CHAPTER I

CELLULAR RESPONSES TO STRESS AND TOXIC INSULTS: ADAPTATION, INJURY and DEATH

INTRODUCTION TO PATHOLOGY
Pathology
o
study of disease
o
Devoted to the study of structural, biochemical and
functional changes in cells, tissues and organs that underlie
the disease.
o
Attempts to explain the whys and wherefores of the signs
and symptoms manifested by patients while providing a
rational basis for clinical care and therapy.
o
serves as bridge between the basic sciences and clinical
medicine
o
Scientific foundation for all of medicine.
o
The study of pathology is divided into:
1.
General Pathology
Concerned with the:
a.
reactions of the cells and tissues to
abnormal stimuli and
b.
to inherited defects, which are the main
causes of disease.
2.
Systemic Pathology
Examines the alterations in specialized organs and
tissues that are responsible for disorders that
involve in these organs.

forms
1.
2.
3.
4.

FOUR ASPECTS OF DISEASE

the core of pathology
Etiology - cause of disease
Pathogenesis - mechanisms of its development
Molecular and Morphological Changes the
biochemical and structural alterations induced in the
cells and organs of the body
Clinical Manifestations - functional consequences of
the different changes

Etiology
o
two major classes of etiologic factors:
1. genetic
(inherited
mutations
and
disease
associated gene variants or polymorphisms)
2. acquired
(infectious,
nutritional,
chemical,
physical)
o
The idea that one etiologic agent is the cause of one disease
is not applicable to majority of disease is not applicable.
o
Most of the common afflictions are multifactorial and arise
from the effects of various external triggers on a genetically
susceptible individual.
o
The relative contribution of inherited susceptibility and
external influences varies in different disease.
Pathogenesis
o
Pathogenesis refers to the sequence of events in the
response of cells or tissues to etiologic agent,
o
from the initial stimulus to the ultimate expression of the
disease.
Molecular and Morphologic Changes
o
Morphologic changes refer to the structural alterations in
cells or tissues that are either characteristic of a disease or
diagnostic of an etiologic process.
o
Diagnostic pathology is devoted to identifying the nature and
progression of disease by studying morphologic changes in
tissues and chemical alterations in patients.
o
Molecular analysis by techniques such as DNA microarrays
has begun to reveal genetic differences that predict the
behavior of the tumors as well as their responsiveness to
different therapies.
Functional Derangement and Clinical Manifestation
o
End result of genetic, biochemical and structural changes in
cells and tissues are functional abnormalities, which lead to
the clinical manifestations of disease as well as its progress.
o
All forms of disease start with molecular or structural
alterations in cells.
o
Injury to cells and to the extracellular matrix ultimately leads
to tissue and organ injury, which determine the morphologic
and clinical patterns of disease.

CELLULAR RESPONSES TO INJURY

Nature of Injurious Stimulus
Altered Physiological Stimuli; Some
Nonlethal injurious Stimuli
increased
demand,
increased
stimulation (GF,Hormomes)
decreased
nutriets,
decreased

stimulation

The normal cell is confined to a fairly narrow range of

function and structure:
by its state of metabolism, differentiation and
specialization
by constraints of neighboring cells
by availability of metabolic substrates

Cellular Response
Cellular Adaptations
Hyperplasia, hypertrophy
Atrophy
Metaplasia

Chronic irritation
Reduced Oxygen Supply, Chemical
Cell Injury
Injury, Microbial Infection
Acute and transient
Acute reversible injury,
cellular swelling fatty
change
Progressive and severe
irreversible injury cell
death,
necrosis,
apoptosis
Metabolic alterations, genetic or
Intracellular
acquired; chronic injury
accumulations,
calcification
Cumulative sublethal injry over
Cellular aging
long life span

OVERVIEW: CELLULAR RESPONSES TO STRESS AND NOXIOUS STIMULI

The normal cell can handle physiologic demands,

maintaining a steady state called homeostasis.
Adaptations

Are reversible functional and structural responses to

more physiologic stress and some pathologic stimuli.

new but altered steady states are achieved

Allows the cell to survive and continue to function.

the adaptive response may consist of:

a.
increase in size of cells (hypertrophy) and
functional activity
b. increase in number of cells (hyperplasia)
c.
decrease in the size and metabolic activity of the
cells (atrophy) or
d. a change in the phenotype of the cell (metaplasia)
When the stress is eliminated, the cell can recover to its
original state without having suffered any harmful
consequences.

CELL INJURY
injury occurs :
if the limits of adaptive responses are exceeded
if the cells are exposed to injurious agents or stress
if the cell is deprived of essential nutrients
if the cell becomes compromised by mutations that
affect essential cellular constituents
Cell injury is reversible up to a certain point.
If the stress or noxious stimuli persists, or it is severe enough
from the beginning, the cell suffers irreversible injury and
ultimately cell death.
Adaptation, reversible cell injury and cell death may be the
stages of progressive impairment following different types of
insults.
CELL DEATH
Cell death

the end result of progressive cell injury

Most crucial events in the evolution of disease in any

tissue or organ.

Results from diverse causes including ischemia

(reduced blood flow), infection and toxins.

Is a normal and essential process in embryogenesis, the

development
of
organs
and
maintenance
of
homeostasis.
there are two principal pathway for cell death:
1. Necrosis
2. Apoptosis
Cell
a.
b.
c.
d.

Nutrient deprivation triggers an adaptive cellular response

call autophagy and may also culminate in cell death
Stresses of different types may induce changes in cells and
tissues other than typical adaptations, cell injury and cell
death:

Metabolic derangements in cells and sub lethal,

chronic injury may be associated with intracellular
accumulations of a number of substances,
including proteins, lipids and carbohydrates

CHAPTER I
CELLULAR RESPONSES TO STRESS AND TOXIC INSULTS: ADAPTATION, INJURY and DEATH
Calcium is often deposited at the sites of cell
death resulting in pathologic calcification

Aging
is
accompanied
by
characteristic
morphologic and functional changes in the cell.
Three other processes that affect cells and tissues are
1. intracellular accumulations
2. pathologic calcification
3. Cell Aging

ADAPTATION OF CELLULAR GROWTH AND DIFFERENTIATION

O
O
O
O
O
O
O

Adaptations are reversible changes in the number, size,

phenotype, metabolic activity, or functions of cells in
response to changes in their environment.

Physiologic adaptations

Usually represent responses of cells to normal

stimulation by hormones or endogenous
chemical mediators (e.g., the hormoneinduced enlargement of the breast and uterus
during pregnancy).

Pathologic adaptations

Are responses to stress that allow cells to

modulate their structure and function and
thus escape injury.

Such adaptations can take several distinct

forms
HYPERTROPHY
HYPERTROPHY
refers to an increase in the size of cells
results in an increase in the size of the organ
the hypertrophied organ has no new cells, just larger cells
Increased size

due to the synthesis of more structural

components of the cells.
Cells capable of division may respond to stress by
undergoing both hyperplasia and hypertrophy
Nondividing cells (myocardial fibers) increased tissue mass is
due to hypertrophy
hypertrophy and hyperplasia may coexist and contribute to
increased sized
Hypertrophy can be physiologic or pathologic and is caused
by increased functional demand or by stimulation by
hormones and growth factors.
striated muscle cells in the heart and skeletal
muscles have only a limited capacity for division
and respond to increased metabolic demands
mainly by undergoing hypertrophy
The most common stimulus for hypertrophy of muscle is
increased workload.
In the heart, the stimulus for hypertrophy is
usually chronic hemodynamic overload, resulting
from either hypertension or faulty valves.
In both the heart and muscle fiber tissues, the muscle cells
synthesize more proteins and the number of myofilaments
increase.

this increases the amount of force each myocyte can

generate and thus increases the strength and work
capacity of the muscle as a whole.

