Inflammation and Repair

INFLAMMATION AND REPAIR
Objectives - We expect you to:
1. Recognize and describe lesions of inflammation

2. Outline the pathogenesis of inflammatory processes
3. Relate the various mediators to the vascular and
cellular events in the inflammatory process
4. Be able to give a morphologic diagnosis
TABLE OF CONTENTS
(Inflammation)
Introduction to Inflammation…………………………………………... 2
Morphologic diagnosis of exudative inflammation……………………. 7
Acute Inflammation ……………………………………………………. 17
Plasma-derived mediators of inflammation……………………………. 24
Cellular-derived mediators of inflammation……..……………………. 32
Cellular components of inflammation…………….……………………. 41
Immune-mediated inflammation………………….…………………… 50
Chronic inflammation……………………………...…………………… 58
Healing and repair………………………………….…………………… 63
1
Introduction to Inflammation
This lesson corresponds to the web lesson of the same name. 
SUMMARY OF IMPORTANT CONCEPTS FOR THIS LESSON
DEFINITION AND CARDINAL FEATURES

Definition:
- Inflammation is the response of living tissue to injury. It involves a well-organized
cascade of fluid and cellular changes within living tissue.
Cardinal features:
 Rubor (redness); Tumor (swelling); Calor (heat); Dolor (pain); Functio laesa (loss
of function)
CAUSES
 Etiologic agents – viruses, bacteria, fungi, parasites
 Hypersensitivity – body reaction is inappropriate and/or excessive, there are four
types of reactions
 Physical and chemical agents - trauma, sunburn, acid
 Necrosis - anoxia, trauma
EFFECTS
What’s good about inflammation? Drugs, antibodies, mediators can get in; fibrin and
then fibrosis can wall it off
What’s bad about inflammation? Cytokines can make you sick, tissue can get destroyed,
swelling won’t quit
           
2
Introduction to Inflammation
What is inflammation?
Inflammation is the response of living tissue to injury. It
involves a well-organized cascade of fluid and cellular
changes. It is recognizable grossly and histologically and
has both beneficial and detrimental effects locally and
systemically.
Some form of an inflammatory response is seen in virtually all living organisms, but the higher
life forms have the unique ability to use the blood vascular system to transport and deposit fluid
and cells in the extravascular space.
Some general characteristics of inflammation are as follows:
1. The inflammatory process is redundant and complex. This makes it a challenging

subject to study. You will see that many mediators of inflammation have the same
functions and many mediators have multiple functions. Also, the same mediator may
have different effects on different tissues.
2. The process is continuous over a period of time. Peracute, acute, subacute, and
chronic are terms used to describe different stages of inflammation.
3. Inflammation is caused by a stimulus and removal of the stimulus should result in
abatement of inflammation. If it doesn’t get fixed in the acute period, it becomes
chronic.
4. Blood is the primary delivery system for inflammatory components.
5. Inflammation is on a continuum with the healing process.
3
RUBOR, TUMOR, CALOR et DOLOR
The four principal effects of inflammation (rubor, tumor,

calor et dolor) were described nearly 2,000 years ago by the
Roman Aulus Cornelius Celsus, more commonly known as
Celsus. (He wasn’t actually a practitioner of medicine.
Rather, he wrote an encyclopedia that had many volumes
about all kinds of subjects. Only the volume concerning
medicine survived.)
Redness (rubor)
An acutely inflamed tissue appears red, due to dilatation of small blood vessels within the
damaged area (hyperemia).
Swelling (tumor)
Swelling results from edema, the accumulation of fluid in the extravascular space as part
of the inflammatory fluid exudate, and to a much lesser extent, from the physical mass of
the inflammatory cells migrating into the area.
Heat (calor)
Increase in temperature is readily detected in the skin. It is due to increased blood flow
(hyperemia) through the region, resulting in vascular dilation and the delivery of warm
blood to the area.
Pain (dolor)
Pain results partly from the stretching and distortion of tissues due to inflammatory
edema and, in part from some of the chemical mediators of acute inflammation,
especially bradykinin and some of the prostaglandins.
Loss of function (functio laesa)
Loss of function, a well-known consequence of inflammation, was added by Virchow
(1821-1902) to the list of features described in Celsus’ written work. Movement of an
inflamed area is inhibited by pain, either consciously or by reflexes, while severe
swelling may physically immobilize the affected area.
Causes of Inflammation
Microbial infections
One of the most common causes of inflammation is microbial infection. Microbes
include viruses, bacteria, protozoa, fungi and various parasites. Viruses lead to death of
individual cells by intracellular multiplication, and either cause the cell to stop
functioning and die, or cause explosion of the cell (cytolytic), in which case it also dies.
Bacteria release specific toxins – either exotoxins or endotoxins. What’s the difference?
Exotoxins are produced specifically for export (like anthrax toxins or tetanus toxins)
whereas endotoxins are just part of the cell walls of Gram negative bacteria and they do
terrible things to the body too but they aren’t as specific in their actions as the exotoxins.
4
Hypersensitivity reactions
A hypersensitivity reaction occurs when an altered state of immunologic responsiveness
causes an inappropriate or excessive immune reaction that damages the tissues. The types
of reaction will be discussed in more detail later (In the lesson on Immune-Mediated
Inflammation).
Physical agents, irritant and corrosive chemicals
Tissue damage leading to inflammation may occur through physical trauma, ultraviolet or
other ionizing radiation, burns or excessive cooling ('frostbite'). Corrosive chemicals
(acids, alkalis, oxidizing agents) provoke inflammation through direct tissue damage.
These chemical irritants cause tissue damage that leads directly to inflammation.
Tissue necrosis
Death of tissues from lack of oxygen or nutrients resulting from inadequate blood flow
(infarction) is a potent inflammatory stimulus. The edge of a recent infarct often shows
an acute inflammatory response.
Effects of Inflammation
The effects of inflammation can be both local and systemic. The systemic effects of acute
inflammation include fever, malaise, and leukocytosis. The local effects are usually clearly
beneficial, for example the destruction of invading microorganisms, but at other times they
appear to serve no obvious function, or may even be harmful.
Beneficial effects of inflammation Harmful effects of inflammation

Dilution of toxins Persistent cytokine release
Entry of antibodies Destruction of normal tissues
Fibrin formation Swelling
Delivery of nutrients and oxygen Inappropriate inflammatory response
Stimulation of immune response
Systemic Effects of Inflammation
Both acute and chronic inflammation, even if well localized, can have effects on the whole body.
The main ones are:
Leukocytosis
Leukocytosis is a common feature of inflammatory reactions. Leukocytosis means that
there is an abnormally high number of circulating white blood cells. A general rule is that
increased neutrophils indicate a bacterial infection whereas increased lymphocytes are
most likely to occur in viral infections. This is one reason why we often do a CBC when
an animal is sick – gives us more clues.
Fever
Fever is a common systemic response to inflammation. Fever is most often associated
with inflammation that has an infectious cause, although there are some non-infectious
5
febrile diseases. Fever is coordinated by the hypothalamus and involves a wide range of
factors. Here are some of the contributors to fever:
What is the function of fever? The elevation of body temperature is thought to improve
the efficiency of leukocyte killing and may also impair the replication of many invading
organisms.
Endotoxemia
Sepsis is the term used for disease due to toxic bacterial products circulating in the blood.
Endotoxemia specifically refers to circulating gram-negative bacterial toxic products
(LPS). There are some cell wall products released from gram-positive bacteria that can
have a similar toxic effect.
6
Morphologic diagnosis in inflammation
MORPHOLOGIC DIAGNOSIS
COMPONENTS OF A MORPHOLOGIC DIAGNOSIS FOR INFLAMMATION:
1. Severity
Mild, moderate, severe
2. Time course
Peracute, acute, subacute, chronic
3. Distribution of lesion
Focal?
Multifocal?
Locally extensive?
Diffuse?
4. Type of Exudate
Difference between exudates and transudate
Serous
Fibrinous
Catarrhal
Purulent/Suppurative
Abscess
Hemorrhagic
Mixed
5. Inflammatory name associated with the organ - usually it is just organ + -itis, but
there are exceptions.
           
