HISTOPATHOLOGY LEC
LECTURE 1.1: Cellular Injury and Death (Part 1)
FRITZ VON GELLA, RMT, MD
JUNE 8, 2021
For updates and corrections → @mar4rii on Twitter
CELLULAR INJURY AND CELL DEATH
- a cell normally interacts with their environment, it is
constantly adjusting their structures and functions to
accommodate changing demands and extracellular
stresses.
- the intracellular milieu of your cell is normally or tightly
regulated. Such that, it remains fairly constant referred
to as your HOMEOSTASIS
- It is very much regulated para ma maintain ang
homeostasis ng ating normal cell.
- However, our normal cell is continuously being exposed
to different stresses that’s why our cells need to adapt.
- If our cell cannot adapt or inability to adapt, there will be
cellular injury.
- If that injury is only mild or transient, then can a
reversible injury and the can go back to normal cell or
homeostatic state
- If it is an injurious stimuli, it will go directly to cellular
injury and this cellular injury may become severe of
progressive-- IRREVERSIBLE INJURY.
- We don't want that to happen because that is now your
cell death.
- TWO TYPES OF CELL DEATH: Necrosis and
Apoptosis.
Normal gross anatomy of your heart
- When your heart is exposed to different stresses, for
example there is an increased blood pressure then the
heart must exert great mechanical effort para maka pag
transport ng blood throughout the body.
- Because of that stress, your normal myocytes will adapt
in response increase load kaya nagiging hypertrophic
ang ating puso.
- If your normal myocytes are injured,pede pa shang ma
reverse however when it becomes severe or
porgressive then there will be possible cell death.
CAUSES OF CELLULAR INJURY
Hypoxia and ischemia
- Hypoxia, which refers to oxygen deficiency, and
ischemia, which means reduced blood supply, are
among the most common causes of cell injury.
- However, the most common cause of hypoxia is
ischemia
- Ischemia is a result from an arterial obstruction so your
ischemia is under your hypoxia.
- Hypoxia is a general term as long as the end result is
oxygen DEFICIENCY.
- Example: Blood vessels are being blocked by a clot
then there will be a reduced blood supply. Pag may
reduce blood supply, is there enough oxygen that can
pass through to that certain organ? Ofcourse, wala na.
Toxins
- Potentially toxic agents are encountered daily in the
environment; these include air pollutants, insecticides,
CO, asbestos, cigarette smoke, ethanol, and drugs.
Infectious agents
- All types of disease-causing pathogens, including
viruses, bacteria, fungi, and protozoans, injure cells.
Immunologic reactions
- Autoimmune reactions against one’s own tissues,
allergic reactions against environmental substances,
and excessive or chronic immune responses to
microbes.
Genetic abnormalities
- Genetic aberrations can result in pathologic changes as
conspicuous as the congenital malformations
associated with Down syndrome or as subtle as the
single amino acid substitution in hemoglobin giving rise
to sickle cell anemia.
- Kahit isang gene defect lang ang nangyari that could
lead to different abnormalities or problems.
- Genetic defects may cause cell injury as a consequence
of deficiency of functional proteins such as enzymes in
inborn error of metabolism or accumulation of your
damaged DNA or misfolded proteins.
Nutritional imbalances
- Protein-calorie insufficiency among impoverished
populations remains a major cause of cell injury, and
specific vitamin deficiencies are not uncommon even in
developed countries with high standards of living.
Physical agents
- Trauma, extremes of temperature, radiation, electric
shock, and sudden changes in atmospheric pressure all
have wide-ranging effects on cells
Aging
- Cellular senescence results in a diminished ability of
cells to respond to stress and, eventually, the death of
cells and of the organism.
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 GENERAL PRINCIPLES OF CELLULAR INJURY
- The cellular response to injurious stimuli depends on the
type of injury, its duration, and its severity.
● For example, low doses of toxin or break
periods of ischemia may lead to a reversible
injury. If larger toxins or longer duration of
ischemia times, it may result in an
IRREVERSIBLE injury.
- The consequences of an injurious stimulus also depend
on the type, status, adaptability, and genetic makeup of
the injured cell.
● Ex: striated skeletal muscle in the leg that can
tolerate complete ischemia for 2-3 hour. If that
happens to our cardiac muscle, it will die to
20-30 minutes of ischemia.
- Cell injury usually results from functional and
biochemical abnormalities in one or more of a limited
number of essential cellular components
MECHANISMS OF CELLULAR INJURY AND CELL
DEATH
Hypoxia and Ischemia
- Deficiency of oxygen leads to failure of many energy
dependent metabolic pathways, and ultimately to death
of cells by necrosis.
Review:
Hypoxia- there is a deficiency of oxygen
Ischemia- under hypoxia as it will result in deficiency in oxygen
but the main mechanism in your ischemia is that there is a
BLOCKAGE or OBSTRUCTION of blood flow.
AEROBIC RESPIRATION
- Glycolysis will convert glucose into pyruvate to provide
energy.
