*

* Inflammation is the reaction of vascularized living tissue to local

injury.

* It is evoked by microbial infections, physical agents, chemicals,

necrotic tissue, and immunologic reactions.

* The roles of inflammation are to contain and isolate injury, to destroy

invading microorganisms and inactive toxins, and to prepare the tissue or organ for healing and repair.

* Inflammation and repair maybe potentially harmful, however, causing

life threatening hypersensitivity reactions and progressive organ damage with chronic inflammation, and may lead to permanent scarring.

ACUTE INFLAMMATION
MAJOR EVENTS IN ACUTE INFLAMMATION

* 3 major components:
1. Alterations in vascular caliber that lead to an increase in blood flow. 2. Structural changes in the microvasculature that permit plasma proteins and leukocytes to leave the circulation and to produce inflammatory exudate. 3. Emigration of the leukocytes from the microcirculation and their accumulation in the focus of injury.

* 5 cardinal signs of inflammation:

1. 2. 3. 4. 5. Heat (calor) Redness (rubor) Edema (tumor) Pain (dolor) Loss of function (functio laesa)

DEFINITIONS

* Exudationthe escape of fluid, proteins, and blood cells from

the vascular system into the insterstitial tissue or body cavities. protein concentration, much cellular debris, & specific gravity above 1.020.

* Exudateinflammatory extravascular fluid that has a high

* Transudatefluid with low protein content and a specific gravity * Edemaexcess of fluid in the interstitial tissue or serous
cavities; can be an exudate or a transudate. parenchymal cell debris.

or less than 1.012; ultrafiltrate of blood plasma and results from hydrostatic imbalance across the vascular endothelium.

* Puspurulent inflammatory exudate rich in leukocytes and

I. Changes in Vascular Flow and Caliber

* Begin immediately after injury and develop at various rate

depending on the severity of the injury

Initially, transient vasoconstriction of arterioles occur. Vasodilation follows, causing increased flow, it accounts for the heat and redness.

Eventually slowing of the circulation occurs as a result of increased vascular permeability leading to stasis. The increased permeability is the cause of edema.
With slowing, the larger white cells fall out of the axial stream, and leukocytic margination appears, a prelude to the cellular events.

II. Increased Vascular Permeability

* Leads to the escape of protein rich fluid into the interstitium. * Normal fluid exchange depends on Starlings law and an intact
endothelium

* Starlings law maintains that normal fluid balance is modulated

mainly by two opposing forces: Hydrostatic pressure causing fluid to move out of the circulation Plasma colloid osmotic pressure causing fluid to move into capillaries In inflammation, there is increased hydrostatic pressure, caused by vasodilation, and decreased osmotic pressure, caused by leakage of high protein fluid across a hyperpermeable endotheliummarked net outflow of fluid and edema

6 mechanisms of increase endothelial permeability 1. Endothelial cell contraction in venulesformation of widened intercellular junctions, or intercellular gaps, most common form; elicited by chemical mediators (e.g., histamine); occurs immediately after injection of the mediator; is short lived (immediate transient response); classically involves venules 20 to 60 m in diameter, leaving capillaries and arterioles unaffected 2. Endothelial retractiondue to cystoskeletal and junctional reorganization; resulting in widened interendothelial junctions; results in delayed response that can be long-lived; induce by cytokine mediators, such as IL-1 & TNF

3. Direct endothelial injuryresulting in endothelial cell necrosis and detachment; caused by severe necrotizing injuries and affects all levels of the microcirculation; the damage usually evokes an immediate and sustained endothelial leakage
4. Leukocyte-mediated endothelial injuryresulting from leukocyte aggregation, adhesion, and emigration across the endothelium; leukocytes release toxic oxygen species and proteolytic enzymes, which cause endothelial injury or detachment, resulting in increased permeability

5. Increased transcytosisacross the endothelial cytoplasm via vesicles and vacuoles of the vesiculvacuolar organelle; growth factors (e.g., VEGF) may cause vascular leakage by increasing the number and size of these channels
6. Leakage from regenerating capillariesduring healing; occurs when new capillaries sprouts are leaky

III. Cellular Events: Leukocyte Extravasation and Phagocytosis

* A critical function of inflammation is the delivery of leukocytes

to the site of injury. The sequence of events in this journey, called extravasation, can be divided into the following steps:

1. Margination, rolling, and adhesion of leukocytes in the lumen

2. Transmigration across the endothelium (diapedesis)

3. Migration in the interstitial tissue toward a chemotactic stimulus (chemotaxis)

Adhesion and Transmigration

* Occur largely as a result of interactions between complementary

adhesion molecules on the leukocytes and on the endothelium modulating the surface expression or avidity of the adhesion molecules

* Chemoattactants and some cytokines affect these process by * Major ligand-receptor pairs include:
The selectins (E,P, and L), which bind through their lectin (sugar binding) domains to oligosaccharides (e.g., sialylated Lewis X), which themselves are covalently bound to cell surface glycoproteins The immunoglobulin family, which includes the endothelial ICAM-1 and VCAM-1 The integrins, which functions as receptors for some of the immunoglobulin family and the extracellular matrix. The principal integrin receptors for ICAM-1 are the 2 integrins, LFA1 and MAC-1 and those for VCAM-1 are the integrins 41 and 47

These molecules induce leukocyte adhesion in inflammation by 3 mechanisms:

1. Redistribution of preformed adhesion molecules to the cell surface

2.
3.