7
Morphologic diagnosis in inflammation
A morphologic diagnosis is the way we describe and communicate about lesions. A

morphologic diagnosis consists of a series of terms that serve to paint a picture with words. The
important categories of words to include in your morphologic diagnosis include –
KNOW THIS TABLE:
S SEVERITY How bad is it? Mild or moderate or marked/severe?
T TIME COURSE Is it peracute, acute, subacute or chronic?
D DISTRIBUTION Is it focal, multifocal, locally extensive, or diffuse?
E What is the character of the inflammatory material –

EXUDATE serous, catarrhal, purulent, fibrinous, granulomatous,
fibrosing?
T TISSUE Where the heck is it? (plus –itis)
So, every inflammatory lesion could consist of FIVE WORDS.
1. Severity
The terms we usually use to describe severity are subjective – mild, moderate, severe. Some
people use “marked” instead of “severe.” Is the problem causing serious compromise (marked)?
Or is it just a little thing that is an annoyance (mild)? You’ll get used to figuring out which word
to use here.
2. Time course designation for inflammation
Peracute happens so fast you hardly even know it has happened. A good example would be a
serious myocardial problem where the animal dies before there is even any evidence, clinically,
grossly, or histologically, that the heart was damaged. Acute inflammation is short-lived, lasting
only a few hours to a few days. If it persists for an extended period, like more than two weeks
or so, then it is referred to as chronic inflammation. The hallmark of chronic inflammation is the
formation of fibrous connective tissue (starts as granulation tissue) in the area of inflammation.
An abundance of macrophages also may be a feature. This fibrous connective tissue formation
results in organization or scarring.
You may have noticed there is a little bit of a time gap between acute and chronic - the term
subacute can be used here.
8
 Peracute – minutes or hours
 Acute – a few hours to a few days
 Subacute – the nebulous period between acute and
chronic
 Chronic – weeks to months
*Note: Peracute and subacute are not used as often as
the other two.
Peracute  Acute  Subacute  Chronic

3. Extent of Lesion
This may be the easiest part of the morphologic diagnosis. If just one small part of the organ is
affected, it is FOCAL. If there are several small parts affected, it is MULTIFOCAL. If the
whole organ is affected, it is DIFFUSE. But what if it is diffuse, but just in one part of the
organ? Then it is FOCALLY (or LOCALLY) EXTENSIVE.
4. Types of Exudates
 Serous exudate
Serous inflammation is characterized by the outpouring of a translucent, thin fluid that may
accumulate on a mucosal surface, skin, or in the peritoneal, pleural, and pericardial cavities.
Serous inflammation is a common manifestation of the acute inflammatory reaction and usually
indicates the insult is mild. What does it look like? Think of a mild skin wound - the clear to
yellowish fluid that oozes out is serous exudate. Other examples would include the fluid that
accumulates in a blister or a runny nose in hay fever. Serous exudates are usually the result of a
mild, often transient irritant.
9
What is the significance of a serous exudate? It may just be the early phase of a more intense
exudate and a harbinger of a more serious problem.
Serous exudate on an ulcerated sarcoptic mange site. Serous fluid accumulating within the pericardial
Just oozing clear fluid – this is serous exudate. sac. Hydropericardium is really serous exudate.
What is the outcome of a serous exudate? If it doesn’t progress to something worse, the fluid is
reabsorbed as the inflammation resolves.
 Fibrinous exudate
Fibrinous exudation occurs in more severe conditions that allow the escape of larger fibrinogen
molecules from the vascular system. As the vascular damage increases, instead of just serous
fluid seeping out, fibrinogen gets out as well. When fibrinogen reaches the tissue it is converted
to fibrin, which is the chief component of fibrinous inflammation. (Who’s buried in Grant’s
Tomb?).
What is the gross appearance of fibrinous exudation? Fibrinous inflammation occurs chiefly on
mucous and serosal membranes. Prime locations include the entire respiratory and digestive
tracts, pleura, peritoneum, and pericardium.
10
Fibrin in the opened thorax of a horse. Very YELLOW Fibrin on the mucosal surface of the intestines in a cow
(typically very yellow in horses) and STRINGY. with salmonellosis. Stringy.
In the earliest phases, the surface with a fibrinous exudate has a slightly roughened appearance,
and will be slightly dull and granular. Think buttered bread, dropped butter side down on the
floor. Pick it up – fibrin deposition looks like this. As the deposition of fibrin increases, there
will be yellowish strands present. These can be peeled off. If the insults are repeated, these
yellowish strands can accumulate into a carpet of fibrin. This thick layering of fibrin that can be
peeled away is termed a pseudomembrane. If there is extensive necrosis of underlying areas so
that the fibrin is tightly adhered to the tissue and is harder to peel away, it is called a diphtheritic
membrane. This term diphtheritic membrane came from human diphtheria, caused by
Corynebacterium diphtheriae. If there is so much fibrin that it gushes out and forms a large
accumulation mimicking the shape of the tubular organ, then it is termed a fibrin cast. This
happens in very severe intestinal infections, such as parvovirus in dogs or salmonellosis in cattle.
Slide #1154, horse pleura - severe pleuritis, showing lots of fibrin on the
surface and beaucoup bacterial colonies.
What is the outcome of fibrinous inflammation? If it is not too severe, it may resolve without
any sequelae. If it is extensive, fibroblasts may migrate in and begin organizing the exudate
through the generation of fibrous connective tissue. Sometimes this can be harmful. For
instance, with fibrinous inflammation in the peritoneal cavity, two fibrin-covered serosal
surfaces of gut may stick to each other. If fibroblasts come in and make permanent connections,
then two loops of intestine are stuck to each other forever. This will impede gut motility! Other
places this can be bad is in the pericardium or pleura. Fibrous adhesions will impede function as
heart or lungs need to be able to slip around freely inside those spaces and not be anchored by
fibrous adhesions. As this connective tissue formation process begins, we refer to it as
“organizing.” Once it is fully organized, it is “fibrous tissue.” Please remember that fibrosis or
fibrous tissue is NOT a type of inflammation, it is growth of new cells and laying down of
collagen leading to repair. The two terms FIBROUS and FIBRINOUS are just way too similar
SOUNDING. It is unfortunate because the processes they represent and the results for the
animal are HUGELY DIFFERENT.
11
Fibrin = acute. Fibrous = chronic. BIG DIFFERENCE
 Catarrhal exudate
Catarrhal exudate is a term that is not used very often. It represents excessive mucus production
and so can only be used for inflammation in organs where mucus is already being produced. It is
most often associated with the mucosal surfaces of the intestinal, reproductive, and respiratory
tracts. It is seen in mild or persistent infections of these areas. Sometimes the word “mucous”
isused synonymously with catarrhal.
What does catarrhal exudate

look like grossly? Catarrhal
inflammation appears as a thin
gray-yellow blanket of excess
mucus. Think snot.
So far, we have covered non-cellular exudates. Now we’ll move into those exudates that contain
cells as a primary component.
 Purulent exudate
Purulent exudate is PUS. Pus is an accumulation of dead neutrophils. Neutrophils have

