Acute and Chronic Inflammation

Prof.Dr.Mulazim Hussain Bukhari

MBBS,DCP,CHPE,MPhil, FCPS, PhD
HOD Pathology UCMD, University of Lahore
 Learning Objectives

• Definition of Inflammatipn
• Causes of Inflammation
• Molecular events of inflammation
• Chemical Mediators of Inflammations
• Consequences of Inflammation
• Conclusion
• References
 Acute Inflammation
• Injurious stimuli cause a protective vascular connective tissue
reaction called “inflammation”
• Dilute
• Destroy
• Isolate
• Initiate repair
• Acute and chronic forms
 Definition
• The host response that accomplishes these goals is called
inflammation.
–This is fundamentally a protective response, designed to
rid the organism of both the initial cause of cell injury
(e.g., microbes, toxins) and the consequences of such
injury (e.g., necrotic cells and tissues).
• Inflammation is a complex reaction in tissues that
consists mainly of responses of blood vessels and
leukocytes
 Acute inflammation
• is rapid in onset (typically minutes) and is of short duration,
lasting for hours or a few days;
• its main characteristics are the exudation of fluid and plasma
proteins (edema) and the emigration of leukocytes,
predominantly neutrophils (also called polymorphonuclear
leukocytes).
 Continued

• When acute inflammation is successful in eliminating

the offenders the reaction subsides, but if the response
fails to clear the invaders it can progress to a chronic
phase.
 Transudate vs. Exudate.
• Transudate vs. Exudate.
• Transudates can be thought of as being fairly pure
water.
• Transudates are water PLUS most serum proteins,
fibrin, and many blood cells often.
• So which one do you think requires bigger holes in
the endothelium, transudates or exudates?
 Inflammatory Fluids
• Transudate
An exudate 1. It is essentially an ultrafiltrate of
1. Extravascular fluid blood plasma that results from
2. High protein concentration, osmotic or hydrostatic imbalance
3. Contains cellular debris, across the vessel wall
4. has a high specific gravity. 2. low protein content (most of
5. Increase in the normal which is albumin),
permeability 3. little or no cellular material, and
4. low specific gravity.
5. without an increase in vascular
permeability
 Type of exudate
• Serous
• Firinous
• Membranous
• Purulent
 Characteristics

• Inflammation is terminated when the offending

agent is eliminated
• The inflammatory response is closely intertwined
with the process of repair
 Inflammation and Disease Process
• Inflammation may contribute to a variety of diseases that
are not thought to be primarily due to abnormal host
responses.
• For instance, chronic inflammation may play a role in
atherosclerosis, type 2 diabetes, degenerative disorders like
Alzheimer disease, and cancer.
 Cont,
• In recognition of the wide-ranging harmful
consequences of inflammation, the lay press has
rather melodramatically referred to it as "the
silent killer."
 Historical Highlights: Cardinal Signs
• Although clinical features of inflammation were described in an Egyptian papyrus dated
around 3000 BC, Celsus, a Roman writer of the first century AD, first listed the four
cardinal signs of inflammation:

1. Rubor (redness),
2.Tumor (swelling),
3.Calor (heat), and
4.Dolor (pain).
functio laesa), was added by Rudolf Virchow in
• A fifth clinical sign, loss of function (
the 19th century.
 HISTORICAL
HIGHLIGHTS
(Egypt, 3000 BC)

Rubor
Calor
Tumor
Dolor
5th (functio laesa)
 STIMULI FOR ACUTE INFLAMMATION
• Infections
• Bacterial, Viral, Fungal, Parasitic and
• Microbial toxins are among the most common and
medically important causes of inflammation.
• Tissue necrosis from any cause, including
• Ischemia (as in a myocardial infarct),
• Trauma , and physical and chemical injury (e.g.,
thermal injury, as in burns or frostbite;
• Irradiation; exposure to some environmental
chemicals
 Hypoxia.
• This response is mediated largely by a protein
called HIF-1α (hypoxia-induced factor-1α),
• which is produced by cells deprived of oxygen and
activates the transcription of many genes involved in
inflammation,
• including vascular endothelial growth factor (VEGF), which
increases vascular permeability
 • Foreign bodies
• typically elicit inflammation because they
cause traumatic tissue injury or carry
microbes.
• Immune reactions
• are reactions in which the normally protective
immune system damages the individual's own
tissues.
 Events of Acute inflammation
• Immediate and early response to tissue injury
• (physical, chemical, microbiologic, etc.)
1. Vasodilation
2. Vascular leakage and edema
3. Leukocyte emigration (mostly PMNs)
 Host Response in Acute Inflammation
• Acute inflammation is a rapid host response that
serves to deliver
• leukocytes and
• plasma proteins, such as antibodies, to sites of
infection or tissue injury
 Acute inflammation has three major
components:
• (1) alterations in vascular caliber that lead to an increase in
blood flow,
• (2) structural changes in the microvasculature that permit
plasma proteins and leukocytes to leave the circulation, and
• (3) emigration of the leukocytes from the microcirculation,
their accumulation in the focus of injury, and their activation
to eliminate the offending agent
The major local manifestations of acute inflammation, compared to normal.
(1) Vascular dilation and increased blood flow (causing erythema and warmth); (2) extravasation and
extravascular deposition of plasma fluid and proteins (edema); (3) leukocyte emigration and
accumulation in the site of injury.
Formation of transudates and exudates.
A, Normal hydrostatic pressure (blue arrows) is about 32 mm Hg at
the arterial end of a capillary bed and 12 mm Hg at the venous end;
the mean colloid osmotic pressure of tissues is approximately 25
mm Hg (green arrows), which is equal to the mean capillary pressure.
Therefore, the net flow of fluid across the vascular bed is almost nil.
B, A transudate is formed when fluid leaks out because of increased
hydrostatic pressure or decreased osmotic pressure.
C, An exudate is formed in inflammation, because vascular
permeability increases as a result of increased interendothelial
spaces.
 Vasodilation
• Brief arteriolar vasoconstriction followed by vasodilation
• Accounts for warmth and redness
• Opens microvascular beds
• Increased intravascular pressure causes an early
transudate (protein-poor filtrate of plasma) into
interstitium (vascular permeability still not increased
yet)
Increased Vascular Permeability (Vascular Leakage)

