Inflammation

Dima
19/10/2010
Isma’eel
M. Bani-Essa
Matalqa
Lec#4 20
10

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Pathology – Lecture 10

Tuesday, October 19, 2010

Done by: Dima M. Bani-Essa

* You can find the slides of this lecture on Sama group website
under the name (patho slides#5 inflamation #3). So follow the slides
while you are reading this lecture in order to understand better,
especially in explaining the figures *

First, the doctor revised what he has explained in the previous

lecture quickly.

We'll start by talking about coagulation cascade and the role of

coagulation factors in the inflammation process.

Coagulation
(Slide 2): This is a good diagram (figure 4-9, page 91 in the book)
which summarizes all the steps and the series of reactions which
occur in coagulation.

In the coagulation cascade, we have the extrinsic pathway and the

intrinsic pathway, and then there's a common pathway. Just know a
couple of things; actually, we'll not go into fine details of the
coagulation because you'll learn this in the hemodynamics, but just
note here that in the extrinsic pathway, the initiative for such
reactions, when will we have coagulation? We have it, usually, if
there is stimulation of the endothelium, the basement membrane or
the surface of the platelets and this occurs either because of some
insults of the endothelium like in atherosclerosis, in some specific
types of infections or in inflammation which also leads to the
activation of the endothelium.

Now, such activation will lead to the initiation of this cascade of

enzymatic reactions or enzymatic activation of the different factors
of coagulation.

For the extrinsic pathway, it is usually in tissue injury, which means

there should be a tissue factor, which is the thromboplastin, and
please note here that there are inactive forms of the factors which

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are in the red boxes and we call them the substrates, and we have
the active forms of these in green color which are the enzymes or
the activated factors leading to the activation of the other factors.

In most of these cascade steps, we need a cofactor which

accelerates and initiates the activation of these proenzymes or
inactive forms of the factors. So these are like (calcium) which is one
of the main cofactor. Another cofactor here is the high molecular
weight kininogen (HMWK). And collagen is another cofactor
which is initial in initiating the in-intrinsic factors.

So we have the substrate, we have the enzyme, and we have

cofactors.

Here you see the tissue factor (thromboplastin) activates factor

VII (7) into tissue factor which is the VIIa factor (all of these with
a are activated forms and they are in the green boxes). On the other
hand, the Hageman factor which is factor XII (12) gets activated
by the HMWK leading to the active form of factor XIIa and then
activation of factor XIa (11).

The common pathway is here, and you see the phospholipid service
(in yellow) which is also needed for the activation, and this with the
calcium cofactor and with those enzymes that will lead to the
activation of factor Xa (10), and this what we call it the common
pathway for the coagulation cascade, and this of course will be
followed by further activation of factor V(5).

The main task of coagulation is to culminate into the activation of

Thrombin which's factor II. So, factor II is the inactive form
present in Prothrombin and gets activated by the common
pathway to Thrombin. Thrombin here is the main target to form the
mesh, it's a soluble protein which is present in the plasma and is
used to convert the Fibrinogen into an insoluble form of protein,
Fibrin, and this Fibrin forms the mesh of the blood clot or the
thrombus, so that we have a lot of fibers. This is actually the main
task of coagulation; the formation of Thrombin and then the fibrin.

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So this Fibrin gets activated by thrombin then by further activation,
this will lead to cross-linked Fibrin and the formation of the
thrombus.

Why do we get this thrombus? If we have endothelial injury or

stimulation of the endothelium, we need this coagulation to be
activated and to start functioning to do its task and purpose.
However, if this is continuous (continuous thrombus formation and
continuous Fibrin activation), this will lead to thrombosis.
Thrombosis by itself is harmful and this will lead to occlusion of the
blood vessels, so we need another mechanism to counter balance
this action which is the Fibrinolytic system, and we'll see that
later.