enzymes that help to liquefy the surrounding tissue, and so the result is a homogenous mass of
creamy pus. Think humus. Think vanilla pudding. Another term for purulent inflammation is
suppurative. The two can be used interchangeably. Pyo- is the prefix for anything with pus -
pyothorax, pyometra. Pyogenic bacteria are, by definition, bacteria that promote the body’s
production of pus. They are strongly chemotactic for neutrophils which accumulate and turn
into….pus.
What does purulent exudate look like grossly? The consistency may vary somewhat, depending
on the host species, the inciting agent, and duration. If pus is present for a while and the inciting
agent is removed, the pus becomes dry, or “inspissated”. Also, the color may vary due to the
inciting agent. Almost all cases of pus formation are due to bacteria. If the purulent
12
inflammation is well circumscribed and surrounded by a fibrous wall or capsule, it is called an
abscess.
Abscess in a vertebral body. Pus can look sort of dry like Or, it can be very fluid, as in this pyometra.
this.
Slide #1560 - calf with bacterial meningitis. The meninges are loaded with
neutrophils, some intact, some degenerating.
What is the significance of purulent inflammation? This is a prompt and violent reaction against
irritants and pathogens. The neutrophils are moving in to neutralize the offending agent. In 99%
of cases, bacteria will be in there, or HAD been in there.
What are the outcomes? One consequence is that localized purulent inflammation can break
loose and spread to other areas. This may result in septicemia if infection spreads to the blood
stream. If it does not spread, the resorption of pus is not without ill effects, including fever and
general signs of illness. If purulent inflammation is close to a body surface, it often discharges to
the outside, which is much better. Sometimes it does this through the formation of a fistulous
tract.
13
An abscess represents a subset of purulent
inflammation. An abscess is defined as a
discrete accumulation of pus surrounded by a
fibrous capsule. They are usually formed in
response to a focal bacterial infection. The
neutrophils are unable to fully overcome the
infection and if they accumulate in large
enough numbers, the body responds by walling
off the focus of infection with a circumferential
band of collagen. Although the inciting cause
is now effectively separated from spreading to
other parts of the body, the fibrous wall also
prevents delivery of antibiotics to the site.
Oops – hard to treat!
Guinea pig abscess (left) and

cleaning out a tomcat abscess
(right) - these things can hold a
LOT of pus!!!
 Hemorrhagic exudate
Hemorrhagic exudates are characterized by large numbers of erythrocytes. The holes in the
blood vessels are large enough that everything comes out so that the appearance of the exudate is
very much like blood. Hemorrhagic exudates are usually mixed with serum, fibrin, and
leukocytes. Distinguishing hemorrhagic exudates from simple hemorrhage can be problematic.
14
What is the significance of hemorrhagic inflammation? This type of inflammation is usually
caused by highly virulent microorganisms or by acute poisoning by certain chemicals. It arises
quickly and is often fatal. There is massive damage to endothelium.
What is the outcome of hemorrhagic inflammation? Often guarded.
 Mixed exudates
Mixed exudates are more common than simple ones because the inflammatory process
frequently persists long enough to evoke the exudation of more than one type of exudate. Lots of
word combinations - fibrinohemorrhagic, mucopurulent, etc. Have fun playing with words.
Opened pericardial sac of a cow with hardware Blackleg in a calf. Here the exudate would be
disease. You would call this exudate characterized as “necrohemorrhagic.”
“fibrinopurulent.”
 Granulomatous “exudate”
These represent exudates where the majority of cells are macrophages. However, these exudates
don’t usually “ooze” and so we generally use the term “granulomatous inflammation” but not
“granulomatous exudate.” We’ll cover this more in the unit on chronic inflammation.
5. Designation of organ or location
The location of inflammation is designated in the morphologic diagnosis by using a prefix that
refers to the organ and the "itis" suffix. For example: inflammation of the skin = derma + titis;
inflammation of the bone marrow = osteomyel + itis. Before moving to the next topic, review the
15
more extensive list of prefixes in the table below. Practice adding “itis” to the end of each prefix
to name an inflammatory process in the designated organ or tissue.
COMMONLY USED ANATOMIC PREFIXES FOR INFLAMMATION (-itis)
Arter ............................................... artery Mening ..................................... meninges

Arthr ................................................. joint Metr ................................................ uterus
Balan ......................................glans penis Myel ....................................... spinal cord
Blephar .......................................... eye lid Myocard .............................. myocardium
Bronch ......................................... bronchi Myos ............................................ muscle
Burs ................................................. bursa Nephr.............................................kidney
Cellul ............................ connective tissue Odont............................................... tooth
Cheil .................................................... lip Omphalo ................................... umbilicus
Cholecyst.............................. gall bladder Oophor ........................................... ovary
Col ...................................................colon Ophthalm............................................ eye
Conjunctiv ............................. conjunctiva Orch.............................................. testicle
Dermat............................................... skin Oste .................................................. bone
Encephal.......................................... brain Osteomyel .......................... bone marrow
Endocard .............................endocardium Ot.........................................................ear
Enter ........................................... intestine Pericard ................................ pericardium
Esophag ................................... esophagus Sialaden ............................. salivary gland
Funicul ............................. spermatic cord Splen ............................................. spleen
Gastr ........................................... stomach Trache .......................................... trachea
Gingiv .............................................. gum Typhl ............................................. cecum
Gloss .............................................tongue Periost .................................... periosteum
Hepat ................................................ liver
Kerat.............................................. cornea
Lamin ............................................... hoof
Laryng ........................................... larynx
Lymphaden ......................... lymph nodes
16
Acute Inflammation
Inflammation has VASCULAR and CELLULAR events:

1. VASCULAR EVENTS
Change in vessel diameter - nitric oxide, PGI2, LTB4
Increase in vascular permeability:
 Transient, 30-60 minutes, due to histamine and bradykinin; delayed, 1-8 hours,
due to prostaglandins, complement, leukotrienes, PAF; prolonged, over 24 hours,
due to direct necrosis of endothelium
 Fluid exudates
 Leukocyte-endothelial cell interactions
Margination, rolling (pavementing), adhering, emigration
2. CELLULAR EVENTS
Adhesion molecules (“let’s stick together” signals)
Between leukocytes and endothelial cells
Chemotactic factors (“come on over” signals)
For neutrophils: C5a, C3a, LTB4, IL8, TNF, bacteria, fibrin
For eosinophils: histamine, IL5 (also known as eotaxin, a chemokine)
For monocytes: C5a, C3a, fibrin
Microbicidal activity (“we’ll smoke ‘em out” tactics)
How do phagocytes kill?
Getting opsonized helps
Lysosomal enzymes, oxygen radicals
Phagocytes get activated
By IFNγ, TNFα, LPS, binding of Fc, C5a, LTB4
           
17
ACUTE INFLAMMATION
In the early stages of inflammation, the affected tissue becomes reddened, due to increased blood
flow, and swollen, due to edema fluid. These changes are the result of vascular response to
inflammation. The vascular events of the acute inflammatory response involve three main
processes:
1. changes in vessel caliber and, consequently, blood flow (hemodynamics)

2. increased vascular permeability and
3. formation of the fluid exudate
1. Changes in Vessel Caliber
The microcirculation consists of the network of small capillaries lying between arterioles, which
have a thick muscular wall, and thin-walled venules. Capillaries have no smooth muscle in their
walls to control their caliber, and are so narrow that red blood cells must pass through them in
single file. The smooth muscle of arteriolar walls forms pre-capillary sphincters that regulate
blood flow through the capillary bed. Flow through the capillaries is intermittent, and some form
preferential channels for flow while others are usually shut down. In other words, there is not
blood flowing through all capillaries all the time. They take turns. When inflammation happens,
none of them gets to take their scheduled coffee break. They are all open.
Experimental evidence indicates that blood flow to the injured area may increase up to ten-fold
as vessels dilate. What causes this to happen? MEDIATORS - including histamine, nitric oxide,
prostaglandins (PGI2) and LTB4.
2. Increased vascular permeability
In acute inflammation, the capillary hydrostatic pressure increases, and there is also escape of
plasma proteins into the extravascular space due to increased vascular permeability (endothelial
contraction allowing proteins to escape between cells). Consequently, much more fluid leaves
the vessels than is returned to them. The net escape of protein-rich fluid is called exudation;
hence, the fluid is called an exudate as opposed to a transudate that is low in protein and
produced primarily by an increase in hydrostatic pressure or decreased blood osmotic pressure
without a change in permeability. Remember these words from Disturbances of Circulation
section?
18
What causes the increase in vascular permeability in acute inflammation?
There are two mechanisms –

