Definitions Exudation the escape of fluid, proteins, and blood cells from the vascular Mila Amor V.

V. Reyes, MD, FPSP system into the insterstitial tissue or body cavities. Anatomic and Clinical Pathologist #vlbdatud Exudate inflammatory extravascular fluid that has a high protein concentration, much cellular debris INFLAMMATION is the reaction of vascularized living tissue to local injury specific gravity above 1.020 evoked by microbial infections, physical agents, chemicals, necrotic tissue, and Transudatefluid with low protein content immunologic reactions SG < 1.012 roles are to contain and isolate injury, to destroy invading microorganisms and ultrafiltrate of blood plasma and results from hydrostatic imbalance inactive toxins, and to prepare the tissue or organ for healing and repair across the vascular endothelium. maybe potentially harmful causing life threatening hypersensitivity Edemaexcess of fluid in the interstitial tissue or serous cavities; reactions and progressive organ damage with chronic inflammation may can be an exudate or a transudate. lead to permanent scarring Puspurulent inflammatory exudate rich in leukocytes and parenchymal cell debris

ACUTE AND CHRONIC INFLAMMATION

I.

CHANGES IN VASCULAR FLOW AND CALIBER

Begin immediately after injury develop at various rate depending on the severity of the injury Initially, transient vasoconstriction of arterioles occur vasodilation follows causing increased flow heat and redness Eventually slowing of the circulation occurs as a result of increased vascular permeability lead 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

ACUTE INFLAMMATION: MAJOR EVENTS

3 major components: a. Alterations in vascular caliber that lead to an increase in blood flow b. Structural changes in the microvasculature that permit plasma proteins and In inflammation: leukocytes to leave the circulation and to produce inflammatory exudate. increased hydrostatic pressure caused by vasodilation c. Emigration of the leukocytes from the microcirculation and their accumulation decreased osmotic pressure caused by leakage of high protein fluid across a in the focus of injury hyperpermeable endothelium marked net outflow of fluid and edema 5 cardinal signs of inflammation: Heat (calor) Redness (rubor) Edema (tumor) Pain (dolor) Loss of function (functio laesa)

*Starlings law maintains normal fluid balance , modulated mainly by two opposing forces: a. Hydrostatic pressure cause fluid to move out of the circulation b. Plasma colloid osmotic pressure cause fluid to move into capillaries

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 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 Direct endothelial injuryresulting in endothelial cell necrosis and detachment caused by severe necrotizing injuries and affects all levels of the microcirculation damage usually evokes an immediate and sustained endothelial leakage Leukocyte-mediated endothelial injuryresulting from leukocyte aggregation, adhesion, and emigration across the endothelium leukocytes release toxic oxygen species and proteolytic enzymes endothelial injury or detachment increased permeability 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 Leakage from regenerating capillariesduring healing occurs when new capillaries sprouts are leaky

2.

3.

4.

5.

6.

ADHESION AND TRANSMIGRATION Occur largely as a result of interactions between complementary adhesion molecules on the leukocytes and on the endothelium Chemoattactants and some cytokines affect these process by modulating the surface expression or avidity of the adhesion molecules Major ligand-receptor pairs include: a. selectins (E,P, and L) bind through their lectin (sugar binding) domains to oligosaccharides (e.g., sialylated Lewis X), which themselves are covalently bound to cell surface glycoproteins b. The immunoglobulin family includes the endothelial ICAM-1 and VCAM-1 c. The integrins functions as receptors for some of the immunoglobulin family and the extracellular matrix principal integrin receptors for ICAM-1 are the 2 integrins, LFA-1 and MAC-1 those for VCAM-1 are the integrins 41 and 47 These molecules induce leukocyte adhesion in inflammation by 3 mechanisms: a. Redistribution of preformed adhesion molecules to the cell surface b. Induction of adhesion molecules on endothelium c. Increased avidity of binding

