
2- Chemical Agents and Drugs: Industrial and
occupational hazards, such as asbestos.
3- Infectious Agents.
4- Tissue necrosis.
5- Immune reaction.
6- Foreign body.
Classification of inflammation:

1- Acute

2- Chronic
Acute inflammation:

Is a rapid host response that serves to

deliver leukocytes and plasma proteins,
such as antibodies, to sites of infection
or tissue injury.
Components of acute and chronic inflammation
Etiology of Acute Inflammation:
Acute inflammatory reactions may be triggered
by a variety of stimuli:
1• Infections (bacterial, viral, fungal, parasitic) and
microbial toxins.
2• Tissue necrosis from any cause, including
ischemia (as in a myocardial infarct), trauma, and
physical and chemical injury.
3• Foreign bodies (splinters, dirt, sutures) typically
elicit inflammation because they cause traumatic
tissue injury or carry microbes.
4• Immune reactions (also called hypersensitivity
reactions).
Macroscopical features of acute inflammation:

Swelling,
Redness,
Hotness,
Pain,
Loss of function.
 Cardinal Signs of Inflammation
The basis of the five cardinal signs

• Increased blood flow due to vascular dilatation gives redness

and heat.

• Increased vascular permeability gives oedema causing tissue

swelling.

• Certain chemical mediators stimulate sensory nerve endings

giving pain. Nerves also stimulated by stretching from edema.

• Pain and swelling result in loss of function.

Changes of acute inflammation:
A- Vascular changes:
(1) Changes in vascular caliber and blood flow:
First: there is a transient constriction of arterioles, lasting a
few seconds.
Second: vasodilation which involves the arterioles and then
leads to opening of new capillary beds, the result is increased
blood flow, which is the cause of heat and redness (erythema)
at the site of inflammation, vasodilation is induced by the
action of several mediators, notably histamine and nitric oxide
(NO).
Third: slowing of blood flow (stasis) as a result of the loss of
fluid, increased vessel diameter, concentration of red cells in
small vessels, and increased viscosity of the blood.
(2) Changes in the in vascular structure: (increased
vascular permeability)

Increased vascular permeability leads to the

escape of a protein-rich exudate into the
extravascular tissue, causing edema. Several
mechanisms are responsible for the increased
vascular permeability:
B- Cellular changes:
(1) Emigration of the leukocytes from the
microcirculation:
Leukocyte Adhesion to Endothelium.
Leukocyte Migration through Endothelium.
(2) Accumulation of the leukocytes in the
focus of injury: Chemotaxis of Leukocytes.

(3) Activation of the leukocytes to eliminate

the offending agent:
Recognition of Microbes and Dead Tissues
Removal of the Microbes and Dead Tissues
(1) Emigration of the leukocytes from the
microcirculation.
Leukocyte Adhesion to Endothelium.
Margination: is the process of leukocyte
redistribution, because blood flow slows
early in inflammation (stasis), more white
cells assume a peripheral position along
the endothelial surface.
Rolling: is the process of leukocytes adhesion
transiently to the endothelium, detach and bind
again, thus rolling on the vessel wall.
Rolling is mediated by a family of proteins called
selectins (adhesion molecules). There are three
types of selectins: one expressed on leukocytes (L-
selectin), one on endothelium (E-selectin), and one
on platelets and on endothelium (P-selectin).