Induction of adhesion molecules on endothelium

Increased avidity of binding

ENDOTHELIAL LEUKOCYTE ADHESION MOLECULES

Endothelial Molecule Leukocyte Receptor Major Role

P-selection
E-selection

Sialyl-Lewis X PSGL-1
Sialyl-Lewis X ESL-1, PSGL-1 CD-11/CD18 (integrins) (LFA-1, Mac-1) 41 (VLA4) (integrins) 47 (LPAM-1) L-selectin

Rolling (neutrophils, monocytes, lymphocytes)

Rolling, adhesion to activated endothelium (neutrophils, monocytes, T cells) Adhesion, arrest, transmigration (all leukocytes) Adhesion (eosinophils, monocytes, lymphocytes) Lymphocyte homing to high endothelial venules Neutrophil, monocyte rolling

ICAM-1 VCAM-1 GlyCam-1 CD34

PMN adhesion and transmigration in acute inflammation occur only by a series of overlapping steps: 1. Endothelial activationmediators present at the inflammatory sites increased the expression of E-selectin and P-selectin by endothelial cells
2. Leukocyte rollinginitial rapid and relatively loose adhesion, resulting from interactions between the selectins and their carbohydrate ligands 3. Firm adhesionleukocytes are then activated by chemokines or other agents to increased the avidity of their integrins

4. Transmigrationmediated by interactions between PECAM-1 on leukocytes and endothelial cells

*
* *

Leukocyte adhesion deficiency type-Idefect in the synthesis of 2 integrins

Leukocyte adhesion deficiency type-IIdefect in fucose metabolism in the absence of sialyl Lewis X, the ligand for Eselectin and P-selectin Both deficiencies result in impaired leukocyte adhesion and recurrent bacterial infections.

Chemotaxis and Leukocyte Activation

* Adherent leukocytes emigrate through interendothelial

juncdtions, traverse the basement membrane, and move toward the site of injury along a gradient of chemotactic agents.

* Neutrophils emigrate first, monocytes and lymphocytes follow

* Chemotactic agents for neutrophils include bacterial products,

complements fragments (e.g., C5a), arachidonic acid metabolites (e.g., leukotriene B4), and chemokines (e.g., IL-8)

* Chemotaxis involves binding of chemotactic agents to specific

receptors on leukocytes and production of second messengers

* Signal transduction process results in activation of

phospholipase C and protein kinase C, increased intracellular calcium and assembly of the contractile elements responsible for cell movement: leukocyte moves by extending a pseudopod that pulls the remainder of the cell in the direction of extension

* Locomotion is controlled by the effects of Ca++ and

phosphoinositols on actin regulatory proteins, such as gelsolin, filanin and calmodulin

* Chemotactic agents also cause leukocyte activation,

characterized by:

Degranulation and secretion of enzymes

Activation of an oxidative burst Production of arachidonic acid metabolites Modulation of the leukocyte adhesion molecule

Phagocytosis

* Release of enzymes by neutrophils and macrophages constitute

two of the major benefits derived from the accumulation of leukocytes at the inflammatory focus

* Phagocytosis involves three steps:

1. Recognition and attachment of the particles to be injected by the leukocytemicroorganisms are coated with specific factors, called opsonins, which enhance the efficiency of phagocytosis because they are recognized by the receptors on the leukocytes.

The two major opsonins are the Fc fragments of the immunoglobulin G and a product of complement C3b

2. Engulfment by pseudopods encircling the phagocytosed particlewith subsequent formation of a phagocytic vacuole or phagosome * The membrane of the phagosome then fuses with the membrane of a lysosomal granule, resulting in discharge of the granules content into the phagolysosome 3. Killing and degradation of bacteriaphagocytosis stimulates a burst of oxygen consumption and production of reactive oxygen metabolites * There are two types of bactericidal mechanisms:
a. Oxygen dependent mechanismstriggered by activation of NADPH oxidase, reducing O2 to O2- and hence to H2O2; MPO from lysosomal granules then converts H2O2, in the presence of a halide such as Cl-, to a highly bactericidal HOCl-; H2O2-MPOhalide system is the most efficient bactericidal mechanism, the reactive O2 species produced during an oxidative burst can kill bacteria directly

b. Oxygen independent mechanismsincludes bactericidal permeability increasing protein, lysozyme, lactoferrin, MBP of eosinophils, and arginine rich defensins; killed organisms are then degraded by hydrolases and other enzymes in lysosomes