- Glycolysis will only provide 4 net ATP and 2 usable
ATP.
- Has 2 (two) phases: INVESTMENT and ENERGY
PRODUCING
- INVESTMENT PHASE: di kapa nakakakuha ng energy
pero umutang ka na ng 2 ATP
- INERGY PRODUCING PHASE: nakakaproduce ka ng 4
na energy. Babawasan sha ng dalawang ATP na
inutang sa investment phase.
- We need Aerobic respiration to produce more ATP
because glycolysis can only provide 2 ATP
- Glycolysis will not require oxygen but will only provide 2
ATP.
- Glucose will be converted into pyruvate however,your
pyruvate will not be able to enter your mitochondria so it
has to be converted to Acetyl CoA so it will undergo
citric acid cycle
- Citric acid cycle will be able to produce a lot of energy
pero it is still not enough, it needs to have oxidative
phosphorylation.
- ATP is produced from your ADP by oxidative
phosphorylation during the reduction of your oxygen in
your electron transport system in your mitochondria.
- If wala ng oxygen, there will be no more aerobic
respiration.
- If there is persistent or severe hypoxia, it will ultimately
lead to the failure of ATP generation and depletion of
ATP in the cells.
- If walang ATP, the cell will not be able to do its function
and the cell will basically die.
Loss of this critical energy store has deleterious effects on many
cellular systems:
- Reduced activity of plasma membrane ATPdependent
sodium pumps
- Increase in anaerobic glycolysis
● Since walang enough na energy na na
pro-produce, the body will go for ANAEROBIC
glycolysis.
● Anaerobic glycolysis will NOT require oxygen
however, the ATP produced is not gonna be
enough.
● Byproduct: tataas ang ating lactate which will
affect the blood pH environment and will still
cause cellular injury and death.
● Anaerobic glycolysis is temporary
- Structural disruption of the protein synthetic apparatus
REVIEW
- Ischemia- may obstruction sa blood flow in short,
mababa ang blood flow→ mababa ang oxygen or
walang oxygen.
- Mitochondria→ oxidative phosphorylation
- If NO or low oxidative phosphorylation = low ATP
● If ATP is low ATP, we will go for Anaerobic
glycolysis to compensate for your loss of ATP
but it's not gonna be enough→ decrease
glycogen store, increase lactate and decrease
or acidic blood pH as it will lead to cellular
injury.
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 - Another effect of low ATP, there will be detachment of
your ribosomes→ decrease protein synthesis. In short,
our cells will not be able to do its function to provide us
with different new proteins.
- Low sodium pump
● increase influx of calcium, water and sodium.
● Increase efflux of potassium.
● Dictum: sodium goes, water follows.
● Increased sodium→ ER swelling, cellular
swelling and loss of microvilli and blebs
Ischemia-Reperfusion Injury
- Under certain circumstances, the restoration of blood
flow to ischemic but viable tissues results, paradoxically,
in increased cell injury.
● May blood flow ka and may bara sa ating blood
vessel and that's gonna be your ischemia in
short, wala tayong blood flow sa kabila pero if
INALIS yung bara mas lalong masisira ang cell
natin.
● This is only true to IRREVERSIBLE or severe
type of injury.
● Reason: new damage may be initiated during
reoxygenation by increased generation of ROS
(reactive oxygen species)
- New damage may be initiated during reoxygenation by
increased generation of ROS
● Pagbalik ng blood flow tataas ang production
ng ROS
- The inflammation that is induced by ischemic injury may
increase with reperfusion because it enhances the influx
of leukocytes and plasma proteins.
● Pinaka importanteng mechanism
Oxidative Stress
- Oxidative stress refers to cellular abnormalities that are
induced by ROS, which belong to a group of molecules
known as free radicals.
- Free radicals are chemical species, extremely unstable,
and readily react with inorganic and organic molecules;
when generated in cells, they avidly attack nucleic acids
as well as a variety of cellular proteins and lipids.
● These free radicals are very toxic to our body
because they can attack different parts of our
cells: nucleic acid, cellular proteins as well as
the lipids.
- The production of ROS is increased by many injurious
stimuli
- Injurious stimuli include:
- Radiation
- Toxins
- Reperfusion
- Free radicals are removed by spontaneously decay and
by specialized enzymatic enzymes enzymatic systems
- Superoxide, Hydrogen peroxide, and hydroxyl radical
(ROS) is being removed by enzymatic systems
- Excessive ROS production will lead to the accumulation
of free radicals as the enzymatic system is no longer
able to remove them
- Pathological effect of free radicals:
- Lipid peroxidation causing membrane damage
- Protein modifications causing breakdown and
misfolding
- DNA damage causing mutations
●ROS are produced by two major pathways.
○ ROS are produced normally in small amounts
in all cells during the reduction-oxidation
(redox) reactions.
○ ROS are produced in phagocytic leukocytes,
mainly neutrophils and macrophages.
■ Produced in minimal amounts that the
body can be able to still remove
SUMMARY:
Cell Injury caused by Toxins
● Toxins, including environmental chemicals and
substances produced by infectious pathogens, induce
