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1) (Concept) Understand the chain,
progression, or sequence of vascular
and cellular events in the histologic
evolution of acute inflammation

2) (Role?) Learn the roles of various chemical

mediators of acute inflammation
3) Know the three possible outcomes of acute
4) Visualize the three morphologic patterns of
acute inflammation
5) Understand the causes, morphologic
patterns, principle cells, minor cells, of chronic
and granulomatous inflammation


Inflame to set fire.

Inflammation is dynamic response of
vascularised tissue to injury.
Is a protective response.
Serves to bring defense & healing
mechanisms to the site of injury.


Inflammation is the process in which healthy

tissue responds to an injury.

Purpose of inflammation
to destroy and remove substances recognized as
being foreign to the body;
to prevent minor infections from becoming
To prepare any damaged tissue for repair.

Defn: Inflammation is a protective response intended

to eliminate the initial cause of cell injury as well as
the necrotic cells and tissues resulting from the
original insult.

Inflammation accomplishes its protective mission by

diluting, destroying, or otherwise neutralizing
harmful agents (e.g., microbes and toxins). It then
sets into motion the events that eventually heal and
repair the sites of injury

Reaction of Blood Vessels, leading to accumulation

of Fluid & WBCs in Extra vascular tissues.



Double edged Sword: Helps the Body to ward

off the agent and can cause Harm to the body
by its reactions.


Acute Inflammation
Chronic inflammation

Acute inflammation is rapid in onset (seconds or

minutes) and is of relatively short duration, lasting for
minutes, several hours, or a few days;
Main characteristics are the exudation of fluid and
plasma proteins (edema) and the emigration of
leukocytes, predominantly neutrophils.

Chronic 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


Celsus in 1st century AD listed the cardinal Signs of

-Rubor, Calor, Tumor, Dolor.
Virchow later added 5th sign- Functio laesa.
Metchnikoff & Paul Ehrlich- WBCs & Serum factors
are critical in defense against the microbes. (Nobel
Prize in 1908)
Russian biologist Elie Metchnikoff discovered the
process of phagocytosis
Sir Thomas Lewis- Chemical mediators in

Classic Signs of Inflammation

Rubor -- erythema due to capillary

Calor -- warmth due to increased blood


Tumor -- edema
Dolor -- pain due to local pressure and
stimulation of nerve
Functio laesa -- alteration in function

Signs of acute
The patient has erysipelas
of the face due to group A
Signs of acute
inflammation that are
present in the photograph
include redness (rubor)
and swelling (tumor). The
infection is associated with
warm skin (calor) and pain

Cardinal signs of inflammation

Rubor (redness) and calor (heat)
Histamine-mediated vasodilation of arterioles
Tumor (swelling)
Histamine-mediated increase in permeability of
Dolor (pain)
Prostaglandin (PG) E2 sensitizes specialized
nerve endings to the effects of bradykinin and
other pain mediators.


Components of Acute inflammation

Alteration in Vascular caliber with increased

blood flow
Micro vascular changes- Plasma proteins &
WBC leakage.
Emigration, accumulation & activation of
WBCs in focus of Injury.

The major local

manifestations of acute
inflammation, compared to
(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

The components of acute and chronic inflammatory responses: circulating cells

and proteins, cells of blood vessels, and cells and proteins of the extracellular

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


The escape of fluid, proteins, and blood cells

from the vascular system into the interstitial
tissue or body cavities is known as exudation.


Inflammatory Extracellular fluid

High Protein content
Cellular debris
Specific gravity > 1.020
Its presence implies an increase in the normal
permeability of small blood vessels in an area
of injury and, therefore, an inflammatory


Ultra filtrate of Plasma

Low protein content (most of which is
Specific gravity < 1.012
Results from osmotic or Hydrostatic
Imbalance across the vessel wall without an
increase in vascular permeability


Excess fluid in the Interstitial or serous cavities, it can

be either an exudate or a transudate


Purulent exudate rich in Neutrophils, dead

cells & Microbes.

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

Stimuli for Acute Inflammation

Physical, Chemical & Radiation
Tissue necrosis
Foreign bodies
Immune reactions


Consists of two main components,

A vascular reaction and
A cellular reaction.
Mediated by chemical factors that are derived from
plasma proteins or cells and are produced in
response to or activated by the inflammatory



In inflammation, blood vessels undergo a

series of changes that are designed to
maximize the movement of plasma proteins
and circulating cells out of the circulation and
into the site of injury or infection.