Physiologic Hypertrophy
o
massive physiologic growth of the uterus during pregnancy
is a good example of hormone-induced increase in the size of
an organ that results mainly from hypertrophy of muscle
fibers.

the cellular enlargement is stimulated by estrogenic

hormones acting on smooth muscle estrogen receptors

results in increased synthesis of smooth muscle

proteins and an increase in cell size.
MECHANISM OF HYPERTROPHY
o
o

Hypertrophy is the result of increased production of cellular

proteins.; understanding is based on the studies of the heart.
Hypertrophy can be induced by the linked actions of
a.
mechanical sensors (triggered by increased workload)
b. growth factors (TGF-, insulin-like growth factor-1 [IGF1], fibroblast growth factor)
c.
vasoactive agents (-adrenergic agonist, endothelin-1,
and angiotensin II)
Mechanical sensors induce production of growth factors and
agonist

these stimuli work coordinately to increase the

synthesis of muscle proteins that are responsible for
hypertrophy.
2 main biochemical pathways involved in muscle
hypertrophy:
1.
Phosphoinositide 3-kinase/Akt pathway
most important in physiologic hypertrophy such as
exercise-induced hypertrophy
2.
signaling downstream of G-protein coupled receptors.
induced by many GF and vasoactive agents
more important in pathologic hypertrophy.
Hypertrophy may also be associated with a switch of
contractile proteins from adult to fetal or neonatal forms.

E.g. during muscle hypertrophy, the isoform of

myosin heavy chain is replaced by the isoform which
has a
slower,
more energetically
economical
contractions.

genes that are expressed only during early

development are re expressed in hypertrophic cells and
the products of these genes participate in the cellular
response to stress.
gene for Atrial Natriuretic Factor (ANF) is
expressed in both the atrium and ventricle in the
embryonic heart, but is down regulated after birth.
Cardiac hypertrophy is associated with reinduction
of ANF gene expression.
ANF

peptide hormone that causes

a.
salt secretion by the kidney
b.
decreases blood volume and pressure
c.
serves to reduce hemodynamic load.
Cardiac hypertrophy eventually reaches a limit beyond which
enlargement of muscle mass is no longer able to
compensate for the increase burden.
Several regressive changes occur in the
myocardial fiber but the most important are
a.
lysis
b.
loss of myofibrillar contractile elements.
extreme cases: myocyte death can occur by either
apoptosis or necrosis.
net result: CARDIAC FAILURE, a sequence of events
that illustrates how an adaptation to stress can
progress to functionally significant cell injury if
stress is not relieved.
A subcellular organelle may also undergo selective
hypertrophy.

hypertrophy of the smooth endoplasmic reticulum in

hepatocytes for patients treated with barbiturates.
adaptive response that increases the amount of
enzymes (cytochrome P40 mixed function oxidase)
available to detoxify the drugs.
patient respond less to drug because of this
adaptation.

HYPERPLASIA
Hyperplasia
increase in the number of cell in an organ or tissue
usually resulting in an increased mass of the organ tissue
hyperplasia and hypertrophy frequently occur together, and
may be triggered by the same stimulus.
Hyperplasia takes place if the cell population is capable of
dividing and thus, increasing the number of cells.
can by physiologic or pathologic.
PHYSIOLOGIC HYPERPLASIA - divided into
1.
hormonal hyperplasia

increases the functional capacity of the tissue when

needed

well illustrated by the proliferation of the glandular

epithelium of the female breast at puberty and during
pregnancy, usually accompanied by enlargement of
the glandular epithelial cells.
2.
compensatory hyperplasia
increases tissue mass after damage or partial
resection.
e.g. in individuals who donate one lobe of the liver
for transplantation, the remaining cells proliferate
so that the organ soon grows back to its original
size.
PATHOLOGIC HYPERPLASIA
most forms are caused by excesses of hormones or growth
factors acting on target cells.

CHAPTER I
CELLULAR RESPONSES TO STRESS AND TOXIC INSULTS: ADAPTATION, INJURY and DEATH
-

Endometrial hyperplasia is an example of abnormal hormoneinduced hyperplasia.

the balance between estrogen and progesterone is

disturbed

results in absolute or relative increases in the amount

of estrogen, with consequent hyperplasia of the
endometrial glands.

this form of hyperplasia is a common cause of abnormal

menstrual bleeding.
benign prostatic hyperplasia

induced by androgens.
Benign prostatic hyperplasia and endometrial hyperplasia are
abnormal but the process remains controlled because there are
no mutations in genes that regulate cell division and the
hyperplasia regress if the hormonal stimulation is eliminated.
Hyperplasia is a characteristic response to certain viral infections
such as papillomaviruses which causes skin warts and several
mucosal lesions composed of masses of hyperplastic epithelium.

growth factors produced by viral genes or by infected

cells may stimulate cellular proliferation.

MECHANISM OF HYPERPLASIA
a result of growth factor-driven proliferation of mature cells
and, in some cases, by increased output of new cells from
tissue stem cells.

E.g. after partial hepatectomy, growth factors are

produced in the liver that engage receptors in the
surviving cells and activate signaling pathways that
stimulate cell proliferation.

If the proliferative capacity of the liver cells is

compromised, hepatocytes can regenerate from
intrahepatic stem cells.
ATROPHY

o
o
o

reduced size of an organ or tissue

resulting from a decrease in cell size and number
can be physiologic or pathologic.

PHYSIOLOGIC ATROPHY
o
common during normal development
o
embryonic structures such as notochord and thyroglossal
duct undergo atrophy during fetal development.
o
uterus decrease in size shorty after parturition
PATHOLOGIC ATROPHY
o
depends on the underlying cause and can be local or
generalized.
o
common causes of atrophy are the following:

Decreased workload (atrophy of disuse)

when a fractured bone is immobilized in a plaster
cast or when a patient is restricted to complete
bed rest, skeletal muscle atrophy rapidly ensues.
initial decrease in cell size is reversible once
activity is resumed.
with more prolonged disuse, skeletal muscle fibers
decrease in number as well as in size. (this
atrophy can be accompanied by increase bone
resorption, leading to osteoporosis of disuse)

loss of innervation (denervation atrophy)

normal metabolism and function of skeletal muscle
are dependent on its nerve supply.
Damage to nerves leads to atrophy of the muscle
fibers supplied by those nerves.

diminished blood supply

decrease in blood supply to a tissue as a result of
slowly developing arterial occlusive disease results
in atrophy of the tissue.
in late adult life, brain may undergo progressive
atrophy because of reduced blood supply as a
result of atherosclerosis. (senile atrophy, affects
the heart)

inadequate nutrition
profound protein-calorie malnutrition (marasmus)
is associated with the use of skeletal muscle as a
source of energy after other reserves such as
adipose stores have been depleted.
results in marked muscle wasting (cachexia)
Cachexia is also seen in patients with chronic
inflammatory diseases and cancer.
In CID, chronic overproduction of the
inflammatory cytokine tumor necrosis factor

is responsible for appetite suppression and

lipid depletion, culminating in muscle atrophy.

loss of endocrine stimulation

hormone responsive tissues, such as breast and
reproductive organs, are dependent on endocrine
stimulation for normal metabolism and function.
loss of estrogen stimulation after menopause
results in physiologic atrophy of the endometrium,
vaginal epithelium and breast.

pressure
tissue compression for any length of time can
cause atrophy.
enlarging benign tumor can cause atrophy in the
surrounding, uninvolved tissues.
atrophy results of ischemic changes caused
by compromise of the blood supply by the
pressure exerted by the expanding mass.
Fundamental cellular changes associated with atrophy are
identical in all pathologic settings.
Initial response is a decrease in cell size and organelles,
which may reduce the metabolic needs of the cell sufficiently
to permit its survival.
In atrophic muscle:
cells contain fewer mitochondria and myofilaments
reduced amount of rough ER
MECHANISMS OF ATROPHY
atrophy results from:
a.
decreased protein synthesis
protein synthesis decrease because of reduced
metabolic activity.
b.
increased protein degradation in cells
degradation of cellular proteins occurs mainly by
the ubiquitin-proteasome pathway.
Ubiquitin-proteasome pathway
nutrient deficiency and disuse may activate
ubiquitin ligases, which attach the small peptide
ubiquitin to cellular proteins and target these
proteins for degradation in proteasomes.
also thought to be responsible for the accelerated
proteolysis seen in a variety of catabolic
conditions, including cancer cachexia.
atrophy is usually accompanied by increased autophagy with
resulting increases in the number of autophagic vacuoles.