1. Chemical mediators of acute inflammation may cause retraction of endothelial
cells, leaving intercellular gaps (chemical mediated vascular leakage).
2. Toxins and physical agents may cause necrosis of vascular endothelium, leading
to abnormal leakage (injury induced vascular leakage).
Although vascular leakage in inflammation is continuous, it can be divided by mechanism into 3

periods.
 A transient immediate response that lasts for 30-60 minutes, and is mediated by histamine
and bradykinin acting on endothelium.
 A delayed response that starts 1-3 hours after injury and lasts for up to 8 or more hours. This
is mediated by factors synthesized by local cells, e.g., PGI2, C5a, C3a, LTC4, LTD4, LTE4,
and platelet activating factor.
 A prolonged response that occurs over 24 hours also is seen if there has been direct necrosis
of endothelium, e.g., in a burn or by a chemical toxin.
The increased vascular permeability means that larger

molecules, such as proteins, can escape from vessels.
Hence, the exudate fluid has a high protein content. The
proteins present include immunoglobulins, which may be
important in the destruction of invading micro-organisms,
and fibrinogen, which results in fibrin deposition on contact
with the extravascular tissues. That’s why acutely inflamed
organ surfaces are commonly covered by fibrinous exudate.
19
Now – for the “let’s stick together” factors that help
white blood cells get out of the circulation.
Leukocyte- Endothelial Interactions
In blood vessels larger than capillaries, blood cells flow mainly in the center of the lumen (axial
flow), while the area near the vessel wall carries only plasma. This feature of normal blood flow
keeps blood cells away from the vessel wall. As blood flow slows, blood cells begin to flow
nearer to the vessel wall, rather than the axial stream. This is called margination of leukocytes.
Next the leukocytes begin rolling or (pavementing) along the surface of the endothelium within
the blood vessel and finally they adhere and line-up along the surface of the vascular epithelium.
After adherence occurs, the next step is leukocyte emigration into the extravascular space.
Cytokines control the expression of the adhesion molecules and thus orchestrate these cellular
events.
3. Formation of the Cellular Exudate
The neutrophil is the primary cellular mediator of acute inflammation. The accumulation of
neutrophils within the extracellular space is one of the diagnostic features of acute inflammation.
BIG QUESTION - HOW DOES THIS HAPPEN?
The normally inactive endothelium has to be activated to allow adhesion of neutrophils.

Normally inactive neutrophils have to be activated to enhance their capacity for phagocytosis,
bacterial killing, and generation of inflammatory mediators. Neutrophils have to develop the
ability to move actively, in a directional fashion, from vessels towards the area of tissue damage.
If tissue damage is slight, an adequate supply of neutrophils is derived from normal numbers of
neutrophils circulating in blood. If tissue damage is extensive, stores of neutrophils, including
20
some immature forms, are released from bone marrow to increase the absolute number of
neutrophils in the blood.
The cytokine tumor necrosis factor alpha (TNF) secreted by macrophages stimulates
endothelial cells to express receptors causing loose attachment of neutrophils and rolling (1-2
hours). Later, under TNF influence, endothelium expresses other receptors that result in stable
adhesion of neutrophils to endothelium (6-12 hours).
Well, this is great – WBCs are on the endothelium, now

how do they get out to where they are needed? By
chemotaxis - these are the “come on over” factors.
Chemotaxis of leukocytes
The movement of leukocytes from the vessel lumen in a directional fashion to the site of tissue
damage is called chemotaxis. All granulocytes and monocytes respond to chemotactic factors
and move along a concentration gradient (kind of like finding your way to the BBQ restaurant by
smell……).
Important neutrophil chemotactic factors
C5a, C3a
Fibrin, fibrinopeptides
Bacterial components
Leukotriene B4 (LTB4)
IL-8 (a chemokine, from macrophages)
Important eosinophil chemotactic factors
Histamine
IL-5 (also known as eotaxin, a chemokine, from mast cells)
Important monocyte chemotactic factors
C5a , C3a
MCPs (monocyte chemoattractant proteins)
Fibrinopeptides
21
Okay, now the WBCs are where they were meant to be.
What’s next? Gotta get to work to eliminate the offender
– this is the “let’s snuff ‘em out” stage.
Microbicidal Activity of Leukocytes

Leukocytes play a very important role in microbial killing. In any inflammatory response,
leukocyte activation is a prerequisite to their full participation in the process. Leukocytes are
activated by binding to numerous cytokines (IFNγ and TNF) or other ligands such as the Fc
portion of antibody, complement components (C5a), or LPS. Activated leukocytes are capable of
a variety of functions – see below.
Leukocytes’ adhesion to micro-organisms

Micro-organisms are opsonized (from the Greek word
meaning 'to butter'), or rendered more amenable to
phagocytosis, either by immunoglobulins or by
complement components. Buttered toast is more palatable
than dry toast, at least that’s how the phagocytic cells feel.
Opsonins are antibody or C3b bound to the bacteria.
Leukocytes and phagocytosis

The process whereby cells ingest solid particles
is termed phagocytosis. The first step in
phagocytosis is adhesion of the particle to be
phagocytosed to the cell surface. This is
facilitated by opsonization. The phagocyte then
ingests the attached particle by sending out
pseudopodia around it. These meet and fuse so
that the particle lies in a phagocytic vacuole
(also called a phagosome) bounded by the cell
membrane. Lysosomes, membrane-bound
packets containing the toxic compounds, then
fuse with phagosomes to form phagolysosomes.
It is within these that intracellular killing of
microorganisms occurs.
22
Intracellular killing of micro-organisms by leukocytes
Neutrophils and macrophages are specialized cells, containing noxious antimicrobial agents.
These include:
 Neutrophils produce hydrogen peroxide (bactericidal by itself) which reacts with
myeloperoxidase in the cytoplasmic granules to create oxygen radicals which are
wickedly damaging.
 Lactoferrin chelates iron which is required for bacterial growth.
 Antibacterial cationic proteins, lysozyme, and defensins all affect bacterial permeability
so the bacteria leak to death.
 Release of lysosomal products from the cell damages local tissues and can kill
microorganisms outside of the cell. Enzymes such as elastase and collagenase will chew
through tissue. Acid hydrolases degrade tissue matrixes.
23
Plasma-derived Mediators of Inflammation
The plasma contains four major protease cascade systems that contribute to acute inflammation –
Complement
Kinins
Coagulation
Fibrinolysis
All are interrelated and produce various inflammatory mediators.
Complement system
 What activates it: ag-ab complexes, bacterial products, plasmin
 There are three pathways, classical, lectin, and alternative
 The lead actors:
 C5a: chemotactic for neutrophils; increases vascular permeability by stimulating mast
cell degranulation and release of histamine
 C3a: similar properties to those of C5a, but less active
 C56789 (membrane attack complex, MAC): cytolytic activity
 C3b: opsonization of bacteria (facilitates phagocytosis by macrophages and
neutrophils).
Kinin system.
 Who they are: Bradykinin is the big one
 Activated by: Hageman factor activates kallikrein from prekallikrein, and the kallikrein
turns HMWK into bradykinin.
 What it does:
 Dilates vessels and increases permeability - VERY IMPORTANT
 Causes pain (ouch!)
Coagulation system. The coagulation system is responsible for the conversion of soluble
fibrinogen into fibrin, a major component of the acute inflammatory exudate. Coagulation factor
XII (the Hageman factor), once activated by contact with extracellular materials can activate the
coagulation, kinin and fibrinolytic systems. Tissue factor is another important initiator of the
coagulation cascade. This system should be a breeze because we covered it just recently!
Fibrinolytic system. Plasmin is responsible for the lysis of fibrin into fibrin degradation
products, which may have local effects on vascular permeability. Kallikrein from the kinin
system can activate the fibrinolytic system by converting plasminogen to plasmin.
           