cell injury that culminates primarily in necrotic cell death.
● Two general mechanism:
○ Direct-acting toxins
■ Some toxins act directly by combining
with a critical molecular component or
cellular organelle
○ Latent toxins
■ Not intrinsically active but must be
converted to reactive metabolites
which then act on the target cells
■ Ex. Carbon tetrachloride will be
converted by the liver into free
radicals
■ Inactive metabolite to an active
metabolite
Endoplasmic Reticulum Stress
● The accumulation of misfolded proteins in a cell can stress
compensatory pathways in the ER and lead to cell death by
apoptosis.
● Intracellular accumulation of misfolded proteins may be
caused by abnormalities that increase the production of
misfolded proteins or reduce the ability to eliminate them.
- Misfolded proteins are also toxic in our body and will lead to
different pathology/disorder/diseases
ADAPTIVE UNFOLDED PROTEIN RESPONSE
- In Mild ER Stress (konti lang ang misfolded proteins),
misfolded proteins attach to the IRE1/Sensor of misfolded
proteins
- Once it is attached, it will cause a signal to increase the
synthesis of your chaperones, reduce protein synthesis,
and increase protein degradation
- Chaperones will also help in the reduction or reduce the
load of your misfolded protein
- Net effect: Reduce the load of misfolded proteins
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TERMINAL UNFOLDED PROTEIN RESPONSE: APOPTOSIS
- Severe ER Stress = more misfolded proteins
- Misfolded proteins attach to the receptors
- Attachment of proteins will lead to signaling of activation of
BH3 proteins
- BH3 proteins oppose the action of BCL which
causes the activation of caspases
- Net effect: Apoptosis
- Body was not able to adapt
- When the amount of misfolded proteins is too great to be
corrected, excessive activation of your ER sensor activates
your mitochondrial pathway for apoptosis
DNA Damage
● Exposure of cells to radiation or chemotherapeutic agents,
intracellular generation of ROS, and acquisition of
mutations may all induce DNA damage, which if severe
may trigger apoptotic death.
● Some toxins act directly by combining with a critical
molecular component of your cellular organelle
● Inflammation and inflammatory cells including neutrophils,
macrophages, lymphocytes and other leukocytes secrete a
product involved in destroying microbes but may also
damage your host issues
Endoplasmic Reticulum Stress
● Inflammatory cells, including neutrophils, macrophages,
lymphocytes, and other leukocytes, secrete products that
evolved to destroy microbes but also may damage host
tissues
COMMON EVENTS IN CELL INJURY FROM DIVERSE
CAUSES
● Mitochondrial Dysfunction
○ There is a possibility of the occurrence of necrosis
or apoptosis
○ In necrosis, with low oxygen there will be a
mitochondrial damage
○ Such causes the increase in the production of
ROS and can cause cellular abnormalities
○ In Apoptosis, with low survival signals and
dna/protein damage, Pro-apoptotic proteins
increase and anti-apoptotic proteins decrease
○ This will lead to the leakage of cytochrome c
○ Cytochrome c will induce your apoptosis
● Defects in Membrane Permeability
○ Increased membrane permeability leading
ultimately to overt membrane damage is a feature
of most forms of cell injury that culminate in
necrosis.
SEQUENCE OF EVENTS IN CELL INJURY AND CELL DEATH
- Cells will have to maintain a homeostatic environment.
However, if there is injurious stimulus, it may cause
reversible injury
- If the cell survives, it goes back to its homeostatic state. But
if it sever or progressive, it will undergo irreversible injury or
cell death
- Cell death could either be:
- Necrosis
- Apoptosis
I. REVERSIBLE INJURY
● is the stage of cell injury at which the deranged function
and morphology of the injured cells can return to normal if
the damaging stimulus is removed
● Morphologic characteristics:
○ Cellular swelling
○ Fatty change
● Cellular Swelling
○ First manifestation of cell injury; not clearly seen
in microscope; but apparent at the level of the
whole organ
○ Result of failure of energy-dependent ion pumps
in the plasma membrane, leading to the inability
of maintaining ionic and fluid homeostasis.
○ Causes pallor(paleness), increased turgor
(degree of elasticity of skin), and an increase in
organ weight
● Fatty Change
○ Occurs in hypoxic injury and various forms of toxic
or metabolic injury
○ Manifested by the appearance of small or large
lipid vacuoles in the cytoplasm
○ Occurs mainly in cells involved in and dependent
on fat metabolism: hepatocytes and myocardial
cells Appearance of triglyceride containing lipid
vacuoles in the cytoplasm
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 ● Other intracellular changes associated with cell
injury include:
○ Plasma membrane alterations such as
blebbing, blunting, or distortion of microvilli and
loosing of intercellular attachments.
○ Mitochondrial changes such as swelling and
the appearance of phospholipid-rich
amorphous densities
○ Dilation of the ER with detachment of
ribosomes and dissociation of polysomes
○ Nuclear alterations such as clumping of
chromatin; “Myelin figures” which are simply
collections of phospholipids resembling myelin
sheaths