(Slide 3): Just to show you, this is an example (figure 4-10, page
92), here the phospholipid surface of the basement membrane, for
example, or of the endothelium or whatever it is, and you see here
there is an inactive coagulation factor which is the substrate and we
have the active coagulation factor, which is in this case IXa(9), and
this is factor X, with the presence of the cofactor which is factor
VIIIa (13) and the presence of the other cofactors like Ca++ ions,
this will lead to the activation of factor X and this in turn will activate
thrombin ( factor II) into thrombin-a (IIa)… etc. This is the way of
cascade reactions that occur to create such coagulation profile.

The Clotting Fibrinolytic System

- The Fibrin clots at the site of injury helps in containing the cause,
Fibrin clot provides a frame work for inflammatory cells.

- Factor Xa causes an increase in vascular permeability and

leukocytes immigration; so that's the rule of coagulation factor in
inflammation and you can see here the role of different factors in
inflammation:

- Thrombin causes leukocyte adhesion, platelets aggregation,

and generation of the fibrinopeptides and it is chemotactic. So,
if we like targeting thrombin (by a drug), this will lead to the
loss of leukocyte adhesion and the loss of platelets

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 aggregation, and this is the main mechanism of action of some
drugs, like warfarin (it is anticoagulant causes fibrinolysis) and
this also will lead to increment of the inflammatory action or
reactions.

- Fibrinopeptides are chemotactic and induce vasopermeability.

- Factor XIIa also activates the fibrinolytic pathway to prevent

widespread thrombosis.

- Fibrin split products increase vascular permeability; because

after the formation of the fibrin, they will get activated by other
mechanisms to transform these fibrins into what we call fibrin
split products, and these themselves will increase the vascular
permeability.

- Plasmin interacts with another system which is the

complement system, and it cleaves C3 to form C3a leading to
dilatation and increased permeability. Also it activates XIIa
amplifying the entire process.

So there is a very close interrelationship between the coagulation

system, the fibrinolytic system, the kinin system, and the
complement system.

So, thrombin as an inflammatory mediator binds to protease-

activated receptors (PARs) which are expressed on platelets,
endothelial cells, and smooth muscles leading to:

• P-selectin mobilization
• Expression of integrin ligands
• Chemokine production
• Prostaglandin production by activating cyclooxygenase-2
• Production of PAF
• Production of NO

The kinin system

The kinin system leads to the formation of bradykinin from HMWK
(hight molecular weight kininogen). The effects of bradykinin are: 1)

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increased the vascular permeability. 2) Arteriolar dilatation. 3)
Bronchial smooth muscle contraction. 4) Pain.

So bradykinin is one of the mediators of pain, and we'll see other

mediators of pain. They have a short half-life which can get
inactivated by kininase.

(Slide 8): The interaction between the four plasma mediator

proteins.

You see here, this is factor XII (12) gets activated by HMWK and
Prekallikerin surface, and once it is activated in this form XIIa, it
will activate the conversion of Prekallikerin into kallikerin, and
kallikerin itself activates factor XII and the transformation of HMWK
into bradykinin. Both of them; the kallikerin and the bradykinin, will
activate the Plasminogen to plasmin, and plasmin will activate the
splitting of the fibrin into fibrin split product to counterbalance the
clot formation of fibrin (fibrinolytic action the of plasmin).

And at the same time, the plasmin also will activate the other
system which is the complement system. So, we are talking about
cascades and series of reactions which are enzymically–mediated
leading to interaction between all the components of plasma
proteins.

(Slides 9 and 10): The doctor repeated the same as the discussed
above.

The Complement System in Inflammation

The C3a and C5a, we call them together anaphylatoxins; because
they are mediators in anaphylaxis (exaggerated allergic reaction to
a foreign protein resulting from previous exposure to it. Sometimes
it can be fatal; anaphylatactic reaction due to mutations, drugs,
toxins... etc might be very fatal). Anaphylatoxins lead to increased
vascular permeability, and cause mast cell to secrete histamine.