Adhesion: is the process of leukocytes adhesion

firmly to the endothelium,firm adhesion is mediated
by a family of proteins called integrins (VLA-4, LFA-
1 and Mac-1)
Leukocyte Migration through Endothelium.
The next step is migration of the leukocytes through
the endothelium, called transmigration or diapedesis.
Transmigration of leukocytes occurs mainly in
postcapillary venules. Chemokines act on the
adherent leukocytes and stimulate the cells to migrate
through interendothelial spaces toward the chemical
concentration gradient, (toward the site of injury or
infection where the chemokines are being produced),
after traversing the endothelium, leukocytes penetrate
the basement membrane, by secreting collagenases,
and enter the extravascular tissue.
(2) Accumulation of the leukocytes in the focus
of injury. Chemotaxis of Leukocytes.
After exiting the circulation, leukocytes emigrate
in tissues toward the site of injury by
a process called chemotaxis, which is defined
as locomotion oriented along a chemical
gradient.
Both exogenous and endogenous
substances can act as chemoattractants.
The most common exogenous agents are
bacterial products.
Endogenous chemoattractants include
several chemical mediators:
(1) Cytokines (e.g., IL-8).
(2) Components of the complement system,
particularly C5a
(3) Arachidonic acid (AA) metabolites,
mainly leukotriene B4 (LTB4).
All these chemotactic agents bind to specific
receptors on the surface of leukocytes result in
increased cytosolic calcium, with actin and
myosin changes at the leading edge of the cell.
The leukocyte moves by extending filopodia
that pull the back of the cell in the direction of
extension, the net result is that leukocytes
migrate toward the inflammatory stimulus in the
direction of the gradient of locally produced
chemoattractants.
Pavementation and diapedesis
The nature of the leukocyte infiltrate varies with the:
1- Age of the inflammatory response.
In most forms of acute inflammation neutrophils
predominate in the inflammatory infiltrate during the
first 6 to 24 hours and are replaced by monocytes in
24 to 48 hours.
After entering tissues, neutrophils are short-lived;
they undergo apoptosis and disappear after 24 to 48
hours.
Monocytes survive longer and proliferate in the
tissues, and thus become the dominant population in
chronic inflammatory reactions.
2- Type of stimulus.
In certain infections—for example, those
produced by Pseudomonas bacteria— the
cellular infiltrate is dominated by continuously
recruited neutrophils for several days.
In viral infections, lymphocytes may be the first
cells to arrive.
In some hypersensitivity reactions, eosinophils
may be the main cell type.
(3) Activation of the leukocytes to eliminate the
offending agent.
Recognition of Microbes and Dead Tissues
Leukocytes express several receptors that recognize
external stimuli:
• Receptors for microbial products.
• G protein–coupled receptors.
• Receptors for opsonins: Leukocytes express
receptors for proteins that coat microbes. The
process of coating a microbe, to target it for
ingestion (phagocytosis) is called opsonization,
and substances that do this are opsonins.
These substances include antibodies, complement
proteins.
Phagocytosis and intracellular killing, involves
three sequential steps:
(1) Attachment of the particle to be ingested by the
leukocyte
(2) Engulfment, with subsequent formation of a
phagocytic vacuole; by extensions of the
cytoplasm (pseudopods) around the microbe, and
the formation of a vesicle (phagosome) that
encloses the particle. The phagosome then fuses
with a lysosomal granule, resulting in discharge of
the granule's contents into the phagolysosome
(3) Killing or degradation of the ingested material
within neutrophils and macrophages,

Microbial killing is accomplished largely by

reactive oxygen species (ROS, also called
reactive oxygen intermediates) and reactive
nitrogen species and action of other substances
in leukocyte granules such as enzymes
( elastase) , lysozyme, which hydrolyzes the
bond found in the coat of all bacteria.
Termination (Control) of the Acute Inflammatory
Response
Acute inflammation, needs tight controls to
minimize the damage.

1- Inflammation declines simply because the

mediators of inflammation have short half-lives, and
are degraded after their release.
2- Neutrophils also have short half-lives in tissues and
die by apoptosis within a few hours after leaving the
blood.
3- There are a variety of stop signals that serve to
terminate the inflammation, including transforming
growth factor-β (TGF-β) and IL-10.
 Chemical mediators of inflammation
• Vasoactive amines
– Histamine
– Serotonin (5-HT)
• Neuropeptides
– Substance P
• Plasma proteases and the complement system
– Action of Hageman factor
• Arachidonic acid metabolites
– Prostaglandins
– Leukotrienes
– Lipoxins
• Cytokines
– IL-1, TNF etc.
• Chemokines .
• Nitric oxide and oxygen-derived free radicals
Chemical mediators of inflammation
(local and systemic)
Plasma proteases
The complement system
Arachidonic acid metabolites
 Effects of mediators of inflammation
Vasodilation:
Prostaglandins, NO
Increased vascular permeability:
Histamine, serotonin, C3a, C5a, bradykinin,Leukotrienes C4, D4,
E4, platelet activating factor
Chemotaxis, leukocyte activation:
C5a, leukotriene B4, bacterial products, chemokines (IL-8)
Fever:
IL-1, IL-6, TNF, prostaglandins
Pain:
Prostaglandins, bradykinin
Tissue damage:
Neutrophil and macrophage lysosomal enzymes, oxygen
metabolites,NO
Sequelae of Acute Inflammation
there are four main possible sequelae of acute
inflammation:
● Resolution: complete resolution occurs following
short-lived tissue injury in which there has been little
tissue damage. The bacterium may be neutralized,
killed and cleared by the acute inflammatory response
and the affected tissues return entirely to normal. This
occurs in some acute bacterial infections and is the
ideal outcome.
● Abscess formation: This is characteristically seen
with certain pyogenic organisms such as staphylococci.
An abscess may discharge spontaneously or require
drainage by surgical intervention.
● Healing by fibrosis and scar formation:
Healing by fibrosis and scar formation
occurs when substantial tissue destruction is
seen during the acute inflammation.The
damaged tissues are unable to regenerate and
are replaced by fibrous tissue.
● Progression to chronic inflammation
 Factors affecting outcome of acute
inflammation