Release of Leukocyte Products and Leukocyte-Induced Tissue Injury

* During phagocytosis, leukocytes release products not only within

the phagolysosome but also potentially into the extracellular space
1. 2. 3. Lysosomal enzymes, by regurgitation during feeding, reverse endocytosis, or cytotoxic release Oxygen derived active metabolites Products of arachidonic acid metabolism including prostaglandins and leukotrienes These products are powerful mediators of tissue damage and amplify the effects of the initial inflammatoy stimulus If persistent, the leukocyte dependent tissue can cause chronic inflammation

* These release products include:

* *

Defects in Leukocytes Function

* Interfere with inflammation and increase susceptibility to

infections

* Include both genetic and acquired defects, such as deficiency in

the number of circulating cells (neutropenia)

* Clinical genetic deficiencies have been identified in most phases

of leukocyte function, from adherence to vascular endothelium to microbicidal activity, and include the following:
1. 2. Defects in leukocyte adhesion, such as leukocyte adhesion deficiency type I and type II Defects in phagocytosis such as Chediak-Higashi syndromePMNs have a giant granules because of abberant organelle fusion and reduced transfer of lysosomal enzymes to phagocytic vacuoles (causing susceptibility to infections) Defects in microbial activity such as CGDinherited defects in NADPH oxidase, leading to a defect in the respiratory burst, H2O2-MPO-halide bactericidal mechanism

3.

CLINICAL EXAMPLES OF LEUKOCYTE-INDUCED INJURY

Acute

Chronic Arthritis Asthma Atherosclerosis Chronic lung disease Chronic rejection Others

Acute respiratory distress syndrome Acute transplant rejection Asthma Glomerulonephritis Reperfusion injury Septic shock Vasculitis

DEFECTS IN LEUKOCYTE FUNCTIONS

Disease Genetic Leukocyte adhesion deficiency 1 Leukocyte adhesion deficiency 2 Neutrophil-specific granule deficiency Chronic granulomatous disease X-linked Autosomal recessive Myeloperoxidase deficiency Chdiak-Higashi syndrome chain of CD11/CD18 integrins Sialylated oligosaccharide (receptor for selectin) Absence of neutrophil-specific granules Defective chemotaxis Decreased oxidative burst NADPH oxidase (membrane component) NADPH oxidase (cytoplasmic components) Absent MPO-H2O2Halide system Membrane-associated protein involved in organelle membrane docking and fusion Defect

Acquired Thermal injury, diabetes, malignancy, sepsis, immunodeficiency Hemodialysis, diabetes mellitus Leukemia, anemia, sepsis, diabetes, neonates, malnutrition
Chemicals

Adhesion Phagocytosis and microbicidal activity

SUMMARY

* The vascular phenomena in acute inflammation are

characterized by increased blood flow to the injured area, resulting mainly from arteriolar dilation and opening of capillary beds. protein-rich extavascular fluid, which forms the exudate.

* Increased vascular permeability results in the accumulation of * Plasma proteins leave the vessels most commonly through
widened interendothelial cell junctions of the venules or by direct endothelial cell injury.

* The leukocytes, initially predominantly neutrophils, adhere

to the endothelium via adhesion molecules, transmigrate across the endothelium, and migrate to the site of injury under the influence of chemotactic agents. to the death of the microorganism.

* Phagocytosis of the offending agent follows, which may lead

* During chemotaxis and phagocytosis, activated leukocytes
may release toxic metabolites and proteases extracellularly, potentially causing tissue damage.

CHEMICAL MEDIATORS OF INFLAMMATION

* The vascular and white cell events described previously are brought

about by the variety of chemical mediators, derived either from plasma or from cells. * Most perform their biologic activity by binding initially to a specific receptors on target cells, although some have direct enzymatic activity (e.g., proteases), and others mediate oxidative damage (e.g., oxygen metabolites). * One mediator can stimulate the release of other mediators by the target cells themselves, providing a mechanism for amplification or in certain instances counteracting the initial mediator action. * Once the activated and released, most mediators are short lived, either quickly decaying or becoming inactivated by enzymes or inhibited by inhibitors. * Thus, a system of checks and balances exist in the regulation of mediators also have potentially harmful effects.

Vasoactive Amines

* Histamine and serotoninavailable from preformed cellular stores;

among the first mediators to be release during inflammation; found in mast cells, basophils, and platelets, and cause vasodilation and increase vascular permeability Physical agents (e.g., trauma, heat) Immunologic reactions involving binding of IgE antibodies to mast cells Complement fragments C3a and C5a (anaphylatoxins) Neuropeptides (substance P) Cytokines (IL-1 and IL-8) Histamine releasing factors derived from leukocytes Released from platelets is stimulated by: contact with collagen, thrombin, ADP, antigen-antibody complexes, and by PAF

Released from mast cells is caused by: 1. 2. 3. 4. 5. 6.

Plasma Proteases There are interrelated plasma derived mediators that play key roles in inflammatory responses:

1. Complement system
2. Kinin sytem 3. Clotting factor system

i.

