INFLAMMATION

Faculty of Medicine
Department of Pathology
 Inflammation

• Definition
– A dynamic process of chemical and cytological
reactions that occur in response of vascularized
tissue to stimuli that cause cell injury.
Inflammation results in:
- accumulation of leukocytes and fluid in
extravascular tissue.
- systemic effects. 2
 Effects of Inflammation

• Elimination of the cause of cell injury.

• Elimination of the necrotic cells.
• Paves the way for repair.
• May lead to harmful results.

3
 Inflammation

Nomenclature
• -itis (- after name of tissue) e.g.
– Appendix Appendicitis
– Dermis Dermatitis
– Gallbladder Cholecystitis
– Duodenum Duodenitis
– Meninges Meningitis, etc.

4
 Inflammation
Causes:
– Microbial infections: bacteria, viruses, fungi,
parasites.
– Immunologic: hypersensitivity (contact with some
substances), autoimmune reactions.
– Physical agents: trauma, heat, cold, ionizing
radiation, etc.
– Chemical agents: acids, alkali, bacterial toxins,
metals, etc.
– Foreign materials: sutures, dirt, etc.
– Tissue necrosis: ischemic necrosis. 5
 Inflammation
The participants
1. White blood cells and platelets
• Neutrophils, monocytes, lymphocytes, eosinophils,
basophils.
2. Plasma proteins
• Coagulation / fibrinolytic system, kinin system,
complement system.
3. Endothelial cells and smooth muscles of vessels.
4. Extracellular matrix and stromal cells
• Mast cells, fibroblasts, macrophages & lymphocytes.
• Structural fibrous proteins, adhesive glycoproteins,
proteoglycans, basement membrane. 6
Components of Inflammation

7
 Inflammation
Acute inflammation Chronic inflammation
– Duration: minutes to – Duration: days to
days. years.

– Predominance of – Predominance of
neutrophils. lymphocytes and
macrphages.

– Fluid & plasma protein – Vascular proliferation

exudation. and fibrosis.
8
 Acute Inflammation

• Early response of vascularized tissue to

injury.
• Aim of acute inflammation:
– Recruitment of neutrophils (1st 3 days), and
monocytes (after 3 days) to clear the cause
of injury and remove necrotic cells.
– Deliver plasma proteins: antibodies,
complement, others.

9
 The two components of acute
inflammation
• Vascular changes
– Vasodilatation.
– Increased vascular permeability.
– Stasis.
• Cellular events
– Emigration of cells from microvessels.
– Accumulation at sites of injury.

The process is orchestrated by release of

chemical mediators 10
Acute Inflammation
(pneumonia)

11
Local Manifestations of Acute
Inflammation

12
Vascular Changes

13
 The five classic signs of acute
inflammation

• Heat.
• Redness.
• Swelling.
• Pain.
• Loss of function.

14
The five classic signs of acute
inflammation

Heat Redness Swelling Pain 15

Loss Of Function.
 Vascular Changes

• Arteriolar dilatation follows transient

vasoconstriction.
• Increased vascular permeability and stasis:
– Arteriolar vasodilatation → ↑hydrostatic pressure
→ transudate.
– Late phase: leaky vessels → loss of proteins →
exudate.
• Margination of leukocytes.
16
 Fluid Movement in
Microcirculation in Normal Tissue

17
Fluid Movement in Microcirculation
in Inflamed Tissue

18
 How does inflammation lead to
leakiness of endothelial cells? (1)

• Endothelial cell contraction

– Reversible.
– Immediate transient response with short life (15-30 minutes).
– Induced by: histamine, bradykinin, leukotrienes,
neuropeptide substance P.
– Mostly in postcapillary venules.
• Endothelial cell retraction
– Reversible.
– Starts 4-6 hours after injury and stays for 24 hours.
– Induced by: IL-1, TNF, and IFN- 19
 How does inflammation lead to
leakiness of endothelial cells? (2)
• Direct endothelial injury
– Severe injury.
– Immediate sustained response.
– All microvessels can be affected.
• Delayed prolonged response
– Begins after delay (2-12 hours), lasts for hours or days.
– Caused by thermal injury, UV radiation, bacterial toxins.
• Leukocyte-dependent endothelial injury.
• Increased intracytosis (transcytosis) of proteins
through vesiculovacuolar pathway
– Stimulated by VEGF.
• Leakage from newly formed blood vessels. 20
Edema in Inflammation

21
 Edema in Inflammation
TRANSUDATE EXUDATE
• Mechanism: hydrostatic • Mechanism: alteration in
pressure imbalance across normal permeability of
vascular endothelium. small blood vessels in
area of injury.

• Fluid of low protein content • Fluid of high protein

(ultrafiltrate of blood plasma). content (>.3g/dl) &
increased cellular debris.

• Specific gravity <1.012.

• Specific gravity >1.020.
22
 Cellular Events

• Margination, rolling and adhesion.