1. Severity of tissue damage

2. Capacity of cells to divide
3. Type of agent causing damage
4. The responsiveness of the host
5. Site involved
 Morphologic PATTERNS
of Acute INFLAMMATION
• Serous (watery)
• Fibrinous (hemorrhagic, rich in FIBRIN)
• Suppurative (PUS)
• Ulcerative
BLISTER, “Watery”, i.e., SEROUS
 PUS
=
PURULENT

ABSCESS
=
POCKET
OF
PUS
 Ulcerative

• Necrotic and eroded epithelial surface

• Underlying acute and chronic inflammation
• Trauma, toxins, vascular insufficiency
Acute Inflammation
Acute Inflammation
Acute Inflammation
(with pus)
Cytokines (IL-1 and TNF)
Nitric oxide (NO)
EFFECTS OF ACUTE INFLAMMATION
Beneficial Effects
1. Dilution of Toxins by the edema fluid
2. Production of protective Antibodies & promotion of immunity
3. Fibrin meshwork formation that forms a scaffold for inflammatory
cell migration & also limits the spread of infections
4. Cell Nutrition
Harmful Effects
1. Swelling & edema that can be detrimental for e.g. acute epiglottitis
that may be life threatening .
2. Rise in tissue pressure that contributes to tissue necrosis
3. Digestion of adjacent viable tissue
4. Sever damaging allergic reaction
5. Generalized increase in vascular permeability can cause shock as
seen in anaphylactic reactions.
 Chronic Inflammation

Chronic inflammation is inflammation of

prolonged duration (weeks or months)
in which

inflammation, tissue injury, and attempts at

repair coexist, in varying combinations.
 Causes of chronic inflammation

• Acute inflammation:
– Progressive: osteomyelitis
– Recurrent: cholycystitis, gastritis.
• Primary: (abinitio) abinitio means "from the
beginning“
• Contents
– TB, fungal inf.
– HSR.
• Persistent factor : foreign bodies
 Primary Chronic Inflammation
It is the cause of tissue damage in some of the most
common and disabling human diseases, such as

rheumatoid arthritis, atherosclerosis, tuberculosis,

and pulmonary fibrosis.

It has also been implicated in the progression of

cancer and in diseases once thought to be purely
degenerative, such as Alzheimer disease.
Mechanism of chronic inf
Macrophages

Activation

Free TGF-B EGF

radicals
Enzymes
Cytokines FGE +
NO GCSF

ue e Fibrosis Angiogenesis
s
T is m a g
da Healing Granulation tissue
 MORPHOLOGIC FEATURES

Chronic inflammation is characterized by:

1. Infiltration with mononuclear cells, which include
macrophages, lymphocytes, and plasma cells
2. Tissue destruction, induced by the persistent
offending agent or by the inflammatory cells
3. Attempts at healing by connective tissue
replacement of damaged tissue, accomplished by
proliferation of small blood vessels (angiogenesis)
and, in particular, fibrosis.
A, Chronic inflammation in the lung, showing all three characteristic
histologic features: (1) collection of chronic inflammatory cells (*), (2)
destruction of parenchyma (normal alveoli are replaced by spaces
lined by cuboidal epithelium, arrowheads), and (3) replacement by
connective tissue (fibrosis, arrows).
Cells of the chronic inflammatory
response
• Lymphocytes
• Monocytes/ macrophages
• Plasma cells
Maturation of circulating
monocytes
to macrophages
Macrophage-lymphocyte
interactions
in chronic inflammation
 GRANULOMATOUS INFLAMMATION
Granulomatous inflammation is a distinctive
pattern of chronic inflammation that is
encountered in a limited number of infectious
and some noninfectious conditions. Immune
reactions are usually involved in the
development of granulomas.
A granuloma is a cellular attempt to contain an
offending agent that is difficult to eradicate.
In this attempt there is often strong activation of
T lymphocytes leading to macrophage
activation, which can cause injury to normal
tissues.
 Giant Cells
Older granulomas develop an enclosing rim of
fibroblasts and connective tissue.
Frequently, epithelioid cells fuse to form giant
cells in the periphery or sometimes in the
center of granulomas.
These giant cells may attain diameters of 40 to
50 μm. They have a large mass of cytoplasm
containing 20 or more small nuclei arranged
either peripherally (Langhans-type giant cell)
or haphazardly (foreign body–type giant cell).
 Types of Granulomas

I. Foreign body granulomas

II. Immune granulomas
 Foreign body granulomas
Incited by relatively inert foreign bodies.
Typically, foreign body granulomas form
around material that are large enough to
preclude phagocytosis by a single
macrophage and do not incite any specific
inflammatory or immune response.
The foreign material can usually be identified
in the center of the granuloma, particularly if
viewed with polarized light, in which it
appears refractile.
 Immune granulomas
Caused by agents that are capable of
inducing an immune response which
produces granulomas usually when
the inciting agent is poorly degradable
or particulate.