Autophagy
self-eating
process in which starved cell eats its own
component in an attempt to find nutrients and
survive.

autophagic vacuole
membrane bound vacuoles
that contain
fragments of cell components
fuse with lysosomes and their contents are
digested by lysosome enzymes.

some of the cell debris within the autophagic vacuole

may resist digestion and persist as membrane bound
residual bodies that may remain as sarcophagus in the
cytoplasm.
example of residual bodies is the lipofuscin
granules.
when present in sufficient amounts, they
impart a brown discoloration to the tissues.
METAPLASIA

Metaplasia
Reversible change in which one differentiated cell type (epithelial
or mesenchymal) is replaced by another cell type.
represent an adaptive substitution of cells that are sensitive to
stress by cell types better able to withstand the adverse
environment.
columnar to squamous epithelial metaplasia

occurs in the RT in response to chronic irritation.

habitual cigarette smoker: normal ciliated columnar

epithelial cells of the trachea and bronchi are often replaced
by stratified squamous epithelial cells

stones in the excretory duct of the salivary gland, pancreas

or bile ducts may also cause replacement of the normal
secretory columnar epithelium by stratified squamous.

CHAPTER I
CELLULAR RESPONSES TO STRESS AND TOXIC INSULTS: ADAPTATION, INJURY and DEATH

deficiency in vitamin A (retinoic acid) induces squamous

metaplasia in the respiratory epithelium.

the more rugged stratified squamous epithelium is able to

survive under circumstances in which the more fragile
specialized columnar cells might have succumbed.

Although the epithelial lining becomes tough, important

mechanism of protection against infection (mucus secretion,
and the ciliary action of the columnar epithelium) are lost.
metaplasia from squamous to columnar
Barrett esophagus in which the esophageal squamous
epithelium is replaced by intestinal-like columnar cells under
the influence of refluxed gastric acid.
Connective tissue metaplasia

formation of cartilage, bone or adipose tissues in tissues that

normally dont contain these elements.

Myositis ossificans

bone formation in the muscle

occurs after intramuscular hemorrhage.

may be a result of cell or tissue injury

o
o
o
o
o

MECHANISMS OF METAPLASIA
does not result from a change in the phenotype of an already
differentiated cell type
result of a reprogramming of stem cells that are known to
exist in normal tissues or of undifferentiated mesenchymal
cells present in connective tissues.
in a metaplastic change, these precursor cells differentiate
along a new pathway.
differentiation of stem cells to a particular lineage is brought
about by signals generated by cytokines, growth factors and
ECM components of the cells environment.
Retinoic acid regulates gene transcription directly through
nuclear retinoid receptors which can influence the
differentiation of progenitors derived from tissue stem cells.
OVERVIEW OF CELL INJURY AND CELL DEATH

REVERSIBLE CELL INJURY

o
in early stages or mild forms of injury, the functional and
morphologic changes are reversible if the damaging stimulus
is removed.
o
hallmarks of a reversible cell injury are:
a.
reduced oxidative phosphorylation with resultant
depletion of energy stores in the form of ATP
b.
cellular
swelling
caused
by
changes
in
ion
concentrations and water influx.
o
various
intracellular
organelles
(mitochondria
and
cytoskeleton) may also show alteration.
CELL DEATH
o
continuing damage
o
injury becomes irreversible
o
cell cannot recover and eventually dies
o
two principal type of cell death:
1. Necrosis
2. Apoptosis

Necrosis

damage to membrane is severe, lysosome

enzymes enter the cytoplasm and digest the
cell

cellular contents leak out

Apoptosis

cells DNA or protein are damaged beyond

repair, the cell kills itself.

form of cell death that is characterized by

a.
nuclear dissolution
b. fragmentation of the cell without
complete loss of membrane integrity
c.
rapid removal of cellular debris
o
o
o
o

Necrosis is always pathologic, apoptosis serves many

normal function and is not necessarily associated with cell
injury.
Cell death is also sometimes the end result of autophagy.
Apoptosis can progress to necrosis
Cell death during autophagy may show many of the
biochemical characteristics of apoptosis.

FEATURES OF NECROSIS AND APOPTOSIS

Feature
Cell size

Necrosis
Enlarged (swelling)

Apoptosis
Reduced (shrinkage)

Enzymatic digestion; may

leak out of cell

Fragmentation
into
nucleosome-size
fragments
Intact; altered structure,
especially orientation of
lipids
Intact; may be released in
apoptotic bodies

Frequent

No

Invariably
pathologic
(culmination
of
irreversible cell injury)

Often physiologic, means

of eliminating unwanted
cells; may be pathologic
after some forms of cell
injury, especially DNA
damage

Nucleus

Pyknosis karyorrhexis
karyolysis

Plasma
membrane

Disrupted

Cellular
contents
Adjacent
inflammation

Physiologic or
pathologic role

CAUSES OF CELL INJURY

OXYGEN DEPRIVATION
o
Hypoxia
deficiency of oxygen
causes cell injury by reducing
aerobic oxidative
respiration.
extremely important and common cause of cell injury
and cell death.
causes of hypoxia:
a.
reduced blood flow (ischemia)
b.
inadequate
oxygenation
of
the
blood
due
to
cardiorespiratory failure
c.
decreased oxygen-carrying capacity
anemia or
carbon monoxide poisoning (producing a stable carbon
monoxyhemoglobin that blocks oxygen carriage)
after severe blood loss
PHYSICAL AGENTS
o
physical agents capable of causing cell injury include:
a.
mechanical trauma
b. extremes of temperature (burns and deep cold)
c.
sudden changes in atmospheric pressure
d. radiation
e.
electric shock
CHEMICAL AGENTS AND DRUGS
o
simple chemicals such as glucose or salt in hypertonic
concentration may cause cell injury directly or by deranging
electrolyte balance in cells.
o
Oxygen at high concentration is toxic
INFECTIOUS AGENTS
IMMUNOLOGIC REACTIONS
o
injurious reactions to endogenous self-antigens are
responsible for several autoimmune diseases.
o
immune reactions to many external agents, such as
microbes and environmental substances are also important
causes of cell and tissue injury.
GENETIC DERANGMENTS
o
may result in a defect as severe as congenital malformations
associated with Down syndrome caused by chromosomal
anomaly or as subtle as the decreased life span of RBC
caused by a single amino acid substitution in hemoglobin in
sickle cell anemia.
o
Genetic defects may cause injury because of
a.
deficiency in functional proteins, such as enzyme
defects in inborn errors of metabolism or
b.
accumulation of damaged DNA or misfolded proteins

both of which trigger cell death when they are beyond

repair.
NUTRITIONAL IMBALANCES
o
major cause of cell injury
o
protein-calorie deficiencies cause death esp. in under
privileged population
MORPHOLOGIC ALTERATIONS IN CELL INJURY
- All stresses and noxious influences exert their effects first at the
molecular or biochemical level.
- the morphologic manifestation of necrosis take more time to develop
than those of reversible damage.

E.g. in ischemia of myocardium, cell swelling is a

reversible morphologic change that may occur in a

CHAPTER I
CELLULAR RESPONSES TO STRESS AND TOXIC INSULTS: ADAPTATION, INJURY and DEATH
matter of minutes and may progress to irreversibility
within an hour or two.

Light microscopic of cell death may not be seen until 4

to 12 hours after total ischemia.
- Reversible injury is characterized by:
a.
generalized swelling of the cell and its organelles
b.
blebbing of the plasma membrane
c.
detachment of the ribosomes from the ER
d.
clumping of nuclear chromatin

these morphologic changes are associated with:

decreased generation of ATP

loss of cell membrane integrity

defects in protein synthesis

cytoskeletal damage

DNA damage
- Irreversible injury and cell death occurs if the injurious stimulus
becomes persistent or in case of excessive injury.

injurious stimuli that induces death associated with

necrosis are:
a.
severe mitochondrial damage with depletion of ATP
b.
rupture of lysosome and plasma membrane
- Necrosis is the principal outcome in many commonly encountered
injuries.

REVERSIBLE INJURY
o
o

Two features of reversible injury:

1.
Cellular swelling
2.
Fatty change
Cellular swelling
appears whenever cells are incapable of maintaining
ionic and fluid homeostasis
result of failure of energy-dependent ion pumps in the
plasma membrane
Fatty change
occurs in hypoxic injury and various forms of toxic or
metabolic injury.
manifested by the appearance of lipid vacuoles in the
cytoplasm.
seen mainly in cells involved in and dependent on fat
metabolism such as hepatocytes and myocardial cells.
MORPHOLOGY OF REVERSIBLE CELL INJURY
cellular swelling is the first manifestation of almost all forms
of injury to cells.
more apparent at the level of the whole organ
when it affects many cells, it causes some pallor,
increased turgor and increase weight in organ
On microscopic examination, small, clear vacuoles may be
seen within the cytoplasm.

represent distended and pinched off segments of the

ER.

hydropic change or vacuolar degeneration.