III. CELLULAR EVENTS: LEUKOCYTE EXTRAVASATION AND PHAGOCYTOSIS

A critical function of inflammation is the delivery of leukocytes to the site of injury. The following are the sequence of events in this journey, called EXTRAVASATION: 1. Margination, rolling, and adhesion of leukocytes in the lumen 2. Diapedesis transmigration across the endothelium 3. Chemotaxis migration in the interstitial tissue toward a chemotactic stimulus Sequence of Leukocyte events in inflammation, shown here for neutrophils. The leukocytes first roll, then
become activated and adhere to endothelium transmigrate across and pierce basement membrane migrate toward chemoattractants emanating from the source of injury

ENDOTHELIAL LEUKOCYTE ADHESION MOLECULES PMN adhesion and transmigration in acute inflammation occur only by a series of overlapping steps: 1. 2. 3. 4. Endothelial activationmediators present at the inflammatory sites increased the expression of E-selectin and P-selectin by endothelial cells Leukocyte rollinginitial rapid and relatively loose adhesion, resulting from interactions between the selectins and their carbohydrate ligands Firm adhesionleukocytes are then activated by chemokines or other agents to increased the avidity of their integrins 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 E-selectin and P-selectin Both deficiencies result in impaired leukocyte adhesion and recurrent bacterial infections.

Chemotactic agents for neutrophils include bacterial products complements fragments (e.g., C5a) arachidonic acid metabolites (e.g., leukotriene B4) chemokines (e.g., IL-8) Chemotaxis involves binding of chemotactic agents to specific receptors on leukocytes production of second messengers Signal transduction process results In: activation of phospholipase C and protein kinase C increased intracellular calcium assembly of the contractile elements responsible for cell movement leukocyte moves by extending a pseudopod 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

CHEMOTAXIS AND LEUKOCYTE ACTIVATION Adherent leukocytes emigrate through interendothelial junctions traverse the basement membrane move toward the site of injury along a gradient of chemotactic agents Neutrophils emigrate first, monocytes and lymphocytes follow

Biochemical events in leukocyte activation. (1) receptor-ligand binding (2) Phospholipase C activation (3) intracellular calcium and (4) activation of Protein Kinase C. The biologic activities (5) resulting include chemotaxis, modulation of adhesion molecules, elaboration of arachidonic acid metabolites, secretion/degranulation, and oxidative burst. PIP2 phosphatidylinositol biphosphate

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 leukocyte microorganisms are coated with specific factors, called OPSONINS, which enhance the efficiency of phagocytosis because they are recognized by the receptors on the leukocytes two major opsonins: a. the Fc fragments of the immunoglobulin G b. a product of complement C3b

2.

3.

Engulfment by pseudopods encircling the phagocytosed particle> subsequent formation of a phagocytic vacuole or PHAGOSOME membrane of the phagosome fuses with the membrane of a lysosomal granule discharge of the granules content into the PHAGOLYSOSOME Killing and degradation of bacteriaphagocytosis stimulates a burst of oxygen consumption and production of reactive oxygen metabolites

b.

c.

Defects in phagocytosis 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, H 2O2-MPO-halide bactericidal mechanism

There are two types of bactericidal mechanisms: a. Oxygen dependent mechanismstriggered by activation of NADPH oxidase reduce O2 to O2 and hence to H2O2; MPO from lysosomal granules then converts H 2O2, in the presence of a halide such as Cl , to a highly bactericidal HOCl ; H2O2-MPO-halide 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

(A) Phagocytosis of a particle (e.g. bacterium) involves attachment and binding of Fe and C3b receptors on the leukocyte membrane. Engulfment and fusion of granules (in red) with phagocytic vacuoles, followed by degranulation. Note that during phagocytosis, granule contents may be released extracellularly (B) Summary of oxygen-dependent bactericidal mechanisms within the phagocytic vacuole

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: a. From regurgitation during feeding, reverse endocytosis, or cytotoxic release Lysosomal enzymes b. Oxygen derived active metabolites c. Arachidonic acid metabolism products prostaglandins and leukotrienes These products are powerful mediators of tissue damage amplify the effects of the initial inflammatoy stimulus ff persistent leukocyte dependent tissue can cause chronic inflammation DEFECTS IN LEUKOCYTES FUNCTION Interfere with inflammation 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: a. Defects in leukocyte adhesion leukocyte adhesion deficiency type I and type II

Clinical Examples Of LeukocyteInduced Injury

Defects In Leukocyte Functions

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.