24
Plasma-derived Mediators of Inflammation
In large part, the acute inflammatory response is orchestrated by plasma-derived and cell-derived
chemical mediators.
This lesson will concentrate on the plasma-derived mediators of inflammation. These mediators
circulate as inactive precursors that become activated when a cascade of proteolytic cleavages
occurs to release biologically active mediators.
The plasma contains four major protease cascade systems that contribute to acute inflammation –
Complement
Kinin
Coagulation
Fibrinolysis
All are interrelated and produce various inflammatory mediators.
The Complement System
What is Complement for? What does Complement do?

The most important function of complement is the elimination of pathogens and harmful
antigens. It is capable of performing this task alone but is greatly augmented in the presence of
specific antibody. The third component of complement, abbreviated as C3, can justly be regarded
as the focal point around which the cascade of activation reactions converge and on which the
major functions depend.
There are three pathways to complement activation. Each arrives at the same result, which
is formation of the Membrane Attack Complex (MAC), or C56789, which punches a hole in
whatever membrane it is attached to. That’ll damage a cell for sure, punching a hole in the
wall, whether it is a bacterial cell or a virus-infected cell, or an innocently standing by body cell.
25
Nomenclature
Most of the components are circulating plasma proteins (about 20 total). They are all
denoted by the letter C followed by a number. You don’t gotta know ‘em all. This course
is about MECHANISMS, not MEMORY.
1. Classical Pathway Activation
Immune complexes consisting of IgM or IgG are potent activators of the classical pathway of
complement activation. This proceeds by activation of C1 and ultimately results in formation of
C3 convertase, which gives us C3b, the OPSONIN, as well as all the other actors.
2. Lectin pathway
The classical pathway can be activated in a more nonspecific way, by lectins. What’s a lectin? It
is a kind of protein that has a special linkage with sugar. Mannose-binding protein made in the
liver attaches to the mannose on bacteria, viruses, and parasites, and bingo, that binds to C1,
causing activation. So the body has developed ways to respond to an offender even before
antibodies are formed.
3. Alternative Pathway Activation
C1 is bypassed in the alternative pathway, that’s why they call it alternative! C3 is cleaved
directly by exposure to bacterial surface structures (like LPS!). So this is the pathway that gets
activated fast when an animal has a Gram negative septicemia.
26
PLEASE JUST FOCUS ON THE
IMPORTANT COMPONENTS,
HOW THEY GET ACTIVATED
AND WHAT THEY DO:
The Membrane Attack Complex  C3 → C3a, C3b
 C5 → C5a, C5b
 C56789
The Big MAC

forms a donut-like
shape that binds to
the membrane,
punches a hole. Uh
oh, stuff leaks out,
cell dies.
27
The three pathways are challenging to visualize - try this:
Other Functions of Complement: What else does it do?- A number of well-defined

biological activities are generated during complement activation. These are vital to host defense
and the inflammatory response.
When C3 is cleaved by the C3 convertases two primary products are formed - these are C3a and
C3b.
 C3a is an anaphylatoxin (promotes histamine release from mast cells). So there is a great
increase in vasodilation and vascular permeability. This results in the exudation of
plasma out of post-capillary venules into the interstitial space. EDEMA. If it’s your
larynx, look out, you’re dead! C3a also has an effect on neutrophils. They find it
irresistible and are attracted (chemotaxis!).
 The primary function of the intact C3b molecule is participation in the C3 and C5
convertase complexes. It also plays a role in opsonization. C3b bound to microbial
surfaces is recognized specifically by phagocytes who find it very tasty and easy to
engulf (i.e., it is an opsonin).
 C5a is VERY important in being irresistible to neutrophils, it brings them running and
swimming in. C5a also serves to stimulate histamine release from mast cells. Too much
histamine and look out - anaphylaxis! Which is why C3a and C5a are also called
anaphylatoxins.
The Kinin System

The kinins are peptides of 9-11 amino acids; the most important vascular permeability factor is
bradykinin. The kinin system is activated by coagulation factor XII (Hageman factor). The
28
coagulation cascade, the fibrinolytic system and the kinin system are closely interconnected. See
below.
Kallikrein, which gets activated by Hageman factor, works

on HMWK (high molecular weight kininogen) which is
present in multiple tissues, breaking a piece off of it and
that piece is BRADYKININ.
Bradykinin acts on endothelium to markedly upregulate production of PGI2 and nitric oxide. As
a result there is lots of VASODILATION and INCREASED VASCULAR PERMEABILITY.
This brings more plasma and cell mediators to where they are needed!
Bradykinin is also thought to be a major mediator of pain, through binding to receptors that send
pain impulses to the brain.
29
Coagulation System - Déjà vu all over again….
The coagulation system is responsible for the conversion of soluble fibrinogen into fibrin, a
major component of the acute inflammatory exudate. The ultimate goal of the pathway is to
produce thrombin, which converts soluble fibrinogen into fibrin. Fibrin is an important
component of inflammatory exudates as well as a very critical component of blood clots.
Fibrinolytic system
Once hemostasis is restored and the tissue is repaired, the clot or thrombus must be removed
from the injured tissue. This is achieved by the fibrinolytic pathway. The end product of this
pathway is the enzyme plasmin, a potent proteolytic enzyme with a broad spectrum of activity.
Plasmin is responsible for the lysis of fibrin into fibrin degradation products, and plasmin acts on
fibrin at over 50 sites, breaking it down into tiny “fibrin degradation products” (FDPs) which can
be easily removed.
Plasmin is formed from plasminogen. How? Through plasminogen activators, which are found
in endothelial cells as well as elsewhere (tissues, for instance).
30
31
Cell-derived Mediators of Inflammation
VASOACTIVE AMINES
Histamine
 from mast cells and basophils, a little bit from platelets
 what releases it? trauma, cross linkage of membrane-bound IgE, stimulation by
cytokines IL-1 and IL-8, binding of anaphylatoxins from the complement cascade
(C3a, C5a)
Serotonin
 from platelets
LIPID MEDIATORS - all come from cell membranes

Arachidonic acid metabolites
 Prostaglandins (from cyclooxygenase pathway) - can dilate or constrict blood vessels,
also increase or decrease vascular permeability, cause pain, fever
 Leukotrienes (from lipoxygenase pathway) - work at vasoconstriction,
bronchoconstriction, chemotaxis, activate leukocytes
Platelet activating factor
 from platelets, leukocytes, endothelial cells
 chemotaxis, adhesion, aggregation, platelet activation, vasodilation, increased
vascular permeability
CYTOKINES -
 IL-1, TNF - central in both local and systemic reactions in inflammation
CHEMOKINES = chemotactic cytokines, all are small

 IL-8 (from macrophages) - recruits neutrophils
 IL-5 (also known as eotaxin, from mast cells) - recruits eosinophils
 Monocyte chemoattractant protein 1 (from many cells) - recruits macrophages
LYSOSOMAL CONTENTS
Oxygen radicals, nitric oxide, nasty enzymes
           
