Topic: Cell Injury & Death

Subtopics: Causes of cell injury, Necrosis, Apoptosis, Subcellular responses.

Causes of cell injury

Introduction:
General considerations
 Adapt or die!
 Reaction patterns in a given cell/tissue are often limited.
 Degree of injury is a function of type, duration and severity of insult.
Definition:
 Cell injury: The effect of a variety of stresses due to etiological agents a cell encounters
resulting in changes in its internal & external environment.
 Cellular response to stress varies & depends upon
1. Host factors: type of cell & tissue involved
2. Factors pertaining to injurious agent: extent & type of cell injury.
• Genetic causes
• Acquired causes
 Hypoxia and ischemia
 Physical agents
 Chemical agents and drugs
-Microbial agents
-Immunological agents
-Nutritional derangements
-Psychological factors
Acquired causes
1. Oxygen Deprivation
 Ischemia ( loss of blood supply from impeded arterial flow or reduce venous
drainage)
• Local e.g. embolus
• Systemic e.g. cardiac failure
 Hypoxia (deficiency of oxygen causing cell injury by reducing aerobic oxidative
respiration)
• Oxygen problems e.g. altitude
• Haemoglobin problems e.g. anaemia
 Oxidative phosphorylation
• E.g. cyanide poisoning.
2. Physical agents
 Direct Physical Effects
 Exposure of tissue to extreme heat or cold results in direct injury that is
often irreversible, resulting in a pattern of coagulative necrosis.
  Sudden changes in pressure can cause cellular disruption (e.g. a hammer
blow to the thumb).
 Electrical currents can cause direct breakdown of cellular membranes that
may be irreversible.
3. Chemical agents & drugs
Common poisons (arsenic, cyanide, mercury) interfere with cellular metabolism. If ATP
levels drop below critical levels, affected cells will die.
 The list of pharmaceuticals that may have toxic effects on cells is
enormous. Some act directly, but most have their effect through
breakdown metabolites. Metabolism of alcohol (a type of drug) to
acetaldehyde is one example.
4. Microbial agent
Injuries by microbes include infections caused by Fungi, Rickettsiae, Bacteria, parasites
and Viruses
5. Immunologic agents
Double -edged sword'- protects the host against various injurious agents but it may also
cause cell injury.
 Hypersensitivity reactions
 Anaphylactic reactions to a foreign body
 Autoimmune diseases
6. Nutritional Imbalances
 Dietary insufficiency of protein, vitamins and/or minerals can lead to injury at
the cellular level due to interference in normal metabolic pathways.
 Dietary excess cellular and tissue alterations that are detrimental e.g. fat is the
biggest offender, or excess ingestion of "health supplements"
7. Psychogenic diseases
No specific biochemical or morphologic changes in acquired mental diseases.
problems of drug addiction, alcoholism & smoking results in various organic diseases
such as liver damage, chronic bronchitis, lung cancer, peptic ulcer, HT, IHD etc,
8. Genetic derangements
Result in a defect as severe as the congenital malformations associated with Down
syndrome, caused by chromosomal abnormalities. Inborn error of metabolism arising
from enzymatic abnormalities.
9. Iatrogenic causes
10. Idiopathic diseases 'Unknown cause'. Exact cause is undetermined. Most common form
of HT ( 9o%) is idiopathic (or essential ) HT.
11. Ageing it is result of a progressive decline in the proliferative capacity & life span of
cells and the effects of continous exposure to exogenous influences that result in
progressive accumulation of cellular and molecular damage.
 NORMALCELL
Homeostasis

ADAPTATION CELL INJURY

REVERSIBLE CELL INJURY SUBCELLULAR ALTERATION

NECROSIS
APOPTOSIS
NE CRO SI S (CELL DEATH)

‘I TR E FE R S T O M O R PH O L O G I C C HANGE S C AUSE D B Y PR OGR E SSI VE DE GR ADAT I V E

AC T I ON OF E NZ Y M E S O N LE T H A L L Y I NJUR E D C E LL ’

CAUSE S O F N E C R O SI S :

N EC R OT I C C H A N G E S I N T I SSU E S AR E C AUSE D B Y ;

D I GE ST I ON O F C E LL B Y E N Z Y M E S . T HI S I S OF TW O T YPE S ;
A )A UT OL Y SI S , I E D I G E ST I O N O F CE L L B Y E NZ YME S DE R I VE D FR OM T HE I R OW N
L YSOSO ME S .

