Maynard Sam Lazo

2B-USTFMS

Slide No. M-10-15 Acute Appendicitis (vascular and early leukocytic phases).

presence of congested
arterioles and venules in the
serosa
vascular changes due to
early leukocytic phase
(rolling and margination)

1. Pathogenesis of vascular dilatation and congestion

Inflammatory mediators such as histamine, leukotriene, nitric oxide, prostaglandin, etc. are released
when there is damage to the tissue. This cause vasodilation and increase vascular permeability of the
blood vessels supplying the area. This initiates an immune response to rid the area of the
microorganisms invading. This would also facilitate repairing the damage on the tissue. The
inflammatory response is initiated by either tissue necrosis, infection, foreign bodies, or hypersensitivity
reactions.

2. Role of red blood cells during the vascular phase of acute inflammation

Inflammation increases the blood volume along the site of injury. Glucose and other nutrients like
oxygen are provided by RBCs as well as fibroblastic functions important in remodeling of the tissue. The
dead and dying cells contribute to pus formation. Red blood cells may likewise help in the clotting
mechanism through the delivery of fibrinogen and fibronectin along the area with haemorrhage.

3. Pathogenesis of rolling, margination, pavementing, and emigration of leukocytes

The leukocytes first roll, eventually they will adhere to endothelium, cross between the endothelial cells,
pierce the basement membrane, and migrate toward the site of injury. There are several mediators in
this process. Selectins in rolling; chemokines (usually displayed bound to proteoglycans) in activating the
neutrophils to increase avidity of integrins; integrins for adhesion and CD31 (PECAM-1) for
transmigration.

In normally flowing blood in venules, red cells are located at the central column which causes
leulkocytes to be displaced to toward the vessel wall. Because of statis, wall shear stress decreases. In
effect, more white cells assume a peripheral position along the endothelial surface, hence called
margination. Individual and then rows of leukocytes adhere transiently to the endothelium, detach and
bind again, thus rolling on the vessel wall. The cells finally come to rest at some point where they adhere
firmly.
Slide No. M-10-22 Acute Appendicitis with Liquefactive Necrosis (Suppurative Appendicitis)

Process involves acute

inflammation, edema
formation and liquefactive
necrosis.
Predominance of
neutrophils in the interstitial
tissue that phagocytize
bacteria and cells.
Numerous fibrin thrombi
present

1. Pathogenesis of liquefactive necrosis

Liquefactive necrosis is characteristic of focal bacterial or fungal infections where the affected cell is
completely undergo enzymatic degradation and hyrdrolysis resulting in a soft, circumscribed lesion
consisting of pus and the fluid remains of necrotic tissue. After the removal of cell debris by white blood
cells, a fluid filled space is left. Abscess formation, typical of liquefactive necrosis, is commonly found in
the central nervous system.

2. Pathogenesis of fibrin thrombi

Thrombus is a solid mass of blood constituents composed of platelets, red cells, fibrin and white
cells formed in the circulating blood stream. Atherosclerosis causes rupture exposing the
subendothelial collagen to the bloodstream. Platelets are activated upon contact with collagen and
forms a complex with GP-Ib. Thrombi may occur anywhere in the cardiovascular system. Lines of
zahn are characteristic feature seen in thrombi within the cardiovascular system. These are
alternating layers of paler platelets admixed with fibrin, separated by darker layers containing more
red blood cells. Thrombus can also be formed when patient has hypercoagulable state and
disturbances to the blood flow.

3. Relationship between the fibrin thrombi and extensive necrosis of mucosa .

There is excessive consumption of coagulation factors and subsequent activation of fibrinolysis

using all of the body's available platelets and clotting factors. This results to hemorrhage and
ischemic necrosis. Acute appendicitis seems caused primarily by obstruction of the lumen of the
appendix. Consequentially, the organ swells causing pressures within the lumen and the walls of the
appendix to increase. This results to thrombosis and occlusion of the small vessels, and stasis of
lymphatic flow. Bacteria begin to leak out through the dying walls, pus forms within and around the
appendix. These cause the appendix to rupture causing peritonitis, septicemia and death.
Slide No. M-10-19 Chronic Inflammation of Skin with Granulation Tissue Formation

Increase in number of
capillaries, blood vessels,
fibroblasts.
Angiogenesis mediated by
fibroblasts, endothelial cells,
and mononuclear fusiform
cells

1. Roles of lymphocytes and macrophages in the acute and chronic phases of inflammation

Acute inflammation

Macrophage have the role of recognizing microbial products and secretes most of the cytokines
important for acute inflammation. TNF and IL-1 are two of the major cytokines that mediate
inflammation. Effects are acute phase reaction- fever, sleep, appetite, acute phase proteins,
shock, neutrophilia. Endothelial effects are increased leukocyte adherence, PGI synthesis, procoagulant
activity, and increased IL-1,6,8 & PDGF. The fibroblast increase in proliferation, collagen synthesis,
collagenase, protease, PGE synthesis. Leukocyte increase cytokine secretion of IL-1,6.

