Acute and Chronic Inflammation

INFLAMMATION
Is

a complex reaction in vascularized tissue to injurious agents such as microbes and damages, usually necrotic, cells that consist vascular responses, migration and activation of leucocytes and systemic reactions Unique feature is reaction of blood vessels accumulation of fluid and leucocytes in extravascular tissue Inflammatory is fundamentally a protective response but potentially harmful (lifethreatening hypersensitivity, rhematoid arthritis)

The inflammatory response consists of two main components :

a

vascular reaction a cellular reaction many tissues and cells are involved in these reactions, including the fluid and proteins of plasma, circulating cells, blood vessels, and cellular and extracellular constituents of connective tissue

The components of acute and chronic inflammatory responses: circulating cells and proteins, cells of blood vessels, and cells and proteins of the extracellular matrix

Inflammation is divided into :

Acute

inflammation is rapid in onset (seconds or minutes) and is of relatively short duration, lasting for minutes, several hours, or a few days; its main characteristics are the exudation of fluid and plasma proteins (edema) and the emigration of leukocytes, predominantly neutrophils. inflammation is of longer duration and is associated histologically with the presence of lymphocytes and macrophages, the proliferation of blood vessels, fibrosis, and tissue necrosis.

Chronic

 The

vascular and cellular reactions of both acute and chronic inflammation are mediated by chemical factors that are derived from plasma proteins or cells and are produced in response to or activated by the inflammatory stimulus Inflammation is terminated when the offending agent is eliminated and the secreted mediators are broken down or dissipated

acute inflammation :
a rapid response to an injurious agent that serves to deliver mediators of host defenseleukocytes and plasma proteins-to the site of injury 3 major component

Alteration in vascular caliber blood flow

structural changes in microvasculature plasma protein and leucocyte leave the circulation Emigration of leucocyte from the microcirculation,accumualtion in focus of injury, activation to eliminate offending

The major local manifestations of acute inflammation, compared to normal. (1) Vascular dilation and increased blood flow (causing erythema and warmth), (2) extravasation and deposition of plasma fluid and proteins (edema), and (3) leukocyte emigration and accumulation in the site of injury

TERMINOLOGI

Eksudasi. Keluarnya cairan, protein, dan sel darah dari sistem vaskuler ke jaringan interstisial atau rongga tubuh. Eksudat. Cairan radang ekstraseluler yang mengandung protein berkonsentrasi tinggi, banyak debris sel, dan gravitas (berat jenis) spesifik di atas 1,020. Transudat. Cairan yang berkadar protein rendah dan gravitas (berat jenis) spesifik di bawah 1,012. Pada hakekatnya cairan ini adalah ultrafiltrat plasma darah dan terjadi akibat ketidakseimbangan tekanan hidrostatik di endotel vaskuler. Edema. kelebihan cairan di jaringan interstisial atau rongga serosa; dapat berupa eksudat atau transudat. Pus Eksudat radang purulen yang kaya akan leukosit dan debris sel parenkimal.

STIMULI FOR ACUTE INFLAMMATION

Infections (bacterial, viral, parasitic) and microbial toxins Trauma (blunt and penetrating) Physical and chemical agents (thermal injury, e.g., burns or frostbite; irradiation; some environmental chemicals) Tissue necrosis (from any cause) Foreign bodies (splinters, dirt, sutures) Immune reactions (also called hypersensitivity reactions)

VASCULAR CHANGES
Perubahan diameter dan arus vaskuler

Pada awalnya terjadi vasokonstriksi arteriol yang sementara dan singkat Kemudian terjadi vasodilatasi sehingga arus bertambah; ini yang menyebabkan panas dan warna kemerahan Peningkatan permeabilitas vaskuler cairan kaya protein ke jaringan ekstravaskuler Konsentrasi sel darah merah di pembuluh kecil viskositas darah naik dilatasi pembuluh kecil terisi eritrosit dan arus darah turun stasis Dengan adanya perlambatan, terjadi marginasi leukosit,terakumulasi sekitar endotelium dan menempel, ini yang merupakan awal dari peristiwa seluler

Increased vascular permeability (vascular leakage)

The hallmark of acute inflammation is increased vascular permeability leading to escape of a protein rich fluid (exudate) into extravascular tissue The loss of protein from plasma intravascular osmotic pressure and interstitial osmotic pressure Together with increase intravascular hydrostatic pressure fluid outflow interstitial accumulation edema