Swelling is reversible.
Cells may show increased eosinophilic staining which
becomes more pronounced with progression to necrosis.
Ultrastructural changes of reversible cell injury include:
1.
Plasma membrane alterations
blebbing, blunting, loss of microvilli
2.
Mitochondrial changes
swelling and appearance of amorphous densities
3.
dilation of the ER
with detachment of polysomes
intracytoplasmic figures may be present
4.
nuclear alterations
disaggregation of granular and fibrillar elements.

NECROSIS
o
Morphologic appearance of necrosis is the result of:
1.
denaturation of intracellular proteins
2.
enzymatic digestion of lethally injured cells
o
Necrotic cells are
unable to maintain membrane integrity and
their contents often leak out, a process that may elicit
inflammation in the surrounding tissue.
o
Enzymes that digest the necrotic cells are derived from
a.
the lysosomes of the dying cells themselves ]
b.
the lysosomes of the leukocytes that are called in as
part of the inflammatory reaction.

MORPHOLOGY OF NECROTIC CELLS

Necrotic cells show increased eosinophilia

attributable in part to the loss of cytoplasmic RNA and

in part to the denatured cytoplasmic
Necrotic cell may have a more glassy, homogenous
appearance than do normal cells, mainly as a result of the
loss of glycogen particles.
When enzymes have digested the cytoplasmic organelles,
the cytoplasm becomes vacuolated and appears moth eaten.
Dead cells may be replaced by large, whorled, phospholipid
masses called myelin figures that are derived from damaged
cell membranes.
phospholipid precipitates are either phagocytized by
other cells or further degraded into fatty acids.
In EM, necrotic cells are characterized by
a.
discontinuities in plasma and organelle membranes
b.
marked dilation of the mitochondria with the
appearance of large amorphous densities
c.
intracytoplasmic myelin figures
d.
amorphous debris
e.
aggregates of fluffy material probably representing
denatured protein.
Nuclear changes appear in one of the three patterns, all due
to nonspecific breakdown of DNA:
1.
KARYOLYSIS
the basophilia of the chromatin may fade
change that presumably reflects loss of DNA because of
enzymatic degradation by endonucleases
2.
PYKNOSIS
seen in apoptotic cell death
characterized by nuclear shrinkage and increased
basophilia.
chromatin condenses into a solid, shrunken basophilic
mass
3.
KARYORHEXIS
pyknotic nucleus undergoes fragmentation.
PATTERNS OF TISSUE NECROSIS

Morphology
1.

COAGULATIVE NECROSIS
architecture of dead tissues is preserved for a span of
at least some days
affective tissues exhibit a firm texture
injury denatures not only on structural proteins but also
in enzymes and so blocks proteolysis of dead cells
eosinophilic, anucleate cells persist for days or weeks.
E.g. ischemia caused by obstruction in a vessel may
lead to coagulative necrosis of the supplied tissue in all
organs except the brain.
Infarct

a localized area of coagulative necrosis

2.

LIQUEFACTIVE NECROSIS
characterized by digestion of the dead cells, resulting in
transformation of the tissues into a liquid, viscous
mass.
seen in focal bacteria, fungal infections
necrotic material is creamy yellow because of the
presence of the dead leukocytes and is called pus.
E.g., hypoxic death of cells within the central nervous
system often manifests as liquefactive necrosis.

3.

GANGRENOUS NECROSIS
usually applied to a limb, generally the lower leg that
has lost its blood supply and has undergone necrosis.
when bacterial infection is superimposed, there is more
liquefactive necrosis because of the actions of
degradative enzymes in the bacteria and the attracted
leukocytes

wet gangrene
CASEOUS NECROSIS
encountered most often in the foci of tuberculosis
infection.
caseous (cheese-like)
friable white appearance of the area of necrosis,
necrotic area appears as a collection of fragmented or
lysed cells and amorphous granular debris enclosed
within a distinctive inflammatory border.
appearance is characteristic of a focus of inflammation
known as granuloma.
FAT NECROSIS

4.

5.

CHAPTER I
CELLULAR RESPONSES TO STRESS AND TOXIC INSULTS: ADAPTATION, INJURY and DEATH
-

6.

O
O

refers to focal areas of fat destruction, resulting from

release of activated pancreatic lipases into the
substance of the pancreas and the peritoneal cavity.
occurs in acute pancreatitis.
necrosis takes the form of foci of shadowy outlines of
necrotic fat cells with basophilic calcium deposits,
surrounded by an inflammatory reaction.
FIBRINOID NECROSIS
usually seen in immune reactions involving blood
vessels.
occurs when complexes of antigens and antibodies are
deposited in the walls of arteries.
deposits of these immune complexes, together with
fibrin that has leaked out of vessels, result in a bright
pink and amorphous appearance in H&E stains called
fibrinoid

b.

Most necrotic cells and their contents disappear by

phagocytosis of the debris and enzymatic digestion by the
leukocytes.
Dystrophic calcification
if necrotic cells and cellular debris are not promptly
destroyed and reabsorbed, they tend to attract calcium
salts and other minerals and to become calcified.

c.
d.

MECHANISM OF CELL INJURY

1.
2.

3.

4.

principles that are relevant to most forms of cell injury:

Cellular response to injurious stimuli depends on the nature
of the injury, its duration and its severity.
Consequence of cell injury depend on the type, state and
adaptability of the injured cell.
cells nutritional and hormonal status and its metabolic
needs are important in its response to injury.
Cell injury results from different biochemical mechanisms
acting on several essential cellular components.
cell components that are most frequently damaged by
injurious stimuli are include

mitochondria

cell membrane

machinery
of
protein
synthesis
and
packaging

DNA nuclei
Any injurious stimulus may simultaneously trigger multiple
interconnected mechanisms that damage cells.

e.

f.

ATP depletion and decreased ATP synthesis are frequently

associated with both hypoxic and chemical injury.
ATP is produced in 2 ways:
1.
major pathway: oxidative phosphorylation of adenosine
diphosphate

reaction that results in the reduction of O2 by the

electron transfer system of mitochondria.
2.
glycolytic pathway

can generate ATP in the absence of O2 using glucose

derived from either body fluids or from the hydrolysis of
O2.
the major causes of ATP depletion are
a.
reduced supply of oxygen and nutrients
b.
mitochondrial damage
c.
actions of some toxins (e.g. cyanide)
Tissues with greater glycolytic capacity (e.g. liver) are able
to survive loss of O2 and decreased oxidative
phosphorylation better than are tissues with limited capacity
for glycolysis. (e.g. brain)
synthetic and degradative processes within the cell that
require high energy phosphate in the form of ATP are:

membrane transport

protein synthesis

lipogenesis

deacylation-reacylation
reactions
for
phospholipid turnover
Depletion of ATP to 5% to 10% of normal levels has
widespread effects on many critical cellular systems:
a.

Activity of the plasma membrane energy

dependent sodium pump (ouabain-sensitive Na,Katpase) is reduce
failure of this active transport system causes:

Cellular energy metabolism is altered

if supply of O2 to cells is reduced (as in ischemia),
a.
oxidative phosphorylation ceases
b.
decrease in cellular ATP
c.
associated increase in adenosine monophosphate.
these changes stimulate phosphofructokinase and
phosphorylase -> increased rate of anaerobic glycolysis
Anaerobic glycolysis

designed to maintain the cells energy

sources
by
generating
ATP
through
metabolism of glucose derived from glycogen

glycogen stores are depleted

results in the accumulation of lactic acid and

inorganic phosphates

reduces the intracellular pH

decreased activity of many cellular

enzymes.
Failure of the Ca pump leads to influx of Ca with
damaging effects on numerous cell components
With prolonged or worsening of ATP depletion,
structural
disruption
of
protein
synthetic
apparatus occurs
manifested as detachment of ribosomes from rough ER
and dissociation of polysomes
consequent reduction in protein synthesis.
in cells deprived of O2 or glucose, proteins may
become misfolded.
misfolded proteins trigger a cellular reaction called
unfolded protein response
irreversible damage to mitochondrial and lysosome
membranes and the cell undergoes necrosis.