Changes in Vascular Flow and Caliber

Increased Vascular Permeability (Vascular

Vasodilatation induced by Chemical

mediators: Histamine & Nitric oxide
Initially starts in the Arterioles later in the
Followed by Increased vascular
Stasis of blood, Loss of Plasma, Proteins
and later the WBCs.

A hallmark of acute inflammation is

increased vascular permeability

Escape of a protein-rich fluid (exudate) into the

extravascular tissue reduces the intravascular osmotic
pressure and increases the osmotic pressure of the
interstitial fluid.

Together with the increased hydrostatic pressure owing

to increased blood flow through the dilated vessels, this
leads to a marked outflow of fluid and its accumulation
in the interstitial tissue

The net increase of extravascular fluid results in edema.

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.

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

Normal fluid exchange and microvascular

permeability are critically dependent on an
intact endothelium.

How then does the endothelium become leaky

in inflammation?

The following mechanisms have been


Principal mechanisms of increased

vascular permeability in
inflammation, and their features and
underlying causes.
NO, nitric oxide; VEGF, vascular
endothelial growth factor

In summary, in acute inflammation

Fluid loss from vessels with increased permeability

occurs in distinct phases:
(1) an immediate transient response lasting for 30
minutes or less, mediated mainly by the actions of
histamine and leukotrienes on endothelium;
(2) a delayed response starting at about 2 hours and
lasting for about 8 hours, mediated by kinins,
complement products, and other factors; and
(3) a prolonged response that is most noticeable
after direct endothelial injury, for example, after

Leukocyte Extravasation


The sequence of events in the journey of leukocytes

from the vessel lumen to the interstitial tissue
Can be divided into the following steps

1.In the lumen: margination, rolling, and adhesion to


2.Transmigration across the endothelium (also

called diapedesis)

3.Migration in interstitial tissues toward a

chemotactic stimulus


WBC Margination, Rolling &
Transmigration across Endothelium
Leukocyte activation

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


In normally flowing blood in venules, erythrocytes

are confined to a central axial column, displacing the
leukocytes toward the wall of the vessel.

Because blood flow slows early in inflammation

(stasis), hemodynamic conditions change (wall shear
stress decreases), and more white cells assume a
peripheral position along the endothelial surface.

Rolling - individual and then rows of

leukocytes tumble slowly along the
endothelium and adhere transiently
Adhesion - finally coming to rest at some
point where they adhere firmly
Pavementing - In time, the endothelium can be
virtually lined by white cells

Transmigration - After firm adhesion, leukocytes

insert pseudopods into the junctions between the
endothelial cells, squeeze through interendothelial
junctions, and assume a position between the
endothelial cell and the basement membrane.

Eventually, they traverse the basement membrane and

escape into the extravascular space.
Neutrophils, monocytes, lymphocytes, eosinophils,
and basophils all use the same pathway to migrate
from the blood into tissues.

WBC Adhesion & Transmigration

Regulated by the binding of complimentary

Adhesion molecules on WBC & Endothelial
Surface expression is modified by Chemical
mediators like cytokines which causes
There are Four classes of Cell Adhesion




Selectins:: L, E, P types
Immunoglobulin family:: ICAM,
Integrins:: Beta-1 & Beta- 2 types.
Mucin like Glycoproteins:: CD 44

Selectin family of adhesion molecules

Selectins are receptors expressed on

leukocytes and endothelium that contain an
extracellular domain that binds sugars (hence
the lectin part of the name).

The three members of this family

E-selectin (also called CD62E), expressed on

endothelial cells;
P-selectin (CD62P), present on endothelium
and platelets; and
L-selectin (CD62L), on the surface of most


Bind sialylated oligosaccharides (e.g., sialyl-Lewis X

on leukocytes) that are attached to mucin-like
glycoproteins on various cells.

The endothelial selectins are typically expressed at low

levels or are not present at all on normal cells. They are
up-regulated after stimulation by specific mediators.

Therefore, binding of leukocytes is largely restricted

to endothelium at sites of infection or tissue injury
(where the mediators are produced).

Endothelial/Leukocyte Adhesion Molecules


Leukocyte Receptor

Major Role


Sialyl-Lewis X ,

Rolling (neutrophils,
monocytes, lymphocytes)


Sialyl-Lewis X

Rolling, adhesion to activated

endothelium (neutrophils,
monocytes, T cells)


CD11/CD18 (integrins)
(LFA-1, Mac-1)

Adhesion, arrest, transmigration

(all leukocytes)


41 (VLA4) (integrins)
47 (LPAM-1)

Adhesion (eosinophils, monocytes,




Lymphocyte homing to high

endothelial venules



Leukocyte migration through


ICAM-1, VCAM-1, and CD31 belong to the immunoglobulin

family of proteins; PSGL-1, P-selectin glycoprotein ligand 1

Functions of cell Adhesion Molecules

Rolling of WBCs in Lumen
Adhesion to Endothelium
Arrest of motion
WBC migration
Leukocyte Homing.