• Transmigration between endothelial cells.
• Migration in the interstitium toward the site
of stimulus.
• Phagocytosis and degranulation.
• Release of leukocyte products.
23
Neutrophil Margination

24
Neutrophil Margination

25
The Process of Extravasation of
Leukocytes

26
 Selectins
• Receptors expressed on the surfaces of
endothelial cells and leukocytes that bind
selected sugars (sialylated oligosaccharides).
• Not expressed on resting endothelial cells, but
expressed within 30 minutes of stimulation.
• Low affinity binding with a fast-off-rate.
• Single chain transmembrane glycoprotein.
• Binding to ligand needs Ca.
• Distribution:
– E-selectin (CD62E): endothelial cells.
– P-selectin (CD62P): platelets & endothelial cells.
– L-selectin (CD62L): leukocytes. 27
 Integrins
• Heterodimeric cell surface proteins ( & 
chains).
• Bind to ligands present in:
– Extracellular matrix.
– Complement system.
– Surface of other cells.
• Many integrins recognize the RGD
sequence.
• Cytoplasmic domains bind with cytoskeleton.
28
 Adhesion between leukocytes
and endothelial cells

• Weak adhesion and rolling

– Mediated by selectins.
• Firm adhesion
– Ig superfamily molecules expressed on endothelial cells
such as:
• ICAM-1
• VCAM-1
– Integrins expressed on leukocytes:
• LFA-1 (CD11a/CD18)
• Mac-1 (CD11b/CD18)
• P150,95 (CD11c/CD18)
• VLA-4
29
Upregulation of Selectins

30
Cytokine Induction of Adhesion
Molecules

31
Chemotactics Increase Affinity of
Integrins to Adhesion Molecules

32
 Endothelial and Leukocyte
Adhesion Molecule Interactions
ENDOTHELIUM WBC FUNCTION
• P & E-selectins Sialyl-Lewis X Rolling

• GlyCAM-1, CD34 L-selectin Rolling

• VCAM-1 VLA-4 Adhesion

• ICAM-1 CD11/CD18 Adhesion,

(LFA1, MAC1)
• CD31 (PECAM-1) CD31 Transmigration
33
General Structure of CAM Families

34
The Process of Rolling, Activation
and Firm Adhesion of Leukocytes

35
Molecules Mediating Endothelial-
Neutrophil Interaction

36
Firm Adhesion via Integrin ICAM
Interactions

37
Transmigration of Neutrophils

38
 Diapedesis

• Transmigration of leukocytes between

endothelial cells at the intercellular
junctions

• Facilitated by PECAM-1
(CD31)/PECAM-1 interaction

39
The Process of Extravasation of
Leukocytes

40
 The Process of Extravasation of
Leukocytes
1. Selectins and their carbohydrate counterligands mediate
leukocyte tethering and rolling.
2. Leukocyte integrins and their ligands including
immunoglobulinlike intercellular adhesion molecules,
mediate firm adhesion.
3. Chemokines play a role in firm adhesion by activating
integrins on the leukocyte cell surface.
4. The leukocytes are directed by chemoattractant
gradients to migrate across the endothelium, and through
the extracellular matrix into the tissue.
41
Lobar Pneumonia

42
Sequence of Events Following
injury

43
 Chemotaxis

• Migration of cells along a chemical

gradient
• Chemotactic factors:
– Soluble bacteial products, e.g. N-formyl-
methionine termini
– Complement system products, e.g. C5a
– Lipooxygenase pathway of arachidonic
acid metabolism, e.g. LTB4
– Cytokines, e.g. IL-8 44
Effects of Chemotactic
Factors on Leukocytes

45
 Effects of Chemotactic
Factors on Endothelial Cells

46
 Effects of Chemotactic Factors
on Leukocytes

• Stimulate locomotion
• Degranulation of lysosomal enzymes
• Production of AA metabolites
• Modulation of the numbers and affinity
of leukocyte adhesion molecules

47
Biochemical Events in Leukocyte
Activation

48
 Phagocytosis

• The process of ingestion and digestion by cells of

solid substances, e.g., other cells, bacteria, necrotic
tissue or foreign material
• Steps of phagocytosis:
– Recognition, attachment and binding to cellular receptors
• IgG, C3b, MBL
– Engulfment
– Fusion of phagocytic vacuoles with lysosomes
– Killing or degradation or ingested material
49
Phagocytosis

50
 Phagocytosis
• Recognition and attachment by receptors:
– Mannose receptors: bind to terminal mannose
residues on microbes cell walls.
Mammalian cells are not recognised by mannose
receptors because they contain terminal sialic acid and
N-acetyl galactosamine.
– Scavenger receptors: oxidized LDL, and
microbes.
– Opsonin receptors (high affinity): IgG, C3b,
MLB.
51
Phagocytosis

52
 Generation of Oxygen
Metabolites

NADPH oxidase
• 2O2 + NADPH 2O2- + NADP+ + H+
Dismutase
• O2- + 2H+ H2O2
Myeloperoxidase
• H2O2 +Cl- HOCl-

The H2O2-MPO-halide is the most efficient bactericidal system

in neutrophils
53
Oxygen Dependent Bactericidal
Mechanisms

54
 How Do Leukocytes Kill
Infectious Agents?

• Oxygen burst products

• Bactericidal permeability increasing
protein
• Lysozyme
• Major basic protein
• Defensins
• Lactoferrin
55
 Genetic defects in leukocyte function
Disease Defect
Leukocyte adhesion deficiency 1 CD18 unit of integrin

Leukocyte adhesion deficiency 2 Sialyl-Lewis X

Neutrophil-specific granule Absent specific granules

deficiency
Membrane component of
CGD, X-linked NADPH oxidase
CGD, autosomal recessive Cytoplasmic component of
NADPH oxidase
MPO deficiency Absent MPO-H2O2 system

Chediak-Higashi disease Organelle trafficking 56

 Acquired defects in leukocyte
function

• Chemotaxis defects
– burns, diabetes, sepsis, etc.