C5a activates lipooxygenase pathway of AA (Arachidonic acid). It

also activates leukocytes and increased integrins affinity and it is
chemotactic.

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Both of them (C3a and C5a) are opsonins; which means that they
participate in the process of opsonization of microbes and bacteria.

Plasmin and proteolytic enzymes split C3 and C5 into C3a and C5a,
respectively.

The Membrane attack complexes (C5-C9) lyse the bacterial

membranes.

(Slide 12): The complement activation pathways

We have the classical pathway and we have the alternative

pathway.

The classical pathway is gotten activated by antigen-antibody

complexes, and you see here C1 (complement 1) which can be
formed into activated C1 and then C4+C2 leading to the classic
pathway C3 convertase and this will lead to the classic pathway
C5 convertase by the activation of C3.

The Anaphylatoxins, as we said, in the classical pathway, cause

vasodilatation and increased vascular permeability, also generated
via plasmin and lysosomal proteases. Whereas in the alternative,
pathway it is usually initiated by the microbial surfaces and
polysaccharides.

There is a newly-described pathway, we call it lectin pathway

which is, more or less, similar to the classical pathway but usually
we don't need antibodies for the activation. So they are, actually,
three pathways: the classical pathway, the alternative pathway, and
the lectin pathway which is usually associated to the classical
pathway.

The alternative pathway is helped by some factors like factor B,

factor D and properdin and then leads to the alternative pathway
C3 convertase leading to what we call it the membrane attack

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complex (MAC), and we will see that MAC is the main one in
digesting and attacking the microbes.

(Slide 13): Here you see, again, the microbe classical, the
alternative and the lectin pathways, and you see here the C3b in the
alternative pathway will lead to recognition of bound C3b by
phagocyte C3b receptor leading to phagocytosis. Also, for the
alternative pathway, this will lead to the formation of MAC and this is
mainly to do with lyses of the microbe. Whereas for C5a and C3a
and their role in inflammation, they are involved in the activation of
further leukocytes and in destruction of microbes by leukocytes.

For the classical pathway, we need antigen-antibody complexes for

activation, while in the alternative pathway we need a microbe or
microbe's metabolites or oligosaccharides to get it activated, but in
the lectin pathway we have the mannose binding lectin with the
other antigens but there's no need for the antibodies.

Defects in the Complement System

• Deficiency of C3 → susceptibility to infections; so the
patients who come, esp. the children, to the clinic of the
infectious diseases complaining of recurrent infections, we
make them immuno-profiling, in one of these immuno-profiling
we look for complement deficiency, we measure the
complements C3, C5… etc. C3 deficiency, because it's one of
the main actions of destruction of the microbes, it will lead to
susceptibility to infections.

Deficiency of C2 and C4 has been proofed to increase the

susceptibility to Systemic Lupus Erythematosus (SLE).
• Deficiency of late components (MAC) is specifically known to
increase the susceptibility to Neisseria infections.
• Decrease inhibitors of C3 and C5 convertase. You know
that C3 is a cascade and after finishing its action, we need an
inhibitor for it. So inhibitors are needed to stop the action of C3;
because every C3's action continues, this will lead to adverse
results or adverse reactions. So if there's a decrease in the
inhibitors of C3, this means there is continuation of action of C3
and C5, in which we have a decrease in the decade

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 accelerating factor (DAF) which is one of the inhibitors of C3,
leading to hemolytic anemia.

• The decrease in levels of C1 inhibitor which initiates

(referring to C1) the complement will lead to a very well-known
serious disease, we call it angioneurotic edema. Because of the
extravasation of the fluid and the continuous initiation of this
reaction, this will lead to edema and this edema in the skin, in
the larynx, in the GI tract and different parts of the body. (here,
the doctor mentioned something about edema in the larynx
and how it leads to death but I couldn't hear it clearly).