Complement system:

* Activation of complement functions in host defense against

microbial agents, culminating in the assembly of the MAC and lysis of the offending agent

* In the process, complement components are

generated that caused increased vascular permeability, chemotaxis and opsonization

* Activation of complement occurs via two general mechanisms:

1. 2. The classic pathwayinitiated by antigen-antibody complexes The alternate pathwayactivated by endotoxin, complex polysaccharides, and aggregated globulins

Complement components with inflammatory activity include:

1. C3awhich increases vascular permeability

2. C5awhich increases vascular permeability and is highly chemotactic to WBCs

3. C3b and C3bithe opsonins important in phagocytosis 4. C5b-9MAC that lyses cells and stimulates arachidonic acid metabolism and production of reactive oxygen metabolites by a leukocytes

The complement system is closely controlled by protein inhibitors including the following: 1. Regulation of C3 and C5 convertases, by decay accelerating factor * Paroxysmal nocturnal hemoglobinuriacells lack the ability to express phosphatidylinositol-linked membrane proteins, including decay accelerating factor; characterized by recurrent bouts of intravascular hemolysis resulting from complement-mediated lysis of red blood cells, leading to chronic hemolytic anemia 2. Binding of active complement components by specific proteins in the plasma, such as by C1 inhibitor * Deficiency of C1 inhibitor is associated with the syndrome of hereditary angioneurotic edemaepisodic edema accumulation in the skin and extremities as well as in the laryngeal and intestinal mucosa, provoked by emotional stress or trauma

ii. Kinin System

* Generates vasoactive peptides from plasma proteins called

kininogens by specific proteases called kallikreins, ultimately resulting in the prouction of bradykinin which converts plasma prekallikrein into kallikrein; the latter cleaves HMWK to produce bradykinin, a potent stimulator of increase vascular permeability

* Surface activation of Hageman factor (factor XII) produces CF XIIa,

* Kallikrein in an autocatalytic loop is a potent activator of Hageman

factor, has chemotactic activity, and causes neutrophil aggregation; resulting in profound amplification of the effects of the initial contact

iii. Clotting System

The clotting system is divided into two interrelated systems, designated as the intrinsic and extrinsic pathways, that converged to activate a primary hemostatic mechanism.
1. The intrinsic pathway consists of plasma proenzymes that can be activated by Hageman factor, resulting in the activation of thrombin, cleavage of fibrinogen, and generation of a fibrin clot

* *

During this process, fibrinopeptides are formed that induce vascular permeability and are chemotactic for leukocytes. Thrombin also has inflammatory properties causing increased leukocyte adhesion to endothelium.

2. At the same time that factor XIIa is inducing clotting, it can also activate the fibrinolytic system, which produces plasmin and degrades fibrin, thereby solubilizing the clot.

Plasmin can contribute to inflammation in several ways:

Cleave C3 to produce C3 fragment Form fibrin split products, which may increase vascular permeability Activate Hageman factor, ampliying the response

Arachindonic Acid Metabolites Eicosanoids are synthesized from arachidonic acids by two major classes of enzymes:

* Cyclooxygenasesgenerate prostaglandins and thromboxanes * Lipoxygenasesproduce leukotriene and lipoxins

The inflammatory prostaglandins and leukotrienes include the following: 1. Prostaglandin I2 (prostacyclin) and prostaglandin E2 cause vasodilation
2. Prostaglandin E2 is hyperalgesicmakes the skin hypersensitive to painful stimuli

3. Thromboxane A2 causes vasoconstriction

4. Leukotrienes C4, D4, and E4cause increased vascular permeability and vasoconstriction 5. Leukotriene B4 is a powerful chemotactic agent 6. Lipoxins may be endogenous negative regulators of leukotriene action

* Cell-cell interactions are important in the biosynthesis of both

the leukotrienes and lipoxins.

* Arachidonic acid products can pass from one cell to another to

generate these classes of eicosanoids.

* This transcellular biosynthesis allows cells that are not capable

of generating specific eicosanoids to produce these mediators from intermediate generated in other cells.

Platelet-Activating Factor
PAF is a bioactive phospholipids-derived mediator.

* Produced by mast cells and other leukocytes * Causes platelet aggregation and release,

bonchoconstriction, vasodilation, increased vascular permeability, increased leukocyte adhesion, and leukocyte chemotaxis

* Can elicit most of the cardinal features of inflammation

Cytokines

* Cytokines are proteins produced principally by activated

lymphocytes and macrophages that modulate the function of other cell types. * Many classic growth factors act as cytokines, and conversely many cytokines have growth-promoting properties. MONOKINEScytokines generated by mononuclear phagocytes LYMPHOKINEScytokines generated by active lymphocytes Colony Stimulating Factors (CSF) cytokines that are produced by monocytes and macrophages that stimulate the growth of immature leukocytes in the bone marrow INTERLEUKINS (IL)broad family of cytokines that are made by the hematopoietic cells and act primarily on leukocytes CHEMOKINEScytokines that share the ability to stimulate leukocyte movement (chemokinesis) and directed movement (chemotaxis), particularly important in inflammation

General Properties and Classes of Cytokines 1. Cytokines are produced during immune and inflammatory responses, and secretion of these mediators is transient and closely regulated. 2. Many cell types produce multiple cytokines. 3. The proteins are pleiotropic in that they can act on different cell types.

