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2. Inflammation is defined as a complex
reaction to injurious agents such as microbes and
damaged, usually necrotic, cells that consists of
vascular responses, migration and activation of
leukocytes, and systemic reactions
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3. 3000 BC – signs of inflammation described by
PAPYRUS ( Egyptian)
1st AD – CELSUS, roman writer listed 4 Cardinal
signs
RUBOR - redness
TUMOR - swelling
CALOR - heat
DOLOR - pain
VIRCHOW – added 5th Cardinal sign
FUNCTIOLAESA - loss of function
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4. 1793 – JOHN HUNTER (Scottish) – it is not a
disease, but non specific response, which has
salutary effect on its Host
1839 – 1884 – JOHN COHNHEIN observed
Inflamed blood vessels (frogs) – Increased vascular
permeability and Leukocyte emigration
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5. 1882 – ELIE METCHNIKOFF (Russian) observed
PHAGOCYTOSIS . Purpose of inflammation is to
get phagocytes in injured area to engulf the bacteria
Same time –– PAUL EHLICH Neutralize the
infectious agent by serum factors ( antibodies)
1908 – METCHNIKOFF and PAUL EHLICH got
NOBLE prize for their work.
Both PHOGOCYTES (CELLULAR) and SERUM
FACTORS ( ANTIBODIES) are responsible to
defense against MICROBES
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6. The Triple Response:
SIR THOMAS LEWIS (1927), established the Concept that
Histamine locally induced by injury mediate the vascular
changes;
This concept underlies the use of anti- Inflammatory agents
in clinical medicine.
Firmly stroking the fore arm with a Blunt instrument, evokes
this response.
Within one min. a red line appears; (because of dilatation of
arterioles, capillaries & venules).
A red flare develops (because of vasodilation of the tissue
surrounding injury);
A wheal forms because of exudation fluid
The flare, which is a minor component is mediated by local
axon reflex;
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7. The major components, red line & wheal were
shown to be independent of neural connections
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8. Unique feature of the inflammatory process is the
reaction of blood vessels, leading to the
accumulation of fluid and leukocytes in
extravascular tissues.
The inflammatory response is closely intertwined
with the process of repair.
Inflammation serves to destroy, dilute, or walloff the
injurious agent, and it sets into motion a series of
events that try to heal and reconstitute the damaged
tissue
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9. Inflammatory response consists of two main
components
1. Vascular Events
2. Cellular Events
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10. Many tissues and cells are involved in these
reactions, including the fluid and proteins of plasma,
circulating cells, blood vessels, cellular and
extracellular constituents of connective tissue.
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11. Inflammation is divided into
1. Acute Inflammation
2. Chronic Inflammation
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12. Rapid in onset (Seconds or Minutes)
Short duration
Lasting for minutes to several hours or a few days
Exudation of fluid and plasma proteins (edema) and
the emigration of leukocytes, predominantly
neutrophils
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13. Longer duration and
Associated histologically with the presence of
lymphocytes and macrophages, the proliferation of
blood vessels, fibrosis and tissue necrosis.
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14. Stimuli for Acute inflammation
Trauma
Physical and chemical agents
Tissue necrosis
Foreign bodies
Immune reactions
Infection
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15. Acute Inflammation
Alteration in vascular caliber
Structural changes in the microvasculature
Emigration of the leukocytes from the microcirculation
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16. Vascular changes:
Change in vascular flow and caliber
Increased vascular permeability(vascular leakage)
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20. Cellular Events
Neutrophils form the first line of defence;
The multi step process of leucocyte migration:
- Neutrophils first roll,
- Then become activated,
- Adhere to endothelium,
- Transmigrate along the endothelium,
- Pierce the Basement membrane
- Migrate toward the chemoattractants
- Emanating from the source of injury.
