Você está na página 1de 180

INFLAMMATION

CHAPTER 2

Inflammation
(5 OBJECTIVES)
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
inflammation
4) Visualize the three morphologic patterns of
acute inflammation
5) Understand the causes, morphologic
patterns, principle cells, minor cells, of chronic
and granulomatous inflammation

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

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
overwhelming;
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.

Useful????

Harmful????

Double edged Sword: Helps the Body to ward


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

Classification

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

Historically

Celsus in 1st century AD listed the cardinal Signs of


Inflammation.
-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
Inflammation.

Classic Signs of Inflammation

Rubor -- erythema due to capillary


Calor -- warmth due to increased blood

dilation

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

Signs of acute
inflammation.
The patient has erysipelas
of the face due to group A
streptococcus.
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
(dolor).

Cardinal signs of inflammation


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

ACUTE INFLAMMATION

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
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.

The components of acute and chronic inflammatory responses: circulating cells


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

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

Exudation

The escape of fluid, proteins, and blood cells


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

EXUDATE

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
reaction

TRANSUDATE

Ultra filtrate of Plasma


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

EDEMA

Excess fluid in the Interstitial or serous cavities, it can


be either an exudate or a transudate

PUS

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
spaces.

Stimuli for Acute Inflammation

Infections
Trauma
Physical, Chemical & Radiation
Tissue necrosis
Foreign bodies
Immune reactions

INFLAMMATORY RESPONSE

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
stimulus

VASCULAR CHANGES IN
INFLAMMATION

VASCULAR CHANGES

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.

VASCULAR CHANGES

Changes in Vascular Flow and Caliber


Increased Vascular Permeability (Vascular
Leakage)

Vasodilatation induced by Chemical


mediators: Histamine & Nitric oxide
Initially starts in the Arterioles later in the
Capillaries.
Followed by Increased vascular
permeability.
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


proposed

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
burns.

CELLULAR EVENTS
Leukocyte Extravasation
and
Phagocytosis

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


endothelium.

2.Transmigration across the endothelium (also


called diapedesis)

3.Migration in interstitial tissues toward a


chemotactic stimulus

PHASES OF CELLULAR EVENTS


WBC Margination, Rolling &
Adhesion.
Transmigration across Endothelium
Chemotaxis
Leukocyte activation
Phagocytosis

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
transmigration.

Margination

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.
Surface expression is modified by Chemical
mediators like cytokines which causes
Chemoattraction.
There are Four classes of Cell Adhesion
Molecules

CEL ADHESION MOLECULES


1.
2.

3.
4.

Selectins:: L, E, P types
Immunoglobulin family:: ICAM,
VCAM
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
leukocytes.

Selectins

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


Endothelial
Molecule

Leukocyte Receptor

Major Role

P-selectin

Sialyl-Lewis X ,

Rolling (neutrophils,
monocytes, lymphocytes)

PSGL-1
E-selectin

Sialyl-Lewis X

Rolling, adhesion to activated


endothelium (neutrophils,
monocytes, T cells)

ICAM-1

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

Adhesion, arrest, transmigration


(all leukocytes)

VCAM-1

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

Adhesion (eosinophils, monocytes,


lymphocytes)

GlyCAM-1

L-selection

Lymphocyte homing to high


endothelial venules

CD31 (PECAM)

CD31

Leukocyte migration through


endothelium

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
Activation
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
blood.
As a result, the bound leukocytes detach and bind
again, and thus begin to roll along the endothelial
surface

Transmigration or diapedesis

PECAM-1 (platelet endothelial cell adhesion molecule) or


CD31
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
needed.

Emigration of Leucocytes
Di
ap

ed

es

is

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
myocardium

Acute inflammation. Histologic section of lung in bronchopneumonia


showing sheets of neutrophils with multilobed nuclei

CHEMOTAXIS

Is Migration of WBCs in tissue towards the


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

Chemoattractants

The most common exogenous agents are bacterial


products.
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

LEUKOCYTE ACTIVATION

Activated by Microbes, Necrotic cells, Ag-Ab


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

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
macrophages.

PHAGOCYTOSIS
1.

2.

3.

Recognition & Attachment of the


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

Recognition & Attachment

Mannose Receptors & Scavenger


Receptors

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,
and
certain plasma lectins, notably MBL, all of
which are recognized by specific receptors on
leukocytes.

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

Engulfment

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
membrane.
Release of lysosomal granules.

Production of microbicidal reactive oxygen


intermediates within phagocytic vesicles

KILLING & DEGRADATION

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
Bactericidal

The microbicidal products generated


from superoxide (O2 )

Hypochlorite (HOCl) and


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

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
OH
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
Lysozymes
Lactoferrin
Major Basic protein
Defensins
Elastase

Leukocyte induced tissue injury

1.
2.
3.