• A hallmark of acute inflammation is increased

vascular permeability leading to the escape of a
protein-rich exudate into the extravascular tissue,
causing edema.
 Mechanism
• Several mechanisms are responsible for the increased
vascular permeability
• Contraction of endothelial cells resulting in increased interendothelial
spaces
 Causes

• Immediate transient response

• histamine,
• bradykinin,
• leukotrienes,
• the neuropeptide substance P, and
• many other chemical mediators
 Delayed Prolonged
• In some forms of mild injury (e.g. after burns, x-
irradiation or ultraviolet radiation, and exposure to
certain bacterial toxins), vascular leakage begins after a
delay of 2 to 12 hours, and lasts for several hours or even
days
• by contraction of endothelial cells or mild endothelial
damage.
• Late-appearing sunburn is a good example of this
type of leakage.
 Vascular leakage
• Vascular permeability (leakiness) commences
• Transudate gives way to exudate (protein-rich)
• Increases interstitial osmotic pressure contributing
to edema (water and ions)
 Vascular leakage

• Five mechanisms known to cause vascular

leakiness
 Immediate and Transient
• 1-Histamines, bradykinins
• cause an early, brief (15 – 30 min.)
• Immediate transient response in the form of
• Endothelial cell contraction that widens intercellular gaps
of venules (not arterioles, capillaries) by Vasoconstriction
of endothelial cells of venular end
 Cytokines Mechanism

• 2-Cytokine mediators (TNF, IL-1) induce endothelial

cell junction retraction through cytoskeleton
reorganization (4 – 6 hrs post injury, lasting 24 hrs
or more) by vasoretraction of endothelial cells of
venular end
 Direct Injury causes Vascular leakage
• 3-Severe injuries may cause immediate direct endothelial cell
damage (necrosis, detachment) making them leaky until
they are repaired (immediate sustained response), or may
cause delayed damage as in thermal or UV injury, (cont’d) or
some bacterial toxins (delayed prolonged leakage)
• On bothe venular end arteriola end
 Vascular leakage by Neutrophils
4-Marginating and endothelial cell-adherent
leukocytes may pile-up and damage the endothelium
through activation and release of toxic oxygen radicals
and proteolytic enzymes (leukocyte-dependent
endothelial cell injury) making the vessel leaky
• More in pulmonary and renal areas
 Vascular leakage
• 5-Certain mediators (VEGF) may cause increased
transcytosis via intracellular vesicles which travel
from the luminal to basement membrane surface
of the endothelial cell (Vesiculo-Vascular
Mechanism)
• 6-All or any combination of these events may
occur in response to a given stimulus
Endothelial injury, resulting in endothelial cell necrosis and detachment.

• Direct damage to the endothelium is encountered in

severe injuries, for example, in burns, or by the
actions of microbes that target endothelial cells.
• Neutrophils injure the endothelial cells
that adhere to the endothelium during
inflammation may also injure the endothelial cells
and thus amplify the reaction.
• In most instances leakage starts immediately
after injury and is sustained for several hours
until the damaged vessels are thrombosed or
repaired.
 Transcytosis
• Increased transport of fluids and proteins, called
transcytosis, through the endothelial cell.
• Certain factors, such as VEGF seem to promote
vascular leakage in part by increasing the number and
perhaps the size of these channels.
• This is more important in newly formed blood vessels
Principal mechanisms
of increased vascular
permeability in
inflammation, and
their features and
underlying causes. NO,
nitric oxide; VEGF,
vascular endothelial
growth factor.
Recruitment of Leukocytes to Sites of Infection and
Injury
 Leukocyte cellular events
• Leukocytes leave the vasculature routinely through the following
sequence of events:
1. Margination and rolling
2. Adhesion and Pavementation
3. Transmigration
4. Chemotaxis and activation

• They are then free to participate in:

• Phagocytosis and degranulation
• Leukocyte-induced tissue injury
 Margination and Rolling
• With increased vascular permeability, fluid leaves the
vessel causing leukocytes to settle-out of the central
flow column and “marginate” along the endothelial
surface
• Endothelial cells and leukocytes have complementary
surface adhesion molecules which briefly stick and
release causing the leukocyte to roll along the
endothelium like a tumbleweed until it eventually
comes to a stop as mutual adhesion reaches a peak
 Margination and Rolling
• Early rolling adhesion mediated by selectin family:
• P-selectin (platelets, endothelium), E-selectin (endothelium),
L-selectin (leukocytes) bind other surface molecules
(i.e.,CD34, Sialyl-Lewis X-modified GP) that are upregulated
on endothelium by cytokines (TNF, IL-1) at injury sites
• Selectins are carbohydrate-binding molecules that bind to
fucosylated and sialylated glycoprotein ligands, and are found
on endothelial cells, leukocytes and platelets.
• They are involved in trafficking of cells of the innate immune
system, T lymphocytes and platelets
 Steps seen in figure
• The multistep process of leukocyte migration through blood vessels,
shown here for neutrophils. The leukocytes first roll, then become
activated and adhere to endothelium, then transmigrate across the
endothelium, pierce the basement membrane, and migrate toward
chemoattractants emanating from the source of injury.
• Different molecules play predominant roles in different steps of this
process-selectins in rolling; chemokines (usually displayed bound to
proteoglycans) in activating the neutrophils to increase avidity of
integrins; integrins in firm adhesion; and CD31 (PECAM-1) in
transmigration.
• Neutrophils express low levels of L-selectin; they bind to endothelial cells
predom in antly via P- and E-selectins. ICAM-1, intercellular adhesion
molecule 1; TNF, tumor necrosis factor.
 Adhesion

• Rolling comes to a stop and adhesion results by integrins

• Other sets of adhesion molecules participate:
• Endothelial: ICAM-1, VCAM-1
• Leukocyte: LFA-1, Mac-1, VLA-4
(ICAM-1 binds LFA-1/Mac-1, VCAM-1 binds VLA-4)
• Ordinarily down-regulated or in an inactive conformation, but
inflammation alters this
 Integrins.

• Integrins mediate the firm adhesion of leukocytes by

binding members of the immunoglobulin family of
adhesion molecules expressed on endothelial cells.
• Integrins are heterodimeric molecules consisting of an
α-subunit and a noncovalently-bound ß-subunit.
 Integrins
• They represent a large protein family that is classified by the ß-
subunits.
• ß1- (CD29), ß2- (CD18), ß3- (CD61), and ß7-integrins are engaged in
leukocyte recruitment, with ß2-integrins playing the key role in
mediating firm adhesion of human PMN subsequent to selectin-
mediated rolling.
 Integrins

• Leukocyte rolling constitutes a prerequisite for

ß2-integrin-mediated firm adhesion in vivo,
since ß2-integrins are not able to bind their
ligands unless the velocity of passing
leukocytes is slowed down to a critical value
by selectin-based rolling.
 Immunoglobulins.
• The most important adhesion molecules of the immunoglobulin superfamily that serve as
ligands for the integrins during leukocyte-endothelial cell interactions are the ICAMs
termed
• ICAM-1 (CD54),
• ICAM-2 (CD102),
• ICAM-3 (CD50), and
• VCAM-1 (CD106).
• ICAM-1 is strongly upregulated on endothelial cells
upon activation by inflammatory mediators such as
TNF-α.
• ICAM-1 binds LFA-1 with strong affinity, shows some
affinity for Mac-1, and putatively binds gp150/95.
• As mentioned above, ICAM-1 serves as the major
endothelial ligand that mediates firm adhesion of
PMN to inflamed endothelial cells and therefore plays
a central role in PMN recruitment to sites of
inflammation
 Regulation of expression of endothelial and leukocyte
adhesion molecules.
• A, Redistribution of P-selectin from intracellular stores to the cell surface.
• B, Increased surface expression of selectins and ligands for integrins upon cytokine
activation of endothelium.
• C, Increased binding avidity of integrins induced by chemokines.
• D. Clustering of integrins contributes to their increased binding avidity .
• Key
• IL-1, interleukin-1; TNF, tumor necrosis factor.
 Transmigration (diapedesis)

• Occurs after firm adhesion within the systemic

venules and pulmonary capillaries via PECAM –1
(CD31)
• Must then cross basement membrane
• Collagenases
• Integrins
 Transmigration (diapedesis)
• Early in inflammatory response mostly PMNs, but
as cytokine and chemotactic signals change with
progression of inflammatory response, alteration
of endothelial cell adhesion molecule expression
activates other populations of leukocytes to adhere
(monocytes, lymphocytes, etc)
 Leukocyte
Endothelial Molecule Molecule Major Role
P-selectin Sialyl-Lewis X- Rolling (neutrophils, monocytes,
modified proteins T lymphocytes)
E-selectin Sialyl-Lewis X- Rolling and adhesion
modified proteins (neutrophils, monocytes, T
lymphocytes)
GlyCam-1, CD34 L-selectin* Rolling (neutrophils, monocytes)

ICAM-1 (Ig family) CD11/CD18 (β2) Adhesion, arrest, transmigration

(Ig: immunoglobulins) integrins (LFA-1, (neutrophils, monocytes,
Mac-1) lymphocytes)