4. Cytokine effects are often redundant, and these proteins can influence the synthesis or action of other cytokines.
5. Cytokines are multifunctional in that an individual cytokine may have both positive and negative regulatory actions.

6. Cytokines mediate their effects by binding to specific receptors on target cells, and the expression of cytokine receptors can be regulated by a variety of exogenous and endogenous signals.

Functions of Cytokines
1. Cytokines that regulate lymphocyte function

Regulate lymphocyte activation, growth, and differentiation (e.g., IL-2 and IL-4, which favor lymphocyte growth; IL-10 and TGF-, which are negative regulators of immune responses) Includes the inflammatory cytokines (e.g., TNF- and IL-1), type I IFN (IFN- and IFN- ), and IL-6
Activate macrophages during cell mediated immune responses (e.g., IFN-, TNF- , IL-5, IL-10, and IL-12)

2. Cytokines involved with natural immunity

*
*

3. Cytokines that activate inflammatory cells

4. Chemokines

* *

Cytokines characterized by chemotactic activity for various leukocytes (e.g., IL-8) Mediate immature leukocyte growth and differentiation (e.g., IL3, IL-7, c-kit ligand, GM-CSF, M-CSF, G-CSF, and stem cell factor)

5. Cytokines that stimulate hematopoiesis

IL-1 and TNF- - major cytokines that mediate inflammation and are produced by activated macrophages. Their most important actions in inflammation are their effects on endothelium, leukocytes and induction of the systemic acutephase reactions.

* Secretion in stimulated by endotoxin, immune complexes, toxins,

physical injury and a variety of inflammatory products

* Induce endothelial activation, which includes induction of

endothelial adhesion molecules and chemical mediators (e.g., other cytokines [IL-6], chemokines [IL-8], growth factors, eicosanoids [PGI2 and PAF], and nitric oxide) production of enzymes associated with matrix remodeling, and increases in the surface thrombogenicity of the endothelium

* Induce the systemic acute-phase responses associated with

infection or injury, including fever, loss of appetite, production of sleep, release of neutrophils into the circulation, release of ACTH and corticosteroids; and particularly with regard to TNF, hemodynamic effects of septic shock hypotension, decreased vascular resistance, increased heart rate, and decreased blood pH In obesityphysiologic actions of TNF- as a signal to control food intake are impaired In cachexiapathologic state characterized by weight loss and anorexia that accompanies some infections and neoplastic diseases, there is an overproduction of TNF-

* TNF- has a key role in the normal control of body mass

Chemokines

* Chemokines act primarily as activators and chemoreactants for

specific types of leukocytes.

* Chemokines are classified into four major classes, which have

relatively distinct biologic activities, according to the arrangement of the conserved cysteine (C) residues:

1. C-X-C or -chemokineshave one amino acid residue separating the first two conserved cysteine residues act primarily on neutrophils; IL-8 is typical of this group

2. C-C or -chemokineshave the two first conserved cysteine residues adjacent: e.g., monocyte chemoattractant protein (MCP-1), generally attract monocytes, eosinophils, basophils, and lymphocytes but not neutrophils: eotoxin selectively recruits eosinophils

3. C or -chemokineslack two (the first and third) of the four conserved cysteines: relatively specific for lymphocytes (e.g., lymphotactin)
4. CX3C chemokinesinclude fractalkine, exist in two forms:
a.
b.

Cell surface-bound proteincan be induced in endothelial cells that promote adhesion of the leukocytes
Soluble formderived from proteolysis of membrane-bound protein, has chemoattractant activity

Chemokines mediate their activities by binding to Gprotein-linked receptors, designated CXCR (1-4) for the C-X-C chemokines, and CCR (1-5) for the C-C chemokines.

Nitric Oxide

* Also known as endothelium-derived relaxation factor * Acts in paracrine manner and causes vasodilation; inhibits platelet
aggregation and adhesion; and may act as a free radical, becoming cytotoxic to certain microbes, tumor cells and also possibly other tissue cells cofactors by the enzyme nitric oxide synthase (NOS)

* Synthesized from arginine, molecular O2, NADPH, and other

* 3 types of NOS:
Endothelial (eNOS), neuronal (nNOS), and cytokine inducible [iNOS] Exhibits two patterns of expression: 1. 2. eNOS and nNOS are present constitutively and are rapidly activated by an increased in cytoplasmic Ca++ iNOS is present in macrophages and is induced by cytokines, such as IFN-, without an increase in intracellular Ca++

* NO has many properties, notable properties are the following:

1.