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21. Molecules that play predominent role in each step:
SELECTINS:- E-Selectin &P-Selectin; In rolling
(tumbling along the endothelium)
CHEMOKINES: Act on the rolling cells & activate
them. Activation results from several signaling
Pathways that result in increase in cytosolic Ca++,&
activation of enzymes such as Protein kinase C &
Phospholipase A2.
INTEGRINS: (Beta 1 & Beta2 ) In firm
adhesion;Integrin superfamily Consisting of 30
proteins,that promote Cell to cell or cell to matrix
inter action. They coordinate signals with
cytoskeleton dependent motility, Phagocytic
response ect.
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22. CD 31 (PECAM-1)- Adhesion molecule in trans-
migration, Leukocyte migration occurs
predominantly. In venules; they pierce the BM by
Secreting collagenases.
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24. Importance Of Adhesion Molecules:
Genetic defects in adhesion molecules result in
Recurrent bacterial infections;
LAD-Type-I- have defect in biosynthesis of Beta
chain;
LAD-TYPE-2-have defects in Fucosyl transferase
enzyme ;
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25. LAD-I (CD11/CD18 Deficiency):
Rare; inherited disorder; Detected in early
childhood; delayed umbilical cord separation may be
Life threatening. Infections of middle ear,
oropharynx ect.
Neutrophils roll, but do not adhere or migrate.
LAD-2:
Short stature &distinct facial appearance;
Recurrent bacterial infections—including
Pneumonias, cellulitis without pus & Periodontitis
Surface CD18 expression is normal;
Lack of CD15 expression seen;
Neutrophils do not roll on endothelial Cells, & do
not adhere
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26. Emigrating Leukocytes:
Varies with the age of the response & With the type
of stimulus;
In most forms, Neutrophils predominate during the
first 6-24 hrs;
After entering the tissue, they undergo Apoptosis &
disappear; In certain infections (Eg. Pseudomonas
inf.), they predominate over 2-4 days;
In viral inf. lymphocytes are the first cells to arrive.
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27. Chemotaxis
Defined as locomotion oriented along a
Chemical gradient.
All granulocytes, monocytes, & to a lesser extent
lymphocytes respond to stimuli with varying rates of
speed.
Exogenous agents- bacterial products,
Endogenous- 1.C5a,
2.Leucotriene (LTB4)
3. Cytokine (IL-8).
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28. Defects In Chemotaxis:
Localised Juvenile Periodontitis: Is characterised by
alveolar bone loss, most prominently of the incisors
& first Molars.
They don’t have extra oral infections;
Abnormal Chemotaxis to FMLP & C5a has been
reported; Neutrophils in these Pts express CR2 on
surface in contrast to control cells;
Normally, CR2 is present only on immature cells &
lost during Maturation, before release from the
marrow.
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29. Leukocyte Activation:
Results from several signals passing through & trigger
leucocytes; result in Increase in cytosolic Ca++ &
activates Enzymes such as Protein kinase C &
Phospholipase A2;
As a result the following responses occur;
1 Production of AA metabolites from Phospholipids;
2 Degranulation & secretion of lysosomal enzymes &
activation of Oxidative Burst.
3 Secretion of Cytokines which amplify & Regulate
inflammatory reactions;
4 Modulation of adhesion molecules allowing firm
adhesion of activated Neutrophils to the endothelium.
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30. Neutrophils express a no. of surface receptors involved
in the activation:
1. Toll like receptors (TLRs) (which play a role in
adhesion & response to LPS)
2. 7mem Gprotein receptors (recognize
chemokines,C5a,PAF,LTB4 &Prosta.E)
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32. Phagocytosis (Cell Eating):
When a neutrophil meets a particle, it envelops it
with pseudopodia which flow around it forming a
phagolysosome that rapidly fuse with Azurophilic &
Specific granules.
Granule Release:
Neutrophil contains 4 types of intracellular
Granules: Azurophilic,specific, Gelatinase(Tertiary)&
Sec.Ves.