Regulation of endothelial and leukocyte adhesion molecules. A,

Redistribution of P-selectin. B, Cytokine activation of endothelium. C,
Increased binding avidity of integrins

Recruitment of leukocytes to sites of injury

Mediators such as histamine, thrombin, and platelet

activating factor (PAF) stimulate the redistribution of
P-selectin from its normal intracellular stores in
granules (Weibel-Palade bodies) to the cell surface.

Resident tissue macrophages, mast cells, and

endothelial cells respond to injurious agents by
secreting the cytokines TNF, IL-1, and chemokines

TNF and IL-1 act on the endothelial cells of

postcapillary venules adjacent to the infection and
induce the expression of several adhesion molecules.

Within 1 to 2 hours, the endothelial cells begin to

express E-selectin.
Leukocytes express at the tips of their microvilli
carbohydrate ligands for the selectins, which bind to
the endothelial selectins.
These are low-affinity interactions with a fast offrate, and they are easily disrupted by the flowing
As a result, the bound leukocytes detach and bind
again, and thus begin to roll along the endothelial

Transmigration or diapedesis

PECAM-1 (platelet endothelial cell adhesion molecule) or

After traversing the endothelium, leukocytes pierce the
basement membrane, probably by secreting collagenases, and
enter the extravascular tissue

Once leukocytes enter the extravascular connective tissue,

they are able to adhere to the extracellular matrix by virtue
of 1 integrins and CD44 binding to matrix proteins.

Thus, the leukocytes are retained at the site where they are

Emigration of Leucocytes




Genetic deficiencies in the leukocyte adhesion proteins result in

impaired leukocyte adhesion and recurrent bacterial infections

Leukocyte adhesion deficiency type 1 (LAD1), patients have a

defect in the biosynthesis of the 2 chain shared by the LFA-1
and Mac-1 integrins leads to impaired leukocyte adhesion to and
migration through endothelium, and defective phagocytosis and generation
of an oxidative burst

Leukocyte adhesion deficiency type 2 (LAD2) is caused by

the absence of sialyl-Lewis X, the fucose-containing ligand
for E-selectin, owing to a defect in a fucosyl transferase, the
enzyme that attaches fucose moieties to protein backbones
Its clinical manifestations are similar to but milder than those
of LAD-1.

The type of emigrating leukocyte varies with the age of the

inflammatory response and with the type of stimulus

Neutrophils predominate in the inflammatory

infiltrate during the first 6 to 24 hours, then are
replaced by monocytes in 24 to 48 hours
In certain infectionsfor example, those produced by
Pseudomonas organismsneutrophils predominate
over 2 to 4 days;
in viral infections, lymphocytes may be the first cells
to arrive;
in some hypersensitivity reactions, eosinophilic
granulocytes may be the main cell type.

Representative of the early (neutrophilic) (left) and later

(mononuclear) cellular infiltrates (right) of infarcted

Acute inflammation. Histologic section of lung in bronchopneumonia

showing sheets of neutrophils with multilobed nuclei


Is Migration of WBCs in tissue towards the

site of Injury
LOCOMOTION oriented along the
Chemoattractants can be Exogenous or
Bacterial products, Complements, leukotriens,
Cytokines are Chemoattractants.


The most common exogenous agents are bacterial

Endogenous chemoattractants, include several
chemical mediators:
(1) components of the complement system,
particularly C5a;
(2) products of the lipoxygenase pathway, mainly
leukotriene B4 (LTB4); and
(3) cytokines, particularly those of the chemokine
family (e.g., IL-8).

Leukocyte Activation

Once leukocytes have been recruited to the site

of infection or tissue necrosis, they must be
activated to perform their functions


Activated by Microbes, Necrotic cells, Ag-Ab

complexes, Chemotactic factors, Cytokines.
Activation leads to::
-Production of Arachidonic acid metabolites
-Secretion of Lysosomal enzymes
-Secretion of cytokines
-Modulation of CAM

Leukocytes express on their surface different kinds

of receptors that sense the presence of microbes

These include Toll-like receptors (TLRs, named for

their homology to Drosophila Toll protein), which
recognize endotoxin (LPS) and many other bacterial
and viral products;

Seven-transmembrane G-protein-coupled receptors,

which recognize certain bacterial peptides and
mediators produced in response to microbes; and