Plays an important role in vascular function during an inflammatory response

eNOS is important in maintaining vascular tone

Increased production of NO from iNOS is an endogenous compensatory mechanism that reduces leukocyte recruitment in inflammatory responses
iNOS production of NO by activated macrophages is also important in the pathogenesis of septic shock Interactions occur between NO and reactive O2 species, leading to the formation of multiple antimicrobial metabolites (e.g., peroxynitrite [OONO], S-nitrosothiols [RSNO], and nitrogen dioxide [NO2]) Each reactive form is distinct, but they share the ability to damage microbes, at the potential cost of inflammatory damage to host cells and tissue

2. Acts in the host response to infection

Lysosomal Constituents of Leukocytes Neutrophils and monocytes contain lysosomal granules, which when released may contribute to the inflammatory response and to tissue injury.
1. Neutrophils have two main types of granules

Smaller specific (or secondary) granulescontain lysozyme,

type IV collagenase, gelatinase, lactoferrin, plasminogen activator, histaminase, alkaline phosphatase, leukocyte adhesion molecules, and phospholipase A2

Large azurophil (or primary) granulescontain myeloperoxidase, bactericidal factors (lysozyme defensins), acid hydrolases, cationic proteins, phospholipase A2, and a variety of neutral proteases (elastase, cathepsin G, nonspecific collagenases, proteinase 3)

2.

3.

Specific and azurophil granulescan empty into phagocytic vacuoles that form around engulfed material, or the contents can be secreted extracellulary, as well as released after cell death * Acid proteases degrade proteins, bacteria, and debris within the acidic environment of the phagolysosome * Neutral proteases can degrade extracellular components * Monocytes and macrophages also contain hydrolases (collagenase, elastase, phospholipase, and plasminogen activator) which maybe particularly active in chronic inflammatory reactions Lysosomal constituentscan potentiate further increases in vascular permeability and chemotaxis and cause tissue damage * These harmful proteases, however, are held in check by a system of antiproteases in the serum and the tissue fluid * 1-antitrypsin is the major inhibitor of neutrophilic elastase. A deficiency of these inhibitor may lead to sustained action of leukocyte proteases, as is the case in patients with 1-antitrypsin deficiency

Oxygen-Derived Free Radicals

* Maybe released extracellularly from leukocytes after exposure

to chemotactic agents, immune complexes, or a phagocytic challenge

* Include O2.-,H2O2, and OH., these metabolites can combine with

1. 2. 3. Endothelial cell damage with resultant increased vascular permeability Inactivation of antiproteases, thus leading to unopposed protease activity Injury to a variety of cell types (e.g., tumor cells, red cells, parenchymal cells)

NO to form other reactive nitrogen intermediates, which cause:

Oxygen metabolites are detoxified by:

* Antioxidantsserum proteins (ceruloplasmin and transferrin),

enzymes (superoxide dismutase, catalase, and glutathione peroxidase) balance between their production and activation

* Net effects on tissue injury of oxygen metabolites depend on the

Neuropeptides

* Neuropeptides play a role in the initiation of an inflammatory

response

* Substance Pbelong to a family of tachykinin neuropeptides in

the central and peripheral nervous system Biologic functions: transmission of pain signals, regulation of blood pressure, and stimulation of secretion by immune and endocrine cells Powerful mediator of vascular permeability

* Released of substance P alters vascular permeability leading to

influx of plasma components at the site of injury and amplification of the initial inflammatory stimulus

SUMMARY OF MEDIATORS OF ACUTE INFLAMMATION

Mediator Source Vascular Leakage Chemotaxis Other

Histamine and serotonin Bradykinin C3a C5a Prostaglandins

Mast cells and platelets Plasma substrate Plasma protein via liver Macrophages Mast cells, from membrane phospholipids Leukocytes

+ + + + Potentiate other mediators

+ Pain Opsonic fragment (C3b) Leukocyte adhesion, activation Vasodilation, pain, fever

Leukotriene B4

Leukocyte adhesion, activation Bronchoconstriction, vasoconstriction Endothelial damage, tissue

Leukotriene C4, D4, E4

Leukocytes, mast cells

Oxygen metabolites

Leukocytes

PAF

Leukocytes, mast cells

Bronchoconstriction, leukocyte priming Acute phase reactions, endothelial activation Leukocyte activation

IL-1 and TNF

Macrophages, other

Chemokines

Leukocytes, other

* During the early course of inflammation, increased vascular

permeability is medicated by histamine; the anaphylatoxins (C3a and C5a); the kinins; leukotrienes C, D, and E; PAF; and substance P. products (leukotriene B4), other chemotactic lipids, and chemokines are the most likely protagonist.

* For chemotaxis, complement fragment C5a, lipoxygenase * Additionally, prostaglandins play an important role in

vasodilation, pain, and fever and in potentiating edema. interactions and with acute phase reactions.

* IL-1 and TNF are involved with endothelial-leukocyte

* Lysosomal products and oxygen-derived radicals are the most
likely candidates as causes of the ensuing tissue destruction.

* Nitric oxide is involved in vasodilation and cytotoxicity.