• Adhesion
– hemodialysis, diabetes

• Phagocytosis and microbicidal activity

– leukemia, sepsis, diabetes, malnutrition, etc
57
 Chemical Mediators of
Inflammation

• What are their sources?

– Circulating plasma proteins
• Coagulation / fibrinolytic factors
• Complement
• Kinins
– Cell derived
• Formed elements normally equestered in granules:
– Vasoactive amines
• Newly synthesized in response to stimulation
– PGs, LT, O2 species, NO, Cytokines, PAF
58
Cellular Derived Mediators of
Inflammation

59
Systemic Mediators of
Inflammation

60
 Chemical Mediators of
Inflammation
• General characteristics
– Bind to specific cellular receptors, or have enzymatic activity
– May stimulate target cells to release secondary mediators
with similar or opposing functions
– May have limited targets, or wide spread activities
– Short lived function
• Short half-life (AA metabolites)
• Inactivated by enzymes (kininase on bradykinin)
• Eliminated (antioxidants on O2 species)
• Inhibited (complement inhibitory proteins)
– If unchecked, cause harm
61
 Vasoactive Amines

Release of histamine Release of serotonin

• Physical injury
• Binding of IgE to Fc
• Platelets aggregation
receptors • PAF
• Anaphylatoxins (C3a, C5a)
binding
• Histamine releasing ptn
derived from PMNs
• Neuropeptides (substance
P)
• Cytokines (IL-1, IL-8)
62
 Histamine and Serotonin

• Stored in granules in mast cells (histamine),

and platelets (serotonin)
• Cause arteriolar dilatation and increases
permeability (immediate phase reaction)
• Induce endothelial cell contraction in
venules
• Binds to H1 receptors
• Inactivated by histaminase
63
Intrinsic Pathway
HMWK
Prekallikerin
Surface
XII XIIa Extrinsic Pathway

XI XIa
VIIa VII
TF
IX IXa
VIIIa
X Xa
Va
Prothrombin Thrombin

Fibrinogen Fibrin
XIIIa
Cross linked fibrin
64
 Clotting / fibrinolytic system
• Fibrin clot at site of injury helps in containing the
cause
• Fibrin clot provides a framework for inflammatory cells
• Xa causes increased vascular permeability and
leukocytes emigration
• Thrombin causes leukocytes adhesion, platelets
aggregation, generation of fibrinopeptides, and is
chemotactic
• Fibrinopeptides are chemotactic & induce
vasopermeability 65
 Clotting / fibrinolytic system
(continued)

• XIIa also activates the fibrinolytic pathway to

prevent widespread thrombosis.
• Fibrin split products increase vascular
permeability
• Plasmin cleaves C3 to form C3a, leading to
dilatation and increased permeability
• Plasmin activates XIIa amplifying the entire
process

66
 Thrombin as an Inflammatory
Mediator

• Binds to protease-activated receptors (PARs)

expressed on platelets, endothelial cells, sm.
muscles leading to:
– P-selectin mobilization
– Expression of integrin ligands
– Chemokine production
– Prostaglandin production by activating
cyclooxygenase-2
– Production of PAF
– Production of NO
67
 Kinin System

• Leads to formation of bradykinin from

HMWK
• Effects of bradykinin
– Increased vascular permeability
– Arteriolar dilatation
– Bronchial smooth muscle contraction
– Pain
• Sort half-life (inactivated by kininases)
68
 Interaction between the four plama mediator systems
XII Kallikerin
HMWK
Prekallikerin
Surface
XIIa Prekallikerin

XI XIa
HMWK Bradykinin

IX IXa
VIIIa Plasminogen Plasmin
X Xa
Va

Prothrombin Thrombin
C3 C3a

Fibrinogen Fibrin
Fibrinopeptides

69
Fibrin split products
 Interaction between the four plama mediator systems

HMWK Bradykinin
XII Plasminogen
kallikerin C3
HMWK
-ve surface
Plasmin

prekallikerin C3a
XIIa

Multiple steps

Fibrinogen Fibrin

Fibrin split products 70

 The Complement System in
Inflammation
• C3a and C5a (anaphylatoxins) increase vascular
permeability, and cause mast cell to secrete
histamine.
• C5a activates lipoxygenase pathway of AA
• C5a activates leukocytes, increased integrins affinity
• C5a is chemotactic
• C3b and C3bi are opsonins
• Plasmin and proteolytic enzymes split C3 and C5
• Membrane attack complex (C5-9) lyse bacterial
membranes
71
Complement Activation
Pathways