Other receptor families

Leukocyte activation. Different classes of cell surface receptors of

leukocytes recognize different stimuli. The receptors initiate responses
that mediate the functions of the leukocytes


Phagocytosis and the release of enzymes by

neutrophils and macrophages are responsible
for eliminating the injurious agents

Constitutes two of the major benefits derived

from the accumulation of leukocytes at the
inflammatory focus

Cellular Response - Phagocytosis

The plasma membrane of the neutrophil flows

around the foreign particle and engulfs it.
Lysosomes release chemicals which digest the
foreign particle.
The phagocyte often dies.
Cellular debris is removed by monocytes and




Recognition & Attachment of the

particles to be ingested by the
Engulfment, with subsequent
formation of a phagocytic vacuole.
Killing & Degradation

Recognition & Attachment

Mannose Receptors & Scavenger


The efficiency of phagocytosis is greatly

enhanced when microbes are opsonized by
specific proteins (opsonins) for which the
phagocytes express high-affinity receptors.

Major opsonins

IgG antibodies,
the C3b breakdown product of complement,
certain plasma lectins, notably MBL, all of
which are recognized by specific receptors on

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


Extensions of the cytoplasm pseudopods

flow around the particle to be engulfed
Formation of phagosome created by plasma
membrane of cell
Phagolysosome formation: fusion of
phagosome membrane with Lysosomal
Release of lysosomal granules.

Production of microbicidal reactive oxygen

intermediates within phagocytic vesicles


Oxygen dependent Killing mechanisms

Burst in O2 consumption, Reactive O2 species.
Increased production of Hydrogen peroxide,
Hydroxyl ions, Superoxide ions, Halide ions.
H2O2 + MPO + Halide is the most efficient

The microbicidal products generated

from superoxide (O2 )

Hypochlorite (HOCl) and

Hydroxyl radical (OH), and
From nitric oxide (NO) it is peroxynitrite

Reactive O2 radicals:

NADPH gets oxidizes into NADP by NADPH

oxidases (Phagocytic oxidase) and releases
Superoxide anion (O2 ) which further converts
H2O2 into highly reactive hydroxyl radical
MPO: present in Neutrophils: converts H 2O2
into HOCl in presence of halides Cl.

Leukocyte Granules
O2 independent Mechanism of killing.
Bactericidal Permeability Increasing protein
(BPI): activates phospholipases
phospholipid degradation
Major Basic protein

Leukocyte induced tissue injury


Substance released during phagocytosis:

Lysosomal enzymes
Reactive oxygen intermediates
Products of arachidonic acid metabolites
(prostaglandins and leukotrienes)
These products causes endothelial damage and
tissue damage.
So---Persistent/ unchecked leukocyte infiltrate itself
can become an offender.

Clinical Examples of Leukocyte-Induced Injury

Defects in Leukocyte function

Leads to Increased susceptibility to
Defects have been identified in all levels
of WBC function
Defects can be genetically inherited or
Defects in WBC Adhesion,
Phagolysosome function, microbicidal

Defects in leukocyte adhesion

LAD 1 is characterized by recurrent bacterial

infections and impaired wound healing.

LAD 2 is clinically milder than LAD 1 but is

also characterized by recurrent bacterial

Defects in microbicidal activity - Chronic

granulomatous disease

A genetic deficiency in one of the several components

of the phagocyte oxidase responsible for generating

In these patients, engulfment of bacteria does not

result in activation of oxygen-dependent killing

In an attempt to control these infections, the microbes

are surrounded by activated macrophages, forming the
"granulomas" that give the disease its distinctive
pathology and its name.

Chronic Granulomatous disease

Due to defect in microbicidal activity

Inherited defects in the genes encoding the
NADPH oxidase which generates
Patients are susceptible for recurrent bacterial

Chronic Granulomatous disease

The most common variants are an X-linked

defect in one of the plasma membrane-bound
components (gp91phox) and autosomal
recessive defects in the genes encoding two of
the cytoplasmic components (p47phox and

Defects in phagolysosome formation - ChdiakHigashi syndrome

An autosomal recessive disease that results

from disordered intracellular trafficking of
organelles, ultimately impairing the fusion of
lysosomes with phagosomes.

The secretion of lytic secretory granules by

cytotoxic T lymphocytes is also affected,
explaining the severe immunodeficiency seen
in the disorder

Chdiak-Higashi syndrome

The gene associated with this disorder encodes

a large cytosolic protein called LYST, which is
believed to regulate lysosomal trafficking.

Chdiak-Higashi syndrome

Defects in phagolysosome function.