B)H ET E R O L Y SI S , IE
D I G E ST I O N O F C E LL B Y E NZ YME S DE R I VE D FR OM L YSOSOM E S
OF I MMI GR A N T LE U K O C Y T E S .
2)D E NAT U R A T I O N O F PR O T E I N S C AUSE D B Y I NT R AC E L L UL AR AC I DOSI S .

M OR PHOL O G Y O F N E C R O SI S :

M ICRO SCO P I C M O R PH O L OG Y :
1|)C H ANG E S I N N U C L E U S:

O NE OF T H RE E FO R M S :
  K AR Y O L Y SI S :
I T RE FE R S T O FA D I N G O F B A SO PHI L I A OF C HR OMAT I N ’ DUE T O DI GE ST I ON OF DNA
B Y DNA SE S A C T I V A T E D B Y D E C P H
 PYK N O SI S :
I T RE FE R S T O ’ C O N D E N SA T I O N A ND SHR I NKAGE OF DNA I NT O A SOL I D MASS O F
I NC B ASOPH I L I A ’
 KAY O R R H E X I S :
I T RE FE R S T O FR E G M E N T A T I O N OF PYKNOT I C ( C ONDE NSE D ) NUC L E AR
MASS ’ NUC L E U S D I SA PE A R S I N O NE OR T W O DAYS .

2) CH ANG E S I N C Y T O P L A SM

A ) I NC E OSI N O P H I L I A ( A C I D O P H I L I A ) DUE T O L OSS OF RNA ( B ASOP HI L I C )

DE NAT UR A T I O N O F C Y T O PL A SM I C PR OT E I NS
B)DIGESTION OF CYTOPLASMIC ORGANELLES CYTOPLASM BECOMES
VACUOLATED AND APEAR MOTH-EATEN.
GROSS MORPHOLOGY( T Y P E S O F NE CRO SIS )

1)coagulative necrosis:

I T RE FE R S T O PR E SE R V A T I O N O F B ASI C OUT L I NE OF C OAGUL AT E D CE L L FOR SO M E

DAYS .
Cause:

I NCI NR AC E LL U L A R A C I D O SI S D E NAT UR E S E NZ YMAT I C AND ST R UC T UR AL

PR OT E I NS .. B L O C K S PR O T E O L Y SI S OF CE L L .

Example:

A LL HYPO X I C D E A T H O F CE L L ( E XCE PT I N B R AI N ) E G MYOC AR DI AL I NFAR C T I ON .

2)Liquefactive NECROSIS:

IT RE FE R S T O PR O G R E SSI V E C A T AL YSI S OF C E LL ST R UC T UR E W I T H T HE L OSS O F

B ASI C OUT L I N E O F C E LL ’
Cause:

AUTOLYSIS O R H ET E R O L Y SI S OF L E UKOC YT E S
EXAMPLE:

A ) FOC AL B A C TE R I A L I N FE C T I O N
B ) HYPO XI C C E LL D E A T H I N CNS
Abcess formation by liquefective Necrosis:

I N LI QUE FE C T I V E N E C R O SI S I M M I GR ANT L E UKOC YT E S ( NE UT R OPHI L S AND

MAC R OP HA G E S ) D I G E ST D E A D C A R C ASSE S OF C E LL S , LE AVI NG A TI SSUE DE FE C T
FI L L E D WI T H N A R C O T I C C E LL S , D E AD MI C R OOR GA NI S M AND I MMI GR ANT
L E UKOC YT E S ; T H I S I S C A L L E D A B SC E SS .
3)caseous Necrosis:

( C ASE OUS = W H I T E A N D C H EE SY ) I T I S DI ST I NC T FOR M OF C OAGUL AT I VE NE C R O SI S

T HAT :
a)Grossly appears white and cheesy

B ) HI ST OL O G I C A L L Y N E C T R O T I C FOC US APE AR S AS AMOR P HOU S GR ANUL AR DE B R I S

C OMPO SE D O F C O A G U L A T E D , FR AGME NT E D C E LL S E NCL OSE D B Y GR ANUL OMAT O U S
I NFL AMM A T O R Y B O R D E R .
EXAMPLE:

T UB E R C UL O U S I N FE C T I O N
4)Enzymic fat necrosis:

IT RE FE R S T O FO C A L A R E A S O F DE ST R UC T I ON OF FAT R E SUL T I NG FR OM AB NOR M A L

R E LE ASE O F A C T I V A T E D PA N C R E AT I C E NZ YME S ( LI PASE S ) FR OM AC I NAR CE L L S
AND DUC T I N T O SU B ST A N C E O F PANC R E AS AND PE R I T ONE AL C AVI T Y ’. L I PASE S A C T
ON TR I GL Y C E R O I D S ( I N FA T S ) A ND R E LE ASE S FR E E FAT T Y AC I DS W HI C H R E AC T
W I T H C A A N D FO R M G R O SSL Y V I SI B L E W HIT E AR E AS .
5)fibrinoid Necrosis:

IT RE FE R S T O ‘ I M M U N O L O G I C I N JUR I E S T O AR TE R I E S AND AR TE R I OL E S
C HR AC T E R I Z E D B Y A C C U M U L A T I ON OF FI B R I N , I MMUNOGL O - B UL I NS AND OT HE R
PL ASMA PR O T E I N S WI T H I N W AL L S OF AFFE C T E D VE SSE L S ,
6)Gangrenous Necrosis (Gangrene)

It refers to’ initial hypoxic coagulative necrosis later modified by liquefective action of enzymes
derived from bacteria and leukocytes’

Types of gangrene.

A)DRY GANGRENE.

IN THIS COAGULATIVE NECROSIS PREDOMINATES.

B)WET GANGRENE.

IN T HI S L I Q U E FE C T I V E N E C R O SI S PR E DOMI N AT E S .

• Apoptosis
Apoptosis: def. programmed cell death.
Chracterized by cell shrinkage, chromatin condensation, formation of cytoplasmic blebs and
apoptotic bodies, phagocytosis by macrophages or adjacent cells. Does not elicit inflammation
(in contrast to necrosis).
 • Biochemical features:
1. Protein cleavage (caspases)
2. Protein cross-linking
3. DNA breakdown (endonuclease)
4. Phagocytic recognition (mediated by phosphatidylserine and thrombospondin expression)