MITOCHONDRIAL DAMAGE
o
Mitochondria can be damaged by:
a.
increases of cytosolic Ca
b.
reactive oxygen species
c.
oxygen deprivation
o
two major consequences of mitochondrial damage:
a.

DEPLETION OF ATP
o

Na to enter and accumulate inside the cell

K to diffuse out of the cell

Net gain of solute is accompanied by isosmotic gain of
water, causing cell swelling and dilation of the ER

b.

Mitochondrial damage often results in the formation of a high

conductance channel in the mitochondrial membrane called
mitochondrial permeability transition pore

opening of tis conductance channel leads to:

loss of mitochondrial membrane potential

resulting in depletion of ATP.

cyclophilin D

component of MPTP

target of cyclosporine
Mitochondria sequester between the outer and inner
membrane several proteins that are capable of activating
apoptotic pathways

includes cytochrome c and proteins

indirectly
activate
apoptosis
inducing
enzymes called caspase.

increase permeability of the outer mitochondrial

membrane may result in leakage of these proteins into
the cytosol, and death by apoptosis.

INFLUX OF CALCIUM AND LOSS OF CALCIUM HOMEOSTASIS

o
o
o

o
a.

Cytosolic free Ca (0.1 umol) is maintained at low

concentrations, while extracellular levels of 1.3 nmol
most intracellular calcium is sequestered in mitochondria
and ER.
Ischemia and certain toxins can cause an increase in
cytosolic Ca concentration because of release of Ca from
intracellular stores

resulting from increased influx of Ca across the plasma

membrane
Increased intracellular Ca causes cell injury by several
mechanisms:
accumulation of Ca results in the opening of the
mitochondrial permeability transition pore, and failure of ATP
generation

CHAPTER I
CELLULAR RESPONSES TO STRESS AND TOXIC INSULTS: ADAPTATION, INJURY and DEATH
b.

c.

increased cytosolic Ca activates a number of enzymes that

has deleterious cellular effects:

phospholipase - cause membrane damage

protease - breaks down both membrane and

cytoskeletal proteins

endonuclease - DNA and chromatin fragmentation

ATPase - hastening ATP depletion

Increase cytosolic Ca levels result in the induction of
apoptosis by direct activation of caspases and by increasing
mitochondrial permeability

ACCUMULATION OF
OXYGEN
DERIVED FREE
RADICALS
(OXIDATIVE STRESS)
o
Free radicals

chemical species that have a single unpaired electron in

an outer orbit.

energy is released through reactions with adjacent

molecules (inorganic and organic compounds)

initiate autocatalytic reactions

o
Reactive oxygen species (ROS)

type of oxygen derived free radical

produced normally in cells during mitochondrial

respiration and energy generation

degraded and removed by cellular defense system.

produced in large amounts by leukocytes (neutrophils

and macrophages) as mediators for destroying microns,
dead tissues and other unwanted substances.

injury caused by ROS often accompanies inflammatory

reactions during which leukocytes are recruited and
activated.
o
cells are able to maintain a steady state in which free
radicals are present transiently at lower concentrations but
do not cause damage.
o
When production of ROS increases or scavenging systems
are ineffective, result is an excess of free radicals leading to
oxidative stress
o
Oxidative stress

implicated in cell injury, cancer, aging and Alzheimer

disease.
GENERATION OF FREE RADICALS
1.
Reduction-Oxidation reactions that occur during normal
metabolic process
different number of electrons have been transferred
from O2.
includes

Superoxide

Hydrogen peroxide

hydroxyl ions
2.
Absorption of radiant energy
E.g. ionizing radiation can hydrolyze water into hydroxyl
ions and hydrogen free radicals
3.
Inflammation
rapid bursts of ROS are produced in activated
leukocytes during inflammations
reaction in plasma membrane multiprotein complex
that uses NADPH oxidase for redox reaction.
Intracellular oxidase (e.g. xanthane oxidase) generate
superoxide
4.
Enzymatic metabolism of exogenous chemicals or drugs can
generate free radicals that are not ROS but have similar
effects
5.
Transition metals such as iron and copper donate or accept
free electrons during intracellular reactions and catalyze free
radical formation
6.
Nitric oxide
important chemical mediator generated by endothelial
cells, macrophages, neurons and other cell types
can act as free radical
can be converted to peroxynitrite anion
REMOVAL OF FREE RADICALS
1.
Antioxidants
block the initiation of free radicals formation or
inactivate free radicals.
E.g. lipid soluble vitamin E and A as well as ascorbic
acid and glutathione in the cytosol
2.
Iron and Copper
3.
Enzymes

Catalase

present
in
peroxisomes,
decomposes H202

Superoxide dismutase (SODs)

convert superoxide to hydrogen

peroxide

includes both manganese SOD,

localized in the mitochondria

copper-zinc-SOD, found in the

cytosol

Glutathione peroxides

catalyzing free radical breakdown

PATHOLOGIC EFFECTS OF FREE RADICALS
o
Lipid Peroxidation in membranes
in the presence of O2, free radicals may cause lipid
peroxidation within the plasma and organelle or
membranes
Oxidative damage is initiated when the double bonds in
unsaturated fatty acids of
membrane lipids are
attacked by O2 derived free radicals, particularly by
hydroxyl ions
Propagation (autocatalytic chain reaction) occurs which
can result to extensive membrane damage.
o
Oxidative modification of proteins
free radicals promote
a.
oxidation of amino acid side chains,
b. formation of protein-protein cross linkages
c.
oxidation of protein backbone
oxidative modification of proteins may:
a.
damage the active sites of enzymes
b. disrupt the conformation of structural proteins
c.
enhance proteosomal degradation of unfolded or
misfolded proteins
o
Lesions in DNA
free radicals cause:
a.
single and double strand breaks in DNA
b. cross linking of DNA strands
c.
formation of adducts

DEFECTS IN MEMBRANE PERMEABILITY

o

o
o
o

a.

b.

c.

Early loss of selective membrane permeability leading

ultimately to overt membrane damage is a consistent
feature of most forms of cell injury (except apoptosis)
MECHANISM OF MEMBRANE DAMAGE
in ischemic cells, membrane defects may be the result of
ATP depletion and calcium mediated activation of
phospholipase.
toxins, viral proteins, lytic complement components, physical
and chemical agents
Some biochemical mechanisms contribute to membrane
damage:
a.
ROS
b.
decreased phospholipid synthesis
c.
increased phospholipid breakdown
d.
Cytoskeletal abnormalities
CONSEQUENCES OF MEMBRANE DAMAGE
the most important sites of membrane damage during cell
injury are the mitochondrial membrane, plasma membrane
and membranes of lysosomes.
Mitochondrial

membrane Damage
opening of the MPTP
decreased ATP
release of proteins that trigger apoptotic
death
Plasma Membrane Damage

loss of osmotic balance and influx of fluids

and ions

loss of cellular contents.

cells leak metabolites that are vital for the

reconstitution of ATP, further depleting
energy stores
Injury to lysosome membranes

results in leakage of enzymes into the

cytoplasm

activation of the acid hydrolase in then acidic

intracellular pH of the injured cell.

cells die by necrosis.

CHAPTER I
CELLULAR RESPONSES TO STRESS AND TOXIC INSULTS: ADAPTATION, INJURY and DEATH
DAMAGE TO DNA AND PROTEINS
o

Leakage of intracellular enzymes and other proteins across

the abnormally permeable plasma membrane and into the
blood provides important clinical indicators of cell death

Creatine Kinase MB and troponin are early signs of MI

and may be seen before the infarct is detectable
morphologically.

Mammalian cells have developed protective responses to

hypoxic stress.

