2. Questions
Inflammation. Definition. Basis. Etiology
and pathogenesis. Nomenclature.
Acute inflammation: tissue response.
Mediators in acute inflammation.
Type of cells in the focus of acute
inflammation. Consequences of acute
inflammation.
Patterns of acute inflammation.
3. Inflammation
A protective response intended to eliminate
the initial cause of cell injury as well as the
necrotic cells and tissues resulting from the
original insult.
Inflammation is a beneficial host response
to foreign invaders and necrotic tissue, but it
is itself capable of causing tissue damage.
4. General Features of Inflammation
The main components of inflammation are a
vascular reaction and a cellular response, activated
by mediators that are derived from plasma proteins
and various cells.
The phases of the inflammatory process are:
Tissue injury, degeneration and necrosis
Acute inflammation
Inactivation and removal of the agent
Restitutio (repair)
Scar /chronic inflammation
5. Inflammation
Acute inflammation
rapid in onset and of short duration, lasting up to few
days
characterized by fluid and plasma protein exudation and
predominantly neutrophilic leukocyte accumulation
= exudative inflammation
Chronic inflammation
longer duration (days to years)
characterized by lymphocytes and macrophages influx
and vascular proliferation and fibrosis (scarring)
= productive inflammation
6. Acute inflammation
The external manifestations of
inflammation, often called its cardinal signs,
result from the vascular changes and cell
recruitment:
heat (calor),
redness (rubor),
and swelling (tumor).
pain (dolor)
and loss of function (functio laesa)
8. Inflammation /Nomenclature
Related to organ localization + itis
Pleura –pleuritis
Myocardium – myocarditis
Cystis – cystitis
Exceptions
Pneumonia, angina
9. ACUTE INFLAMMATION
Acute inflammation is a rapid
response to injury or microbes
and other foreign substances
that is designed to deliver
leukocytes and plasma proteins
to sites of injury.
The principal leukocytes in
acute inflammation are
neutrophils (polymorphonuclear
leukocytes).
Granulocytes,
Neutrophilic
granulocytes
Polymorph
10. Role of the neutrophil polymorph
The neutrophil polymorphs =
acute inflammatory infiltrate
Movement
Adhesion to micro-organisms
Phagocytosis
Intracellular killing of micro-
organisms
Oxygen-dependent mechanisms –
RAS
Oxygen-independent mechanisms
11. ACUTE INFLAMMATION
Acute inflammation has 3 major
components:
Vascular changes:
alterations in vessel caliber resulting
in increased blood flow (vasodilation)
and (increased vascular permeability).
Cellular events:
emigration of the leukocytes from the
microcirculation and accumulation in
the focus of injury (cellular recruitment
and activation).
Mediators, derived from plasma
proteins and cells
12. Vascular Reactions in Acute
Inflammation
Vasoconstriction (for seconds)
Vasodilation is induced by chemical mediators
such as histamine
is the cause of erythema and stasis of blood flow.
Increased vascular permeability
by histamine, kinins and other mediators that produce
gaps between endothelial cells,
by direct or leukocyte-induced endothelial injury, and
by increased passage of fluids through the endothelium
13. Exudates
Exudates
increased vascular permeability allows
plasma proteins and leukocytes to enter
sites of infection or tissue damage;
fluid leak through blood vessels results in
edema.
Exudates v/s transudates
Exudate - in inflammation because of
increased vascular permeability as a
result of increased interendothelial
spaces.
Transudates - when fluid leaks out
because of increased hydrostatic
pressure or decreased osmotic pressure.
14. Responses of Lymphatic Vessels
In inflammation, lymph flow is increased and helps
drain edema fluid from the extravascular space
In severe inflammatory reactions, especially to
microbes, the lymphatics may transport the
offending agent.
lymphangitis and lymphadenitis
Inflamed lymph nodes are often enlarged, because of
hyperplasia of the lymphoid follicles and increased numbers of
lymphocytes and phagocytic cells lining the sinuses of the lymph
nodes = reactive, or inflammatory, lymphadenitis.
For clinicians, the presence of red streaks near a skin wound is a
sign of an infection in the wound.
15. Cellular Events
Leukocyte Recruitment
Leukocytes are recruited from the blood into the
extravascular tissue to the site of infection or tissue injury,
and are activated.