• Cytogenetic features:
1. ced genes
2. Fas-Fas ligand model: CD95 receptor on cell surface, TNF and TNFR-mediated apoptosis
3. Bcl-2: supresses apoptosis by direct action on mitochondria (preventing increased
permeability) & by binding other proteins (Apaf-1)
4. caspase (cysteine proteases that cleave after aspartic acid) mediated proteolytic cascade
• Morphological Forms of Programmed Cell Death Type I = Apoptosis Type II =
Autophagic Cell Death Type III = Non-lysosomal
• Apoptosis  This process helps to eliminate unwanted cells by an internally
programmed series of events effected by dedicated gene products. It serves several vital
functions and is seen under various settings.  During development for removal of
excess cells during embryogenesis  To maintain cell population in tissues with high
turnover of cells, such as skin, bowels.  To eliminate immune cells after cytokine
depletion, and autoreactive T- cells in developing thymus.  To remove damaged cells
by virus  To eliminate cells with DNA damage by radiation, cytotoxic agents etc. 
Hormone-dependent involution - Endometrium, ovary, breasts etc.  Cell death in
tumours.
• Apoptosis …. In the human body ~ 100,000 cells are produced every second by mitosis
and a similar number die by apoptosis.  Development and morphogenesis  During
limb formation separate digits evolve  Ablation of cells no longer needed (tadpole) 
Homeostasis  Immune system  >95% T and B cells die during maturation (negative
selection) …… Deletion of damaged/ dangerous
• Mechanisms of Apoptosis  Apoptosis can be induced by various factors under both
physiological and pathological conditions: It is an energy-dependent cascade of
molecular events which include protein cleavage by a group of enzymes (caspases),
protein cross- linking, DNA breakdown. Apoptosis is regulated by a large family of
genes some of which are inhibitory (bcl-2) and some are stimulatory (bax).
• There are a number of mechanisms through which apoptosis can be induced in cells. 
The sensitivity of cells to any of these stimuli can vary depending on a number of factors
such as:  the expression of pro- and anti-apoptotic proteins (eg. the Bcl-2 proteins or the
Inhibitor of Apoptosis Proteins),  the severity of the stimulus and  the stage of the cell
cycle.
• Role of mitochondria in apoptosis The pro-apoptotic bcl-2 proteins are often found in
the cytosol where they act as sensors of cellular damage or stress. Following cellular
stress they relocate to the surface of the mitochondria where the anti- apoptotic proteins
are located. This interaction between pro- and anti- apoptotic proteins disrupts the
normal function of the anti-apoptotic bcl-2 proteins and can lead to the formation of
pores in the mitochondria and the release of cytochrome C and other pro-apoptotic
molecules from the intermembrane space. This in turn leads to the formation of the
apoptosome and the activation of the caspase cascade. The release of cytochrome C from
the mitochondria is a particularly important event in the induction of apoptosis. Once
cytochrome C has been released into the cytosol it is able to interact with a protein called
Apaf-1. This leads to the recruitment of procaspase 9 into a multi- protein complex with
cytochrome C and Apaf-1.
• Caspases and Apoptosis  One of the hallmarks of apoptosis is the cleavage of
chromosomal DNA into nucleosomal units. The caspases play an important role in this
process by activating DNases, inhibiting DNA repair enzymes and breaking down
structural proteins in the nucleus.
• 2 pathways
• Death receptor (left) …Mitochondrial (right) ….. Both Converge  Caspase 3 activation
……Then branch causing eventual cell death

• Morphology of Apoptosis Shrinkage of cells

• Condensation of nuclear chromatin peripherally under nuclear membrane
• Formation of apoptotic bodies by fragmentation of the cells and nuclei. The fragments
remain membrane-bound and contain cell organelles with or without nuclear fragments.
• Phagocytosis of apoptotic bodies by adjacent healthy cells or phagocytes.
• Unlike necrosis, apoptosis is not accompanied by inflammatory reaction
• In this fetal thymus there is involution of thymic lymphocytes by the mechanism of
apoptosis. Individual cells fragment and are consumed by phagocytes to give the
appearance of clear spaces filled with cellular debris.
• Apoptosis is controlled by many mechanisms.
• Genes such as Bcl-2 are turned off and Bax genes turned on.
• Proteolytic enzymes called caspases produce much cellular breakdown.
• Apoptosis is a more orderly process of cell death in which there is individual cell
necrosis, not necrosis of large numbers of cells.
• In this example, liver cells are dying individually (arrows) from injury by viral hepatitis.
• The cells are pink and without nuclei.
Mechanism of apoptosis..

Pathology
Sub Cellular Responses

-Certain agents and stresses can affect only Subcellular organelles.

- Some are seen in lethal injury, some in adaptive Responses.
Lysosomes are the cytoplasmic bodies that contain hydrolytic enzymes used to breakdown
phagocytose material .
Autophagy
Digestion of cells own components . It is also called a survival mechanism ( in times of nutrient
deprivation)
Heterophagy
Ingestion of outside material for intracellular destruction
For example :
Macrophage
Hypertrophy
( induction) of smooth endoplasmic reticulum .Involved in metabolism of chemicals
Hypertrophy is adaptive response to chemical stimuli .

Physical sites of damaged injury