32
Cell-derived Mediators of Inflammation
Introduction
Cellular derived mediators are important in both immediate and sustained inflammatory
responses. They fall into three main categories:
1. Vasoactive amines
2. Lipid mediators
3. Cytokines and chemokines
4. Contents of granules and lysosomes
1. Vasoactive Amines
The vasoactive amines (histamine and serotonin) are responsible for the immediate and
short-lived responses in inflammation including vasodilation, increased vascular
permeability and smooth muscle contraction in the respiratory and digestive tract.
YOU KNOW THESE ALREADY – WE COVERED THEM IN THE DISTURBANCES

OF CIRCULATION. (LIFE IS CUMULATIVE.)
Histamine is found primarily in mast cells that are distributed throughout tissues and in basophils
in the circulation. It is a pre-formed mediator that is released upon degranulation. Mast cell
degranulation can be stimulated by trauma, cross linkage of membrane-bound IgE with antigen
in allergic reactions, stimulation by cytokines IL-1 and IL-8, and binding of C3a and C5a.
Histamine is also present in platelet granules. Remember what causes platelets to release their
granules? Thrombin, ADP, and platelet activating factor (PAF).
Histamine is the primary mediator of

immediate vasodilation and increased
vascular permeability in acute
inflammation.
Serotonin is another vasoactive amine. It is

found in platelets.
33
Vasoactive amine Cellular sources Effect
Histamine mast cells, basophils vasodilation, increased vascular permeability
Serotonin platelets vasodilation, increased vascular permeability
2. Lipid mediators - all come from the cell membranes
Arachidonic acid metabolites

The arachidonic acid CASCADE happens when cell membranes, especially those of white blood
cells, get stimulated. Arachidonic acid gets released from the membrane and forms a bewildering
array of mediators, most of which are called PROSTAGLANDINS or LEUKOTRIENES.
Arachidonic acid is acted upon by one of

two major enzymes resulting in one of two
classes of metabolites.
1. Cyclooxygenases (COX1 and COX2)

produce prostaglandins (all of which
have a “PG” designation, except for
thromboxane which has a TXA
designation).
2. 5-lipoxygenase produces leukotrienes,

all of which have an “LT” designation.
Prostaglandins are so named because they were first described from prostate tissue; leukotrienes
because they have three double bonds (therefore the tri-ene part) and they come mostly from
white cells (the leuko- part).
More detail (hopefully not too much) on these two classes of arachidonic acid metabolites:
Prostaglandins
What are prostaglandins?

Chemicals derived from arachidonic acid that participate in a wide range of body
functions with effects mostly on smooth muscle and blood vessels.
34
Prostaglandins are abbreviated as PG + a letter to indicate its structure and a subscript to
designate the number of double carbon bonds. Each prostaglandin has a specific action and
tissue distribution.
Mediators Cellular sources Effects

PGI2 Endothelium Vasodilation, keeps platelets from aggregating
Vasoconstriction, promotes platelet
TXA2 platelets
aggregation
PGD2 leukocytes, mast cells vasodilation, edema
PGE2 all leukocytes pain, fever, vasodilation, edema
P.S. Do you remember our old friends prostacyclin and thromboxane from Disturbances of
Circulation??? Or was it just a meaningless summer romance?
Leukotrienes
What are leukotrienes?

Chemicals derived from arachidonic acid that work very acutely
to constrict blood vessels, constrict bronchioles, and bring lots of
neutrophils in. Most leukotrienes come from leukocytes.
Mediators Cellular sources Effects

LTB4 all leukocytes chemotactic for neutrophils
LTC4
vasoconstriction, increased vascular
LTD4 all leukocytes
permeability, bronchospasm
LTE4
PAF Platelets, leukocyte chemotaxis, adhesion, aggregation,
(platelet leukocytes, platelet activation and aggregation, increased
activating factor) endothelium vascular permeability
Many anti-inflammatory and pain medications inhibit some portion of the arachidonic acid
pathway. That’s a good thing because some of the prostaglandins are needed for healthy body
function.
THIS IS SO MUCH INFORMATION, WE ARE TRYING TO MAKE SURE IT

IS NOT TOO MUCH INFORMATION! SO, WHAT TO REMEMBER? MOST
PG’S ARE PRO-INFLAMMATORY SO ADMINISTERING CYCLOOXYGENASE
INHIBITORS WILL DECREASE INFLAMMATION.
35
3. Cytokines
What’s a cytokine?
A signalling molecule especially important in the immune response. From cyto (cell)
and kinein (Greek for move) - serves to MOVE the cellular response against an invader.
Cytokines can be divided into functional groups based on their major biological actions:
1. Those that mediate the acute inflammatory response and work in nonspecific
immunity - TNF and IL-1
2. Others also work on the inflammatory response but may also have a role in the
development of the specific immune response: IL-2, IL-4, IL-5, IL-10, IL-12, IFN
In this course, we will only focus on those that are involved in the first category. You have
already covered those in the second category in your course on Immunology last year. We are
ever hopeful that there is good memory.
Major cytokines involved in inflammation are those associated with the innate response (or
nonspecific immunity), IL-1 and TNF from monocytes and macrophages. In general,
endothelial cells respond to these two inflammatory cytokines by expressing leukocyte adhesion
molecules (selectins, integrins). Leukocytes respond to IL-1 and TNF by becoming activated
and expressing surface molecules that bind to endothelial adhesion molecules. Hey, there’s
some coordination going on here!
36
What’s an interleukin?
A secreted signalling molecule that helps the body respond to inflammation.
Originally thought to only be produced by white blood cells for white blood cells
(therefore inter- and -leukin) but now known to be produced by other cell types as well.
(Interleukins are cytokines.)
IL-1 and TNF have many similar activities. Once synthesized and released from macrophages,
these cytokines have the following effects:
 Fever, cachexia, acute-phase protein release from the liver, hemodynamic changes,
neutrophilia (due to release of cells from the bone marrow)
 Endothelial cell activation - increased expression of leukocyte adhesion molecules, PGI2
synthesis
 Fibroblast activation - proliferation of fibroblasts, collagen synthesis
 Leukocyte activation - increased cytokine secretion and priming
IFN secreted by T-lymphocytes and NK cells is responsible for activating macrophages. Also,
IFN has important functions in immunologic responses.
Cellular
Cytokines Effects
sources
Fever, neutrophilia, activation of endothelial
activated
cells, procoagulant activity, increased
IL-1 macrophages
prostacyclin, acute phase proteins, stimulates
and monocytes
more IL-1, IL-6
activated
Fever, neutrophilia, activation of neutrophils and
macrophages
TNF endothelial cells, stimulates production of other
and monocytes
cytokines, promotes shock
37
What’s a chemokine?
A small cytokine, that functions primarily in
chemotaxis (CHEMOtactic cytoKINE)
(Chemokines are a kind of cytokine.)
Chemokines Sources Effects

Macrophages neutrophil activation and recruitment,
IL-8
mostly induces TNF and IL1 secretion
Mast cells
Eotaxin (IL-5) eosinophil recruitment
mostly
MCP-1 monocyte
all cells macrophage chemotaxis
chemoattractant protein
4. Oxygen-derived free radicals, nitric oxide, and lysosomal components

(otherwise known as nasty stuff designed to kill cells)
Oxygen-derived free radicals

Activated phagocytic leukocytes produce oxygen-derived free radicals, all of which are potent
oxidizing agents that can kill bacteria. Unfortunately, they can also harm innocent bystanders,
like endothelial cells.
38
Nitric oxide
Nitric oxide (NO) is produced by endothelial cells and macrophages. NO causes vasodilation and
reacts with oxygen-derived radicals to produce reactive nitrogen-containing metabolites that are
both antimicrobial and may damage tissue.
Other lysosomal components