Leukocyte Activation- to perform their functions
ingest offending agents, kill bacteria and other microbes,
and eliminate necrotic tissue and foreign substances.
they may induce tissue damage and prolong inflammation,
since the leukocyte products that destroy microbes can
also injure normal host tissues.
key to the normal function of leukocytes in host defense is to
ensure that they are recruited and activated only when needed
16. Leukocyte Recruitment – a multiple steps
process
Margination, adhesion, and rolling along the vessel wall
Firm adhesion to the endothelium
Transmigration between endothelial cells;
Migration in interstitial tissues toward a chemotactic stimulus
mediated by the binding of complementary adhesion molecules on
leukocytes and endothelial surfaces – selectins, integrins
Chemical mediators-chemoattractants
17. Leukocyte Activation
Stimuli for activation
microbes, products of necrotic cells, and several
mediators
opsonization
components of the microbes and dead cells, or host proteins,
(opsonins), that coat microbes and target them for
phagocytosis
Leu express on their surface different kinds of receptors
receptors for opsonins that facilitate rapid phagocytosis of the
coated microbes
Fc receptor for IgG, complement receptors 1 and 3, and
C1q (collectins).
18. Leukocyte Activation
Stimuli for activation
microbes, products of necrotic cells, and several
mediators
Leu express on their surface different kinds of receptors and
engagement of these receptors by microbial products or by
various mediators of inflammation induces leukocyte activation
Leukocyte functions:
Phagocytosis of particles
an early step in the elimination of harmful substances.
Production of substances that destroy phagocytosed
microbes and remove dead tissues
lysosomal enzymes and reactive oxygen and nitrogen species.
Production of mediators that amplify the inflammatory
reaction- arachidonic acid metabolites, cytokines.
19. Leukocyte Effector Mechanisms
The culmination of the phagocytosis of
microbes is killing and degradation of the
ingested particles.
Destruction is caused by free radicals (ROS, NO)
and lysosomal enzymes
leukocyte NADPH oxidase (phagocyte oxidase) -
superoxide ion and hydrogen peroxide
lysosomes of neutrophils (called azurophilic granules)
-enzyme myeloperoxidase (MPO) - hypochlorous
radical.
Enzymes and ROS may damage normal tissues
20. CHEMICAL MEDIATORS OF
INFLAMMATION
Cell-derived mediators - produced locally by cells at the
site of inflammation
In intracellular granules and are rapidly secreted upon cellular activation
(e.g., histamine in mast cells) or are synthesized de novo in response to
a stimulus (e.g., prostaglandins and cytokines).
Plasma-protein-derived mediators- circulating in the
plasma (typically synthesized by the liver) as inactive
precursors that are activated at the site of inflammation
complement proteins, kinins, which undergo proteolytic cleavage to
acquire their biologic activities.
Once activated and released from the cell, mediators are
inactivated by enzymes, eliminated or inhibited
25. SEROTONIN
5HT, 5-Hydroxy-
Tryptamine)
Platelets and
Enterochromaffin Cells
Vasoactive mediator, with
effects similar to those of
histamine
Evokes NO synthetase
26. Arachidonic Acid (AA) Metabolites
(EICOSANOIDS)
Affect a variety of biologic processes, including
inflammation and hemostasis.
Leukocytes, mast cells, endothelial cells, and platelets are the
major sources of AA metabolites in inflammation.
= Products derived from the metabolism of AA
AA is a 20-carbon polyunsaturated fatty acid, a component
of cell membrane phospholipids.
It is released from these phospholipids via cellular phospholipases,
activated by mechanical, chemical, or physical stimuli, or by
inflammatory mediators (C5a).
AA metabolism - 2 enzymatic pathways:
Cyclooxygenase ⇒ prostaglandins and thromboxanes,
lipoxygenase ⇒ leukotrienes and lipoxins
28. Platelet-Activating Factor (PAF)
It is generated from the membrane
phospholipids of many cells
• neutrophils, monocytes, basophils,
endothelial cells, and platelets
Activate platelets
Vasoconstriction and
bronchoconstriction
Vasodilation and increased
vascular permeability
29. CYTOKINES/CHEMOKINES
Proteins produced by many cells –
TNFα, IL-1,interferon-γ (IFN-γ)
Lymphocytes, macrophages.