The Arachidonic Acid Metabolism

Cell membrane has a component of phospholipid A2 and under
the action of phospholipase A2. These phospholipids can lead to
the formation of platelet activation factor or AA metabolites.

We have two main pathways for the AA metabolism: one of them

is the Cyclooxygenase and the other is Lipooxygenase.

You see here the products of cyclooxygenase pathway are mainly

prostaglandins (F2, D2, I2) and thromboxanes (A2) and we will
see later that PGI2 (prostacyclin) and TXA2 (thromboxanes A2)
have opposite functions, although they are produced via the same
pathway.

The lipooxygenase products are leukotrienes (LTC4, LTD4, and

LTE4) and other products like Hete.

(Slide 16): this is very important:

There are some other lipooxygenases that we are not interested

about at this moment leading to the formation of Hpete and Hete.
We are interested about the two main pathways; the
cyclooxygenase and the lipooxygenase.

For the lipooxygenase, we have the main 5-lipooxygenase and we

have the 12-lipooxygenase which is another subtype of the
lipooxygenase leading to the formation of lipoxins.

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In summary, for AA metabolites; we have two main pathways:
the cyclooxygenase and the lipooxygenase. The cyclooxygenase
leads to the formation of prostaglandins and thromboxanes. The
lipooxygenase leads to the formation of leukotrienes and there is
subset on this leading to the formarion of what we call lipoxin
(this is a newly-described pathway in the AA metabolism, by the
way. So you may not find this in all the books, it is probably in the
8th edition, you might not find it in the 7th edition).

Cyclooxygenase leads to prostaglandin formation which is PGG2

and then prostaglandin H2 (PGH2) which also lead to the
formation of prostacyclin I2 (PGI2) and this is the most important
one of these prostaglandins and this (referring to PGH2), also, can
get activated to thromboxane A2 (TXA2). Prostacyclin causes
vasodilatation and inhibits platelets aggregation, on the other
hand, thromboxane A2 causes vasoconstriction and promotes
platelets aggregation. So PGI2 and TXA2 are opposite in terms of
function.

The other prostaglandins like the PGD2 and PGE2 cause

vasodilatation (the same as prostacyclin) and increased vascular
permeability.

For the lipooxygenase, this will lead to the Hpete and Hete which
is one of the chemotactics leading to chemotaxis, then to the
leukotrienes. Leukotrienes A4 (LTA4) lead to leukotrienes B4
which act as a chemotactant, and the other leukotrienes cause
vasoconstriction, bronchospasm and increased vascular
permeability. So the actions of leukotrienes are, more or less, like
thromboxane, In addition to this, leukotrienes also have their
effect on the smooth muscle of the bronchi leading to
bronchospasm.

For the liopxin A4 (LXA4) and lipoxin B4 (LZB4), they inhibit

neutrophil adhesion and chemotaxis, so they have, more or less,
like anti-inflammatory or inhibitory effect on the action of other
leukotriene.

Look at these main steps; we can block this step (step of action of
phospholipase) by steroids and glucocorticoids. Actually, this is

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the main target of the action of steroids, they are the magic
medication, and they are used a lot in many diseases. If we look
at the site of action, we can appreciate why steroids are helpful in
many diseases, actually, because they will inhibit all these
processes.

For the cyclooxygenase there are some more specific ones, they
are COX-1 and COX-2 inhibitors which block the cyclooxygenase
like the aspirin and indomethacin.

Non-steroidal anti-inflammatory medications are used to be acting

specifically on the cyclooxygenase but this has been found to
inhibit the prostaglandins and we will see later that prostaglandin
is needed as a protective mechanism and for mucus secretion in
the stomach and that's why those who are taking a non-steroidal
anti-inflammatory medications are advised to take such
medications after meals, and if you have any gastric problems
you shouldn't take them; because they inhibit the action of
prostaglandin which is the protective mechanism in the stomach
and this, of course, will aggravate direct mechanical and chemical
activation of the gastric mucosa. New medications have been
invented which are COX-2 and don't interfere with the
prostaglandin action and therefore they are more selective and
safe.