VCAM-1 (Ig family) VLA-4 (β1) integrin Adhesion (eosinophils,

monocytes, lymphocytes)
 Recognition of Microbes and Dead Tissues
• Once leukocytes (neutrophils and monocytes) have
been recruited to a site of infection or cell death, they
must be activated to perform their functions. The
responses of leukocytes consist of two sequential sets of
events:
• (1) recognition of the offending agents, which deliver
signals that
• (2) activate the leukocytes to ingest and destroy the offending agents and
amplify the inflammatory reaction.
 Leukocytes receptors that recognize external stimuli
and deliver activating signals
1. Receptors for microbial products: Toll-like receptors (TLRs) recognize components of different types of
microbes
2. G protein-coupled receptors found on neutrophils, macrophages, and most other types of leukocytes
recognize short bacterial peptides containing N-formylmethionyl residues
3. Receptors for cytokines: Leukocytes express receptors for cytokines that are produced in response to
microbes. One of the most important of these cytokines is interferon-γ (IFN-γ), which is secreted by
natural killer cells reacting to microbes and by antigen-activated T lymphocytes during adaptive immune
responses
4. Receptors for opsonins: Leukocytes express receptors for proteins that coat microbes. The process of
coating a particle, such as a microbe, to target it for ingestion (phagocytosis) is called opsonization, and
substances that do this are opsonins. These substances include antibodies, complement proteins, and
lectins.
 Chemotaxis
• Leukocytes follow chemical gradient to site of injury
(chemotaxis)
• Soluble bacterial products
• Complement components (C5a)
• Cytokines (chemokine family e.g., IL-8)
• LTB4 (AA metabolite)
• Chemotactic agents bind surface receptors inducing calcium
mobilization and assembly of cytoskeletal contractile elements
 Chemotaxis and Activation
• Leukocytes:
• extend pseudopods with overlying surface adhesion molecules (integrins) that bind
ECM during chemotaxis
• undergo activation:
• Prepare AA metabolites from phospholipids
• Prepare for degranulation and release of lysosomal enzymes (oxidative burst)
• Regulate leukocyte adhesion molecule affinity as needed
 Phagocytosis and Degranulation
• Once at site of injury, leukocytes:
• Recognize and attach
• Engulf (form phagocytic vacuole)
• Kill (degrade)
• 1-MPO system
• O2 Independent system
 Recognition and Binding
• Opsonized by serum complement,
immunoglobulin (C3b, Fc portion of IgG)
• Corresponding receptors on leukocytes (FcR,
CR1, 2, 3) leads to binding
Oxygen dependant Myeloperoxidase system (MPO)
 Phagocytosis and Degranulation
• Triggers an oxidative burst (next slide)
engulfment and formation of vacuole which
fuses with lysosomal granule membrane
(phagolysosome)
• Granules discharge within phagolysosome and
extracellularly (degranulation)
 Oxidative burst
• Reactive oxygen species formed through oxidative burst that includes:
• Increased oxygen consumption
• Glycogenolysis
• Increased glucose oxidation
• Formation of superoxide ion by NADPH oxidase
• 2O2 + NADPH  2O2-rad + NADP+ + H+ (NADPH oxidase)
• Formation of peroxidase
• O2 + 2H+  H2O2 (dismutase)
 Production of Bleech
• Hydrogen peroxide alone insufficient
• MPO (azurophilic granules) converts hydrogen
peroxide to hypochlorus free radicals HOCl- (in
presence of Cl- ), an oxidant/antimicrobial agent
• Therefore, PMNs can kill by halogenation, or
lipid/protein peroxidation
 Degradation and Clean-up

• Reactive end-products only active within

phagolysosome
• Hydrogen peroxide broken down to water and
oxygen by catalase
• Dead microorganisms degraded by lysosomal
acid hydrolases
 O2 Independent system:Leukocyte granules
 Other antimicrobials in leukocyte granules:
1. Bactericidal permeability increasing protein (BPI)
2. Lysozyme
1. cathelicidins, antimicrobial proteins found in neutrophils and other
cells
3. Lactoferrin
4. Defensins (punch holes in membranes). cationic arginine-rich granule
peptides that are toxic to microbes
5. Cathelicidins, antimicrobial proteins found in neutrophils and other
 Leukocyte-induced tissue injury
• Destructive enzymes may enter extracellular space in event of:
• Premature degranulation
• Frustrated phagocytosis (large, flat)
• Membranolytic substances (urate crystals)
• Persistent leukocyte activation (RA, emphysema)
 Defects of leukocyte function
• Defects of adhesion:
• LFA-1 and Mac-1 subunit defects lead to impaired adhesion (LAD-1)
• Absence of sialyl-Lewis X, and defect in E- and P-selectin sugar epitopes (LAD-
2)
• Defects of chemotaxis/phagocytosis:
• Microtubule assembly defect leads to impaired locomotion and lysosomal
degranulation (Chediak-Higashi Syndrome)
 Defects of leukocyte function
 Defects of microbicidal activity:
 Deficiency of NADPH oxidase that generates superoxide, therefore no oxygen-
dependent killing mechanism (chronic granulomatous disease, it is X-Linked Recessive
disease)
 Nitroblue tetrazolium test: The dye is converted blue if Neutrophic NADH system is
working and H2O2 is produced
 MPO deficiency
 It is recessive disorder
 H2O2 is there but no HOCl-
 NADPH defiency leads to Gl-6phos dehydrogenenase def
Disorders Cells and Molecules Involved in Injury
ACUTE

Acute respiratory distress syndrome Neutrophils

Acute transplant rejection Lymphocytes; antibodies and complement

Asthma Eosinophils; IgE antibodies

Glomerulonephritis Neutrophils, monocytes; antibodies and complement

Septic shock Cytokines

Lung abscess Neutrophils (and bacteria)

CHRONIC

Arthritis Lymphocytes, macrophages; antibodies?

Asthma Eosinophils; IgE antibodies

Atherosclerosis Macrophages; lymphocytes?