Chronic Inflammation

Macrophages display antigens to T cells, and produce membrane molecules (costimulators) and
cytokines (notably IL-12) that stimulate T-cell responses. Activated T lymphocytes produce cytokines like
IFN-y, a major activator of macrophages. Plasma cells develop from activated B lymphocytes and
produce antibody directed either against persistent antigen in the inflammatory site or against altered
tissue components.

2. Pathogenesis by which these roles are effected

After digesting a pathogen, macrophage serves as antigen presenting cell to the helper T-cell.
Presentation is done by integrating it into the cell membrane and displaying it attached to an MHC class
II molecule, indicating to other white blood cells that the macrophage is not a pathogen, despite having
antigens on its surface. After which, production of antibodies that attach to the antigens for easier
elimination by the cells. In some cases, pathogens are very resistant to adhesion by the macrophages.
The antigen presentation on the surface of infected macrophages (in the context of MHC class II) in a
lymph node stimulates TH1 (type 1 helper T cells) to proliferate (mainly due to IL-12 secretion from the
macrophage). When a B-cell in the lymph node recognizes the same unprocessed surface antigen on the
bacterium with its surface bound antibody, the antigen is endocytosed and processed. The processed
antigen is then presented in MHCII on the surface of the B-cell. TH1 receptor that has proliferated
recognizes the antigen-MHCII complex (with co-stimulatory factors- CD40 and CD40L) and causes the B-
cell to produce antibodies that help opsonisation of the antigen so that the bacteria can be better
cleared by phagocytes.

Macrophages also protect us against tumor cells and infected somatic cells in cases of fungal
infection. Once a T cell has recognized its particular antigen on the surface of an aberrant cell, the T cell
becomes an activated effector cell, lymphokines are produced that stimulate macrophages to engulf and
digest affected cells much more readily. The macrophage does not generate a response specific for an
antigen, but attacks the cells present in the local area in which it was activated.

3. Roles of fibroblasts and endothelial cells in chronic inflammation and healing

Endothelial cells are for angiongenesis, or formation of new vessels. Fibroblast is for
proliferation and migration into the granulation tissue framework of new blood vessels and loose ECM
that initially forms at the repair site. Fibroblasts also deposit increased amounts of ECM. Fibrillar
collagens form a major portion of the connective tissue in repair sites and are important for the
development of strength in healing wounds.

4. Factors that determine the transformation of an acute to a chronic inflammatory response.

Persistence of infections or other injurious agents can promote transformation of an acute

inflammation to chronic inflammation.

Slide No. M-10-09 Chronic Granulomatous Inflammation of Lung

Granuloma formation
Composed of lymphocytes
rimming the granuloma
Fibroblast surrounding
epithelioid cells
Langhans cells (with U-
shaped appearance)

1. Pathogenesis of caseous necrosis.

Caseous necrosis, is encountered most often TB infection. Microscopically, the necrotic
focus appears as amorphous granular debris seemingly composed of fragmented, coagulated
cells and amorphous granular debris enclosed within a distinctive inflammatory border known
as a granulomatous reaction. Granulomatous inflammation is a distinctive pattern of chronic
inflammatory reaction where focal accumulations of active macrophages, which often develop
an epithelial-like appearance. Tuberculosis is the prototype of the granulomatous diseases.
Recognition of the granulomatous pattern in a biopsy specimen is important because of the
limited number of possible conditions that cause it and the significance of the diagnoses
associated with the lesions.