Hypoxia-inducible factor-1
promotes new blood vessel formation
stimulate cell survival pathway
enhances anaerobic glycolysis.
The strategy that is most useful in ischemic brain and SC
injury is the transient induction of hypothermia (reducing the
core body temp to 92F)

this treatment:
a.
reduces the metabolic demands of the stressed
cells
b.
decrease cell swelling
c.
suppress the formation of free radicals
d.
inhibits host inflammatory response

Two phenomena consistently characterize irreversibility:

1. inability to reverse mitochondria dysfunction
2. profound disturbances in membrane function.
EXAMPLES OF CELL INJRY AND NECROSIS

A.
o
o

ISCHEMIC AND HYPOXIC INJURY

most common type of cell injury.
Hypoxia
reduced oxygen availability
energy production by anaerobic glycolysis can continue
Ischemia
the supply of oxygen and nutrients is decreased
because of reduced blood flow as a consequence of
a.
a mechanical obstruction in the arterial system.
b.
by reduced venous drainage
ischemia compromises the delivery of the substrates for
glycolysis
aerobic metabolism is compromised
anaerobic energy generation also stops after glycolytic
substrate are exhausted or glycolysis is inhibited by the
accumulation of metabolites that would have been
removed otherwise by blood flow.
tends to cause more rapid and sever cell and tissue
injury than does hypoxia in the absence of ischemia.
MECHANISMS OF ISCHEMIC CELL INJURY
As oxygen tension within the cell decreases, there is
a.
loss of oxidative phosphorylation and
b.
decreased generation of ATP

results in failure of the sodium pump, loss of potassium,

influx of calcium.

progressive loss of glycogen and decreased protein

synthesis.

loss of contractility does not mean cell death

If hypoxia continues, worsening of ATP depletion causes

further deterioration.

they cytoskeleton disperses

resulting in the loss of Ultrastructural features

such as microvilli and the formation of blebs
at the cell surface.

Myelin figures may be seen within the cytoplasm or

extracellularly.

Mitochondria are swollen as a result of loss of volume

control

ER remains dilated

entire cell is markedly swollen with

a.
increased concentrations of water, Na and Cl
b.
decreased concentration of K.
IF O2 is restored, all of these disturbances are
reversible

If ischemia persists, irreversible injury and necrosis ensue.

Irreversible injury is associated morphologically with

a.
severe swelling of mitochondria
b.
extensive damage to plasma membranes (giving
rise to myelin figures)
c.
swelling of lysosomes
d.
large, flocculent, amorphous densities develop in
the mitochondrial matrix.

in the myocardium, the alterations are indications of

irreversible injury and can be seen as early as 30 to 40
minutes after ischemia.

Massive influx of Ca into the cell occurs

Death is mainly by necrosis but apoptosis also

contributes.

Apoptotic pathway is activated by release of

proapoptotic
molecules
from
leaky
mitochondria.

Dead cells may become replaced by large

masses composed of phospholipids in the
form of myelin figures.

Myelin figures are phagocytized or degraded

into fatty acids.

Calcification of fatty acid residues may occur

with the formation of Ca soaps.

B.

ISCHEMIA-REPERFUSION INJURY

When blood flow is restored to cells that have been ischemic

but have not died, injury is paradoxically exacerbated and
proceed at an accelerated phase.

As a consequence, reperfused tissue may sustain loss

of cells in addition to cells that are irreversible damaged
at the end of ischemia
Ischemia-reperfusion injury
contributes to tissue damage during myocardial and
cerebral infarction
occurs when new damaging processes are set in motion
during reperfusion, causing the death of cells that
might have recovered.
the mechanisms are as follows:
a.
mew
damage
may
be
initiated
during
reoxygenation by increased generation of reactive
oxygen and nitrogen species from parenchymal
and endothelial cells and from infiltrating
leukocytes.
b.
ischemic injury associated with inflammation as a
result of production of cytokines and increased
expression of adhesion molecules by hypoxic
parenchymal and endothelial cells.
c.
Activation of the complement system

IgM antibodies have a propensity to

deposit in ischemic tissues.

When
blood
flow
is
resumed,
complement proteins bind to deposited
anitbodies, are activated and cause
more cell injury and inflammation.

C.
o
o

CHEMICAL (TOXIC) INJURY

major limitation to drug therapy.
chemicals induce cell injury by one of two general
mechanisms:
1.
Chemicals injure cells directly by combining with critical
molecular components.
2.
Most toxic chemicals are not biologically active in their
native form but must be converted to reactive toxic
metabolites, which them act on target molecules.

This modification is accomplished by cytochrome P-450

mixed function oxidases in the smooth ER of the liver
and other organs.

the toxic metabolites that cause membrane damage

and cell injury mainly by:
a.
formation of free radicals
b.
subsequent lipid peroxidation
c.
direct covalent binding to membrane proteins and
lipids may also contribute.
APOPTOSIS
Apoptosis
is a pathway of cell death that is induced by a tightly
regulated suicide program
cells destined to die activated enzymes that degrade
the cells own nuclear DNA and nuclear and cytoplasmic
proteins.

CHAPTER I
CELLULAR RESPONSES TO STRESS AND TOXIC INSULTS: ADAPTATION, INJURY and DEATH
o

o
o
o

Apoptotic cells break up into fragments called apoptotic

bodies.

contain portions of cytoplasm and nucleus

plasma membrane remains intact

structure is altered to become tasty targets for

phagocytes.
dead cells and fragments are devoured before the contents
have leaked out.
Cell death by this pathway does not elicit an inflammatory
reaction in the host.
Apoptosis induced by pathologic stimuli may progress to
necrosis.
CAUSES OF APOPTOSIS

APOPTOSIS IN PHYSIOLOGIC CONDITIONS

o

Embryogenesis
including implantation, organogenesis, developmental
involution and metamorphosis
death of specific cell types at defined times during
development of an organism.
Involution of hormone dependent tissues upon hormone
withdrawal
endometrial cell breakdown during menstrual cycle
ovarian follicular atresia in menopause
regression of lactating breast after weaning
prostatic atrophy after castration.
Cell loss in proliferating cell population
immature lymphocytes in the bone marrow and thymus
that fail to express useful antigen receptors
B lymphocytes in germinal centers
epithelial cells in intestinal crypts to maintain a
constant number.
Elimination of potentially harmful self-reactive lymphocytes
either before or after they have completed their
maturation to prevent reactions against ones own
tissue.
Death of host cells that have served useful purpose such as:
neutrophils in an acute inflammatory response
lymphocytes ate the end of an immune response

cells undergo apoptosis because they are deprived of

essential survival signals such as GFs.

APOPTOSIS IN PATHOLOGIC CONDITIONS

eliminates cells that are injured beyond repair without
eliciting a host reaction, thus limiting collateral tissue
damage.
o
DNA Damage
radiation, cytotoxic anticancer drugs, hypoxia
elimination of cells may be a better alternative than
risking mutations in damaged DNA which may result to
malignant transformation.
larger doses may result in necrotic cell death
o
Accumulation of misfolded proteins
improperly folded proteins arise because of mutations
in the genes encoding thee proteins.
ER Stress

Excessive accumulations of misfolded proteins in the ER

culminates in apoptotic cell death

degenerative diseases of the CNS and other organs
o
cell death in certain infection
viral infections
loss of infected cells is due to apoptosis that may be
induced by the virus or by the host immune response.
o
Pathologic atrophy in parenchymal organs after the duct
obstruction
MORPHOLOGIC AND BIOCHEMICAL CHANGES IN APOPTOSIS
MORPHOLOGY
a.
Cell shrinkage
cell is smaller
cytoplasm is dense
organelles are normal but more tightly packed.
b.
Chromatin condensation
most characteristic feature of apoptosis
chromatin aggregates peripherally
nucleus may break up, producing two or
fragments
c.
Formation of cytoplasmic blebs and apoptotic bodies
first show extensive surface blebs

d.