Chronic transplant rejection Lymphocytes; cytokines

Pulmonary fibrosis Macrophages; fibroblasts

Disease
GENETIC
Leukocyte adhesion deficiency 1
Leukocyte adhesion deficiency 2
Chronic granulomatous disease
X-linked
Autosomal recessive
MPO deficiency
Chédiak-Higashi syndrome
ACQUIRED
Bone marrow suppression: tumors,
radiation, and chemotherapy
Diabetes, malignancy, sepsis, chronic
dialysis
Leukemia, anemia, sepsis, diabetes,
Defect
Defective leukocyte adhesion because of mutations in β chain of CD11/CD18 integrins
Defective leukocyte adhesion because of mutations in fucosyl transferase required for
synthesis of sialylated oligosaccharide (ligand for selectins)
Decreased oxidative burst
Phagocyte oxidase (membrane component)
Phagocyte oxidase (cytoplasmic components)
Defects in Leukocyte Functions
Decreased microbial killing because of defective MPO-H2O2 system
Decreased leukocyte functions because of mutations affecting protein involved in
lysosomal membrane traffic
Production of leukocytes
Adhesion and chemotaxis
Phagocytosis and microbicidal activity
• Q-1. After Migration of neutrophils from the blood vessels, these do
unidirectional movements to the site of injury. The whole process takes place
with the help of chemical mediators. Complements system being a part of
Plasma Proteins plays an important role in acute inflammation. . All statements
given below are true. except one. Complement products are involved in
a)Chemotaxis
b)Increased vascular permeability
c)Neutrophil activation
d)Phagocytosis
e)Killing of bacteria in the phagocytic vacuole
 Q-2. Cellular event in acute inflammation is comprised of, margination, rolling,
adhesions, Pavementation and emigration of neurophils. Following emigration from
blood vessels, leucocyte migration to the site of infection or injury is mediated by
a) Bradykinin
b) Chemokines
c) Complement C5a
d) Histamine
e) Leukotrine
 Q-3.Acute inflammation is immediate response of vascular connective tissue against the
injury. It is comprised of vascular and cellular events. Leukocyte emigration from venules
is influenced by
a) Selectins and Integrins
b) Chemokines and opsonins
c) Complement C3a and C5a
d) Prostaglandins and Leukotrines
 Q-4.Aspirin is an important drug use during acute inflammation. The anti-inflammatory
property of aspirin affects. On the production of chemical mediators and causing
vasodilatation through
a) Inhibition of Cyclooxygenase
b) Inhibition of lipoxygenase pathway
c) Inhibition of Phagocytosis
d) Inhibition of Leucocyte emigration
e) Release of leukocytes from the bone marrow
 Q-5. There five cardinal signs of acute inflammation, Rubar, Calor, Dolar, tumor, and
functio laesa. Dolar is due to.
a) C3a
b) C5a
c) Histamine
d) PGD
e) Bradykinin
 Q-6. The following are oxygen-dependent killing mechanisms in neutrophils except.
a) Lysozyme
b) Lactoferrin
c) Myeloperoxidase
d) Cathelicidins
e) Hydrogen peroxidase
 Q-7. The following are oxygen-independent killing mechanisms in
neutrophils except.
a) Cationic Proteins
b) Bactericidal permeability increasing protein (BPI)
c) Lysozyme
d) Lactoferrin
e) Defensins
 Q-8. Defects of adhesion is due to
a) LAD
b) Microtubule assembly
c) NADPH
d) MPO
e) Argenine
• Q-9.There two types of granules in the Neutrophisl. Primary and secondary and
Both can be released into phagosomes, specific granules are much more readily
released extracellularly after cell death. Which substances is found in the
specific cytoplasmic granules of neutrophils..
a)Myeloperoxidase
b)Cationic proteins
c)Lactoferrin
d)Elastase
e)Defensins
• Q.10. During acute inflammation, there is a ‘burst’ of oxygen consumption
(respiratory burst) in neutrophils. This is an essential step for which of the
following events?
a) Increased neutrophil production in the bone marrow
b)Attachment to the endothelial cells
c) Opsonization of bacteria
d)Phagocytosis of bacteria
e) Generation of microbicidal activity
Chemical mediators of the Inflammation
Mediator Principal Sources Actions
CELL-DERIVED

Histamine Mast cells, basophils, platelets Vasodilation, increased vascular

permeability, endothelial activation

Serotonin Platelets Vasodilation, increased vascular

permeability

Prostaglandins Mast cells, leukocytes Vasodilation, pain, fever

Leukotrienes Mast cells, leukocytes Increased vascular permeability,

chemotaxis, leukocyte adhesion and
activation

Platelet-activating factor Leukocytes, mast cells Vasodilation, increased vascular

permeability, leukocyte adhesion,
chemotaxis, degranulation, oxidative burst

Reactive oxygen species Leukocytes Killing of microbes, tissue damage

Nitric oxide Endothelium, macrophages Vascular smooth muscle relaxation, killing

Cytokines (TNF, IL-1) Macrophages, endothelial cells, mast cells Local endothelial activation (expression of
adhesion molecules),
fever/pain/anorexia/hypotension, decreased
vascular resistance (shock)

Chemokines Leukocytes, activated macrophages Chemotaxis, leukocyte activation

PLASMA PROTEIN-DERIVED

Complement products (C5a, C3a, C4a) Plasma (produced in liver) Leukocyte chemotaxis and activation,
vasodilation (mast cell stimulation)

Kinins Plasma (produced in liver) Increased vascular permeability, smooth

muscle contraction, vasodilation, pain

Proteases activated during coagulation Plasma (produced in liver) Endothelial activation