Numerous roles in acute and
chronic inflammation
CHEMOKINES are small proteins
(>40)
act primarily as chemoattractants for
different subsets of leukocytes
30. FREE RADICALS
Synthesized via the NADPH oxidase (phagocyte
oxidase) pathway and are released from neutrophils
and macrophages
O2 – (SUPEROXIDE)
H2O2 (PEROXIDE)
OH-
(HYDROXYL RADICAL)
Very destructive
within lysosomes they function to destroy phagocytosed microbes and
necrotic cells
At higher levels -responsible for tissue injury
31. NITRIC OXIDE
Synthesized from arginine
by endothelial cells (type III
nitric oxide synthase, eNOS)
by macrophages (type II NO
synthase,iNOS)
Effects
Vasodilation
reduces platelet and
leukocyte adhesion
NO produced in phagocytes is
cytotoxic to microbes.
32. Lysosomal enzymes
The lysosomal granules of neutrophils and
monocytes contain many molecules that can
mediate acute inflammation.
Myeloperoxidase
Lysozyme (Bact.)
Acid Hydrolases
Lactoferrin
Lysozyme
Alkaline Phosphatase
Proteases – collagenase, elastases
The potentially damaging effects of lysosomal
enzymes are checked by antiproteases present in
the serum and tissue fluids-α1-antitrypsin, α2-
macroglobulin.
33. Plasma Protein-Derived
Mediators of Inflammation
Complement proteins, >20 proteins
Coagulation proteins
Activated factor XII triggers the clotting, kinin and
complement cascades, and activates the fibrinolytic
system, production of fibrin
Kinins (bradykinin)
Produced by proteolytic cleavage of precursors;
increased permeability, Smooth muscle contraction
(non vascular), pain
34. COMPLEMENT SYSTEM
>20 components, in circulating plasma
Plays an important role in host defense
(immunity) and inflammation
Upon activation, different
complement proteins coat
(opsonize) particles, such as
microbes, for phagocytosis and
destruction
increase vascular permeability -
C3a and C5a
leukocyte chemotaxis
lysis of cell membranes, after an
extensive “cascade”
36. Outcomes of acute
inflammation
Resolution of inflammation
when the injury is limited or short-lived and
there has been no or minimal tissue damage,
when the tissue is capable of replacing any
irreversibly injured cells
Termination of the acute inflammatory
response involves:
neutralization, decay or enzymatic degradation
of the various chemical mediators, normalization
of vascular permeability, cessation of leukocyte
emigration, death (by apoptosis) of extravasated
neutrophils.
leukocytes produce mediators that inhibit
inflammation and thus limit the reaction
lymphatic drainage and macrophage ingestion of
necrotic debris lead to the clearance of the
edema fluid, inflammatory cells, and detritus
37. Outcomes of Acute Inflammation
Progression to chronic inflammation - if the
offending agent is not removed
In some instances, signs of chronic inflammation may be
present at the onset of injury (e.g., in viral infections or
immune responses to self-antigens).
Scarring or fibrosis - after substantial tissue
destruction or when inflammation occurs in tissues
that do not regenerate.
Extensive fibrinous exudates may not be completely
absorbed and are organized by ingrowth of connective
tissue, with resultant fibrosis.
The usual outcome of abscess formation is scarring
because of the underlying tissue destruction
38. ACUTE INFLAMMATION-
Summary
Initial reaction of tissue to injury
Vascular component: dilatation of vessels
Exudative component: vascular leakage of
protein-rich fluid
Neutrophil polymorph -the characteristic cell
recruited to the tissue
Outcome - resolution, suppuration (e.g.
abscess), organisation, or progression to
chronic inflammation
40. MORPHOLOGIC PATTERNS OF
ACUTE INFLAMMATION
Distinctive morphologic patterns depend on:
the severity of the inflammatory response, its specific
cause and the particular tissue
Serous inflammation
Catarrhal inflammation
Fibrinous inflammation
Haemorrhagic inflammation
Suppurative (purulent) inflammation
Putrefactive (gangrenous) inflammation
Importance to know the morphologic patterns
often associated with different eliciting stimuli and clinical
situations.
41. Serous inflammation
Characterized by the outpouring of a watery,
relatively protein and cells-poor fluid
Depending on the site of injury, the fluid derives either
from the serum or from the secretions of mesothelial
cells lining the peritoneal, pleural, and pericardial
cavities.