An autosomal recessive condition characterized by

neutropenia (decreased numbers of neutrophils),
defective degranulation, and delayed microbial

The neutrophils (and other leukocytes) have giant

granules, readily seen in peripheral blood smears and
which are thought to result from aberrant organelle

Chdiak-Higashi syndrome

Reduced transfer of lysosomal enzymes to

phagocytic vacuoles in phagocytes (causing
susceptibility to infections) and

Abnormalities in melanocytes (leading to

albinism), cells of the nervous system
(associated with nerve defects), and platelets
(generating bleeding disorders).


Principles of Chemical mediators

Origin is either from cells or Plasma

Production is triggered by microbes, damaged
proteins or endogenous compounds.
Initially bind to specific receptors and act.
Stimulate the release of other mediators
Can act on one or few target cell types.
Once activated these are short lived.
Potentially harmful

Chemical mediators of inflammation.

EC, endothelial cells

Classes of Chemical mediators



Vasoactive Amines histamine,

Complement system
Kinin System
Clotting System
Arachidonic acid metabolites
Platelet Activating factors
Cytokines & Chemokines
Nitric oxide, Neuropeptides and Others

Vasoactive amines-Histamine

Present as Preformed stores in cells

First mediators to be released
Present in mast cells, basophils & Platelets
Released on Injury stimuli, heat, immune
reactions, complement mediated (C3a, C5a).
Causes Arteriolar dilatation, increases
permeability of venules, constricts large
Acts on H1 receptors on endothelial cells.

Vasoactive Amines-Serotonin

Action similar to Histamine
Platelets, Mast cells, Enterochromaffin cells.
Causes platelet aggregation, increased
Acts along with PAF.



Plasma proteins- 20 component proteins

Functions in both innate & adaptive immunity
for defense
Needs to be activated in body at the time of
Present as inactive compounds in plasma from
C1 to C9.
Component C3 is biologically more Important

Activation of C3 occurs by one of the Three

- Classical pathway
-Alternate Pathway
-Lectin Pathway
Activation in 2 steps:: Early and late.
Early is Proteolytic cleavage of C3.
late is formation of major breakdown
products:: C3a, C3b, C5a, and the Membrane
attack complex.

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).

Classical Pathway:: Triggered by fixation of

C1 to IgG or IgM.
Alternate pathway is triggered by microbial
surface molecules (Endotoxins, LPS, Venom)
Spontaneous cleavage of C3 occurs in
alternate pathway.
Lectin pathway:: Mannose binding Lectin
activates C1.
The final path is formation of C3 convertase
which activates C3 to C3a & C3b.

The Late Steps of Complement


The C3b that is generated by any of the pathways

binds to the C3 convertase and produces a C5
convertase, which cleaves C5.
C5b remains attached to the complex and forms a
substrate for the subsequent binding of the C6-C9
Polymerized C9 forms a channel in lipid membranes,
called the membrane attack complex, which allows
fluid and ions to enter and causes cell lysis

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

Biologic Functions of Complements

C3a, C5a :: (Anaphylotoxins) Stimulate

Histamine release from the mast cells,
Increased vascular permeability,
C5a:: Activates lipoxygenase pathway.
C5a:: WBC adhesion, Chemotaxis &
C3b:: Opsonisation, fixes to bacterial cell wall
C5-C9 (membrane attack complex): cell lysis

Complement activation can be controlled at

several steps:

Regulation of C3 and C5 convertases by enhancing the

dissociation (decay acceleration) of the convertase complex
(e.g., decay-accelerating factor [DAF]) or by proteolytically
cleaving C3b (e.g., factor I)

The first step in the classical pathway, which is triggered by C1

binding to an immune complex, is blocked by a plasma protein
called C1 inhibitor (C1INH).

C1INH interferes with the enzymatic activity of two of the

proteins in the C1 complex.

Excessive complement activation is also prevented by a number

of proteins that act to inhibit MAC formation (e.g., CD59, also
called membrane inhibitor of reactive lysis)

Disorders of complement system

Deficiency of C3 Increased infections

Deficiency of MAC Niesseria infection
Deficiency of C1 inhibitor Hereditary
angioneurotic edema
Deficiency of C2 & C4 Autoimmune

Hereditary angioneurotic edema

Deficiency of C1 inhibitor (C1INH)

Characterized by episodic edema accumulation in the

skin and extremities as well as in the laryngeal and
intestinal mucosa, provoked by emotional stress or

In patients with this disorder, activation of C1 by

immune complexes is not properly controlled, and
increased breakdown of C4 and C2 occurs.