72
Complement Role in
Inflammation

73
 Defects in the Complement
System

• Deficiency of C3 → susceptibility to
infections.
• Deficiency of C2 and C4 → susceptibility to
SLE.
• Deficiency of late components → low MAC
→ Neisseria infections.
• ↓ inhibitors of C3 and C5 convertase (↓
DAF) → hemolytic anemia
• ↓C1 inhibitor → angioneurotic edema 74
Arachidonic Acid Metabolism

Cell membrane
PLA2

PAF

AA

Cyclooxygenase Lipooxygenase
PGE2 LTB4
PGF2 LTC4, D4, E4
PGD2 HETE
PGI2
75
TXA2
 Products of the cycloxygenase
pathway of AA metabolism

• TXA2
– Vasoconstriction
– Simulates platelets aggregation
• PGI2
– Vasodilatation
– Inhibits platelets aggregation
• PGD2, PGE2, PGF2a
– Vasodilatation
– Edema formation
– Pain (PGE2)

76
 Products of the lipoxygenase
pathway of AA metabolism

• 5-HETE and LTB4

– Chemotactic
• LTC4, LTD4 and LTE4
– Vasoconstriction
– Bronchospasm
– Increased vascular permeability
• Lipoxins (LXA4 & LXB4)
– Vasodilatation
– Inhibit neutrophil chemotaxis and adhesion
– Stimulate monocyte adhesion

77
Generation of AA Metabolites

78
 Platelet-activating Factor
• Generated from memranes phosphlipids by
Phospolipase A2
• Aggregates and degranulates platelets
• Potent vasodilator and bronchoconstrictor
• Increase vascular permeability
• Effects on leukocytes
– Increase adhesion to endothelial cells
– Chemotactic
– Degranulation
– Oxygen burst
79
 Cytokines

• Hormone-like polypeptides produced by

cells, involved in cell to cell
communication
• Pleiotropic effects
• Secretion is transient
• Redundant
• Effects: autocrine, paracrine, endocrine
80
 Classes of cytokines

• Regulators of lymphocyte function

– IL-2 stimulates proliferation
– TGF inhibits lymphocytes growth
• Primary responders to injury (innate immunity)
– IL-1 & TNF
• Activators of cell mediated immunity
– INF- & IL-12
• Chemotactics
– IL-8
• Hematopoietic growth factors
– IL-3 & GM-CSF 81
 TNF & IL-1

• Produced mainly by macrophages

• Secretion stimulated by: bacterial
products, immune complexes,
endotoxins, physical injury, other
cyotkines.
• Effects on endothelial cell, leukocytes,
fibroblasts, and acute phase reactions

82
Major Effects of IL-1 & TNF

83
 Chemokines
• A group of related chemotactic polypeptides, all of which have 4
cysteine residues
• Regulate adhesion, chemotaxis and activation of leukocytes
• Important for proper targeting of leukocytes to infection sites
• The largest family consists of CC chemokines, so named
because the first 2 of the 4 cysteine residues are adjacent to
each other.
• Examples of CC chemokines:
– CCL2: Monocyte chemoattractant protein 1 (MCP-1)
– CCL3 & CCL4: Macrophage inflammatory protein 1 (MIP-1a & 1b)
– CCL5: RANTES
– CCL11: Eotaxin
• Examples of CXC chemokines:
– CXCL8: IL-8, neutrophil chemotactic 84
 Chemokines
• Chemokines released in extravascular tissue move
by trascytosis to the luminal surfaces of endothelial
cells
• Buildup of chemokine at the luminal surface of the
endothelium occurs by chemokine immobilization
mediated by interactions with cell surface
proteoglycans such as heparan sulfate.
• The chemokines interact with the G-protein coupled
receptors on the leukocyte cell surface, resulting in
activation of integrins and firm attachment to the
endothelium. 85
 Nitric Oxide

• Produced from arginine by the effect of

nitric oxide synthase (NOS)
• Role in inflammation:
– Vasodilator (smooth muscle relaxant)
– Antagonist of platelets adhesion, ↓ inflammatory
aggregation and stimulation response

– Reduces leukocytes adhesion and

recruitment
– Microbicidal in activated macrophages
86
Nitric Oxide

87
 Oxygen derived free radicals

At low levels At high levels

• Increase: • Endothelial damage
– Chemokines & thrombosis
– Cytokines • Protease activation &
– Adhesion molecules inhibition of
antiproteases
• Direct damage to
other cells
Protective mechanisms against free radicals include: transferrin,
ceruloplasmin, catalase, superoxide dismutase, and glutathione
88
 Lysosomal constituents
• Released in:
– After cell death
– Leakage upon formation of phagocytic vacuoles
– Frustrated phagocytosis (fixed on flat surfaces)
– After phagocytosis of membranolytic substance, e.g. urate
• Neutral proteases effects:
– Elastases, collagenases, and cathepsin
– Cleave C3 and C5 producing C3a & C5a
– Generate bradykinin like peptides
• Minimizing the damaging effects of proteases is
accomplished by antiproteases:
– Alpha 2 macroglobulin
– Alpha 1 antitrypsin 89
 Morphologic Appearance of
Acute Inflammation
• Catarrhal
– Acute inflammation + mucous hypersecretion (e.g.
common cold)
• Serous
– Abundant protein-poor fluid with low cellular content,
e.g. skin blisters and body cavities
• Fibrinous:
– Accumulation of thick exudate rich in fibrin, may
resolve by fibrinolysis or organize into thick fibrous
tissue (e.g. acute pericarditis) 90
 Morphologic Appearance of
Acute Inflammation