Blood pressure and plasma colloid osmotic forces in normal and inflamed microcirculation. A, Normal hydrostatic pressure (red 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. Although fluid tends to leave the precapillary arteriole, it is returned in equal amounts via the postcapillary venule, so that the net flow (black arrows) in or out is zero. B, Acute inflammation. Arteriole pressure is increased to 50 mm Hg, the mean capillary pressure is increased because of arteriolar dilation, and the venous pressure increases to approximately 30 mm Hg. At the same time, osmotic pressure is reduced (averaging 20 mm Hg) because of protein leakage across the venule. The net result is an excess of extravasated fluid.

Diagrammatic representation of five mechanisms of increased vascular permeability in inflammation

In acute inflammation, fluid loss from vessels with increased permeability occurs in distinct phases :
An immediate transient response lasting for 30 minutes or less A delayed response starting at about 2 hours and lasting for about 8 hours mediated by kinins, complement products etc A prolonged response that is most noticeable after direct endothelial injury

1. 2.

3.

Cellular events: leukocyte extravasation and phagocytosis

The sequence of events in the journey of leukocytes from the vessels lumen to the interstitial tissue (extravasation): 1. in the lumen : margination, rolling, and adhesion to the endothelium 2. transmigration across the endothelium

(diapedesis)
3. migration in interstitial tissues toward a chemotactic stimulus

process-selectins in rolling; chemokines in activating the neutrophils to increase avidity of integrins (in green); integrins in firm adhesion; and CD31 (PECAM-1) in transmigration

The multistep process of leokocyte migration through blood vessels, shown here for neutrophils

Leukocyte adhesion and transmigration

Are regulated largely by the binding of complementary adhesion molecules on the leukocyte and endothelial surfaces, and chemical mediators-chemoattractants and certain cytokines-affect these processes by modulating the surface expression or avidity of such adhesion molecules The adhesion receptors involved belong to 4 molecular families : - selectin - immunoglobulin superfamily - integrins - mucin;like glycoproteins

Endothelial/Leukocyte Adhesion Molecules

Endothelial Molecule Leukocyte Receptor Major Role

P-selectin
E-selectin ICAM-1

Sialyl-Lewis X PSGL-1
Sialyl-Lewis X CD11/CD18 (integrins) (LFA-1, Mac-1) 41 (VLA4) (integrins) 47 (LPAM-1) L-selectin CD31

Rolling (neutrophils, monocytes, lymphocytes)

Rolling, adhesion to activated endothelium (neutrophils, monocytes, T cells) Adhesion, arrest, transmigration (all leukocytes)

VCAM-1

Adhesion (eosinophils, monocytes, lymphocytes)

GlyCam-1 CD31 (PECAM)

Lymphocyte homing to high endothelial venules Leukocyte migration through endothelium

Regulation of endothelial and leukocyte adhesion molecules. A, Redistribution of P-selectin. B, Cytokine activation of endothelium. C, Increased binding avidity of integrins
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Chemotaxis

After extravasation, leukocytes emigrate in tissues toward the site of injury chemotaxis All granulocytes, monocytes, lymphocytes respond to chemotactic stimuli Both exogenous and endogenous substances can act as chemoattrsactants Exogenous agents : bacterial product Endogenous agents : complement system (C5a), lipoxigenase pathway (leukotriene B4), cytokines (IL-8)

Leukocyte activation
The functional responses that are induced on leukocyte activation include : - production of arachidonic acid
metabolites from phospholipids - degranulation and secretion of lysosomal enzymes and activation of the oxidative burst - secretion of cytokines - modulation of leukocyte adhesion molecules

Figure: Leukocyte activation. Different classes of cell surface receptors of leukocytes recognize different stimuli. The receptors initiate responses that mediate the functions of the leukocytes. Only some receptors are depicted

Phagocytosis
Involves 3 distinct but interrelated steps : 1. Recognition and attachment 2. Engulfment, with subsequent formation of phagocytic vacuole 3. Killing or degradation of the ingested material