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. Increased vascular permeability results in the accumulation of protein-rich extavascular fluid, which forms the exudate. 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. Phagocytosis of the offending agent follows, which may lead to the death of the microorganism.

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 cause vasodilation and increase vascular permeability

Released from mast cells is caused by: 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

Complement components with inflammatory activity include: C3awhich increases vascular permeability C5awhich increases vascular permeability and is highly chemotactic to WBCs C3b and C3bithe opsonins important in phagocytosis C5b-9MAC that lyses cells and stimulates arachidonic acid metabolism and production of reactive oxygen metabolites by a leukocytes Protein inhibitors: 1. decay accelerating factor regulation of C3 and C5 convertases 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 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 Kinin System Generates vasoactive peptides from plasma proteins called kininogens by specific proteases called kallikreins, ultimately resulting in the production of bradykinin Surface activation of Hageman factor (factor XII) produces CF XIIa converts plasma prekallikrein into Kallikrein latter cleaves HMWK to produce Bradykinina potent stimulator of increase vascular permeability 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

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 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 complement components are generated that caused increased vascular permeability, chemotaxis and opsonization Activation of complement occurs via two general mechanisms: a. The classic pathwayinitiated by antigen-antibody complexes b. The alternate pathwayactivated by endotoxin, complex polysaccharides, and aggregated globulins

2.

At the same time that factor XIIa is inducing clotting, it can also activate the fibrinolytic system produces plasmin and degrades fibrin solubilize the clot. Plasmin can contribute to inflammation in several ways: Cleave C3 to produce C3 fragment Form fibrin split products 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: a. Cyclooxygenasesgenerate prostaglandins and thromboxanes b. Lipoxygenasesproduce leukotriene and lipoxins

Clotting System divided into two interrelated that converges to activate a primary hemostatic mechanism: 1. Intrinsic pathway consists of plasma proenzymes that can be activated by Hageman factor 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.

Inflammatory prostaglandins and leukotrienes: Prostaglandin I2 (prostacyclin) and prostaglandin E2 cause vasodilation Prostaglandin E2 is hyperalgesicmakes the skin hypersensitive to painful stimuli Thromboxane A2 causes vasoconstriction Leukotrienes C4, D4, and E4cause increased vascular permeability and vasoconstriction Leukotriene B4 is a powerful chemotactic agent 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) 2. Cytokines involved with natural immunity Includes the inflammatory cytokines (e.g., TNF- and IL-1), type I IFN (IFN- and IFN- ), and IL-6 3. Cytokines that activate inflammatory cells Activate macrophages during cell mediated immune responses (e.g., IFN, TNF- , IL-5, IL-10, and IL-12) 4. Chemokines Cytokines characterized by chemotactic activity for various leukocytes (e.g., IL-8) 5. Cytokines that stimulate hematopoiesis Mediate immature leukocyte growth and differentiation (e.g., IL-3, IL-7, ckit ligand, GM-CSF, M-CSF, G-CSF, and stem cell factor) *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 acute-phase 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 *TNF- has a key role in the normal control of body mass 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-

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

3. 4.

monocytes, eosinophils, basophils, and lymphocytes but not neutrophils: eotoxin selectively recruits eosinophils C or -chemokineslack two (the first and third) of the four conserved cysteines: relatively specific for lymphocytes (e.g., lymphotactin) CX3C chemokinesinclude fractalkine, exist in two forms: a. Cell surface-bound proteincan be induced in endothelial cells that promote adhesion of the leukocytes b. hSoluble formderived from proteolysis of membrane-bound protein, has chemoattractant activity Chemokines mediate their activities by binding to G-protein-linked receptors: a. CXCR (1-4) for the C-X-C chemokines b. CCR (1-5) for the C-C chemokines.