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35. Oxygen dependent mechanisms
Free O2 radicals:
Phagocytosis initiates HMP shunt; causing a burst in
O2 consumtion, glucose oxidation & Production of
reactive O2 metabolites;
O2 is reduced to Superoxide ion which is then
converted to H2O2 by spontaneous dismutation.
This H2O2 is not powerful bactericidal.
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36. Production of reactive O2 Species
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37. O2 Independent Mechanisms
LYSOZYME-in neutrophil granules can lyse the
cellwall of some bacteria, -gram +ve cocci;
Lactoferrin-a protein that binds Iron &inhibits
bacterial growth by depriving them of it;
BPI-Bactericidal permeability increasing factor.
Elastase (found in granules)
Defensins Ect.contribute for killing the bacteria.
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38. Mediators originate from either –
Plasma – e.g. complement proteins & kinins -
These are present in precursor forms that must be
activated by series of proteolytic cleavage →
acquire biologic properties
Cells – present in intracellular granules that need to
be secreted (e.g. Histamine in mast cells) or
synthesized denovo in response to stimulus (e.g.
Prostaglandins, cytokines)
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40. Mediators perform activity by –
Mostly by binding to receptors on target cells
Direct enzymatic activity e.g. Lysosomal proteases
Mediate oxidative damage e.g. reactive oxygen
species & nitrogen intermediates
Mediators can act on –
One or few target cells Can have diverse targets
Have different effect on different cell types
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41. Once activated & released from the cell the mediators
are short lived.
They either –
Quickly decay e.g. Arachidonic acid metabolites
Inactivated by enzymes e.g. kininase inactivates
Bradykinin
Scavenged e.g. antioxidants scavenge toxic oxygen
metabolites
Inhibited e.g. complement regulatory proteins breakup
& degrade activated complement components
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42. Vasoactive amines:
First mediators to be released during
inflammation are-
Histamine
Serotonin
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43. Histamine:
Richest source –mast cells
-also in platelets & Basophils
Stimuli for degranulation of Mast cells –
Physical injury such as trauma , cold or heat
Immune reactions involving binding of antibodies
to Mast cells
Fragments of complement called Anaphylotoxins
(C3a & C5a )
Neuropeptides (substance P )
Cytokines (IL – 1 & IL – 8 )
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44. Action of Histamine
Dilation of arterioles ( but constriction of large
arterioles )
Increased permeability of venules
Principle mediator of immediate transient phase of
increased vascular permeability
Acts on microcirculation mainly via binding to H1
receptor on endothelial cells
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45. Serotonin:
Action similar to that Histamine
Source – platelets & Enterochromaffin cells
Release from platelets occurs when platelets aggregate
after contact with –
Collagen
Thrombin
ADP
Ag- Ab complexes
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46. Plasma proteins that mediate inflammatory response
belong to 4 interrelated systems
Complement system
Kinin system
Clotting system
Fibrinolytic
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47. Complement system-
Complement system consists of 20 component proteins
that are found in greatest concentration in plasma
Complement components causes –
Increasing vascular permeability
Chemotaxis
Opsonisation
Activation of complement cascade consists of 2 steps i.e.
early step & late step
Early steps consists of 3 different pathways & lead to
proteolytic cleavage of C3
Late steps – all 3 pathways converge & major
breakdown products of C3, C3b activate a series of
other complement components
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48. The early steps in complement activation consists of
3 pathways i.e. –
Classical pathway
Alternate pathway
Lectin pathway
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54. PLASMA PROTEINS
Regulation of complement activation
Regulation of C3 & C5 convertase by enhancing
dissociation of convertase complex e.g. Decay
accelerating factor
Binding of active complement components by
specific proteins in plasma
C1 inhibitor interferes with enzymatic activity of C1
Proteins that inhibit MAC formation e.g. CD59
inhibit excessive complement activation
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55. The biologic function of complement system
Cell lysis by MAC
Vascular phenomenon – increased vascular
permeability & vasodilatation
Leukocyte adhesion, chemotaxis & activation
Phagocytosis
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56. Disorders of complement system
Deficiency of complement components lead to
increased susceptibility to infections
Deficiency of C4 & C2 – autoimmune diseases e.g.