Tissue: Kidney tubules (simple cuboidal epithelium)

Reversible:
- Increase eosinophilia
- Swelling of cells
- Presence of surface blebs
- Distortion of microvilli
Irreversible:
- Fragmentation of cells
- Loss of nucleus
- Leakage of cellular contents

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 HISTOPATHOLOGY LEC

LECTURE 1.2: Cellular Injury and Death (Part 2)

FRITZ VON GELLA, RMT MD
JUNE 8, 2021
For updates and corrections → @mar4rii on Twitter

II. IRREVERSIBLE INJURY Types of Necrosis

● Irreversible injury invariably leads to cell death, which goes 1. Coagulative necrosis
as either apoptosis or necrosis. 2. Liquefactive necrosis
● Necrosis 3. Gangrenous necrosis
○ Major pathway of cell death in many commonly 4. Caseous necrosis
encountered injuries 5. Fat necrosis
○ Ischemia, exposure to toxins, infections, trauma 6. Fibrinoid necrosis
○ Always due to pathologic process
● Apoptosis 1. Coagulative necrosis
○ Cell kills itself; Caused by ● Characterized by the preservation of the
■ Deprivation of growth factors in cells architecture/outline of the coagulated cells.
■ DNA is beyond repair ● The denaturation of proteins is the primary mechanism,
○ Nuclear dissolution without complete loss of which create a delineation of the necrotic tissue in gross
membrane integrity examination
○ Active, energy-dependent, tightly regulated cell ● Coagulative necrosis is characteristic of hypoxic death of
death cells in all tissues except the brain.
○ Not only physiologic but also pathologic ● Intact architecture brought about by the denaturation of
proteins
Table. Features of Necrosis and Apoptosis ● Brought about by a hypoxic condition in all tissue except
Feature Necrosis Apoptosis brain
Cell size Enlarged (swelling) Reduced (shrinkage)
Nucleus Pyknosis → karyorrhexis Fragmentation into
→ karyolysis Nucleosome-sized
fragments
Plasma Disrupted Intact; altered structure,
membrane especially orientation of
lipids
Cellular Enzymatic digestion; ay leak Intact; may be released
contents out of cell in apoptotic bodies
Adjacent Frequent No
inflammation
(kidney)
Physiologic or Invariably pathologic Often pathologic means - Wedge shaped kidney infarct with preservation in the
pathologic role (culmination of irreversible of eliminating unwanted outline brought about by the coagulation of protein
cell injury) cells; may be (right pic)
pathologic after some - N = normal kidney;
forms of cell injury, - I = necrotic cells (has delineation) (loss of nuclei)
especially DNA and
protein damage
2. Liquefactive necrosis
Necrosis (enlargement)
- Pyknosis = nuclear shrinkage ● Characteristic of focal bacterial, or occasional fungal
- Karyorrhexis = nucleus undergo fragmentation infections
- Karyolysis = destruction/dissolution of nucleus Complete digestion of cells
- Necrosis is always pathologic ● Transformation of cells into liquid viscous mass due to the
- NECROSIS = NI GROW inflammatory response elicited by the microbes.
Apoptosis (shrinkage) ● Necrotic material becomes creamy yellow (pus) due to
- No inflammation presence of dead leukocytes
- Could either be: ● Seen in the hypoxic death of cells in the nervous system.
- Physiologic (most of the time) ● Same mechanism with coagulative necrosis (hypoxic
- Pathologic (during protein damage) death) but happens in the nervous tissue
A. Necrosis ● Infarct - blockage of blood flow
● Necrosis is a form of cell death in which cellular
membranes fall apart, and cellular enzymes leak out and
ultimately digest the cell.
● The biochemical mechanisms of necrosis:
○ Failure of energy generation in the form of ATP
because of reduced oxygen supply or
mitochondrial damage
○ Damage to cellular membranes, including the
plasma membrane and lysosomal membranes,
which results in leakage of cellular contents
including enzymes
○ Irreversible damage to cellular lipids, proteins,