 Chemical mediators
• Plasma-derived:
• Complement,
• kinins,
• coagulation factors
• Many in “pro-form” requiring activation (enzymatic cleavage)
• Cell-derived:
• Preformed,
• sequestered and released (mast cell histamine)
• De novo: Synthesized as needed (prostaglandin)
 Chemical mediators
• May or may not utilize a specific cell surface receptor for activity
• May also signal target cells to release other effector molecules
that either amplify or inhibit initial response (regulation)
• Are tightly regulated:
• Quickly decay (AA metabolites), are inactivated enzymatically (kininase), or are
scavenged (antioxidants)
 Specific mediators
• Vasoactive amines
• Histamine: vasodilation and venular endothelial cell contraction, junctional widening;
released by mast cells, basophils, platelets in response to injury (trauma, heat), immune
reactions (IgE-mast cell FcR), anaphylatoxins (C3a, C5a fragments), cytokines (IL-1, IL-
8), neuropeptides, leukocyte-derived histamine-releasing peptides

• Serotonin: vasodilatory effects similar to those of histamine; platelet dense-body

granules; release triggered by platelet aggregation
 Specific mediators
• Plasma proteases
• Clotting system
• Complement
• Kinins
 Specific Mediators
Arachidonic acid metabolites (eicosanoids)
 Prostaglandins and thromboxane: via cyclooxygenase pathway; cause vasodilation and
prolong edema; but also protective (gastric mucosa); COX blocked by aspirin and NSAIDS
 Leukotrienes: via lipoxygenase pathway; are chemotaxins, vasoconstrictors, cause increased
vascular permeability, and bronchospasm
PAF (platelet activating factor)
 Derived also from cell membrane phospholipid, causes vasodilation, increased vascular
permeability, increases leukocyte adhesion (integrin conformation)
 Clotting cascade

• Cascade of plasma proteases

• Hageman factor (factor XII)
• Collagen, basement membrane, activated platelets converts XII to XIIa (active
form)
• Ultimately converts soluble fibrinogen to insoluble fibrin clot
• Factor XIIa simultaneously activates the “brakes” through the fibrinolytic
system to prevent continuous clot propagation
 Kinin system
• Leads to formation of bradykinin from cleavage of precursor
(HMWK)
• Vascular permeability
• Arteriolar dilation
• Non-vascular smooth muscle contraction (e.g., bronchial smooth muscle)
• Causes pain
• Rapidly inactivated (kininases)
 Complement system
• Components C1-C9 present in inactive form
• Activated via classic (C1) or alternative (C3) pathways to generate MAC (C5 –
C9) that punch holes in microbe membranes
• In acute inflammation
• Vasodilation, vascular permeability, mast cell degranulation (C3a, C5a)
• Leukocyte chemotaxin, increases integrin avidity (C5a)
• As an opsonin, increases phagocytosis (C3b, C3bi)
 More specific mediators
• Cytokines
• Protein cell products that act as a message to other cells, telling them how to
behave.
• IL-1, TNF- and -, IFN- are especially important in inflammation.
• Increase endothelial cell adhesion molecule expression, activation and
aggregation of PMNs, etc., etc., etc.
 Specific mediators
• Nitric Oxide
• short-acting soluble free-radical gas with many functions
• Produced by endothelial cells, macrophages, causes:
• Vascular smooth muscle relaxation and vasodilation
• Kills microbes in activated macrophages
• Counteracts platelet adhesion, aggregation, and degranulation
 Specific mediators
• Lysosomal components
• Leak from PMNs and macrophages after demise, attempts at phagocytosis, etc.
• Acid proteases (only active within lysosomes).
• Neutral proteases such as elastase and collagenase are destructive in ECM.
• Counteracted by serum and ECM anti-proteases.
Patterns of acute and chronic inflammation
 Serous Inflammation

• Watery excessive accumulation of fluid, protein-poor

effusion (e.g. skin blister)
• initial phases of inflamm.
• modification - catarrhal - accumulation of mucus
 Serous exudates
• is marked by the outpouring of a thin fluid
that may be derived from the plasma or from
the secretions of mesothelial cells lining the
peritoneal, pleural, and pericardial cavities.
• Accumulation of fluid in these cavities is
called an effusion.
• The skin blister resulting from a burn or viral
infection represents a large accumulation of
serous fluid, either within or immediately
beneath the epidermis of the skin
 Fibrinous and
• fibrinous - higher vascular permeability - exsudation of fibrinogen -> fibrin - e.g.
pericarditis (cor villosum, cor hirsutum - "hairy" heart
• fibrinolysis  resolution; organization  fibrosis  scar
 Fibrinous Exudate
 With greater increase in vascular permeability,
large molecules such as fibrinogen pass the
vascular barrier, and fibrin is formed and
deposited in the extracellular space.
 A fibrinous exudate develops when the vascular
leaks are large or there is a local procoagulant
stimulus (e.g., cancer cells).
 A fibrinous exudate is characteristic of
inflammation in the lining of body cavities, such
as the meninges, pericardium
 Purulent
• This type of inflammation is characterized by the
production of large amounts of pus or purulent
exudate consisting of neutrophils, liquefactive
necrosis, and edema fluid.
• Certain bacteria (e.g., staphylococci) produce this
localized suppuration and are therefore referred to
as pyogenic (pus-producing) bacteria.
• A common example of an acute suppurative
inflammation is acute appendicitis
 Suppurative
• Suppurative (purulent) - accumulation of neutrophillic leucocytes -
formation of pus (pyogenic bacteria)
• Presence of pus (pyogenic staph spp.), Often walled-off if persistent
• Interstitial
• phlegmone – diffuse soft tissue
• abscess - localized collection
• acute – border – surrounding tissue
• chronic – border - pyogenic membrane
• Pseudoabscess – pus in lumen of hollow organ
• formation of suppurative fistule, accumulation of pus in preformed cavities
- empyema (gallbladder, thoracic)
 Complications of suppurative inflamm
1. bacteremia (no clinical symptoms!; danger of formation of secondary foci of
inflamm. (endocarditis, meningitis)
2. sepsis (= massive bacteremia) - septic fever, activation of spleen, septic shock
 Cont,
1. thrombophlebitis - secondary inflammation of wall of the
vein with subsequent thrombosis - embolization - pyemia
- hematogenous abscesses (infected infarctions)
2. lymphangiitis,
3. lymphadenitis
 Pseudomembranous - fibrinous
• pseudomembrane (diphtheria - Corynebacterium, dysentery -
Shigella) - fibrin, necrotic mucosa, etiologic agens, leucocytes
 Necrotizing
• inflammatory necrosis of the surface - ulcer (skin, gastric)
• gangrenous - secondary modification by bacteria - wet gangrene - apendicitis,
cholecystitis - risk of perforation - peritonitis
 Ulceration
• Necrotic and eroded epithelial surface
• Underlying acute and chronic inflammation
• Trauma, toxins, vascular insufficiency
Possible outcomes of acute inflammation
 Possible outcomes of acute inflammation