Location
Skin - viruses
Mesothelial linings (serosa) of peritoneal, pleural, and
pericardial cavities
Fluid in a serous cavity is called an effusion
Mucosa of GIT, respiratory tract (rhinitis)
Catarrhal inflammation – mucous + epithelial cells
Liver, myocardium
42. Serous inflammation
Skin blister -from a burn or viral
infection
a serous effusion accumulated
either within or immediately
beneath the epidermis of the skin
Outcome of serous
inflammation
Recovery
Exceptions
Serous meningitis
Cholera - dehydratation
burns
43. Fibrinous inflammation
Occurs as a consequence of more severe
injuries, resulting in greater vascular
permeability and the exudate is rich of
fibrinogen⇒ converts to fibrin
Location
Serous cavities
Pericarditis, pleuritis, peritonitis
Mucosa of respiratory tract
Diphtheria of the larynx
Lobar pneumonia –alveoli
Mucosa of gastrointestinal tract
Histologically, the accumulated extravascular
fibrin appears as an eosinophilic meshwork of
threads
Cor villosum
Weigert staining– violet-blue reaction
44. Fibrinous inflammation
Two types
Superficial – easy removing of fibrin, without
loss of tissue
Serous cavities
Lobar pneumonia (crupousa)
Diphtheria of larynx
Deep –pseudomembraneous, necrosis of sub
lying epithelium
Diphtheria of tonsils
C. difficile
48. Outcome of fibrinous inflammation
Resolution
exudates may be degraded by fibrinolysis, and the accumulated
debris may be removed by macrophages, resulting in restoration of
the normal tissue structure
Organization
the failure to completely remove the fibrin results in the ingrowth of
fibroblasts and blood vessels, leading ultimately to scarring that may
have significant clinical consequences
organization of a fibrinous pericardial exudate forms dense fibrous scar
tissue that bridges or obliterates the pericardial space and restricts
myocardial function
Pneumonia crouposa – carnification, pneumosclerosis
Death
Diphtheria of larynx – asphyxia
Intoxication – peritonitis, pneumonia crouposa
49. Suppurative (purulent) inflammation
Characterized by the presence of large amounts of purulent
exudate (pus) consisting of neutrophils, macrophages, necrotic
cells, and edema fluid
Yellowish colour to grey
Staphylococci induce most often suppuration = pyogenic.
Two types
Local (focal collections of pus) – abscesses
Directly, by seeding of pyogenic organisms into a tissue
hair follicle - fulunculus, carbunculus
Ductullar way - bronchi, bile ducts
Hemaetogenic- several organs
by secondary infections (suppuration)
Diffuse – phlegmone
No localization of the suppuration, neutrophils + tissue decay
Adipose tissue-panniculitis
Empyema – in cavities
Gall bladder, pleura
50. Bronchopneumonia
Purulent inflammation. A, Multiple bacterial abscesses in the lung B. The abscess
contains neutrophils and cellular debris, and is surrounded by congested blood
vessels.
54. Suppurative (purulent) inflammation
Chronic abscess
Morphology
a central, largely necrotic
region rimmed by a layer of
neutrophils, with a
surrounding zone of dilated
vessels and fibroblastic
proliferation
may become completely
walled off and replaced by
pyogenic membrane, 4 layers
Neutrophils
Macrophages-lipids,
pseudoxantomas cells
Lymphocytes
connective tissue capsule
Abscessus cerebri
55. Outcome of suppurative inflammation
Local factors
Bile stasis,
lithiasis
General condition of the patient
immunity
diabetes
Local effects
Break in the cavities
Suppurative peritonitis
Systemic effects-generalization of the inflammation
Sepsis
Pyaemia-multiple abscesses
56. Haemorrhagic inflammation
Characterized by increased erythodiapedesis due to
vascular wall injury
Often combined fibrinohaemorrhagic
Vasotropic agents- viruses
Grippe – rhinitis, tracheitis, pharyngitis
hemorrhagic fever
Pestis
Anthrax
Impaired coagulation
Thrombocytopenia
↓ Vit C
57. Ulcerative inflammation
An ulcer is a local defect (or
excavation), of the surface of an organ
or tissue -necrotic tissue
Ulceration can occur only when tissue
necrosis and inflammation exist on or
near a surface:
inflammatory necrosis of the mucosa of
the mouth, stomach, intestines, or
genitourinary tract;
tissue necrosis and subcutaneous
inflammation of the lower extremities
Peptic ulcer of the stomach, duodenum -
acute and chronic inflammation coexist.
acute stage - intense polymorphonuclear
infiltration and vascular dilation in the
margins of the defect.
Chronic stage - the margins and base of
the ulcer develop scarring with
accumulation of lymphocytes,
macrophages, and plasma cells.