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

NITRIC OXIDE 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 Synthesized from arginine, molecular O2, NADPH, and other cofactors by the enzyme nitric oxide synthase (NOS) 3 types of NOS: a. Endothelial (eNOS b. neuronal (nNOS) c. cytokine inducible [iNOS] Exhibits two patterns of expression: 1. eNOS and nNOS are present constitutively and are rapidly activated by an ++ increased in cytoplasmic Ca 2. iNOS is present in macrophages and is induced by cytokines, such as IFN-, ++ without an increase in intracellular Ca

Two types of NO synthesis in endothelium (left) and macrophages (right). NOS = NO synthase

Properties: Plays an important role in vascular function during an inflammatory response 1. 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 Acts in the host response to infection Interactions occur between NO and reactive O 2 species, leading to the formation of multiple antimicrobial metabolites (e.g., peroxynitrite [OONO], Snitrosothiols [RSNO], and nitrogen dioxide [NO2])

LYSOSOMAL CONSTITUENTS OF LEUKOCYTES can potentiate further increases in vascular permeability and chemotaxis and cause tissue damage harmful proteases are held in check by a system of antiproteases in the serum and the tissue fluid ex.: 1-antitrypsin major inhibitor of neutrophilic elastase If (+) deficiency sustained action of leukocyte proteases ex: patients with 1-antitrypsin deficiency Lysosomal granules found in neutrophils and monocytes which when released may contribute to the inflammatory response and to tissue injury. Neutrophils have two main types of granules a. Smaller specific (or secondary) granulescontain lysozyme, type IV collagenase, gelatinase, lactoferrin, plasminogen activator, 12istaminases, alkaline phosphatase, leukocyte adhesion molecules, and phospholipase A 2 b. 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, non-specific collagenases, proteinase 3)

2. 3. 4.

Both can 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 degrade extracellular components Hydrolases (collagenase, elastase, phospholipase, and plasminogen activator) found in monocytes and macrophages bb, which maybe particularly active in chronic inflammatory reactions

C5a Prostaglandins Leukotriene B4 Leukotriene C4, D4, E4 Oxygen metabolites PAF IL-1 and TNF Chemokines Nitric oxide

Macrophages Mast cells, from membrane phospholipids Leukocytes Leukocytes, mast cells Leukocytes Leukocytes, mast cells Macrophages, other Leukocytes, other Macrophages, endothelium

+
Potentiate other mediators

+ + + + + +

Leukocyte adhesion, activation Vasodilation, pain, fever Leukocyte adhesion, activation Bronchoconstriction, vasoconstriction Endothelial damage, tissue Bronchoconstriction, leukocyte priming Acute phase reactions, endothelial activation Leukocyte activation Vasodilation, cytotoxicity

+ + + +

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 NO to form other reactive nitrogen intermediates, which cause: 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) Oxygen metabolites are detoxified by: ANTIOXIDANTSserum proteins (ceruloplasmin and transferrin), enzymes (superoxide dismutase, catalase, and glutathione peroxidase) Net effects on tissue injury of oxygen metabolites depend on the balance between their production and activation 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 Vascular Mediator Source Chemotaxis Leakage Histamine and Mast cells and + platelets serotonin Bradykinin C3a
Plasma substrate Plasma protein via liver + + -

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 For chemotaxis, complement fragment C5a, lipoxygenase products (leukotriene B4), other chemotactic lipids, and chemokines are the most likely protagonist prostaglandins role in vasodilation, pain, and fever and in potentiating edema. IL-1 and TNF involved with endothelial-leukocyte interactions and with acute phase reactions. Lysosomal products and oxygen-derived radicals most likely candidates as causes of the ensuing tissue destruction. Nitric oxide is involved in vasodilation and cytotoxicity

Other

Pain Opsonic fragment (C3b)

OUTCOME OF ACUTE INFLAMMATION 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. Complete resolutionregeneration of native cells and restoration of the site to normal 2. Abscess formationinfections by pyogenic organisms

3.

4.