• Suppurative (purulent):
– Pus: Creamy yellow or blood stained fluid
consisting of neutrophils, microorganisms & tissue
debris e.g. acute appendicitis
– Abscess: Focal localized collection of pus
– Empyema: Collection of pus within a hollow organ
• Ulcers:
– Defect of the surface lining of an organ or tissue
– Mostly GI tract or skin
91
Subcutaneous Abscess

92
Lung Abscess

93
Fibrinous Pericarditis

94
Gastric Ulcers

95
Foot Ulcer

96
Burn Blister

97
 Outcomes
of Acute Inflammation
• Complete resolution (back to normal)
– Clearance of injurious stimuli
– Removal of the exudate, fibrin & debris
– Reversal of the changes in the microvasculature
– Replacement of lost cells (regeneration)
• Healing
– organization by fibrosis through formation of Granulation tissue. Why?
• Substantial tissue destruction or
• Tissue cannot regenerate or
• Extensive fibrinous exudates
• Abscess formation
• Progression to chronic inflammation
98
Complete Resolution of
Inflammation

99
 Outcomes
of Acute Inflammation

Usual result RESOLUTION

ABSCESS
ACUTE FORMATION
INFLAMMATION Pyogenic organism
REPAIR &
ORGANIZATION
Excessive destruction

CHRONIC
INFLAMMATION FIBROSIS
100
Persistence
 Role of Lymphatic System
in Inflammation
• The local inflammatory reaction may fail in
containing the injurious agent
• Secondary lines of defense:
– Lymphatic system:
• Lymphatic vessels drain offending agent, edema fluid & cellular
debris, and may become inflamed (LYMPHANGITIS).
• Lymph nodes may become inflamed (LYMPHADENITIS).
• Secondary lines of defense may contain infection, or may be
overwhelmed resulting in BACTEREMIA.
– MPS:
• Phagocytic cells of spleen, liver & BM
• In massive infections, bacterial seeding may occur
in distant tissues. 101
 Effects
of Acute Inflammation
BENIFITIAL: HARMFUL:
• Elimination of injurious • Digestion of normal
stimulus
• Dilution of toxins tissues
• Entry of antibodies • Swelling
• Drug transport • Inappropriate
• Fibrin formation inflammatory
• Delivery of nutrients & response
oxygen
• Stimulation of the
immune response
102
Chronic Inflammation
 Chronic Inflammation

• Inflammation of prolonged duration

(weeks, months, or years) that starts
either rapidly or slowly.
• Characterized by an equilibrium of:
– Persistent injurious agent
– Inability of the host to overcome the
injurious agent

104
 Chronic Inflammation

• Characteristics:
– Chronic inflammatory cell infiltrate
• Lymphocytes
• Plasma cells
• Macrophages
– Tissue destruction
– Repair
• Neovascularization
• Fibrosis
105
 Inflammation
Acute inflammation Chronic inflammation
– Duration: minutes to – Duration: days to
days years

– Predominance of – Predominance of
neutrophils lymphocytes and
macrphages

– Fluid & plasma protein – Vascular proliferation

exudation and fibrosis
106
Chronic and Acute
Pneumonia

107
 Chronic Inflammation
• Under what circumstances, does it develop?
– Progression from acute inflammation
• Tonsillitis, osteomyelitis, etc.
– Repeated exposure to toxic agent
• Silicosis, asbestosis, hyperlipidemia, etc.
– Viral infections
– Persistent microbial infections
• Mycobacteria, Treponema, Fungi, etc.
– Autoimmune disorders
• Rhumatoid arthritis, SLE, systemic lupus, etc. 108
 Macrophages & the Mononuclear
Phagocytic System
• Macrophages:
– Derived from circulating monocytes
– Scattered in tissues:
• Kupffer cells (liver),
• sinus histiocytes (spleen & LN),
• alveolar macrophages (lung),
• microglia (CNS)
• Activated mainly by IFN- secreted from T lymphocytes
– Increased cell size
– Increased lysosomal enzymes
– more active metabolism, i.e. greater ability to kill ingested organisms
– Epithelioid appearance

109
How do Macrophages Accumulate
at Sites of Chronic Inflammation?
• Recruitment of monocytes from circulation
by chemotactic factors:
– Chemokines, C5a, PDGF, TGF,
fibrinopeptides, fibronectin, collagen
breakdown fragments.
• Proliferation of macrophages at foci of
inflammation
• Immobilization of macrophages at sites of
inflammation
110
 Products Activated
macrophages

• Proteases
• Complement and clotting factors
• Oxygen species and NO
• AA metabolites
• IL-1 & TNF
• Growth factors (PDGF, FGF,
TGF) 111
Role of Activated Macrophages
in Chronic Inflammation

112
Macrophage-Lymphocyte
Interactions

113
Complete Resolution of
Inflammation

114
 Granuolmatous Inflammation
• A distinctive form of chronic inflammation
characterized by collections of epithelioid
macrophages
• Granuloma, in addition to epithelioid
macrophages, may have one or more of the
following:
– a surrounding rim lymphocytes & plasma cells
– a surrounding rim of fibroblasts & fibrosis
– giant cells
– central necrosis e.g. caseating granulomas in 115
TB
Histopathology of Granuloma