2. Reason why granulomas are formed in some conditions of chronic inflammation

A granuloma is a focus of chronic inflammation where there is aggregation of
macrophages that are transformed into epithelium-like (epitheloid) cells surrounded by a collar
of mononuclear lymphocytes or plasma cells. The epitheloid cells have a pale pink granular
cytoplasm with indistinct cell boundaries, often appearing to merge into one another. The
nucleus is less dense than that of a lymphocyte, is oval and elongate, and may show folding of
the nuclear membrane. Epitheloid cells fuse to form giant cells in the periphery or sometimes in
the center of granulomas. Tubercle bacilli, either free or within phagocytes, drain to the regional
 nodes, which also often caseate. This combination of parenchymal lung lesion and nodal
involvement is referred to as the Ghon complex. During the first few weeks, there is also
lymphatic and hematogenous dissemination to other pats of the body. In approximately 95% of
cases, development of cell-mediated immunity controls the infection. Hence, the Ghon complex
undergoes progressive fibrosis, often followed by radiologically detectable calcification and
despite seeding of other organs, no lesions develop. Histologically, sites of active involvement
are marked by a characteristic granulomatous inflammatory reaction that forms both caseating
and non-caseating tubercles. Individual granulomas are microscopic; it is only when multiple
granulomas coalesce that they become macroscopically viable. The granulomas are usually
enclosed within a fibroblastic rim punctuated by lymphocytes. Multinucleate giant cells are
present in the granulomas. Immunocompromised people do not form the characteristic
granulomas.

3. Relationship between the epitheloid cells, Langhans giant cells, and lymphocytes; what are
these cells saying to one another and how are they communicating it?
The coalescence of granulomas may produce small nodules that are palpable o visible as
1- to 2-cm, noncaseating, noncavitated consolidations. The lesions are distributed in the
lymphatics, around bronchi and blood vessels. Macrophages define a ganuloma. They fuse to
form giant multinucleated cells. The macrophages in granulomas are epithelial-like thus often
referred to as epitheloid. Epitheloid macrophages differ from ordinary macrophages in that they
have elongated nuclei that often resemble the sole of a slipper of shoe. They also have larger
nuclei than ordinary macrophages and their cytoplasm is typically more pink when stained with
eosin.

4. Pathogenesis in the formation of epitheloid and Langhans giant cell

Epithelioid histiocytes are activated macrophages resembling epithelial cells: elongated with
finely granular, pale eosinophilic (pink) cytoplasm and central, ovoid nucleus(oval or elongate),
which is less dense than that of a lymphocyte. Langhans giant cells are large cells found in
granulomatous conditions. They are formed by the fusion of epithelioid cells (macrophages),
and contain nuclei arranged in a horseshoe-shaped pattern in the cell periphery.Although
traditionally their presence was associated with tuberculosis, they are not specific for
tuberculosis or even for mycobacterial disease. In fact, they are found in nearly every form of
granulomatous disease, regardless of etiology.

5. Healing process of granulomas.

Granulomatous inflammation occurs only in immune-competent host since a cell-mediated

immune response is necessary for granuloma formation. Granuloma formation occurs during
chronic inflammation wherein it helps in the isolation of injury by fibrosis and intracellular
sequestration within epitheloid cells. It also prevents destructive acute inflammation due to
persistent agent through sustained immune response. And it also initiates repair.
Slide No. M-10-20 Keloid of Skin (scar)
Atrophy of rete pegs due to
pushing of collagen
Presence of flattened rete
pegs due to large amount of
fibrous tissue

1. Pathogenesis of the healing process

During the early phases, Thrombosis leads to formation of a growth factor-rich barrier having
significant tensile strength. Next, inflammation occurs where necrotic debris and microorganisms must
be removed by neutrophils; the appearance of macrophages signals and initiates repair. Re-
epithelialization occurs. Epithelium then establishes a permanent barrier to microorganisms and fluid.
Granulation tissue forms and this Is the site of extracellular matrix and collagen secretion. It is
vascular, edematous, insensitive, and resistant to infection. Contraction of fibroblasts transform to
actin-containing myofibroblasts, linked to each other and collagen and contract upon stimulation by
TGF-1 or 2. Cross-linking leads to accretion of final tensile strength results primarily from the
cross-linking of collagen. The wound site devascularizes and conforms to stress lines in the skin, this
process is called remodeling.

2. Factors that influences the type of healing in acutely and chronically injured tissues .
Nutrition
Metabolic status
Circulatory status- can modulate
Hormones glucocoriticoids
Infection
Mechanical factors
Foreign bodies
Location and type of wound

