CELLULAR INJURY

Wenyan Zhang
Department of Pathology
West China School of Medicine
Sichuan University
March, 2018
Causes of cell injury
• Ischemia/hypoxia (e.g. heart attack)
• Chemical agents (toxins, acid, drugs)
– Active oxygen species: free radicals, oxidants,
electrophiles
• Infectious agents (bacterial, virus, parasite)
• Immunologic reactions (hypersensitivity)
• Genetic defects (e.g. Down’s syndrome)
• Nutritional imbalances (protein insufficiency)
• Physical agents (trauma, temperature)
• Iatrogenic causes
• Aging
Overview of Cell Injury and
Cell Death
 Reversible cell injury
• Initially, injury is manifested as functional and
morphologic changes that are reversible if the
damaging stimulus is removed
• The hallmarks of reversible injury are reduced
oxidative phosphorylation, adenosine triphosphate
(ATP) depletion, and cellular swelling caused by
changes in ion concentrations and water influx
• These changes are called “ degenerations” in old
textbooks of pathology
 Irreversible injury
• Irreversibly injured cells invariably undergo
morphologic changes that are recognized as cell
death
– Necrosis
– Apoptosis
• When damage to membranes is severe, lysosomal
enzymes enter the cytoplasm and digest the cell,
and cellular contents leak out, resulting in
necrosis
• Apoptosis, which is characterized by nuclear
dissolution without complete loss of membrane
integrity
Schematic representation of a normal cell and the changes in reversible and
irreversible cell injury.
 Mechanisms of cell injury
• The cellular response to injurious
stimuli depends on the type of injury,
its duration, and its severity.
• The consequences of an injurious
stimulus depends on the type, status,
adaptability, and genetic makeup of
the injurious cell.
– Ischemia:
Skeletal muscle: 2-3 hours normal
Cardiac muscle: 20-30 minutes death
 Mechanisms of cell injury
• The vulnerable intracellular systems:
– Cell membrane integrity (ionic and osmotic balance)
– ATP generation
– Protein synthesis
– DNA
• Cellular function is lost far before cell death
occurs, and the morphologic changes of cell
injury ( or death) lag far behind both
General Biochemical Mechanisms
of cell injury
• ATP depletion
• Oxygen deprivation or generation of
reactive oxygen species
• Loss of calcium homeostasis
• Defects in plasma membrane permeability
• Mitochondria damage
 General Biochemical Mechanisms
of cell injury
• ATP depletion
• Oxygen deprivation or generation of
reactive oxygen species
• Loss of calcium homeostasis
• Defects in plasma membrane
permeability
• Mitochondria damage
 General Biochemical Mechanisms
of cell injury
• ATP depletion
• Oxygen deprivation or generation of
reactive oxygen species
• Loss of calcium homeostasis
• Defects in plasma membrane
permeability
• Mitochondria damage
Mechanism of ischemic and hypoxic injury
General Biochemical Mechanisms
of cell injury
• ATP depletion
• Oxygen deprivation or generation of
reactive oxygen species
• Loss of calcium homeostasis
• Defects in plasma membrane
permeability
• Mitochondria damage
General Biochemical Mechanisms
of cell injury
• ATP depletion
• Oxygen deprivation or generation of
reactive oxygen species
• Loss of calcium homeostasis
• Defects in plasma membrane
permeability
• Mitochondria damage
 Cell mechanisms of injury
Free radicals/ reactive chemicals

O 2 Cell membrane
Normal
Metabolisms OH• Mitochondria
Inflammation Endo. Retic.
H2O2 DNA
Radiation
Oxygen toxicity NO
Chemicals
Reperfusion injury
Detoxification

SOD/Catalase
Glutathione peroxidase/GSSG (Fenton reaction)
Vitamin E, C
Neutralization of free radicals