SLE
Genetic defeciency of complementary regulatory
protein – significant disease – e.g. Paroxysmal
Nocturnal Hematuria
Defeciency of C1 inhibitor – Hereditory
angioneurotic edema
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57. Kinin & Clotting system
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59. Protease activated receptors
These are 7- Transmembrane G – protein receptors
present on platelets, endothelial cells, smooth muscle
cells, etc.
Engagement of PAR by proteases particularly
Thrombin triggers several responses like-
Mobilization of P- selectin
Production of chemokines
Expression of endothelial adhesion molecule
Production of Prostaglandins, PAF, & NO
Changes in endothelial shape
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60. ARACHIDONIC ACID METABOLITES
Membrane lipids
↓
Biologically active lipid products
(Autocoids – short range of hormones- formed
rapidly – exert their effects locally – either decay
spontaneously or destroyed enzymatically )
↓
Serve as extracellular or intracellular signals to affect
variety of biologic process including inflammation &
hemostasis
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62. Eicosanoids + G-protein coupled receptors on
various cell types – mediate steps of inflammation
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63. LIPOXINS
Lipoxins are generated by transcellular biosynthetic
mechanisms involving two cell population
Leukocytes produce intermediates in Lipoxin
synthesis which are converted to Lipoxin by platelets
interacting with leukocytes
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64. Biosynthesis of Leukotrienes & Lipoxins
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65. The principle action of Lipoxins are –
Inhibit leukocyte recruitment & cellular components
of inflammation
Inhibit neutrophil chemotaxis & adhesion to
endothelium
Lipoxins may be endogenous negative regulators of
Leukotrienes leading to resolution of inflammation
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66. Anti inflammatory therapy can be directed at many
targets along the Eicosanoids biosynthetic pathway
Cyclooxygenase inhibitors – (COX 1, COX 2) e.g.
NSAIDS like Indomethacin inhibit Prostaglandin
synthesis by irreversibly acetylating & inhibiting
Cyclooxygenase
Lipoxygenase pathway – used in treatment of Asthma
Broad spectrum inhibitors – e.g. Glucocorticoids.
They act by down regulating the expression of genes like
genes encoding for COX2, Phospholipase A2, NO
synthetase e.t.c. They also up regulate the genes encoding
for anti-inflammatory proteins like Lipocortin-1
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67. PLATELET ACTIVATING FACTORS
PAF is bioactive phospholipid derived mediators
PAF is derived from antigen stimulated IgE
sensitized Basophils that cause platelet aggregation
Sources – Neutrophils, Platelets, Basophils, Mast cells,
Endothelial cells.
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68. Functions –
Platelet stimulation
Vasoconstriction ( in low conc. It induces
vasodilatation & increased venular permeability)
Increased leukocyte adhesion to endothelium
Chemotaxis
Degranulation
Increased synthesis of other mediators by leukocytes
& other cells
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69. CYTOKINES & CHEMOKINES
Cytokines are proteins produced by many cell types
principally activated Lymphocytes, Macrophages,
Endothelium, Epithelium & Connective tissue cells
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70. TUMOR NECROSIS FACTOR & INTERLEUKIN-1
They are produced mainly by activated macrophages &
they mediate inflammation
Secretion of TNF & IL-1 is stimulated by – endotoxins,
microbial products, immune complexes, physical injury
e.t.c.
Functions –
Effects on Endothelium, leucocytes, & fibroblast
Induction of systemic & acute phase reactants
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71. ENDOTHELIAL EFFECTS
Increased synthesis of endothelial adhesion
molecules & chemical mediators like cytokines,
chemokines, growth factors, eicosanoids & NO.