Outcome of Acute Inflammation

* The process of acute inflammation can be altered by the nature

and intensity of the injury, the site and the tissue affected, and the responsiveness of the host, but generally the process has one of the 4 outcomes:
1. 2. 3.

Complete resolutionregeneration of native cells and restoration of the site to normal Abscess formationinfections by pyogenic organisms Healing by connective tissue replacement (fibrosis) and scarring occurs after substantial tissue destruction, when the inflammation occurs in tissues that do not regenerate, or when there is abundant fibrin exudation Progression to chronic inflammation

4.

CHRONIC INFLAMMATION

* Inflammation of prolonged duration (weeks or months) in * Arises in several ways:

which active inflammation, tissue destruction, and attempts at healing may be all proceeding simultaneously
1. May follow acute inflammation, because of the inciting stimulus or because of some interference in some process of healing 2. May results from repeated bouts of acute inflammation 3. Begins insidiously as a low grade, smoldering response that does not follow classic acute inflammation in one of the following settings: Persistent infections by intracellular microbes which are of low toxicity but evoked an immunologic reaction

 Prolonged exposure to potentially toxic exogenous or endogenous substances

Immune reactions, perpetuated against the individuals own tissues

* In contrast to acute inflammation, which is manifested by

1.
2. 3.

vascular changes, edema and largely neutrophilic infiltration, chronic inflammation is characterized by:
Infiltration with mononuclear cells (macrophages, lymphocytes, and plasma cells)a reflection of a persistent reaction to injury
Tissue destruction, largely induced by the inflammatory cells Attempts at repair by connective tissue replacement, proliferation of small blood vessels (angiogenesis) and fibrosis

Mononuclear Infiltration: Cells and Mechanisms MACROPHAGES

Macrophages are the major cellular players in chronic inflammation

* Derived from peripheral blood monocytes that have been induced

to emigrate across the endothelium by chemokines as well as well as other chemotactic agents; when the monocytes reaches the extravascular tissue; it transform into a large phagocytic cell, the macrophage biologically active products they can secrete; can be activated by cytokines produced by immune activated T-cells or by nonimmune factors (e.g., endotoxin) to secrete numerous factors including:

* Central figures in chronic inflammation great number of

a. b. c. d. e.

Neutral proteases Chemotactic factors Arachidonic acid metabolites Reactive oxygen and nitrogen species Complement components

f. Coagulation factors g. Growth factors h. Cytokines (eg, IL-1 & TNF) i. Other factors (eg, PAF & -IFN)

* Macrophages are important host defense, some of these mediators

induce the tissue damage characteristic of chronic inflammation
oxide metabolites) or extracellular matrix (protease)

* Secretory products can be toxic to cells (reactive oxygen and nitric * Other products cause fibroblast proliferation, connective tissue
production, and angiogenesis (cytokines and growth factors)

* Macrophage accumulation persists primarily through continued

recruitment of monocytes from circulationresults from the steady expression of adhesion molecules and chemotactic factors

PRODUCTS RELEASED BY MACROPHAGES

Enzymes Neutral proteases Elastase Collagenase Plasminogen activator Acid hydrolases Phosphates Lipases Plasma proteins Complement components (e.g., C1 to C5, properdin) Coagulation factors (e.g., factors V, VIII, tissue factor) Reactive metabolites of oxygen Eicosanoids Cytokinesis, chemokines (IL-1, TNF, IL-8) Growth factors (PDGF, EGF, FGF TGF-) Nitric oxide

Other Cells Chronic Inflammation 1. LYMPHOCYTESmobilized by antibody and cell-mediated immune reactions and by nonimmunologic reactions

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Have a unique reciprocal relationship to macrophages in chronic inflammation Can be activated by contact with antigen and nonspecifically by bacterial endotoxin Activated lymphocytes produce lymphokines, and these (particularly IFN-) are major stimulators of monocytes and macrophages Activated macrophages produces monokines, which, in turn, Bcell and T-cell function (particularly IL1, TNF)

Plasma cells produce antibodies directed against either foreign antigen or altered tissue components

2. MAST CELLSwidely distributed in connective tissues and participate in both acute and persistent inflammatory reactions

Express on their surface the receptor that binds the Fc portion of the IgE antibody

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In acute reactions, IgE antibodies bound to the cells Fc receptors specifically recognize antigen, and the cells degranulate and release mediators, such as histamine
This type of response occurs during anaphylactic reactions to food, insect venom, or drugs, frequently with catastrophic results Specific types of parasite infections are also associated with increased levels of IgE and activation of mast cells

3. EOSINOPHILScharacteristic of immune reactions mediated by IgE and of parasitic infections

Recruitment depends on eotoxin, a member of the C-C family of chemokines

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Have granules that contain MBP a highly cationic protein that is toxic to parasites but also causes lysis of mammalian epithelial cells
May be of benefit in parasitic infection but contribute to tissue damage in immune reactions