SOD
• 2O2 + 2H+ H2O 2 + O2
catalase
• 2H2O2 2H2O + O2

glutathione peroxidase
• 2OH• + 2GSH GSSH + 2H2O
glutathione reductase
 General Biochemical Mechanisms
of cell injury
• ATP depletion
• Oxygen deprivation or generation of
reactive oxygen species
• Loss of calcium homeostasis
• Defects in plasma membrane
permeability
• Mitochondria damage
 General Biochemical Mechanisms
of cell injury
• ATP depletion
• Oxygen deprivation or generation of
reactive oxygen species
• Loss of calcium homeostasis
• Defects in plasma membrane
permeability
• Mitochondria damage
 General Biochemical Mechanisms
of cell injury
• ATP depletion
• Oxygen deprivation or generation of
reactive oxygen species
• Loss of calcium homeostasis
• Defects in plasma membrane
permeability
• Mitochondria damage
 General Biochemical Mechanisms
of cell injury
• ATP depletion
• Oxygen deprivation or generation of
reactive oxygen species
• Loss of calcium homeostasis
• Defects in plasma membrane
permeability
• Mitochondria damage
 General Biochemical Mechanisms
of cell injury
• ATP depletion
• Oxygen deprivation or generation of
reactive oxygen species
• Loss of calcium homeostasis
• Defects in plasma membrane
permeability
• Mitochondria damage
 General Biochemical Mechanisms
of cell injury
• ATP depletion
• Oxygen deprivation or generation of
reactive oxygen species
• Loss of calcium homeostasis
• Defects in plasma membrane
permeability
• Mitochondria damage
 Summary
• Any stimuli and stresses can result in cell injuries.

• The injurious consequences depend on not only the type

of injury, its duration, its severity, and also the type,
status, adaptability and genetic makeup of the injured
cell.

• Cell injury can be divided into reversible and irreversible.

• The loss of cell function is far before the cell death,

but the morphological visible changes appear far behind
the cell death.
Timing of biochemical and morphologic changes in cell injury.
Morphologic Changes of

Cell Injury
 Reversible cell injuries:

Intracellular Accumulations
 So called “degeneration”
• “Degeneration” is a traditional word used in
old textbooks of pathology. You could
understand it as
• Accumulation of exceeding normal substances
and abnormal substances in cells, usually in
the cytoplasm and/or in the stroma
• Exceeding normal and abnormal substances
come from the affected cells or elsewhere
• When the stimulus is removed in time, it is
reversible if it occurs in cytoplasm, but
irreversible in the stroma
 So called “degeneration”
According to the today’s view, so called
“degeneration” covers
• “real” reversible cellular injuries
– Cell swelling (hydropic change)
– Fatty change
• Intracellular accumulations (cholesterol,
proteins, glycogen)
• Extracellular accumulations (most proteins)
 Cellular swelling
• Cellular swelling
When the injurious cell can not maintain its ionic
and fluid homeostasis, the water surrounding cell
can enter the cytoplasm
– Grossly, the affected organ becomes pallor,
increased turgor, increased weight with dulled
edge
– Microscopically, small and clear vacuoles in
cytoplasm (hydropic change, ballooning
degeneration)
Left: ballooning degeneration in liver cells
Right: hydropic change in proximal convoluted tubules of the kidney
Hydropic change in the proximal tubules of kidney
 Morphologic changes
in reversible and
irreversible cell injury.
A, Electron
micrograph of a
normal epithelial cell
of the proximal
kidney tubule. Note
abundant microvilli
(mv) lining the lumen
(L). N, nucleus; V,
apical vacuoles.