The main two mediators of pain in inflammation are Bradykinin

and PGE2.

Platelet-activating Factor is another chemical mediator which is

generated from membranes phospholipids by phospholipase A2. It
aggregates and degranulates platelets, is a potent vasodilator
and bronchoconstrictor, and increases vascular permeability. Its
effects on the leukocytes are:

– Increase adhesion to endothelial cells

– Chemotactic
– Degranulation
– Oxygen burst

The Cytokines

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The cytokines are hormone-like polypeptides produced by cells,
involved in cell-to-cell communication; they have pleiotropic
effects which means that they can exert their effects with
opposite functions, sometimes. Secretion is transient and they
have their effect either in autocrine (at the same place), paracrine
(in adjacent areas) or endocrine (through the blood stream). So
they can exert their function either locally at the site of infection,
in the adjacent area or through the blood stream.

The Classes of Cytokines

We can divide them into these 5 main classes:
• Regulators of lymphocyte function
– Interleukin 2 (IL-2) stimulates proliferation
– Transforming grow factor β (TGFβ) inhibits lymphocytes
growth

• Primary responders to injury (innate immunity)

– Interleukin 1 (IL-1) and tumor necrosis factor α (TNFα)

• Activators of cell mediated immunity

– Interferon ϒ (INF-ϒ) and interleukin 12 (IL-12)

• Chemotactics
– Interleukin 8 (IL-8)

• Hematopoietic growth factors

– Interleukin 3 (IL-3) and Granulocyte-macrophage colony-
stimulating factor (GM-CSF)

TNF and IL-1 are the most important of these cytokines, they are
produced mainly by macrophages and their secretion is
stimulated by: bacterial products, immune complexes,
endotoxins, physical injury or other cytokines and they have
effects on endothelial cells, leukocytes, fibroblasts, and acute
phase reactions.

(Slide 24): this summarized the major effects of IL-1 & TNF. So
bacterial products, immune complexes, toxins, physical injury and

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 other cytokines will activate microphages which will produce TNF
and IL-1 but they can be produced by other cells but microphages
are the main source of these mediators.
We have the acute-phase reactions of inflammation which
include: fever, increase sleep, decrease appetite, increase the
acute phase proteins which we measure them in the blood and
Hemodynamic effect leading to shock and neutrophilia. All these
we call them acute-phase reactions which are the initial multi-
stations of infections.
The endothelial effect of these cytokines will lead to increase in
the leukocyte adherence, increase in the production of PGI2,
increase in the procoagulant activity (and therefore the activation
of coagulation cascase), increase the anticoagulant activity and
increase in the production of IL-1, IL-8, IL-6 and PDGF.
The fibroblast effects: increase proliferation, increase collagen
synthesis, increase collagenases, increase proteases and increase
PGE synthesis. And we will see the importance of these effects on
the fibroblast in the regeneration and repair process.
And they have other effects on the leukocytes by further cytokine
secretion (IL-1, IL-6).

...‫ن ستعيشون حياة العطاِء ِبل ُمقابل‬ ْ ‫إليكم يا َم‬

،‫ش لنفسنا حياًة ُمضاعفًة عندما نعيش للخرين‬ ُ ‫ "إننا نعي‬:‫يقوُل سيد قطب في كتابه أفراح الروح‬
..."‫سنا بحياِتنا‬
َ ‫ف إحسا‬ ُ ‫سنا بالخرين نضاع‬ َ ‫ف إحسا‬ ُ ‫ع‬ِ ‫وبقدر ما نضا‬

... ‫ل في قواكم وصنَع على أيديكم كّل خير‬

ُ ‫كا‬
َ ‫فبار‬

*‫*ديما بني عيسى‬

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