Hereditary angioneurotic edema

The mediators of edema formation in patients

with the disease include a proteolytic fragment
of C2, called C2 kinin, and bradykinin .

C1INH is an inhibitor of other plasma serine

proteases besides C1, including kallikrein and
coagulation factor XII, and both activated
kallikrein and factor XII can promote
increased formation of bradykinin.

Paroxysmal nocturnal hemoglobinuria

Genetic deficiencies of complement regulatory


Mutations in the gene encoding the enzyme required

to synthesize phosphatidylinositol linkages for
membrane proteins.

Defective expression of phosphatidylinositol-linked

membrane proteins, including DAF and CD59

Result is uncontrolled complement activation on

these cells

Paroxysmal nocturnal

Characterized by recurrent bouts of

intravascular hemolysis resulting from
complement-mediated lysis of red blood cells,
leading to chronic hemolytic anemia



(a) Normal RBCs express complement regulatory proteins

including the terminal complement inhibitor CD59.
CD59 is tethered to the RBC lipid bilayer of the cell
membrane by a GPI anchor.
The presence of CD59 protects these cells from autologous
complement-mediated destruction.
(b) PNH RBCs lack GPI-anchored proteins including CD59.
Continuous complement activation leads to formation of the
terminal complement complex (TCC) that transverses the lipid
These complexes form numerous pores in the RBC membrane,
as shown by the electron micrograph (inset).
As pores form in the membrane, water enters the RBC
(arrows), resulting from osmotic pressure.

The kinin system

Generates vasoactive peptides from plasma proteins,

called kininogens,
By the action of specific proteases called kallikreins
Activation of the kinin system results in the release of
the vasoactive nonapeptide bradykinin.
Bradykinin increases vascular permeability and
causes contraction of smooth muscle, dilation of
blood vessels, and pain when injected into the skin.
These effects are similar to those of histamine

KININ System

Inactive plasma proteins are HMWK (High

Mol Wt. Kininogens)
These are activated by proteases called
The vasoactive peptides so released are
The action of Bradykinins are short lived and
inactivated by Kininase.

Bradykinin functions

Increases vascular Permeability

Contraction of Smooth muscle
Blood vessel dilatation
Pain when injected to skin

Interrelationships between the four plasma mediator systems triggered by activation of factor XII
(Hageman factor). Note that thrombin induces inflammation by binding to protease-activated
receptors (principally PAR-1) on platelets, endothelium, smooth muscle cells, and other cells.
HMWK, high molecular weight kininogen.

The clotting system

Divided into two pathways that converge,

culminating in the activation of thrombin and
the formation of fibrin

The intrinsic clotting pathway is a series of

plasma proteins that can be activated by
Hageman factor (factor XII), a protein
synthesized by the liver that circulates in an
inactive form until it encounters collagen or
basement membrane or activated platelets (as
occurs at the site of endothelial injury).

Factor XII then undergoes a conformational

change (becoming factor XIIa), exposing an
active serine center that can subsequently
cleave protein substrates and activate a variety
of mediator systems


Has Two pathways converging onto a

Common pathway:: Intrinsic & Extrinsic.
Each reaction has an
-Enzyme:: Activated Coagulation factor.
-Substrate:: Proenzyme form of factor
-Cofactor:: Reaction accelerator
-Product:: Activated Factor.

The protease thrombin provides the main link

between the coagulation system and inflammation
Binds to receptors that are called protease-activated
receptors (PARs) type 1 receptor
Triggers several responses that induce inflammation.

They include mobilization of P-selectin, production

of chemokines, and expression of endothelial
adhesion molecules for leukocyte integrins;

these responses promote the recruitment of

leukocytes and many other reactions of



When cells are activated by diverse stimuli, their

membrane lipids are rapidly remodeled to generate
biologically active lipid mediators that serve as
intracellular or extracellular signals to affect a variety
of biologic processes, including inflammation and

These lipid mediators are thought of as autocoids, or

short-range hormones


Prostaglandins, Leukotrienes & Lipoxins

Autocoids:: Short range hormones. Exert
effects locally.
Two pathways:: Cyclooxygenase &
Lipooxygenase pathway.
End products are PGI2, PGD2, PGE2, PGF2 ,
LTB4, C4, D4, E4.