Production of enzymes associated with matrix
remodeling
Increase in the surface thrombogenecity of the
endothelium
Increased procoagulant activity, Decrease in
anticoagulant activity
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73. LEUKOCYTE EFFECT
Increased cytokine secretion ( IL-1, IL-6 )
IL-1 & TNF induces systemic acute phase
response which include-
Fever
Loss of appetite
Release of Neutrophils into circulation
Hemodynamic effects like hypotension, decreased
vascular resistance, increased heart rate e.t.c.
Regulates body mass by regulating lipid & protein
mobilization & by suppressing appetite
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74. CHEMOKINES
Chemokines are a family of small proteins that
act primarily as chemoattractant
They are classified into 4 major groups based on
the arrangement of conserved cysteine residues
in the mature proteins
C-X-C chemokines (Alpha chemokine)
C-C chemokines (Beta chemokines)
C chemokines (Gamma chemokines)
CX,C chemokines
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76. LYSOSOMAL CONSTITUENTS OF
LEUKOCYTES
Neutrophils & monocytes contain granules that
produce inflammatory response
Neutrophils contain 2 main types of granules-
Small specific granules
Large Azurophilic granules
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80. Acute inflammation-Morphology
1. Pseudomembranous inflammation
It is the response of mucous membrane (Oral,
respiratory, bowel) to toxins of the diphtheria, or
irritant gases. Due to denudation of epithelium,
plasma exudes on the surface, where it coagulates &
together with Necrosed epithelium, forms false
membrane that gives the name.
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81. 2. Ulcer
Ulcers are local defects on surface of an organ
produced by inflammation, i.e. discontinuity of the
lining epithelium.
Common sites are stomach, intestines(e.g. Typhoid
fever), intestinal Tuberculosis, Bacillary & Amoebic
dysentery etc.
Ulcers of legs due to Varicose veins.
May be acute or chronic
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82. 3.Abscess formation (Suppuration-Purulent
inflammation)
Abscesses are focal collections of pulse that may be
caused by deep seeding of Pyogenic organisms or by
secondary infection of necrotic foci. They have a central
necrotic region rimmed by a layer of preserved
neutrophils with a zone of dilated vessels & Fibroblastic
proliferation.
Abscess
The purulent exudate or pus is creamy & or opaque in
appearance & is composed of numerous dead as well as
living neutrophils, red cells, tissue debris & fibrin.
In old pus macrophages & Cholesterol crystals may be
present.
It may discharge to the surface due to increased pressure
inside or may require drainage.
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83. 4.Cellulitis
It is a diffused inflammation of soft tissues resulting
from spreading effects of substances like
Hyaluronidase released by some bacteria.
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84. Fate of acute inflammation
Acute inflammatory process can result in one of the
following outcomes
1.Resolution
2.Healing by scarring
3.Progression to suppuration
4.Progression to chronic inflammation.
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85. Resolution
It means complete return to normal tissue following
acute inflammation.
This occurs when the injury is limited or with
minimal tissue damage & when the tissue is capable
of replacing the injured cells.
E.g Resolution in Lobar Pneumonia
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86. Healing by Scarring
This takes place when the tissue destruction is
extensive; there is no regeneration, extensive
fibrinous exudate occurs which cannot be
completely absorbed.
There is healing by Fibrosis.
E.g Healing of Abscess(In certain bacteria or fungal
infections due to Pyogenic infections)
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87. Progression to Suppuration
When Pyogenic bacteria cause acute inflammation
resulting in severe tissue necrosis, Suppuration sets
in.
Initially, there is intense neutrophilic infiltration.
Subsequently mixture of neutrophils, bacteria,
fragments of Necrotic tissue, cell debris & Fibrin
comprise “pus” which is contained in a cavity
forming an Abscess. If it is not drained, it may get
organised & in time get calcified.
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88. Progression to Chronic inflammation
Acute inflammation may progress to chronic
inflammation in which the process of inflammation
& healing proceed side by side.
Depending on the extent of initial injury & the
capacity of the tissue, there may be regeneration or
Scarring.
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