Figure : A, Phagocytosis of a particle (e.g., bacterium) involves attachment and binding of Fc and C3b to receptors on the leukocyte membrane, engulfment, and fusion of lysosomes with phagocytic vacuoles, followed by destruction of ingested particles within the phagolysosomes. Note that during phagocytosis, granule contents may be released into extracellular tissues. B, Production of microbicidal reactive oxygen intermediates within phagocytic vesicles

Release of leukocyte products and leukocyteinduced tissue injury

During activation & phagocytosis, leukocytes release microbial and other products The most important of these substances in neutrophils & macrophages are : lysosomal enzymes, reactive oxygen intermediates, products of arachidonic acid metabolism (Pg and leukotrienes)

Table 2-2. Clinical Examples of LeukocyteInduced Injury

Acute Acute respiratory distress syndrome Acute transplant rejection Asthma Glomerulonephritis Reperfusion injury Septic shock Vasculitis Chronic Arthritis Asthma Atherosclerosis Chronic lung disease Chronic rejection

Defects in Leukocyte Function

defects

in leukocyte function, both genetic and acquired, lead to increased vulnerability to infections the existence of clinical genetic deficiencies in each of the critical steps in the process has been described : 1. defects in leukocyte adhesion 2. defects in phagolysosome function 3. defects in microbicidal activity

Table 2-3. Defects in Leukocyte Functions

Disease Defect

Genetic
Leukocyte adhesion deficiency 1 Leukocyte adhesion deficiency 2 Chronic granulomatous disease X-linked chain of CD11/CD18 integrins Fucosyl transferase required for synthesis of sialylated oligosaccharide (receptor for selectin) Decreased oxidative burst NADPH oxidase (membrane component)

Autosomal recessive
Myeloperoxidase deficiency Chdiak-Higashi syndrome

NADPH oxidase (cytoplasmic components)

Absent MPO-H2O2 system Protein involved in organelle membrane docking and fusion

Acquired
Thermal injury, diabetes, malignancy, sepsis, immunodeficiencies
Hemodialysis, diabetes mellitus Leukemia, anemia, sepsis, diabetes, neonates, malnutrition

Chemotaxis
Adhesion Phagocytosis and microbicidal activity

TERMINATION OF THE ACUTE INFLAMMATORY RESPONSE

switch in the production of pro-inflammatory leukotrienes to anti-inflammatory lipoxins from arachidonic acid the liberation of an anti-inflammatory cytokine, transforming growth factor- (TGF-), from macrophages and other cells neural impulses (cholinergic discharge) that inhibit the production of TNF in macrophages.

Chemical mediators of

inflammation

General Principles of the Mediators

1. 2. M. originate either from plasma or cells are present in plasma in precursors form that must be activated. Major source platelets, neutrophyl, monocytes etc Active M is triggered by microbial products or by host proteins, such as complement, kinin and coagulation systems Perform their biologic activity by binding to specific receptor on target cell, direct enzymatic activity or mediate oxidative damage Can stimulate the release of M. by target cell themselves Can act on one of few target cell type Short-lived (quickly decay, inactivated, scavenged or inhibited) Have the potential to cause harmful effects

3.
4. 5. 6. 7.

Figure: Chemical mediators of inflammation. EC, endothelial cells

Vasoactive Amines
Histamin
The mast cells (also found in basophills & platelets) Stimulated by : - physical injury - immune reaction ( ab-mast cells) - anaphylatoxins (C3a & C5a) - histamine-releasing proteins derived from leucocytes - neuropeptides (substance P) - cytokines (IL-1, IL-8) It acts on the microcirculation mainly via H1 receptors

Serotonin (5-OH tryptamine)

Present in platelets & enterochromaffin cells

Actions = histamine
Release of S is stimulated when platelets aggregate

Platelet aggregation & release are also stimulated by PAF derived from mast cell during IGE-mediated reactions increased permeability during immunologic reactions

Plasma Proteins
A variety of phenomena in the inflammatory response are mediated by 3 interrelated plasmaderived factors :
1. Complement system
2. Kinin system 3. Clotting system

Figure : Interrelationships between the four plasma mediator systems triggered by activation of factor XII (Hageman factor). Note that thrombin induces inflammation by binding to proteaseactivated receptors (principally PAR-1) on platelets, endothelium, smooth muscle cells, and other cells

Complement System
Consist of 20 component proteins, greatest cons in plasma As inactive forms in plasma are numbered C1-C9 (C3 & C5 are the most important inflam-mediators) The biologic functions : 1. Cells lysis by the MAC (Membrane Attack Complex) 2. Proteolytic The most critical step is the activation of the 3 rd compl, C3, by the classic pathway, the alternative pathway or lectin pathway.