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

CHRONIC INFLAMMATION
Inflammation of prolonged duration (weeks or months) in which active inflammation, tissue destruction, and attempts at healing may be all proceeding simultaneously Arises in several ways: May follow acute inflammation, because of the inciting stimulus or because of some interference in some process of healing May results from repeated bouts of acute inflammation Begins insidiously as a low grade, smoldering response that does not follow classic acute inflammation in one of the following settings: a. Persistent infections by intracellular microbes which are of low toxicity but evoked an immunologic reaction b. Prolonged exposure to potentially toxic exogenous or endogenous substances c. Immune reactions, perpetuated against the individuals own tissues

Characteristic of Chronic Inflammation: 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 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 Central figures in chronic inflammation great number of 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 Events in resolution of inflammation: (1) return to normal vascular permeability, (2) drainage of edema fluids and proteins into lymphatics, or (3) by pinocytosis in macrophages; (4) phagocytosis of apoptotic neutrophils; including: (5) necrotic debris by macrophages; and (6) disposal of macrophages. Note the central role of macrophages a. Neutral proteases in resolution. b. Chemotactic factors c. Arachidonic acid metabolites d. Reactive oxygen & nitrogen species e. Complement components f. Coagulation factors g. Growth factors

h. Cytokines (eg, IL-1 & TNF) i. Other factors (eg, PAF & - IFN) important host defense some of these mediators induce the tissue damage characteristic of chronic inflammation Secretory products can be toxic to cells (reactive oxygen and nitric oxide metabolites) or extracellular matrix (protease) 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

Maturation of Macrophage:

Macrophage Activation:

PLASMA CELLS produce antibodies directed against either foreign antigen or altered tissue components 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 In acute reactions, IgE antibodies specifically recognize antigen cells degranulate and release mediators, such as histamine 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 EOSINOPHILScharacteristic of immune reactions mediated by IgE and of parasitic infections Recruitment depends on eotoxin, a member of the C-C family of chemokines 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 cell epithelioid cells may coalesce to form multinucleated giant cells central necrosis may also be present in some granulomas two types of granulomas: a. Foreign body granulomasincited by relatively inert foreign bodies b. Immune granulomasformed by immune T-cell-mediated reactions to poorly degradable antigens lymphokines, principally IFN- from activated T-cells cause transformation of macrophages to epitheloid cells and multinucleated giant cells Ex: TUBERCLE immune granuloma caused by the M. tuberculosis, characterized by the presence of central caseous necrosis

Products released By Macrophages - Enzymes - Lipases - Neutral proteases - Plasma proteins - Elastase - Complement components (e.g., C1 to C5, properdin) - Collagenase - Coagulation factors (e.g., factors V, VIII, tissue factor) - Plasminogen activator - Reactive metabolites of oxygen - Acid hydrolases - Eicosanoids - Phosphates - Cytokinesis, chemokines (IL-1, TNF, IL-8) - Nitric oxide - Growth factors (PDGF, EGF, FGF TGF-) Other Cells of Chronic Inflammation LYMPHOCYTESmobilized by antibody and cell-mediated immune reactions and by nonimmunologic reactions Have a unique reciprocal relationship to macrophages in chronic inflammation 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 B-cell and T-cell function (particularly IL1, TNF)

Examples Of Granulomatous Infections

DISEASE CAUSE TISSUE REACTION a. Noncaseating tubercle (granuloma prototype) focus of epithelioid cell, rimmed by fibroblast, lymphocytes, histiocytes, occasional Langhans giant cell b. 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

Tuberculosis

M. tuberculosis

Leprosy

M. leprae Treponema pallidum Gram-negative bacillus

Syphillis Cat-scratch disease

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: a. b. 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 ascitis 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 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 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

c.

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 Other major systemic manifestations: o Fever is an elevation of body temperature, usually by 1 to 4 C. 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 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 Leukocytosisa common feature of inflammatory reactions, especially those induced by bacterial infection Extreme elevations are referred to as leukemoid reactions occurs because of the proliferation of precursors in the bone marrow and the accelerated released of cells from the bone marrow, induced by CSF Neutrophilia induced by most bacterial infections Lymphocytosis induced by some viral infections Eosinophilia bronchial asthma, hay fever, and parasitic infestations Leukopenia caused by certain infections (e.g., typhoid fever and infections caused by viruses, rickettsiae, and certain protozoa) 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.

d. e.

major systemic manifestations: Endocrine and metabolicsecretion of acute-phase proteins by the liver (including CRP, serum amyloid A, complement and coagulation proteins)