3. Pathogenesis of scar formation

Migration of Fibroblasts and ECM Deposition. Scar formation builds on the granulation tissue
framework of new vessels and loose ECM that develop early at the repair site. It occurs in two steps: (1)
migration and proliferation of fibroblasts into the site of injury and (2) deposition of ECM by these cells.
The recruitment and stimulation of fibroblasts is driven by many growth factors, including PDGF, FGF-2
(described above), and TGF-. One source of these factors is the activated endothelium, but more
importantly, growth factors are also elaborated by inflammatory cells. Macrophages, in particular, are
important cellular constituents of granulation tissue, and besides clearing extracellular debris and fibrin
at the site of injury, they elaborate a host of mediators that induce fibroblast proliferation and ECM
production. Sites of inflammation are also rich in mast cells, and with the appropriate chemotactic
milieu lymphocytes may also be present. Each of these can contribute directly or indirectly to fibroblast
proliferation and activation.
As healing progresses, the number of proliferating fibroblasts and new vessels decreases. The
fibroblasts progressively assume a more synthetic phenotype, and hence there is increased deposition
of ECM. Collagen synthesis, in particular, is critical to the development of strength in a healing wound
site. As described later, collagen synthesis by fibroblasts begins early in wound healing (days 3 to 5) and
continues for several weeks, depending on the size of the wound. As described below, many of the same
growth factors that regulate fibroblast proliferation also participate in stimulating ECM synthesis. Net
collagen accumulation, however, depends not only on increased synthesis but also on diminished
collagen degradation (discussed later). Ultimately, the granulation tissue scaffolding evolves into a scar
composed of largely inactive, spindle-shaped fibroblasts, dense collagen, fragments of elastic tissue, and
other ECM components. As the scar matures, there is progressive vascular regression, which eventually
transforms the highly vascularized granulation tissue into a pale, largely avascular scar. .

Growth Factors are involved in ECM Deposition and scar formation, including TGF-, PDGF, and
FGF. Because FGF is also involved in angiogenesis, it was described earlier. Here we briefly describe
some properties of TGF- and PDGF. TGF- is a potent fibrogenic agent. It stimulates the production of
collagen, fibronectin, and proteoglycans, and it inhibits collagen degradation by both decreasing
proteinase activity and increasing the activity of tissue inhibitors of proteinases known as TIMPs. TGF-
is also involved in the development of fibrosis in lung, liver, and kidneys that follows chronic
inflammation.TGF- inhibits lymphocyte proliferation and can have a strong anti-inflammatory effect.
Cytokines may also function as growth factors and participate in ECM deposition and scar
formation. IL-1 and TNF, for example, induce fibroblast proliferation and can have a fibrogenic effect.
They are also chemotactic for fibroblasts and stimulate the synthesis of collagen and collagenase by
these cells.

Slide No. M-10-21 Cirrhosis of the Liver (scar formation)

Ductal proliferation as a
mechanism of overcoming
obstruction
regenerating liver lobule is
due to scarring that seem to
form a new lobule but
actually there is no active
regeneration of new cells

1.) Factors that determine scar formation in tissues whose parenchymal cells are capable of
regenerating

Liver is one of the organs whose parenchymal cells are capable of regeneration.
Restoration of liver mass is achieved by regrowth of the lobes that remain after an operation
through the process of compensatory hyperplasia or compensatory growth. Hepatocyte
proliferation in a regenerating liver is triggered by the combined actions of cytokines and
polypeptide growth factors.
However, a liver that has undergone severe or chronic injury results to damage to both
parenchyma and stromal tissue. Regeneration in these cases is not going to occur but instead,
scar forms. There is no restoration of the original tissue but a restitution of tissue components,
mainly by deposition of collagen to replace the parenchymal cells (in case of heart MI) and other
components of the extracellular matrix. In the skin, these events are involved in wound healing.
2.) Pathogenesis of connective tissue framework remodeling
This process involves the replacement of granulation tissues by a scar by changing the
ECM composition. The repair process is determined by the balance between ECM synthesis and
degradation. This process is achieved by MMPs or matrix metalloproteinases which include
interstitial collagenases (MMP1,2,3). These serve to cleave fibrillar collagen types I,II,III;
gelatinases (MMP 2,9) that degrade amorphous collagen, and stromelysins (MMP 3, 10, 11)
which act on proteoglycans, laminin, fibronectin, and amorphous collagens. And lastly is ADAM
(disintegrin and metalloproteinase-domain family) family of MMPs . It includes ADAM-17 (TACE
TNF-converting enzyme(which cleaves the membrane bound precursors of TNF and TNF-alpha.
Deficiency of ADAM-17 leads to neonatal or embryonic fatality involving pulmonary hypoplasia
and pathogenesis of bronchial asthma and thrombotic microangiopathies.

3.) Roles of lymphocytes, macrophages, and fibroblasts in connective tissue framework remodeling
Fibroblasts, macrophages, neutrophils and synovial cells produce MMPs necessary in
establishing balance of collagen synthesis and degradation, ultimately leading to the connective
tissue remodeling as described above. . Their secretory activity is stimulated by PDGF and FGF
growth factors, cytokines (Il-1, TNF). With persistent stimulus during chronic inflammation, this
activates macrophages and lymphocytes to produce collagen thru production of cytokines (TNF,
IL-1, 4, 13). This is balanced by MMPs collagenase activity by the fibroblasts and some
macrophages.