Overview of Complement Activation Pathways

Complement-Derived Factors Affect a Variety of Phenomena in AcuteInflammation

1. Vascular phenomena : C3a, C5a & to a small extent, C4a (anaphylatoxins) vasc. permeab. & vasodilation (histamin from mast cells). C5a also activates the lipoxygenase pathway of AA metab. in neutrophils & monocytes release of inflam med. 2. Leucocyte adhe, chemotaxis and activation. C5a is powerful chemotaxis agent for neutro, mono, eosino & basophyls 3. Phagocytosis : C3b & C3bi, when fixed to the bact. cell wall, act as opsonins & favor phagocytosis by neutro & macrophages

Figure The activation and functions of the complement system. Activation of complement by different pathways leads to cleavage of C3. The functions of the complement system are mediated by breakdown products of C3 and other complement proteins, and by the membrane attack complex (MAC)

Regulation of Complement Activation

Complement activation can be controlled at several steps : Regulation of C3 & C5 convertases Decay acceleration of convertase complex (DAF) Proteolytically cleaving C3b Binding of active complement components by specific proteins in the plasma : C1-inhibitor Membrane inhibitor of reactive lysis to inhibit MAC formation

Disorders of the Complement System

Deficiency of C3 : results in increased susceptibility to infections Deficiency of C2 & C4 : are associated with auto immune disease (exp. SLE) Deficiency of C1 inhibitor is associated with the syndrome of hereditary angioneurotic edema

A Few General Conclusion

B. kinin, C3a & C5a C5a Thrombin : mediators of vasc permeab : mediator of chemotaxis : are likely to be the most important in vivo, also leuco adhesion & fibroblast proliferation

C3 & C5 can be generated by : classic pathway, alternative pathway, lectin pathway & agents with little in immuno. specificity (plasmin, kallikrein) Activated Hageman factor (f.XIIa) initiated 4 system involved in inflamm. response : the kinin, the clotting, the fibrinolytic & the complement system

Coagulation & Inflammation are Tightly Linked

Acute inflammation, by activating or damaging the
endothelium can trigger coagulation and induce thrombus formation Conversely, the coagulation cascade induces inflammation, primarilly via the action of thrombus

Arachidonic Acid (20-carbon polyunsaturated FA/5,8,11,14eicosatetraenoic acid

Dietary sources or by conversion from the essen. FA Linoleic acid

Normally esterified in membran phospholipids

It is released through the action of cellular phospholipase, which may be activated by mechanical, chemical & physical stimuli or by other mediators (exp. C5a)

Arachidonic Acid Metabolites (Eicosanoids)

1. Prostaglandins 2. Leukotrienes 3. Lipoxins are synthesized by 2 major classes of enzymes :
1. 2. Cyclooxygenases (prostaglandins & thromboxanes) Lipoxygenases (leukotrienes & lipoxins)

Eico. bind to G protein-coupled receptors on many cell types and can mediate virtually every step of inflammation

Figure: Generation of arachidonic acid metabolites and their roles in inflammation. The molecular targets of action of some anti-inflammatory drugs are indicated by a red X. COX, cyclooxygenase; HETE, hydroxyeicosatetraenoic acid; HPETE, hydroperoxyeicosatetraenoic acid

Table : Inflammatory Actions of Eicosanoids Action Vasoconstriction Metabolite Thromboxane A2, leukotrienes C4, D4, E4 PGI2, PGE1, PGE2, PGD2 Leukotrienes C4, D4, E4 Leukotriene B4, HETE, lipoxins

Vasodilation Increased vascular permeability Chemotaxis, leukocyte adhesion

Anti-inflammatory Therapy
Aspirin and NSAIDs (indomethacin or ibuprofen) inhibit cyclooxygenase thus inhibit prostaglandin syntesis. Glucocorticoids which are powerful anti-inflammatory agents, may act by down-regulating the expression of spec target genes, including COX2, genes encoding proinflammatory cytokines (such as IL-1 and TNF-), and nitric oxide synthase (iNOS). Also up-regulate genes that encode potent anti-inflammatory proteins, such as lipocortin 1 inhibits release of AA from memb. Phospho. Leukotrienes from fatty acids found in fish oil are less potent than those derived from the Arach. Acid found in most animal or vegetable fat.