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

Agents that inhibit leukotriene production by

inhibition of 5-lipoxygenase (e.g., Zileuton) or
block leukotriene receptors (e.g.,

Inflammatory Actions of Arachidonic

acid metabolites
Increased vascular
Chemotaxis, WBC

TXA2, LTC4, D4, E4
LTC4, D4, E4
LTB4, Lipoxins


A new class of arachidonic acid-derived

Inhibit leukocyte recruitment and activation , in
part by inhibiting the production of cytokines.
Thus, the anti-inflammatory activity of aspirin
is likely attributable to its ability to inhibit
cyclooxygenases and, perhaps, to stimulate the
production of resolvins


Its a Phospholipid with a glycerol backbone

Platelets, basophils, neutrophils, macrophages,
endothelial cells elaborate PAF
Stimulates platelets, vasoconstriction,
bronchoconstriction, Leukocyte adhesion,
Active role in inflammation.


Proteins produced by many cell types

(principally activated lymphocytes and
macrophages, but also endothelium,
epithelium, and connective tissue cells) that
modulate the functions of other cell types

Tumor Necrosis Factor and Interleukin-1


Short acting soluble mediators.

Important cytokines are TNF & Interleukins.
Secretion is stimulated by endotoxins,
bacterial products, injury etc.
Most effect is on endothelium, WBCs &

Major effects of interleukin-1 (IL-1) and

tumor necrosis factor (TNF) in inflammation

IL-1 and TNF (as well as IL-6) induce the systemic

acute-phase responses associated with infection or

Increased sleep
Decreased Appetite



Family of small proteins (8 10 kD)

Chemoattractants for specific types of leukocytes
Classified as four major groups based on the
arrangement of Cysteine residues in the protein
Alfa Chemokines:: C-X C. Act on Neutrophils,
secreted by macrophages, endothelial cells.
causes activation and chemotaxis of neutrophils
------IL-8 belongs to this group.

2. Beta Chemokines:: C-C. These include

Monocyte chemoattractant protein, eotaxin,
macrophage inflammatory protein.
***They attract Monocytes, eosinophils,
basophils, lympho; but not neutrophils.
3. Gamma chemokines:: C type (e.g.,
lymphotactin). Specific for lymphocytes.
4. CX3C chemokines:: Fractalkine. Promotes
strong adhesion of monocytes &

Chemokines stimulate leukocyte recruitment in

inflammation and control the normal
migration of cells through various tissues


Called EDRF (endothelium-derived relaxing

Soluble gas produced by endothelium,
macrophages & neurons
Induces cyclic GMP which mediated
relaxation of smooth muscle cells.
Half life is only in seconds.
NO is synthesized from L-arginine by enzyme
NO synthase.

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


NO is synthesized from L-arginine by the enzyme

nitric oxide synthase (NOS)
There are three different types of NOSendothelial
(eNOS), neuronal (nNOS), and inducible (iNOS)
eNOS and nNOS can be activated rapidly by an
increase in cytoplasmic calcium ions.
iNOS, in contrast, is induced when macrophages and
other cells are activated by cytokines (e.g., TNF, IFN) or other agents.

Potent vasodilator
Reduces platelet aggregation
Inhibits mast cell induced inflammation
Production of NO is an endogenous compensatory
mechanism that reduces inflammatory responses
Abnormalities in endothelial NO production leads to
Atherosclerosis, Diabetes, Hypertension.
NO is also Microbicidal.
Reactive nitrogen intermediates like ROS are

Lysosomal constituent of leukocytes

Primary granules

Secondary granules

Larger granules

Small & specific granules


Non Azurophilic

MPO Positive

MPO negative

Present normally till the

stage of Promyelocytes

Present after Myelo, Meta

and in Neutrophils

Ultrastructure and contents of neutrophil granules, stained for peroxidase activity. The
large peroxidase-containing granules are the azurophil granules; the smaller
peroxidase-negative ones are the specific granules (SG). N, portion of nucleus; BPI,
bactericidal permeability increasing protein


Primary granules

Secondary granules

Acid hydrolases

Alkaline phosphatase
Type IV collagenase

Non-specific collagenase
Cathepsin G

WBC adhesion molecules

Plasminogen activator
Phospholipase A2

Harmful proteases vs. 1-antitrypsin

Neutrophils and monocytes contain lysosomal

granules, which, when released, may contribute to the
inflammatory response

Neutrophil elastase has been shown to degrade

virulence factors of bacteria and thus combat bacterial

Because of the destructive effects of lysosomal

enzymes, the initial leukocytic infiltration, if
unchecked, can potentiate further increases in vascular
permeability and tissue damage


Substance P and neurokinin A

Play a role in the initiation and propagation of
an inflammatory response

Substance P

Has many biologic functions, including the

Transmission of pain signals,

Regulation of blood pressure,
Stimulation of secretion by endocrine cells,
Increasing vascular permeability.