• Complete resolution
• Little tissue damage
• Capable of regeneration
• Scarring (fibrosis)
• In tissues unable to regenerate
• Excessive fibrin deposition organized into fibrous tissue
 Outcomes (cont’d)
• Abscess formation occurs with some bacterial or fungal infections
• Progression to chronic inflammation (next)
Outcomes of acute inflammation
• 1. resolution - restoration to normal, limited injury
• chemical substances neutralization
• normalization of vasc. permeability
• apoptosis of inflammatory cells
• lymphatic drainage

• 2. healing by scar
• tissue destruction
• fibrinous inflammtion
• purulent infl.  abscess formation (pus, pyogenic membrane, resorption - pseudoxanthoma
cells - weeks to months)

• 3. progression into chronic inflammation

 Systemic effects
• Fever
• One of the easily recognized cytokine-mediated (esp. IL-1, IL-6, TNF) acute-phase reactions
including
• Anorexia
• Skeletal muscle protein degradation
• Hypotension
• Leukocytosis
• Elevated white blood cell count
Systemic Effects of Inflammation
 Why fever
• Fever is produced in response to substances called pyrogens that act by stimulating
prostaglandin synthesis in the vascular and perivascular cells of the hypothalamus.
• Bacterial products, such as LPS (called exogenous pyrogens), stimulate leukocytes
to release cytokines such as IL-1 and TNF (called endogenous pyrogens) that
increase the enzymes (cyclooxygenases) that convert AA into prostaglandins
 Continued
• In the hypothalamus, the prostaglandins, especially PGE2, stimulate
the production of neurotransmitters such as cyclic AMP, which
function to reset the temperature set-point at a higher level.
 Continued
• NSAIDs, including aspirin, reduce fever by inhibiting cyclooxygenase
and thus blocking prostaglandin synthesis.
• One hypothesis is that fever may induce heat shock proteins that
enhance lymphocyte responses to microbial antigens.
 Acute-phase proteins are plasma proteins

 mostly synthesized in the liver, whose plasma concentrations may increase several hundred-fold as
part of the response to inflammatory stimuli.
 Three of the best-known examples of these proteins are C-reactive protein (CRP), fibrinogen, and
serum amyloid A protein (SAA).
 Synthesis of these molecules by hepatocytes is upregulated by cytokines, especially IL-6 (for CRP
and fibrinogen) and IL-1 or TNF (for SAA).
 Many acute-phase proteins, such as CRP and SAA, bind to microbial cell walls, and they may act as
opsonins and fix complement. They also bind chromatin, possibly aiding in the clearing of necrotic
cell nuclei.
 Why ESR rises
• The rise in fibrinogen causes erythrocytes to form stacks (rouleaux)
that sediment more rapidly at unit gravity than do individual
erythrocytes. This is the basis for measuring the erythrocyte
sedimentation rate (ESR)
 What happens with macrophages
• During the acute phase response, serum amyloid A protein replaces
apolipoprotein A, a component of high-density lipoprotein particles.
• This may alter the targeting of high-density lipoproteins from liver
cells to macrophages, which can utilize these particles as a source of
energy-producing lipids.
• causes secondary amyloidosis in chronic inflammation
 MI and CRP
• Elevated serum levels of CRP are now used as a marker for increased
risk of myocardial infarction in patients with coronary artery disease.
 Atherosclerosis and CRP
• It is believed that inflammation involving atherosclerotic plaques in
the coronary arteries may predispose to thrombosis and subsequent
infarction, and CRP is produced during inflammation.
• On this basis, anti-inflammatory agents are being tested in patients
to reduce the risk of myocardial infarction.
 Leukocytosis
• Leukocytosis is a common feature of inflammatory reactions, especially those induced
by bacterial infection.
• The leukocyte count usually climbs to 15,000 or 20,000 cells/μl, but sometimes it may
reach extraordinarily high levels of 40,000 to 100,000 cells/μl.
• These extreme elevations are referred to as leukemoid reactions because they are
similar to the white cell counts obtained in leukemia.
• Corticosteroids, catecholamine and lithium inhibits adhesion molecules and there is
leukocytosis especially neutrophilia in the periphery
 Why leukocytosis
1. The leukocytosis occurs initially because of accelerated release of
cells from the bone marrow postmitotic reserve pool (caused by
cytokines, including IL-1 and TNF) and is therefore associated with
a rise in the number of more immature neutrophils in the blood
(shift to the left).
2. Prolonged infection also induces proliferation of precursors in the
bone marrow, caused by increased production of colony stimulating
factors (CSFs).
 Systemic effects (cont’d)
• Bacterial infection (neutrophilia)
• Neutrophilia refers to an increase in the blood neutrophil count. Most bacterial infections induce
neutrophilia.
• Parasitic infection (eosinophilia)
• In an additional group of disorders, which includes
bronchial asthma, hay
fever, and parasitic infestations, there is an absolute increase
in the number of eosinophils, creating an eosinophilia
 Cont,
• Viral infection (lymphocytosis)
• Viral infections such as infectious mononucleosis, mumps, and German
measles produce a leukocytosis by virtue of an absolute increase in the number
of lymphocytes (lymphocytosis).
 leukopenia
• Leukopenia is also encountered in infections that overwhelm patients
debilitated by disseminated cancer or rampant tuberculosis.
• Certain infections (typhoid fever and infections caused by viruses,
rickettsiae, and certain protozoa) are associated with a decreased
number of circulating white cells (leukopenia).
• Endotoxins enhance activation of adhesion molecules and cause a
decrease neutrophils in the peripheral blood
 Why pulse and BP rises, decrease sweating