and nucleic acids, which may be caused by
reactive oxygen species (ROS)

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 ○ An infarct in the brain shows dissolution of the
tissues (nice characteristic of liquefactive
necrosis)
■ Common in patients with stroke
■ Irreversible damage
○ Comes with slurred speech, difficulty in walking,
weakness in left or right side of the body, loss of
consciousness
○ Cerebrovascular disease
■ Cerebro - brain
■ Vascular - blood supply of the brain
■ Problem in blood supply to the brain
● There is hypoxic event
○ Infarct or bleeding
● Identify why it had a hypoxic
death either from an infarct or
bleeding
■ Infarct - ischemia
● Blockage in the blood vessel
● Cerebrovascular disease
● Decreased blood vessel (no
enough oxygen)
■ Bleeding
● Blood goes out from the blood
vessel, it will not go directly to
the brain
● Can't supply enough oxygen to
brain
● Hypoxic cell death
● Identify whether its hemorrhagic or ischemic, because the
management will be different
○ To prevent progression of the disease
3. Gangrenous necrosis
● Not specific pattern of cell death, but usually applied to a
limb that lost its blood supply that has undergone
coagulative necrosis (dry gangrene)
○ Dry gangrene is like coagulative necrosis but
applied in the limb
● Particularly in limb and extremities
● Patient with a diabetic foot infection can develop into
gangrenous necrosis
● Wet gangrene - coagulative necrosis plus superimposed
bacterial infection (liquefactive necrosis) because of actions
of degradative enzymes in the bacteria
● Debridement
○ Take off necrotic area and wait for
wound healing
4. Caseous necrosis
● Distinctive form of coagulative necrosis often seen in TB
infection
● Characterized by cheesy white gross appearance of
necrotic area (hence “caseous”)
● On microscopic examination, caseous necrosis exhibit a
granulomatous reaction:
a. Amorphous granular debris composed of
fragmented coagulated cells
b. The granular debris is enclosed within a distinct
inflammatory border
● Unlike in coagulative necrosis, the tissue architecture is
obliterated
● Usually TB of lungs
○ Large area of caseous necrosis containing
yellow-white cheesy debris
○ Amorphous granular debris composed of
fragmented coagulated cells, the granular debris
is enclosed with distinct inflammatory border
○ In the cell, it looks pink
■ Amorphous granular eosinophilic debris
material
■ Surrounded by different inflammatory
cells
● Giant cells
● Epithelioid cells
● And other products
● This combination is called
granuloma
5. Fat necrosis
● Not specific pattern but not denoting descriptive focal areas
of fat destrucction due to release of pancreatic lipases
● Release fatty acids combine with calcium visible chalky
white areas - shadowy outline of necrotic fat cells with
basophilic calcium deposits plus surrounding inflammatory
cells
● Pancreatic enzymes that have leaked out of the acinar cells
liquify the membrane of the fats in your peritoneum and
lipases; and split your triglycerides or esters contained
within the fat
● Lipases will degrade the different areas in the body
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 - Areas of white chalky deposits represent foci of fat necrosis
with calcium salt formation or saponification at sites of
breakdown in your mesentery
Pathologic Apoptosis
6. Fibrinoid necrosis ● Eliminates cells that are genetically altered or injured
● a special form of necrosis usually seen in immune reactions beyond repair without eliciting severe host reaction,
involving blood vessels. keeping the damage as contained as possible.
● occurs when complexes of antigens and antibodies are ● Abnormally happening
deposited in the wall of arteries
● The immune complexes along with leaked fibrin forms
fibrinoid (fibrin-like), amorphous and bright-pink structures.