B, Epithelial cell of the proximal tubule

showing reversible ischemic changes. The
microvilli (mv) are lost and have been
incorporated in apical cytoplasm; blebs have
formed and are extruded in the lumen (L).
Mitochondria are slightly dilated. (Compare with
A.) C, Proximal tubular cell showing irreversible
ischemic injury. Note the markedly swollen
mitochondria containing amorphous densities,
disrupted cell membranes, and dense pyknotic
nucleus.
 Fatty Change (Steatosis)
• Usually in liver, heart and kidney
• Storage of triglycerides in parenchymal cells
• Clear vacuoles in parenchymal cells by H&E
slide (fat is dissolved by alcohol in the
process of tissue preperation)
• Reasons of fatty liver:
– Alcohol abuse
– Toxins (tetrachloromethane,CCl4, endotoxins)
– Protein malnutrition (lack of choline and amino
acid)
– Diabetes mellitus
Fatty liver compares with
a normal liver in adult grossly
Fatty change in the liver cells
Here are lipid vacuoles within hepatocytes in a case of
macrovesicular steatosis (fatty change).
Fatty change in the
hepatocytes
by Sudan III stain.
EM shows the fatty drops
in hepatocytes.
Fatty change in the
epithelium of renal
proximal tubules
by Sudan III stain.
The orange areas
indicate the fatty
accumulated
cells
Fatty infiltration (left) and fatty change (right)
of the heart
 Intracellular Accumulations
• Three kinds of accumulated materials
– a normal cellular constituent accumulated
in excess, such as water, lipids, proteins,
and carbohydrates
– an abnormal substance, either exogenous,
such as a mineral or products of
infectious agents, or endogenous, such as
a product of abnormal synthesis or
metabolism;
– a pigment
The mechanisms of intracellular
accumulation
• A normal endogenous substance is produced at
a normal or increased rate, but the rate of
metabolism is inadequate to remove it
e.g. fatty change in the liver
• A normal or abnormal endogenous substance
accumulates because of genetic or acquired
defects in the metabolism, packaging,
transport, or secretion of these substances
e.g. storage diseases
The mechanisms of intracellular
accumulation
• Defects in protein folding
– Chaperones (Heat shock protein and
ubiquitin)
• An abnormal exogenous substance is
deposited and accumulates
– accumulations of carbon and silicon
Mechanisms of
intracellular
accumulations: (1)
abnormal metabolism,
as in fatty change in the
liver; (2) mutations
causing alterations in
protein folding and
transport, as in alpha-1-
antitrypsin deficiency;
(3) deficiency of critical
enzymes that prevent
breakdown of substrates
that accumulate in
lysosomes, as in
lysosomal storage
diseases; and
(4) inability to degrade
phagocytosed particels,
as in hemosederosis
and carbon pigment
Accumulation of Complex Lipids
and Carbohydrates
• Cholesterol and cholesterol esters
– Atherosclerosis (cholesterol in macrophages:
foamy cells)
– Xanthoma
– Cholesterolosis (in gallbladder)
• Gaucher’s disease
• Niemann-Pick disease
• Iatrogenic accumulations
– Lipogranuloma in lymph node
Coronary artery, severe
atherosclerosis

Many foam cells

(macrophages) full of
lipid material) and a
cholesterol cleft are
seen in this
atheromatous plaque.
Cholesterolosis.
Cholesterol-laden macrophages (foam cells) from a focus of gallbladder
cholesterolosis (arrow).
Deposition of lipids complex in the macrophages
Many inherited disorders of metabolism can lead to accumulation of storage
products in cells, as seen here with Gaucher's disease involving spleen.
 Protein Accumulations
(intracellular hyaline deposition)
• Protein re-absorption droplets in the
renal tubular epithelium (pinocytosis)
• Mallory bodies (alcohol hyalin) in liver
cells (accumulation of microfilaments)
• Dutcher bodies in some neoplastic plasma
cells (interfering of protein secretion)
• Negri bodies (rabies virus)
Intracellular protein accumulation (hyaline change in
proximal convoluted tubules, reabsorbed protein)
The liver of alcohol abuse (chronic alcoholism). Hyaline inclusions in
the hepatic parenchymal cell in the center appear as eosinophilic
networks disposed about the nuclei (arrow). B, Electron micrograph of
alcoholic hyalin. The material is composed of intermediate (prekeratin)
filaments and an amorphous matrix.
The red cytoplasmic inclusion body seen here is a Negri body in a Purkinje cell
of the cerebellum as a consequence of infection with the rabies virus.
Intracellular accumulation: Dutcher body (red round globule) in neoplastic
plasma cells (PAS stain).
Extracellular Accumulations
• Abnormal substances deposit in outside of
cells (in interstitial tissue)
• Irreversible changes
• Main types:
– Extracellular hyaline changes
• Hyaline changes of connective tissue (fibrosis, scar)
• Hyaline changes of blood vessels
– Amyloid change
– Mucoid change
Hyaline changes of connective
tissue
• The end stage of repair processes (scar,
sclerosis of glomeruli)
• The main content of the hyaline material
is mature collagen fiber
• It plays an important role in the wound
healing
Hyaline change of connective tissue. Left: spleen in gross specimen. Right:
microscopic appearance
Keloid (micro)
Hyaline change of blood vessels
• It is also called as “arteriolesclerosis”
• It could be found in the patient with
systemic hypertension, especially in
his/her spleen, kidney and brain
• Ischemia and increasing of peripheral
resistance of blood flow are the most
severe complications
Hyaline change in the walls of
arterioles of kidney in a patient with
essential hypertension
 Amyloid change (Amyloidosis)
• The deposition of abnormal extracellular
fibrillar protein (amyloid) in different
tissue
• Most common in spleen, kidney, chronic
inflammation and bone marrow
• Amorphous, meshwork deposition in bright
pink hyaline material and occupying the
original normal tissue
Amyloid degeneration of the spleen.
Left: Meckel staining.
Amyloidosis:
Upper: spleen is enlarged, firm and waxy.
Down: normal spleen.
Amyloid material stains orange by HE and Congo red stain.
 Amyeloid change
in renal vascular
wall and glomerulus