Granulomatous Inflammation

* Distinctive chronic inflammatory reaction in which the

predominant cell type is an activated macrophage with a modified epithelial-like (epithelioid cell) appearance Encountered in a relatively few but widespread chronic immune and infectious diseases, such as tuberculosis, sarcoidosis, and syphilis Characterized by granulomasfocal collections epithelioid macrophages that are surrounded by a collar of mononuclear leukocytes, principally lymphocytes and occasionally plasma cells; epithelioid cells may coalesce to form multinucleated giant cells; central necrosis may also be present in some granulomas

* There are two types of granulomas:

1. Foreign body granulomasincited by relatively inert foreign bodies

2. Immune granulomasformed by immune T-cellmediated reactions to poorly degradable antigens; lymphokines, principally IFN- from activated T-cells, cause transformation of macrophages to epitheloid cells and multinucleated giant cells; e.g., immune granuloma caused by the M. tuberculosis bacillusthe granuloma is referred to as a tubercle and is classically characterized by the presence of central caseous necrosis

EXAMPLES OF GRANULOMATOUS INFECTIONS

Disease Cause Tissue Reaction

Tuberculosis

Mycobactrium tuberculosis

Noncaseating tubercle (granuloma prototype): a focus of epithelioid cell, rimmed by fibroblast, lymphocytes, histiocytes, occasional Langhans giant cell; caseating tubercle: central amorphous granular debris, loss of all cellular detail; acid-fast bacilli Acid-fast bacilli in macrophages; granulomas and epithelioid types Gumma: microscopic to grossly visible lesion, enclosing wall of histiocytes; plasma cell infiltrate; center cells are necrotic without loss of cellular outline Rounded or stellate granuloma containing central granular debris and recognizable neutrophils; giant cells uncommon

Leprosy

Mycobacterium leprae

Syphillis

Treponema pallidum

Cat-scratch disease

Gram-negative bacillus

Morphologic Patterns in Acute and Chronic Inflammation

* Inflammatory responses often have certain features that point to their

possible cause and create a distinctive morphologic patterns:
1. Serous inflammationimplies a modest increase in vascular permeability; marked by an accumulation of fluid (e.g., skin burn blisters) when it occurs in the peritoneal, pleural, and pericardial cavities, is called an effusion If in pleural cavity = effusion (pleural effusion, ascitis or peritoneal effusion)
Fibrinous inflammationoccurs when the injury causes a more marked increased in vascular permeability
exudate contains large amounts of fibrinogen, which is converted to fibrin as a result of the coagulation system when a serosal surface is involved, such as the pericardium, pleura, or peitoneum, it is referred to as fibrinous pericarditis, pleuritis, or peritonitis, respectively

2.

3.

Suppurative or purulent inflammationcharacterized by the production of purulent exudates or pus consisting of white cells and necrotic cells
abscess refers to a localized collection of purulent inflammatory tissue that is accompanied by liquefactive necrosis; there is a wall to separate it from environment

4.

Ulcerslocal defects, or excavation, of the surface of an organ or tissue that are produced by the sloughing (shedding) of inflammatory necrotic tissue Granulomatous inflammation

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Systemic Effects of Inflammation

* The major systemic manifestation of acute inflammation

involved a wide range of endocrine, autonomic, and behavioral responses, as follows:

1. Endocrine and metabolicsecretion of acute-phase proteins by the liver (including CRP, serum amyloid A, complement and coagulation proteins) Autonomicredirection in blood flow from cutaneous to deep vascular beds, to minimize heat loss through the skin; increased pulse and blood pressure; and decrease sweating Behavioralrigors (shivering), chills (search for warmth), anorexia, somnolence, and malaise

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Other major systemic manifestations are as follows: 1. The principal manifestation of fever is an elevation of body temperature, usually by 1 to 4oC.

2. Cytokines play a key role in signaling a feverIL-1, IL-6, and TNF-, produced by leukocytes in response to infectious agents or immunologic reactions, are released into the circulation

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IL-1 acts directly and also by inducing IL-6, which has essentially similar effects in producing the acute-phase responses IL-1 and TNF interact with vascular receptors in the thermoregulatory centers of the hypothalamus, inducing local prostaglandin E2 production, resulting in a sympathetic nerve stimulation, vasoconstriction of skin vessels, and fever

3. Leukocytosisa common feature of inflammatory reactions, especially those induced by bacterial infection

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Extreme elevations are referred to as leukemoid reactions Leukocytosis occurs because of the proliferation of precursors in the bone marrow and the accelerated released of cells from the bone marrow, induced by CSF

4. Most bacterial infections induced neutrophilia, but some viral infections produce lymphocytosis

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Eosinophiliaoccur in bronchial asthma, hay fever, and parasitic infestations

Certain infections (e.g., typhoid fever and infections caused by viruses, rickettsiae, and certain protozoa) can cause leukopenia; also encountered in infections that overwhelm patients debilitated by disseminated cancer

Thus the major systemic effects of a significant inflammatory reaction are fever, leukocytosis (most often owing to an increased number of circulating neutrophils, sometimes lymphocytes) and chills, well known to all who have had a respiratory infection.

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