• Mainly because of redirection of blood flow from cutaneous to deep vascular

beds, to minimize heat loss through the skin;
• rigors (shivering), chills (search for warmth), anorexia, somnolence, and malaise,
probably because of the actions of cytokines on brain cells.
 Why DIC
 In severe bacterial infections (sepsis), the large amounts of organisms and LPS in the blood
stimulate the production of enormous quantities of several cytokines,
notably TNF and IL-1.
 As a result, circulating levels of these cytokines increase and the form of the host response
changes.
 High levels of TNF cause disseminated intravascular coagulation (DIC).
 Why DIC
• Thrombosis results from two simultaneous reactions:
• LPS and TNF induce tissue factor (TF) expression on endothelial
cells, which initiates coagulation;
• the same agents inhibit natural anticoagulation mechanisms, by decreasing the
expression of tissue factor pathway inhibitor (TFPI) and endothelial cell
thrombomodulin.
 Why Liver function tests altered
• Cytokines cause liver injury and impaired liver function, resulting in a
failure to maintain normal blood glucose levels due to a lack of
gluconeogenesis from stored glycogen.
• Overproduction of NO by cytokine-activated cardiac myocytes and
vascular smooth muscle cells leads to heart failure and loss of
perfusion pressure, respectively, resulting in hemodynamic shock.
 Why septic shock
• The clinical triad of DIC, hypoglycemia, and cardiovascular failure is
described as septic shock.
 Why multiple organs failure
• Multiple organs show inflammation and intravascular thrombosis, which can
produce organ failure.
• Tissue injury in response to LPS can also result from the activation of neutrophils
before they exit the vasculature, thus causing damage to endothelial cells and
reduced blood flow.
 Liver, Lungs and Kidneys damage
• The lungs and liver are particularly susceptible to injury by
neutrophils.
• Lung damage in the systemic inflammatory response, commonly
called the adult respiratory distress syndrome (ARDS), results when
neutrophil-mediated endothelial injury allows fluid to escape from
the blood into the airspace.
• The kidney and the bowel are also injured, largely due to reduced
perfusion. This condition is often fatal
• What are adhesion molecules
• Β2-Intergrin (CD11&CD18)
• Adhesion molecules activation is caused by
• C5a and leucotrines LTB4
• What are mediators of fever
• IL-1 Prostaglandin
• What are mediators of exudate on formation
• Histamine and bradykinin
• What are mediators of chemotaxis
• C-5a and interleukin 8
• What are mediators of pain
• Prostaglandins and bradykinin
• What are mediators of vasodilatation
• NO and Prostaglandins
• What are mediators of phogocytosis
• C3b
Action Eicosanoid
Vasodilation PGI2 (prostacyclin), PGE1, PGE2, PGD2

Vasoconstriction Thromboxane A2, leukotrienes C4, D4,

E4
Increased vascular Leukotrienes C4, D4, E4
permeability
Chemotaxis, leukocyte Leukotriene B4, HETE
adhesion
Cytokine Principal Sources Principal Actions in Inflammation
IN ACUTE INFLAMMATION
TNF Macrophages, mast cells, T lymphocytes Stimulates expression of endothelial adhesion
molecules and secretion of other cytokines;
systemic effects

IL-1 Macrophages, endothelial cells, some Similar to TNF; greater role in fever
epithelial cells
IL-6 Macrophages, other cells Systemic effects (acute-phase response)

Chemokines Macrophages, endothelial cells, T Recruitment of leukocytes to sites of

lymphocytes, mast cells, other cell types inflammation; migration of cells to normal
tissues
IN CHRONIC INFLAMMATION
IL-12 Dendritic cells, macrophages Increased production of IFN-γ
IFN-γ T lymphocytes, NK cells Activation of macrophages (increased ability
to kill microbes and tumor cells)

IL-17 T lymphocytes Recruitment of neutrophils and monocytes

 Pathology:
The science behind the cure
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