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
Infections
Defects have been identified in all levels
of WBC function
Defects can be genetically inherited or
Acquired.
Defects in WBC Adhesion,
Phagolysosome function, microbicidal
activity

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
infections

Defects in microbicidal activity - Chronic


granulomatous disease

A genetic deficiency in one of the several components


of the phagocyte oxidase responsible for generating
ROS.

In these patients, engulfment of bacteria does not


result in activation of oxygen-dependent killing
mechanisms.

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
Superoxide.
Patients are susceptible for recurrent bacterial
infections.

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
p67phox).

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
killing.

The neutrophils (and other leukocytes) have giant


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

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).

CHEMICAL MEDIATORS
OF INFLAMMATION

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


1.

2.
3.
4.
5.
6.
7.
8.

Vasoactive Amines histamine,


serotonin
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
vessels.
Acts on H1 receptors on endothelial cells.

Vasoactive Amines-Serotonin

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

COMPLEMENT SYSTEM

Complements

Plasma proteins- 20 component proteins


Functions in both innate & adaptive immunity
for defense
Needs to be activated in body at the time of
injury.
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


Pathways.
- 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


Activation

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
components.
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
(MAC)

Biologic Functions of Complements

C3a, C5a :: (Anaphylotoxins) Stimulate


Histamine release from the mast cells,
Increased vascular permeability,
vasodilatation.
C5a:: Activates lipoxygenase pathway.
C5a:: WBC adhesion, Chemotaxis &
activation.
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
disorders.

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
trauma.

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


proteins

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
hemoglobinuria

Characterized by recurrent bouts of


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

PNH

PNH

(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
bilayer.
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
Kallikrein.
The vasoactive peptides so released are
Bradykinins.
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

CLOTTING SYSTEM

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
inflammation.

ARACHIDONIC ACID METABOLITES:


PROSTAGLANDINS, LEUKOTRIENES, AND LIPOXINS

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
hemostasis.

These lipid mediators are thought of as autocoids, or


short-range hormones

ARACHIDONIC ACID
METABOLITES

Prostaglandins, Leukotrienes & Lipoxins


Autocoids:: Short range hormones. Exert
effects locally.
Two pathways:: Cyclooxygenase &
Lipooxygenase pathway.
End products are PGI2, PGD2, PGE2, PGF2 ,
TXA2.
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.,
Monteleukast).

Inflammatory Actions of Arachidonic


acid metabolites
ACTION
Vasoconstriction
Vasodilatation
Increased vascular
Permeability
Chemotaxis, WBC
adhesion

METABOLITE
TXA2, LTC4, D4, E4
PGI2, PGE1, PGE2,
PGD2
LTC4, D4, E4
LTB4, Lipoxins

Resolvins

A new class of arachidonic acid-derived


mediators,
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

PLATELET ACTIVATING
FACTOR

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.

Cytokines

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

CYTOKINES

Short acting soluble mediators.


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

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
injury

Fever
Increased sleep
Decreased Appetite
Shock
Neutrophilia

CHEMOKINES

1.

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 &
lymphocytes.

Chemokines stimulate leukocyte recruitment in


inflammation and control the normal
migration of cells through various tissues

NITRIC OXIDE

Called EDRF (endothelium-derived relaxing


factor)
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

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
antimicrobial.

Lysosomal constituent of leukocytes


Primary granules

Secondary granules

Larger granules

Small & specific granules

Azurophilic

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

Examples:

Primary granules

Secondary granules

Myeloperoxidase
Lysozyme
Acid hydrolases
Elastase

Lactoferrin
Lysozyme
Alkaline phosphatase
Type IV collagenase

Non-specific collagenase
Phospholipase-A
Defensins
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
infections

Because of the destructive effects of lysosomal


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

NEUROPEPTIDES

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,
and
Increasing vascular permeability.

SUMMARY OF CHEMICAL MEDIATORS OF


ACUTE INFLAMMATION

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
chemokines.
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
(fibrosis)
Progression of the tissue response to chronic
inflammation

Outcomes of acute inflammation: resolution, healing


by fibrosis, or chronic inflammation

Inflammation Outcome
Chronic
Inflammation
Injury

Acute
Inflammation
Abscess
Ulcer
Fistula

Sinus

Resolution/Healing
& Repair

Abscess

Abscess
----Micro

Normal
Meninges

Meningitis
PMNs
and
Exudate

Brain

Morphologic Patterns of Acute


Inflammation

SEROUS INFLAMMATION
FIBRINOUS INFLAMMATION
SUPPURATIVE OR PURULENT
INFLAMMATION
ULCERS

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

FIBRINOUS INFLAMMATION

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
pleura.

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

Histologically

Fibrin appears as an eosinophilic meshwork


of threads or sometimes as an amorphous
coagulum

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)

Organization

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

Abscesses

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

Abscesses

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.

ULCERS

A local defect, or excavation, of the surface of


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

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.

Ulcerations

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

Thank you