Mechanisms of Apoptosis
- Antigen antibody complex will be deposited in the lining of
our blood vessels
- Shows a circumferential bright pink area of necrosis with
protein deposition and inflammation
- ●
B. Apoptosis
Apoptosis is a pathway of cell death in which cells activate enzymes
that degrade the cells’ own nuclear DNA and nuclear and
cytoplasmic proteins.
● Process that eliminates cells with a variety of intrinsic
abnormalities and promotes clearance of the fragments of
the dead cells without eliciting inflammation.
● Little leakage of cellular contents hence no inflammatory
reaction
● Apoptosis is regulated by biochemical pathways that control
the balance of death and survival-inducing signals and
ultimately the activation of enzymes called caspases
(cysteine proteases that cleave proteins after aspartic acid
residues)
● Two distinct pathways converge on caspase activation
(completely destroys the cell):
○ Mitochondrial Pathway
○ Death Receptor Pathway
Mitochondrial Pathway
Responsible in most physiologic and pathologic situations
● Cytochrome c
○ Protein in mitochondria that is capable of inducing
apoptosis; leaks out into the cytoplasm when
mitochondrial membrane becomes permeable;
activate caspase, triggers apoptotic death

Physiologic Apoptosis vs Pathologic Apoptosis

Physiologic Apoptosis
● Death of cells that are no longer needed; to maintain a
steady number of various cell populations in tissues.
● Normally happening

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 ● It mediates interaction with other proteins involved in cell
death
● Involved in the elimination of self-reactive lymphocytes and
in the killing of target cells by some cytotoxic T lymphocytes
(CTLs) that express FasL.

A. VIABLE CELL
Surviving signal causes the cell to survive ex. Growth factor
↓
Growth factor will attach to the receptor
↓ - FasL molecule are being crossed link with your Fas
This yields the production of anti-apoptotic proteins molecule
(BCL 2 - prevents cell death) - They will bind to an adaptor protein via death domain, it
↓ will now activate your caspases and will undergo
BCL2 inactives Bax channel (green in the picture) apoptosis.
↓
No leakage of cytochrome c
(we prevent the leakage because cytochrome c activates caspase
and triggers cell death

B. APOPTOSIS
Lack of survival signals (no more growth factor)/ Irradiation which
leads to DNA damage
Remember: apoptosis can happen in physiologic or pathologic
condition
↓
Both will lead to the activation of sensors
And activation of BH3 only proteins
↓
Antagonism of BCL2; cannot attach to the bax channel
(Bax channel is pro apoptosis)
↓
Cytochrome c goes out
↓
Activation of caspases
↓ - End effect: to activate your caspases to do now its
APOPTOSIS action of endonuclease activation, breakdown
cytoskeleton
Death Receptor Pathway (Extrinsic) - In short,you are going to degrade now your cells
● Many cells express surface molecules called death
receptors that trigger apoptosis.
● Most are members of the tumor necrosis factor family which
contain in their cytoplasmic regions a conserved “death
domain”.