Plasma membranes are thought to remain intact during

apoptosis until the last stages when they become permeable
to normally retained solutes.
o
Apoptosis does not elicit inflammation.
BIOCHEMICAL FEATURES OF APOPTOSIS
1.
Activation of Caspases
Caspases

c refers to cysteine protease

aspase refers to unique ability of the enzymes to cleave

after aspartic acid residues.

can be divided into 2 groups:

a.
initiator

include caspase 8 and caspase 8

b.
executioner

caspase 3 and caspase 6

exist as inactive pro-enzymes or zymogens

must undergo enzymatic cleavage to become active

presence of cleaved, active caspase is a marker for

cells undergoing apoptosis.
2.
DNA and protein breakdown
3.
Membrane alteration and Recognition by Phagocytes
movement of some phospholipids (phosphatidylserene)
from the inner leaflet to the outer leaflet of the
membrane.
annexin V
o

MECHANISMS OF APOPTOSIS
The basic mechanisms of apoptosis are conserved in
multicellular organisms.
o
The process of apoptosis may be divided into
a.
initiation phase
caspases becomes catalytically active
occurs principally by signals from two distinct
pathways:

intrinsic or mitochondrial pathway

extrinsic
or death receptor-initiated
pathway
b. execution phase
other caspase trigger the degradation of critical cellular
components.
Initiation Phase
INTRINSIC (MITOCHONDRIAL PATHWAY
o

major mechanism
result of increased mitochondrial permeability and release of
pro apoptotic molecule into the cytoplasm
o
cytochrome c
proteins that when released into the cytoplasm, initiate
a suicide program of apoptosis.
release of these proteins is controlled by balance
between pro and anti-apoptotic members of the Bcl
family.

Growth factors are other survival signals stimulate

production of anti-apoptotic proteins , the main ones
are:
a.
Bcl-2
b.
Bcl-x
c.
Mcl-1

these proteins reside in cytoplasm and

mitochondrial membranes

control mitochondrial proteins that have

the ability to trigger cell death
o
When cells are deprived of survival signals, or their DNA is
damaged, or misfolded proteins induce ER stress, sensors of
damage or stress are activated

these sensors are members of the Bcl family and

include
a.
Bim
b.
Bid
c.
Bad
EXTRINSIC (DEATH RECEPTOR-INTIATED) PATHWAY OF APOPTOSIS
o
o

O
more

undergoes fragmentation
Phagocytosis of apoptotic cells or cell bodies usually by
macrophage

pathway is initiated by engagement of plasma membrane

death receptors on a variety of cells.
Death receptors are members of the TNF receptor family that
contain a cytoplasmic domain called death domain because
it is essential for delivering apoptotic signals.

CHAPTER I
CELLULAR RESPONSES TO STRESS AND TOXIC INSULTS: ADAPTATION, INJURY and DEATH

the best known death receptors are

a.
the type 1 TNF receptor
b.
Fas (CD95)

a.

Execution Phase of Apoptosis

O
Two initiating pathways converge to a cascade of caspase
activation, which mediates the final phase of apoptosis.
O
the mitochondrial pathway leads to activation of caspase 9.;
the death receptor pathway to caspase 8 and 10.
O
After the initiator caspase is cleaved to generate its active
form, the enzymatic death program is set in motion by
activation of executioner caspase:

Caspase 3 and 6
act on many cellular components
once activated, cleave an inhibitor of a cytoplasmic
DNase and make DNase active.
degrade structural components
promote fragmentation of nuclei.

o
o
o

REMOVAL OF DEAD CELLS

in healthy cells, phosphatidylserene is present on the inner
leaflet of the membrane
in apoptotic cells, phosphatidylserene flips out and is
expressed on the outer layer of the membrane, where it is
recognized by several macrophage receptors.
Cells that are dying by apoptosis secrete soluble factors that
recruit phagocytes

thrombospondin
adhesive glycoprotein
recognized by phagocytes

C1q
natural antibodies
proteins of complement system

CLINICOPATHOLOGIC CORRELATIONS: APOPTOSIS IN HEALTH

AND DISEASE
1. Growth Factor deprivation
2. DNA damage
3. Protein misfolding
4. Apoptosis induced by the TNF receptor family
5. Cytotoxic T Lymphocyte Mediated Apoptosis
Granzymes

ability to cleave protein at aspartate resides

activate a variety of cellular caspases

kills target cells by directly inducing the effector phase

of apoptosis
Disorders Associated with Dysregulated Apoptosis
A. Defective Apoptosis and Increased Cell Survival
low rate of apoptosis permit the survival of abnormal
cells
defective apoptosis: autoimmune disorder
B. Increased Apoptosis and Excessive Cell Death
diseases characterized by a loss of cells
include:
1. neurodegenerative diseases
2. ischemic injury
3. death of virus-infected cells
o
o
o
o

AUTOPHAGY
Autophagy
cell eats its own content
survival mechanism in times of nutrient deprivation
intracellular organelles and portions of cytosol are first
sequestered from the cytoplasm in an autophagic vacuole.
AV fuses with lysosomes to form autophagolysosomes, and
the cellular components are digested by lysosome enzymes
Regulated by Autophagy genes (Atgs)

b.

c.
d.

One manifestations of metabolic derangements in cells is the

intracellular accumulation of abnormal amounts of various
substances.
stockpiled substances fall into two categories
1. normal cellular constituent that accumulate in excess
water
lipids
proteins
carbohydrates
2. abnormal substance
substances may be located in either the cytoplasm
(phagolysosomes) or nucleus

a normal endogenous substance is produced at a

normal or increased rate, but the rate of metabolism is
inadequate to remove it
fatty change in the liver
reabsorption protein droplets in the kidney tubules
abnormal endogenous substance (product of mutated
gene ) accumulates because of
defects in protein folding and transport
inability to degrade the abnormal protein efficiently
E.g. accumulation of mutated alpha1-antitrypsin in liver
cells
normal endogenous substance accumulates because of
defects in enzymes that are required for the
metabolism
abnormal exogenous substance is deposited and
accumulates because cell has neither the
ability to transport
enzymatic machinery to degrade the substance

LIPIDS

o
o
o

triglycerides
cholesterol/cholesterol esters
phospholipids
Phospholipids - components of myelin figures found in
necrotic cells.
Abnormal complexes of lipids and carbohydrates accumulate
in the lysosome storage disease.
TG and cholesterol accumulation

STEATOSIS (FATTY CHANGE)

o
abnormal accumulations of TGs within parenchymal cells.
o
often seen in the liver because it is the major organ involved
in fat metabolism.
o
also occurs in heart, muscle and kidney.
o
causes include:
a.
toxins
b.
protein malnutrition
c.
DM
d.
obesity
e.
anoxia
o
Mechanism may be that:

free fatty acids from adipose tissue or ingested food are

normally transported into hepatocytes

in the liver:

esterified to Tgs

converted into cholesterol or phospholipid

oxidized to ketone bodies

some are synthesized as acetate as well

Excess accumulation of TGs within the liver may result

from excessive entry or defective metabolism and
export of lipids
o
induced by alcohol that alters mitochondrial and microsomal
function, leading to increased synthesis and reduced
breakdown of lipids
o
CCl and protein malnutrition cause fatty change by reducing
synthesis of apoproteins
o
hypoxia inhibits fatty acid oxidation
o
starvation increases fatty acid mobilization from peripheral
stores.

INTRACELLULAR ACCUMULATIONS
o

most accumulations are attributable to four types of

abnormalities:

MORPHOLOGY
often seen in liver and heart
in all organs: appears as
parenchymal cells.

clear

vacuoles

within

Liver
mild fatty change may not affect the gross appearance
organ enlarges
becomes increasingly yellow
in extreme cases, liver may weigh two to four times
and transformed into a bright yellow, soft, greasy
organ.
fatty change begins with the development of minute
membrane bound inclusions closely applied to the ER.
Heart
lipid is found in cardiac muscle in the form of small
droplets occurring in two patterns

10

CHAPTER I
CELLULAR RESPONSES TO STRESS AND TOXIC INSULTS: ADAPTATION, INJURY and DEATH
1.

2.

prolonged moderate hypoxia causes intracellular

deposits of fat

creates grossly apparent bands of

yellowed myocardium

alternating with bands of darker red

brown, uninvolved myocardium (tigered
effect)
other pattern of fatty change is produced by more
profound hypoxia or by some forms of myocarditis

shows
more
uniformly
affected
myocytes

CHOLESTEROL AND CHOLESTEROL ESTERS

a.
Atherosclerosis
smooth muscle cells within the intimal layer of the
aorta and large arteries are filled with lipid vacuoles,
most are made up of cholesterol and cholesterol esters.
foamy appearance ; intima: yellow cholesterol-laden
atheromas
EC cholesterol esters may crystalize in the shape of
long needles, producing quite distinctive clefts in tissue
sections
b. Xanthomas
intracellular
accumulation
of
cholesterol
within
macrophages is characteristic of acquired and
hereditary hyperlipidemic states
clusters of foamy cells in subepithelial connective
tissues of the skin and tendons
c.

d.