Vasodilation, an early event in inflammation, is caused by

histamine, prostaglandins, and nitric oxide.
Increased vascular permeability is caused by histamine; the
anaphylatoxins (C3a and C5a); the kinins; leukotrienes C, D,
and E; PAF; and substance P.
For chemotaxis, the most likely contributors are complement
fragment C5a, lipoxygenase products (LTB4), and
Prostaglandins play an important role in vasodilation, pain,
and fever, and in potentiating edema.
IL-1 and TNF are critical for endothelial-leukocyte
interactions and subsequent leukocyte recruitment, and for the
production of acute-phase reactants.

Outcomes of Acute Inflammation

Complete resolution
Healing by connective tissue replacement
Progression of the tissue response to chronic

Outcomes of acute inflammation: resolution, healing

by fibrosis, or chronic inflammation

Inflammation Outcome



& Repair






Morphologic Patterns of Acute



The characteristic histopathology of acute inflammation. A, Normal lung shows thin

(virtually invisible) blood vessels in the alveolar walls and no cells in the alveoli. B, The
vascular component of acute inflammation is manifested by congested blood vessels
(packed with erythrocytes), resulting from stasis. C, The cellular component of the
response is manifested by large numbers of leukocytes (neutrophils) in the alveoli.

Serous inflammation

Marked by the outpouring of a thin fluid that is

derived from either the plasma or the secretions of
mesothelial cells lining the peritoneal, pleural, and
pericardial cavities (called 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

Serous inflammation. Low-power view of a cross-section of a

skin blister showing the epidermis separated from the dermis
by a focal collection of serous effusion


Severe injuries and the resulting greater vascular

permeability, larger 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 enough or there is a procoagulant stimulus
in the interstitium (e.g., cancer cells)

Characteristic of inflammation in the lining of body

cavities, such as the meninges, pericardium, and

Fibrinous pericarditis. A, Deposits of fibrin

on the pericardium

Fibrinous inflammation. The epicardial surface of the

heart is covered by a shaggy layer of fibrin material


Fibrin appears as an eosinophilic meshwork

of threads or sometimes as an amorphous

when the fibrin is not removed, it may

stimulate the ingrowth of fibroblasts and blood
vessels and thus lead to scarring.

A pink meshwork of fibrin exudate (F)

overlies the pericardial surface (P)


Conversion of the fibrinous exudate to scar

tissue (organization) within the pericardial sac
leads to the development of fibrous strands
that reduce and may even obliterate the
pericardial space

Suppurative or purulent inflammation

Characterized by the production of large amounts of

pus or purulent exudate consisting of neutrophils,
necrotic cells, and edema fluid

Certain bacteria (e.g., staphylococci) produce this

localized suppuration and are therefore referred to as
pyogenic (pus-producing) bacteria

Example - acute appendicitis.

Purulent inflammation. A, Multiple bacterial abscesses in the lung, in a

case of bronchopneumonia. B, The abscess contains neutrophils and
cellular debris, and is surrounded by congested blood vessels.

Suppurative inflammation. A, A subcutaneous

bacterial abscess with collections of pus

The abscess contains neutrophils, edema fluid, and

cellular debris


Localized collections of purulent inflammatory

tissue caused by suppuration buried in a tissue,
an organ, or a confined space

Produced by deep seeding of pyogenic

bacteria into a tissue


Central necrotic leukocytes and tissue cells

surrounded by zone of preserved neutrophils,
and outside this region vascular dilation and
parenchymal and fibroblastic proliferation
occur, indicating the beginning of repair.


A local defect, or excavation, of the surface of

an organ or tissue that is produced by the
sloughing (shedding) of inflammatory necrotic

Occurs only when tissue necrosis and resultant

inflammation exist on or near a surface.

The morphology of an ulcer. A, A chronic duodenal ulcer. B,

Low-power cross-section of a duodenal ulcer crater with an
acute inflammatory exudate in the base

Most commonly encountered

(1) inflammatory necrosis of the mucosa of the
mouth, stomach, intestines, or genitourinary
tract; and
(2) subcutaneous inflammation of the lower
extremities in older persons who have
circulatory disturbances that predispose to
extensive necrosis

Ulcerations are best exemplified by peptic

ulcer of the stomach or duodenum , in which
acute and chronic inflammation coexist.


Acute stage - intense polymorphonuclear

infiltration and vascular dilation in the margins
of the defect.

Chronic - the margins and base of the ulcer

develop fibroblastic proliferation, scarring, and
the accumulation of lymphocytes,
macrophages, and plasma cells

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