Upper: H & E stain, left: Congo red stain,

right: under a polarizing microscope
 Mucoid Change
• It is also called as mucoid degeneration
• Accumulation of mucopolysaccharide and
hyaluronic acid in the interstitial tissue
• It could be seen in some tumors,
rheumatic fever, atherosclerosis,
hypothyroidism, dystrophic bone marrow
and fat tissue
Cardiac
myxoma
 Pigments Depositions
• Pathologic pigmentation
– Endogenous:
• Lipofuscin (lipochrome),
hemosiderin, melanin, bilirubin
– Exogenous:
• carbon (tattoo and inbreath)
The yellow-brown granular pigment is lipofuscin (lipochrome)
which accumulates over time in cells (particularly liver and
heart) as a result of "wear and tear" with aging.
Lipofuncin in liver cells: They result of the process of autophagocytosis in
which intracellular debris is sequestered and turned into these residual bodies
as seen under the EM.
Lipofuscin in the myocardial fiber under the EM: the
high electronic density materials are residual bodies (arrow).
Hemosiderin in pulmonary alveoli (brown). This is usually
a reaction to old hemorrhage.
Hemosiderosis in liver.
The Kupffer cells in sinusoids next to plates of hepatocytes are seen
prominently here because of the brown granules of hemosiderin that they
contain.
Hemosiderosis in liver.
A Prussian blue reaction is seen in this iron stain of the liver to demonstrate
large amounts of hemosiderin that are present in hepatocytes and Kupffer cells.
Cholestasis of the liver.
The yellow-green globular material seen in small bile ductules
in the liver here is bilirubin pigment.
Jaundice
Increased amounts of circulating bilirubin in the blood can lead to the
"icterus" or jaundice. The easiest place to see icterus is on the sclera of the
eye.
Anthracosis (deposition of carbon) in the lung
Anthracotic pigment in macrophages in a hilar lymph node
 This skin lesion demonstrates
a malignant melanoma, which
is much larger and more
irregular than a benign nevus.

Under the microscopy there are

brown pigments in the cytoplasm of
tumor cells.
 Pathologic Calcification
• Abnormal deposition of calcium salts
except in the bone and teeth
• Dystrophic calcification occurs in dead or
dying tissues with a normal serum calcium
levels
• Metastatic calcification occurs in normal
tissue with hypercalcimia
Here is so-called "metastatic calcification" in the lung of a patient with a very
high serum calcium level (hypercalcemia, for example in hyperparathyroidism).
 SUMMARY OF CELLULAR
ACCUMULATIONS
• All kinds of intracellular accumulations are
reversible if the injurious facts move
• All kinds of extracellular accumulations are
irreversible
• The important accumulations
– Fatty change
– Hyaline change
• Intracellualr
• Extracellular (connective tissue and blood vessel wall)
– Hydropic change
 Summary
• Intracellular
accumulations • Extracellular
– Localized in accumulations
cytoplasm or – Localized in stroma
organelles – Replacement of
– Keep the original original structures
structures – Result from a
– An adaptation series of pathologic
– Reversible processes
– Irreversible
 Requirements
• Concepts and recognition of lesions
– Cellular swelling (hydropic degeneration)
– Fatty change
– Intracellular hyaline change
– Hyaline change of the connective tissue
– Hyaline change of the blood vessels
– Amyloid change
– Mucoid change
– Pathological calcification and pigmentation
• Give samples of various forms of accumulations
and understand their significances