116
Histopathology of Granuloma

117
Caseating Granuloma

118
AFB Stain in Caseating
Granuloma

119
 Examples of Granulomatous
Inflammation
Mycobacterium tuberculosis
Mycobacterium Leprae
Bacterial
Trepnema pallidum
Bartonella henslae
Parasitic Scistosomiasis
Histoplasma capsulatum
Balsomycosis
Fungal
Cryptococcus neoformans
Coccidioides immitis
Inorganic metals Silicosis, Byrelliosis

Foreign body Suture, other prosthesis, keratin

Unknown Sarcoidosis 120

 Morphologic Appearance of
Chronic Inflammation

• Ulceration
– Ulcer: Local defect or loss of continuity in
surface epithelia
• Chronic abscess cavity
• Induration & fibrosis
• Thickening of the wall of a hollow viscus
• Caseous necrosis

121
Ulcer

122
Systemic Acute-phase Reactions

123
 Systemic Effects of Inflammation
(Acute phase reactions)
• Mediated by IL-1, IL6, TNF, which interact with
vascular receptors in the thermoregulatory center of
hypothalamus via local PGE production
• Systemic manifestations include:
– Fever
– Catabolism
– Increased slow wave sleep, decreased appetite
– Hypotension & other hemodynamic changes
– Synthesis of acute-phase proteins by liver, e.g. CRP,
fibrinogen, serum amyloid A protein (SAA)
– Leukocytosis: neutrophilia, lymphocytosis, eosinophilia
– Leukopenia
– Increased ESR 124
 Consequences of Defective
Inflammation

• Susceptibility to infections
– Defective innate immunity
• Delayed repair
– Delayed clearance of debris and necrotic
tissue
– Lack of stimuli for repair

125
 Consequences of Excessive
Inflammation

• Allergic reactions
• Autoimmune disorders
• Atherosclerosis
• Ischemic heart disease

126
Tissue Repair
 The two processes of repair
• Regeneration
– Replacement of damaged cells by similar
parenchymal cells, e.g. liver regeneration
– Requires intact connective tissue scaffold
• Fibrosis
– Replacement by connective tissue
– ECM framework is damaged

Healing is a combination of regenerative and

fibrotic processes
128
Regeneration and Healing

129
Regulation of Cell
Populations

130
 The Proliferative Potential of
Different Cell Types
• Labile cells (continuously dividing & continuously dying)
– Stem cells divide: self renewal and differentiation
– Examples:
• Skin epidermis
• GIT epithelium
• Bone marrow cells
• Stable cells (quiescent)
– Examples:
• Liver
• Kidney,
• Smooth muscles.
• Permanent (nondivivding),
– Examples:
• Cardiac muscle
• Neurones 131
 Cell Cycle Phases

S
G1

G0
G0 (Labile cells)

(Stable G2
cells)

(Permenant M 132
cells)
Cell-cycle Landmarks

133
134
"the most promising "morally
research in health care, unacceptable." the
perhaps in the history of U.S. Conference of
the world;" A U.S. Bishops
senator

The Stem Cell Divide 135

 Stem Cells
• Self renewal capacity
• Asymmetric replication
• Capacity to develop into multiple lineages
• Extensive proliferative potential

Embryonic stem cells: Pluripotent cells that can

give rise to all tissues of the body
Adult stem cells: Restricted differentiation
capacity (lineage specific) 136
 Impact of Embryonic Stem
Cells on Medicine

• Study of specific cell signaling and

differentiation steps
• Production of knockout mice
• Potentially, generation of specific cell
types to regenerate damaged tissue
(therapeutic cloning)

137
Steps Involved in Therapeutic
Cloning

138
Examples of Adult Stem Cells
Locations (1)

139
Examples of Adult Stem Cells
Locations (2)

140
Examples of Adult Stem Cells

• Bone marrow Hemetopoietic stem cells

• Liver Hering canal

• Skeletal muscle Satellite cells

• Intestine Base of crypts

• Skin Hair follicle bulge

141
 Cyclins
• Family of proteins that control entry of the cells at
specific stages of cell cycle
• Level of a specific cyclin increases at a specific stage,
then decreases rapidly after the cell departs that stage
• In order to accomplish their function, they have to bind
to CDKs
• Different combinations are associated with each phase
of the cell cycle
• They exert their function by phosphorylating certain
proteins (kinase phosphorylate proteins)
• Examples:
– Cyclin B-CDK1 activate G2 to M transition
– Cyclin D-CDK4,6 activate G1 to S phase 142
 Cyclins and Retinoblastoma
Gene

• Hypophosphorylated RB, forms a complex with E2F

transcription factor and DP1, blocking the effect of
E2F.
• Blocking is mediated by histone deacetylase causing
chromatin compaction.
• CyclinD/CDK4, and cyclinE/CDK2 phosphorylate RB.
• Phosphorylated RB dissociated from the complex,
leading to activation of E2F.
• Target genes for E2F include: cyclin E, DNA
polymerase, thymidine kinase, dihydrofolate
reductase, and others.
143
 CDK inhibitors