Platelet Activating Factor

Is acetyl-glyceryl-ether-phosphorylcholine (AGEPC) A phospholipid, mediates its effects via a single G protein-coupled receptor

Its effects are regulated by a family of inactivating PAF acetylhydrolases

A variety of cell types, including platelets, basophils (& mast cells), neutro, mono, macrophages and endoth. can elaborate PAF

The Effect of PAF

Vasoconstriction, bronchoconstriction.

At extremely low concentration it induces. vasodilation and venular permeability with a potency 100 10.000 x greater than that of histamine.
leuco adhesion to endothelium, chemotaxis, degranulation, oxidative hurst. Also boosts the synthesis of other mediators, particularly Eicosanoids by leuco and other cells

Structure, Source and main inflammatory action of PAF

Source Mast cell/basophils Neutrophils Monocyte/macroph Endothelium Platelets Others Major inflammatory actions Increased vasc. permeab Leucocyte aggregation Leucocyte adhesion L. priming/chemotaxis Platelet activation Stimulation of other mediators (leucotrienes)

Cytokines and Chemokines

Cytokines are proteins produced by many cells types (activated lympho, macroph, also endo, epithel & conn. tissue cells) To be involved in cellular immune responses Colony stimulating factors (CSFs) stimulate the growth of immature peuco in the BM. Interleukins, a broad family of cytokines, are made by hematopoetic cells and act primarily on leucocytes. Chemokines are cytokines that share the ability to stimulate leukocyte movement (chemokinesis) and directed movement (chemotaxis)

General Properties of Cytokines

Are produced during immune & inflamm. responses
Secretion is transient and closely regulated Many cell types produce multiple cytokines

The protein are pleotropic in that they can act on different cell types
C can influence the synthesis or action of other C Are multifunctional in that an individual C may have both pos. and neg. regulatory actions

Cytokines can be grouped into 5 classess, depending on their major function as the nature of the target cells

1. C that regulate lymphocyte function (IL-2, IL-4, IL-10 & TGF-)

2. C involved with natural immunity (TNF & IL1; type 1 interferons (IFN-, IFN- ) and IL-6 3. C that active inflammatory cells 4. Chemokines 5. C that stimulate hematopoiesis

Biosynthesis of leukotrienes and lipoxins by cell-cell interaction

Biosynthesis of leukotrienes and lipoxins by cell-cell interaction. Activated neutrophils generate LTB4 from arachidonic acid-derived LTA4 by the action of 5-lipoxygenase, but they do not possess LTC4-synthase activity and consequently do not produce LTC4. In contrast, platelets cannot form LTC4 from endogenous substrates, but they can generate LTC4 and lipoxins from neutrophil-derived LTA4. (Courtesy of Dr. C. Serhan, Brigham and Women's Hospital, Boston, MA.)

Figure : Major effects of interleukin-1 (IL-1) and tumor necrosis factor (TNF) in inflammation

Figure : Functions of nitric oxide (NO) in blood vessels and macrophages, produced by two NO synthase enzymes. NO causes vasodilation, and NO free radicals are toxic to microbial and mammalian cells. NOS, nitric oxide synthase.

Table : Summary of Mediators of Acute Inflammation

Action Mediator Histamine and serotonin Source Mast cells, platelets

Vascular Leakage
+

Chemotaxis Other
-

Bradykinin
C3a C5a Prostaglandins

Plasma substrate
Plasma protein via liver Macrophages Mast cells, from membrane phospholipids

+
+ + Potentiate other mediators

Pain
Opsonic fragment (C3b) Vasodilation, pain, fever

+ Leukocyte adhesion, activation

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

Leukocytes
Leukocytes, mast cells Leukocytes Leukocytes, mast cells Macrophages, other Leukocytes, others Macrophages, endothelium

+ + + +

+ Leukocyte adhesion, activation

Bronchoconstriction, vasoconstriction Endothelial damage, tissue damage

+ Bronchoconstriction, leukocyte priming + Acute-phase reactions, endothelial activation + Leukocyte activation + Vasodilation, cytotoxicity