Cholesterolosis
focal accumulations of cholesterol-laden macrophages
in the lamina propria of the gallbladder.
unknown mechanism of accumulation
Niemann-Pick Disease, type C
caused by mutations affecting an enzyme involved in
cholesterol trafficking = cholesterol accumulation in
multiple organs

PROTEINS
o
appear as rounded, eosinophilic
droplets, vacuoles or
aggregates in the cytoplasm
o
can be amorphous, fibrillar or crystalline in appearance
o
Amyloidosis: abnormal proteins deposit primarily in the
extracellular spaces
o
causes:
1.
reabsorption droplets in proximal renal tubules: renal
disease with proteinuria
2.
Proteins that accumulate may be normal secreted
proteins that are produced in excessive amounts,
(plasma cells engaged in active synthesis of
immunoglobulins.):
ER becomes distended
Russel
bodies
large,
homogenous,
eosinophilic inclusions called Russell bodies.
3.
Defective intracellular transport and secretion of critical
proteins
4.
Accumulation of cytoskeletal proteins
cytoskeletal proteins include:

microtubules (20-25 nm)

thin actin filaments (6-8 nm)

thick myosin filaments (15 nm)

intermediate filaments (10 nm)

IF provide a flexible intracellular scaffold

that organize the cytoplasm and resist
forces applied to the cell

divided into 5 classes:

1.
keratin filaments - epithelial cells
2.
neurofilaments - neurons
3.
desmin filaments - muscle cells
4.
vimentin filaments - connective
tissue cells
5.
glial
cells
astrocytes;
Neurofibrillary tangle found in the
brain in Alzheimer disease contains
neurofilaments and other proteins
5.
Aggregation of abnormal proteins - Proteinopathies

Amyloidosis
abnormal or misfolded proteins
deposit in tissues and interfere with
normal funcitons
deposits can be extracellular , or
both

aggregates may either directly or

indirectly
cause
pathological
changess

HYALINE CHANGE
o
Hyaline

refers to an alteration within cells or in the extracellular

space

homogenous, glassy pink

o
hyaline change is produced by a variety of alterations
o
does not represent a specific pattern of accumulation.
o
Extracellular hyaline
GLYCOGEN
o
Glycogen - readily available energy source stored in the
cytoplasm of healthy cells.
o
excessive intracellular deposits of glycogen are seen in
patients with an abnormality in either glucose or glycogen
metabolism.
o
glycogen masses appear as clear vacuoles within the
cytoplasm.
o
DM
prime example of glucose metabolism disorder.
glycogen is found in renal tubular epithelial cells, within
liver cells, beta cells of islet of Langerhans, and heart
muscle cells
o
Glycogen storage disease/ glycogenoses
enzymatic defects in the synthesis or breakdown of
glycogen result in massive accumulation, causing cell
death
PIGMENTS
o

Pigments are colored substances

EXOGENOUS PIGMENTS
o
most common is carbon (coal dust).
o
when inhaled, it is picked up by macrophages within the
alveoli -> transported through lymphatic channels to the
regional lymph nodes in the tracheobronchial region
o
Anthracosis
accumulation of pigment blacken the tissues of the
lungs
o
Coal workers pneumoconiosis
aggregates of carbon dust may induce a fibroblastic
reaction or even emphysema.
o
Tattooing - form of localized exogenous pigmentation
ENDOGENOUS PIGMENTS
o
Lipofuscin
insoluble pigment
also known as lipochrome or wear and tear pigment
composed of polymers of lipid and phospholipid in
complex with protein
sign of free radical injury and lipid peroxidation
appears as yellow brown, finely granular cytoplasmic,
often perinuclear pigment.
seen in cells undergoing slow, regressive changes
prominent in liver and heart of aging patients or px with
severe malnutrition and cancer cachexia
o
Melanin
endogenous, non-hemoglobin derived
brown black pigment
formed when enzyme tyrosinase catalyzes the oxidation
of tyrosine to dihydroxyphenylalanine in melanocytes
o
Hemosiderin
hemoglobin derived, golden yellow to brown
granular or crystalline pigment
major storage form of iron
iron is:

transported by transferrins

stored by apoferritin, to form ferritin micelles.

Ferritin is a consistent of most cell types.

When there is local or systemic excess in iron, ferritin
forms hemosiderin granules.
hemosiderin represents aggregates of ferritin micelles.
Local excess results from hemorrhage in tissues

heme moiety is converted to biliverdin then to

bilirubin
Systemic overload : hemosiderosis; caused by:
a.
increased absorption of dietary iron

11

CHAPTER I
CELLULAR RESPONSES TO STRESS AND TOXIC INSULTS: ADAPTATION, INJURY and DEATH
b.
c.

o
o
o
o

hemolytic anemia
repeated blood transfusions

MORPHOLOGY
iron pigment appears as a coarse, golden, granular pigment
lying within the cells cytoplasm
Colorless potassium ferrocyanide converted by iron to blue
black ferrocyanide.
underlying cause is the localized breakdown of red cells:
hemosiderin is only found initially in the phagocytes in the
area
Systemic hemosiderosis
hemosiderin is found at first in the mononuclear
phagocytes on the liver, bone marrow, spleen and
lymph nodes and in the scattered macrophages
throughout other organs such as skin, pancreas, and
kidneys
Bilirubin
normal major pigment found in bile.
derived from hemoglobin but contains no iron

2.

Phosphatases associated with the membrane

generate phosphate groups which bind to the Ca
3.
cycle of Ca and phosphate binding is repeated ->
raising the local concentrations
4.
structural change occurs in the arrangement of Ca
and phosphate group, generating a microcrystal
which can propagate and lead to Ca deposition.
Metastatic Calcification
o
may occur in normal tissues whenever there is
hypercalcemia.
o
Hypercalcemia accentuates dystrophic calcification.
o
four principal causes:
1.
increased PTH with subsequent bone resorption
(hyperparathyroidism)
2.
destruction of bone tissue secondary to primary tumors
or diffuse skeletal metastasis
3.
vitamin D related disorders
4.
renal failure
o
may occur widely throughout the body but principally affects
the interstitial tissues of the gastric mucosa, kidneys, lungs,
systemic arteries and pulmonary veins.

PATHOLOGIC CALCIFICATION
abnormal tissue deposition of Ca salts, together with small
amounts of iron, magnesium and other mineral salts.
o
2 forms of pathologic calcification:
1.
dystrophic calcification
deposition occurs locally in dying tissues
occurs despite normal serum levels of Ca and in the
absence of derangements in Ca metabolism.
2.
metastatic calcification
deposition of Ca in normal tissues
almost always results from hypercalcemia secondary to
some disturbance in Ca metabolism.
Dystrophic Calcification
o
encountered in area of necrosis
o
almost always present in the atheromas of advanced
atherosclerosis
o
commonly developed in damaged or aging heart valves
o
Appear macroscopically as fine, white granules or clumps,
often felt as gritty deposits.
o
tueberculous lymph node is converted to stone
o

MORPHOLOGY: DYSTROPHIC CALCIFICATION

Ca salts have a basophilic, amorphous, granular,
clumped appearance.
heterotrophic bone may be formed in the focus of
calcification.
single necrotic cells may constitute seed crystals that
become encrusted by mineral deposits.
psammoma bodies

lamellated configurations caused by

progressive acquisition of outer layers

resembling grain of sands

PATHOGENESIS
Final common pathway is the formation of crystalline Ca
phosphate mineral in the form of apatite similar to that
hydroxyapatite of bone.
Ca is concentrated in vesicles
steps:
1.
Ca binds to phospholipids present in vesicle
membranes

o
o

CELLULAR AGING
result of a progressive decline in cellular function and
viability caused by genetic abnormalities
the known changes that contribute to cellular aging include:
1.
Decreased cellular replication

concept that most normal cells have a limited

capacity for replication was developed from a
simple experimental model for aging.

senescence

Werner syndrome - rare disease; characterized

by symptom of premature aging; defective in
DNA replication
2.
Accumulation of metabolic and genetic change
Sirtuins - histone deacetylase activity; thought to promote
the expression of several genes whose products increase
longevity

gssabidomd2
If any of you lacks wisdom, he should ask God, who gives generously to
all without finding fault, and it will be given to him
James 1:5

12