• Regulate cell cycle checkpoints (G1-S,

& G2-M)
• Cip/Kip family: p21, p27 and p57
• INK4/ARF family: p16NK4A, p14ARF

144
 P53 and the cell cycle

• If mutation occurs, TP53 is stabilized

• TP53 induce p21(CDKN1A)
transcription
• P21 is a CDK inhibitor, thus arresting
the cell at G1 until DNA is repaired
• If DNA damage cannot be repaired,
TP53 induces apoptosis

145
 Signals for Cell Growth and
Differentiation

• Soluble polypeptide growth factors

• Insoluble elements of ECM interacting
with integrins

146
 Polypeptide Growth Factors
• Chemical mediators that affect cell growth by
binding to specific receptors on the cell
surface or intracellularly. They are the most
important mediators affecting cell growth
• Present in serum or produced locally
• Exert pleiotropic effects; proliferation, cell
migration, differentiation, tissue remodeling
• Regulate growth of cells by controlling
expression of genes that regulate cell
proliferation (protooncogenes) 147
 Examples of Growth Factors
(1)

• EGF (epidermal growth factor) & TGF-

– Binds to its receptor ERB B1
– Mitogenic for epithelial cells & fibroblasts;
migration of epithelial cells
• PDGF (platelet-derived growth factor)
– Migration & proliferation of fibroblast, smooth
muscle cell & monocyte; chemotactic

148
Examples of Growth Factors (2)

• FGFs (fibroblast growth factors)

– Mitogenic for fibroblast & epithelial cells;
angiogenesis; chemotactic for fibroblasts
– Wound healing
• VEGF (vascular endothelial growth factor)
– Angiogenesis
– Increased vascular permeability
• HGF/scatter factor (hepatocyte growth factor)
– Mitogenic to most epithelial cells including
hepatocytes
– Promotes scattering and migration of cells 149
Transforming Growth Factor Beta
(TGF-):

• TGF- binds to 2 receptors (types I &II)

with serine/threonine kinase activity
• Rectors phosphorylates cytoplasmic
transcription factors smads
• Smads enter the nucleus and associate
with other DNA binding proteins
activating or inhibiting gene transcription

150
Transforming Growth Factor Beta
(TGF-):

• Inhibitor of most epithelial cells and

leukocytes. Increases expression of cell cycle
inhibitors (Cip/Kip, INK4/ARF)
• Stimulates proliferation of fibroblasts &
smooth muscles
• Stimulates fibrosis (fibroblasts chemotaxis,
production of ECM, ↓ proteases, ↑ protease
inhibitors)
• Strong anti-inflammatory effect

151
TGF- Signaling
The role for the cytoplasmic form of
promyelocytic leukaemia protein (cPML).At
the cell surface, cPML might interact with
the two TGF- receptors (TRI and TRII) and
act as a bridging factor between SARA and
Smad2/3. Upon stimulation with TGF-,
cPML promotes the transfer of the complex
containing TRI, TRII, SARA and Smad2
into early endosomes. There, cPML might
dissociate from the complex (a), allowing
Smad2/3 to interact with SARA (b) and to
be phosphorylated (c) by TRI.
Phosphorylated Smad2/3 moves into
the nucleus to propagate TGF- signalling.

152
Patterns of Intercellular Signaling

153
 Receptors for Growth Factors

• Receptors with intrinsic tyrosine kinase

activity
• Receptors lacking intrinsic tyrosine
kinase activity that recruit kinases
• Seven transmembrane G-protein
coupled receptors
• Steroid hormone receptors

154
Examples of Signal Transduction
Systems

155
Signals from Tyrosinase Kinase
Receptors

156
 Extracellular Matrix

A major component of all tissues, provides the

backbone & support. It regulates growth,
movement and differentiation of cells.
– Basement membrane:
• Type IV collagen
• Adhesive glycoproteins
• Laminin
– Interstitial matrix:
• Fibrillary and nonfibrillar collagens
• Elastin
• Proteoglycans
• Fibronectin 157
Major Components of the
ECM

158
 Components of the Extracellular
Matrix (1)

• Collagen
– The most common protein in animals
– Fibrillar & nonfibrillar
– Hydroxylation, mediated by vit C, provides strength
– Fibrillar collagens form most of CT in wounds & scars
– Non-fibrillar (type IV) main component of BM
• Elastin
– Provides elasticity
– Surrounded by a meshlike network of fibrillin which supports
elastin deposition
– Defective fibrillin leads to Marfan syndrome

159
 Components of the Extracellular
Matrix (2)

• Proteoglycans
– Form highly hydrated gel like material
– Protein core with many attached long polysaccharides
(glycosaminoglycans)
– Act as a reservoir for bFGF
– Integral cell membrane proteins (e.g. syndecan)
• Adhesive glycoproteins
– Fibronectin
• Domains bind collagen, elastin, proteoglycans, etc.
• Bind to integrins via RGD domains
– Laminin
160
• Connects cells to collagen and heparan sulfate
Proteoglycan

161
Fibronectin

162
Laminin

163
 Cadherins (Calcium Dependent
Adherence Proteins)
• Homotypic interactions between cells
• Involved in 2 types of junctions:
– Zonula adherens (apical)
– Desmosomes
• -catenin links cadherins with a catenin, which
connects them with actin and cytoskeleton
• Regulate cell motility, proliferation, differentiation,
and contact inhibition
• Free -catenin regulates nuclear transcription
factors through Wnt signaling pathway
• Abnormalities of the -catenin pathway is involved
in GI carcinomas 164
Interaction Between GF, ECM
and Cells

165
 Repair by Regeneration

• Replacing injured tissue by same type of original

tissue cells.
• Labile & stable cells
• Involves two tissue components:
– Cellular proliferation, regulated by growth factors & growth
inhibitors.
– Extracellular matrix (ECM) & cell-matrix interaction
• An intact basement membrane directs epithelial cell
polarity & is essential for its orderly regeneration166
 Repair by Connective Tissue

• Severe injury with damage to

parencymal cells and stroma precludes
parenchymal regeneration
• Repair occurs by CT
• Components of CT repair:
– Neovascularization (angiogenesis)
– Proliferation of fibroblasts
– Deposition of ECM
– Remodeling
167
Granulation Tissue

168
 Angiogenesis

• From Endothelial precursor cells

• From pre-existing vessels

VEGF effects on endothelial cells :

– ↑ migration
– ↑ proliferation
– ↑ Differentiation
– ↑ permeability
Angioipoietins 1 and 2, PDGF, and TGF- stabilize
the newly formed vessels. 169
Angiogenesis from Endothelial
Precursor Cells

170
Angiogenesis from Pre-existing
Vessels

171
 Angiogenesis from Pre-existing
Vessels

• A parent vessel sends out capillary sprouts to

produce new vessels
• Steps involned:
– Degradation of the parent vessel BM
– Migration of endothelial cells (EC)
– Proliferation of endothelial cells
– Maturation of EC and organization into capillary tubes
• Growth factors involved:
– Basic fibroblast growth factor (FGF)
– Vascular endothelial growth factor (VEGF)
172
Angiogenesis

173
 Angiogenesis from Endothelial
Precursor Cells (EPCs)

• Hemangioblast → Hematopoietic stem cells

and angioblasts (EPCs)
• EPCs are stored in bone marrow
• EPCs express markers of hematopoietic
stem cells and of endothelial cells
• EPCs play a role in neovascularization,
replacement of endothelial cells, re-
endothelialization of vascular implants.
174
 Fibrosis

• Emigration and proliferation of

fibroblasts
– Growth factors: PDGF, FGF, EGF,
TGF-
• Deposition of ECM
– Growth factors: PDGF, FGF, TGF-
and cytokines (IL-1 &TNF)

175
 Scar Remodeling

• Shift and change of the composition of the ECM of the scar

as a result of synthesis and degradation
• Metalloproteinases: Enzymes produced by many cells and
capable of degrading different ECM constituents
– Interstitial collagenases
– Gelatinases
– Stromelysins
• Metalloproteinases (Zn dependent) activated by HOCl or
proteases (plasmin). Inactivated by tissue inhibitors of
metalloproteinases (TIMP) and steroids.

176
Matrix Metalloproteinase
Regulation

177
 Wound Healing
• Fibrin clot formation → filling the gap
• Induction of acute inflammatory response by an
initial injury
– Neutrophils (1st 24 h), Monocytes by 3rd day
• Parenchymal cell regeneration
• Migration and proliferation of parenchymal and
connective tissue cells and granulation tissue
• Synthesis of ECM proteins
• Remodeling of parenchymal elements to restore
tissue function
• Remodeling of connective tissue to achieve wound
strength 178
 Healing by First Intention
Focal Disruption of
Basement
Membrane and loss
of only a few
epithelial cells
e.g. Surgical Incision

179
 Healing by Second
Intention
• Larger injury,
abscess, infarction
Results in much
larger Scar and then
CONTRACTION

180
Phases of Wound Healing

181
 Wound Strength

• Sutured wounds have 70% of the

strength of unwounded skin
• After sutures are removed at one week,
wound strength is only 10% of
unwounded skin
• By 3-4 months, wound strength is about
80% of unwounded skin

182
 Factors affecting Healing:
• SYSTEMIC • LOCAL
– Nutritional – Infection
• Protein deficiency
• Vitamin C deficiency – Poor blood supply
• Zinc deficiency – Type of tissue
– Systemic diseases – Presence of foreign
• Diabetes mellitus
body material
• Arteriosclerosis
• Renal failure – Ionizing irradiation
• Infections (systemic) – Mechanical factors
– Corticosteroid treatment • Excessive movement
– Age • Hematoma
– Immune status • Apposition 183
 Pathologic Aspects of Repair
• Aberrations of growth may occur
– Exuberant granulation:
• Excessive amount of granulation tissue during wound
healing
– Keloid:
• Excessive collagen accumulation during wound healing
resulting in raised tumorous scar
– Excessive fibrosis:
• Cirrhosis, pulmonary fibrosis, rheumatoid arthritis (RA)
• Tissue damage
– Collagen destruction by collagenases in RA 184
Keloid

185
Keloid

186
Repair Outcomes After Injury

187