Acid proteases, neutral proteases, esterases and nucleases are all kept within the lysosome
compartment because if they were free in the cell cytoplasm, they would kill the cell. When they
are released, into the environment around the cell, they can kill bacteria, but sometimes also
cause extensive tissue damage.
At this point, you might be asking, why do I have to know all of

this? In medicine, inflammation is often center stage in all
pathologic processes. You will be treating the inflammation and
in order to do so, you will need an understanding of how to block
various aspects of the whole complicated picture of inflammation.
The discovery of these cell-derived mediators of inflammation

has been the focal point for development and use of anti-
inflammatory drugs.
39
NOTE: This is not a course in pharmacology – you are not responsible for
knowing all about these drugs. But we think you might be curious about how
each of these anti-inflammatory drugs acts in the inflammatory process!
Maybe there is some synergy with your other course, we hope so!!!!
Target mediator Drug Action

Histamine Chlorpheniramine Blocks histamine receptors in target
cells
Cromolyn Inhibits release of histamine from mast
cells
Meclizine Blocks blood vessel response to
histamine; also blocks
neurotransmitters in key areas of brain
(anti-emetic)
Diphenhydramine Blocks H1 receptors
All arachidonic acid Dexamethasone Inhibits formation of phospholipase
metabolites A2; also depresses immune response
Tepoxalin Blocks cyclooxygenase and
lipoxygenase
Prostaglandins Flunixin meglumine Potent inhibitor of cyclooxygenase
Indomethacin Blocks cyclooxygenases
Acetaminophen Blocks cyclooxygenases
Phenylbutazone Irreversibly binds to cyclooxygenases
Ibuprofen Inhibits COX-1 and COX-2, also
slows platelet aggregation
Aspirin Irreversibly binds to COX-1 and
COX-2, also binds to platelets
Etodolac Inhibits COX-2>COX-1
Meloxicam Inhibits COX-2>COX-1
Carprofen Inhibits COX-2>COX-1
Deracoxib Inhibits COX-2
Leukotrienes Montelukast (Singulair) Inhibits the LTs that cause
bronchospasm
40
Cellular Components of Inflammation
GRANULOCYTES
Neutrophils
 Usually most abundant leukocyte in the blood
 Important in acute inflammation (first cell to arrive)
 nucleus is multilobed (starts out with only two lobes, kind of like a horseshoe, or
“band”)
 very phagocytic
 Granules:
o Azurophilic (or primary) granules contain myeloperoxidase, lysozyme,
defensins, and a variety of neutral proteases
o Neutrophil-specific, or secondary granules, contain lysozyme, collagenase
 Short-lived once in tissue, survive only 6-72 hours
 End stage cell, don’t divide
Eosinophils
 Have big pink or orange granules
 Granules contain Major Basic Protein, which will help to kill parasites
 Live 8-12 days in tissue
 End stage cell, don’t divide
Basophils and mast cells
 Different origin of each of these cells but similar function
 Not very many anywhere, in blood (basophils) or in tissue (mast cells)
 When you see them, it usually means allergy
 They are strongly chemotactic for eosinophils so the two cell types may occur
together
 Can continue to divide, even when in tissue
 Can be powerful vasodilators (‘cause they got lots o’ histamine)
MONONUCLEAR CELLS
Lymphocytes
 Small round cells with large non-lobed nucleus
 Come in B cell and T cell varieties
Mononuclear phagocytes
 Big cells, lots of cytoplasm, big indented nucleus
 Monocytes in blood become macrophages when they go to the tissue
 Can live for as long as one month in tissue
 Heavy duty phagocytes
           
41
Cellular Components of Inflammation
In order to understand types of inflammation, it is essential to grasp the different categories of
inflammatory cells, to be able to recognize them morphologically, and to understand the different
situations in which they occur.
Granulocytes
Granulocytes consist of neutrophils, eosinophils, basophils, and heterophils in some species.
 Neutrophils
Neutrophilic leukocytes are also known as polymorphs, “polys”, and polymorphonuclear cells.
In some species, notably guinea pigs, rabbits, and birds, the term heterophil is used to describe
the functional counterpart. These cells are key cells involved in the earliest events associated
with inflammation.
Neutrophils are formed in the bone marrow from granulocytic stem cells, the myeloblasts. What
causes their release from the bone marrow when needed in inflammation? Some of our old
friends – C5a, TNFα, IL-8, as well as numerous “colony stimulating factors”. The nucleus of a
very immature neutrophil is slightly indented; after that, it assumes a “U” or “C” shape, and is
called a “band” neutrophil. As the neutrophil continues to mature, the nucleus becomes hyper-
42
indented to take on a multilobed configuration with multiple constrictions (therefore called
PolyMorphoNuclear cells, or PMNs). Even with the vast numbers of neutrophils in the body,
there are severe infections in which tissue demand exceeds the vascular supply. The body
responds by releasing neutrophils from the storage pool in the bone marrow to increase the
number in the circulation. This increase is called a neutrophilic leukocytosis. If the tissue
demand for neutrophils persists or increases, many of the immature forms, or “bands,” will be
released as well. This is referred to as a “left shift.”
Both azurophilic (or primary) and

neutrophil-specific (or secondary)
granules contain enzymes that
promote inflammation and bacterial
killing.
The granules fuse with phagosomes to

form phagolysosomes where digestion
of phagocytized material takes place.
If activated, the neutrophil-specific
granules may also fuse with the plasma
membrane, spewing their damaging
enzymes out into the extracellular
environment.
Neutrophils leave the blood in response to tissue

damage. They migrate rapidly to areas where they
are needed. Why? - The “come on over” signals are
shouting to them, and the tubules in the cytoplasm
respond by moving them on over (smell the
barbecue….). Some of the main chemotactic signals
that call neutrophils into an area include bacterial
components, C5a, IL-8, and LTB4.
Neutrophils have a short half-life. Depending on the severity of the lesion, they survive less than
3 days at a site of inflammation. They last less than a day in blood.
43
Once at the site, neutrophils’ main functions are to phagocytose small particles and kill microbes.
There are three phases to phagocytosis. First, the particles must attach to the cell surface. Then
the particle must be ingested. Third, the particle has to be digested within the cell. Attachment
is greatly enhanced if the particle is coated, or opsonized, by specific IgG antibodies or non-
specific C3b fragments from plasma. They eat faster and more efficiently if the toast is
buttered….
Ingestion occurs after the particle has attached to the cell. Pseudopodia extend to surround and
engulf the material, creating a phagosome, and internalizing the particle.
Digestion occurs when the lysosomes move

toward the phagosome and eventually fuse,
emptying their enzymes into the pocket, and
inactivating the particle. The digestive vacuole
then migrates toward the cell membrane, where
it fuses with the outside of the cell, discharging
the remnants into the extracellular environment
to be removed by the lymph.
Neutrophils are the most common cell in

purulent exudate. In fact, that’s what pus is -
an accumulation of dead neutrophils. Most
bacteria produce very strong chemotactic
factors that attract neutrophils. Consequently, any accumulation of pus should trigger the
suspicion that bacteria are present.
How can you recognize neutrophils in tissue microscopically? The multilobed nucleus makes
this cell an easy one to recognize. The cytoplasmic granules are not discernible in H&E sections
and the cytoplasm usually appears pink to slightly lavender.
Slide #1560 - calf with bacterial meningitis. The meninges are loaded with
neutrophils, some intact, some degenerating.
Because the neutrophil life span is so short, often at sites of inflammation, only dead neutrophils
are visible. These are more difficult to recognize as the nucleus may condense and lose its lobed
appearance.
Secret of the day:

PUS IS DEAD NEUTROPHILS
44
As neutrophils die in large numbers within inflamed tissues, their contents are released into the
extracellular fluids. Their enzymes cause local tissue digestion with liquefaction which mixes
with the pus and makes it all ever so much gooey-er.
 Eosinophils
Eosinophilic granulocytes are so called because of the presence of big red-pink cytoplasmic
granules. Eosin is the pink stain and because the granules pick up so much of the stain, the cells
are “eosin-loving” or eosinophils. The eosinophilic granules vary in size in the different species,
being large and prominent in the horse, and quite small and almost inconspicuous in the cat. The
granules contain Major Basic Protein, which is toxic to parasites.
Eosinophils are similar to neutrophils in their maturation and release sequences, but there are a
heck of a lot less of them in the blood. Like neutrophils, eosinophils are also end cells that do
not replicate after release. Extravascularly, they are slightly more long-lived than neutrophils, on
the order of 8-12 days. Eosinophils are commonly found in mucous membranes.
What do they look like in tissue? Hooray, eosinophils are the easiest cell to recognize, especially
in horses, where the granules are especially big and bright.
Slide #1489, horse with diarrhea due to parasites - see all the eosinophils in
the mucosa and submucosa!
Eosinophils are most often associated with 4 main types of reactions:

 surrounding fungi and metazoan parasites in tissues
 hypersensitivity reactions, including allergy and anaphylaxis
 certain tumors, especially mast cell tumors (why? Because mast cells attract eosinophils!)
 in the brain of pigs and cattle poisoned by excess salt, or prolonged water deprivation
(Why? No clue - nobody knows!)
45
Some of the strongest chemotactic factors for eosinophils include histamine and IL-5 (also
known as eotaxin), both of which come from mast cells.
Once eosinophils reach the tissue, what are their functions?

First, they can do some damage to bacteria (they have high levels of peroxidase, but lack
lysozyme). They are not as effective as neutrophils, but they try.
Second, eosinophils are very effective at killing metazoan parasites. They attach via
antibody and then release their Major Basic Protein which causes parasites to
disintegrate.
 Basophils and Mast Cells

Both basophils and mast cells possess distinct spherical basophilic to metachromatic cytoplasmic
granules. They have different origins but have similar functions.
Basophils are the third type of granulocytic

leukocyte. Produced in the bone marrow, they
occur in the circulation in very low numbers.
They emigrate into extravascular tissues at sites
of inflammation. They have a multilobed
nucleus.
Mast cells are widely distributed in connective tissue

and mucosal tissues throughout the body. They are
particularly abundant in skin, gastrointestinal mucosa,
and respiratory tract, all the host-environment interfaces.
Nucleus is round to oval and contains a prominent
nucleolus.
These cells are not phagocytic and are only sluggishly motile. Their main function is the
degranulation of their cytoplasmic contents when stimulated. This degranulation releases a
number of preformed proinflammatory products, including histamine, serotonin, eotaxin (IL-5),
and heparin, plus some others.
46
The degranulation of these cells
usually is dependent on prior fixation
of antibody (IgE) to the cell surface at
Fc receptors and subsequent binding
of antigen to these antibodies. This is
the primary mechanism of
degranulation in allergic responses.
However, there are other mechanisms
of mast cell degranulation including
binding of C5a and C3a.
The end result is increased vascular permeability, vasodilation, anticoagulation, tissue

destruction, and attraction of eosinophils. Basophils and mast cells are not end stage cells and
both are capable of continued division at the site of inflammation.
Mononuclear cells
 Lymphocytes
There are many types of lymphocytes but all appear similar morphologically. They are small
round cells with a round, hyperchromatic nucleus and scant, light blue staining cytoplasm. Under
the microscope, T and B cells look the same.
You learned all about T and B lymphocytes in detail last year in Immunology (life is
cumulative!).
When B cells start to produce antibodies, they turn into…..
47
Plasma cells have a unique appearance. They have more cytoplasm than a lymphocyte and this
is often basophilic, with a pale area or “halo” just next to the nucleus. This “halo” represents the
Golgi apparatus. Why such a big Golgi? ‘Cuz they are really busy making and exporting protein
(antibodies!). The nucleus is usually eccentrically placed and the chromatin often is clumped at
the periphery, creating a “clock-face”. Takes a little imagination to see the clock, in my opinion.
Seeing numerous plasma cells in an organ or a lymph node is an indication of chronic

antigenic stimulation.
Slide #1504, dog with chronic cystitis - the submucosa has many
lymphocytes and plasma cells. Can you identify them?
 Mononuclear phagocytes
The term macrophage means “big eater.” Macrophage is the term we use to describe a
monocyte that has emigrated from the blood to the tissue. In addition, macrophages are routinely
found in a number of organs, as fixed cells within the vasculature, sampling all the material that
floats by. Some of these fixed macrophage cells include: Kupffer cells in the liver, pulmonary
intravascular macrophages (PIMs) in the lung, sinusoidal lining cells in the spleen, and microglia
in the CNS.
Macrophages can do some dividing at the site of inflammation, so their numbers may increase by
both local replication as well as continual recruiting from the bloodstream. Compared to
neutrophils, macrophages are more long-lived, surviving at an inflammatory site for as long as a
month. They are also slower to arrive at the site of inflammation, usually taking about 48 hours
to get there.
48
They appear as large cells with bean shaped or oval nuclei with fine, diffusely scattered
chromatin. The cytoplasm stains a pale pinkish-blue and may contain vacuoles or particulate
debris.
The functions of macrophages are phagocytosis and destruction of foreign material and
presentation of antigen to lymphocytes. As with neutrophils, the presence of receptors for C3b
and Fc on their surface greatly enhances their phagocytic prowess. The process is nearly
identical to that described for the neutrophil. The appreciate the buttered toast.
In addition to their phagocytic function, activated macrophages produce and secrete a wide
variety of biologically active substances. Some of these include: cytokines, toxic oxygen
metabolites, proteases, nitric oxide, growth factors that promote fibrosis, and angiogenesis
factors. As such these cells are central figures in subacute and chronic inflammation.
When the inciting cause remains for a long

time, often macrophages will fuse, creating an
unusual cell, the multinucleated giant cell.
“Let’s join forces to fight the enemy.”
49
IMMUNE MEDIATED INFLAMMATION
There are 4 main types of immune-mediated disease, or hypersensitivity:
Type I – IMMEDIATE
 “allergic” or “anaphylactic” type
 Dependent on production of IgE (some individuals make more than they should) 
 On re-exposure, IgE binds mast cells and basophils, releasing vasoactive amines and
other mediators 
 Result is local inflammation, edema
 Examples of local Type I: hay fever, urticaria
 Systemic Type I: anaphylaxis
Type II – CYTOTOXIC
 Production of IgG or IgM, they attach to target cells 
 Then, one of three things happens, any of which kills the cell:
1. Complement attaches, punching a hole in the cell or facilitating phagocytosis
2. Killer cells attach to the antibody and kill the cell (ADCC)
3. Antibody kills the cell by binding to a key molecule
 Examples: immune-mediated anemia, myasthenia gravis
Type III – IMMUNE COMPLEX

 Requires persistent antigenemia, to which host makes lots of antibody 
 Many antigen-antibody complexes floating around 
 Some IgE gets produced, increased vascular permeability 
 Antigen-antibody complexes get lodged in the vessel wall, glomerulus 
 Complement is activated, pulls neutrophils in, they chew up vessel wall
 Examples: FIP, membranous glomerulonephritis
TYPE IV - DELAYED
 Is mediated by CELLS rather than antibodies
 Occurs 24-48 hours after antigen is presented
 Most cells in the reaction are mononuclear
 CD4 cells create (classical) delayed type hypersensitivity
 CD8 cells create cytoxicity-mediated hypersensitivity
 Examples include: tuberculin reaction, immune response to some viruses
           
50
IMMUNE MEDIATED INFLAMMATION
Introduction
Immune mediated inflammation is simply inflammation that is caused by the immune

response. All immune responses are directed by lymphocytes. Therefore, lymphocytes and their
products drive immune mediated inflammation.
The immune response is not supposed to damage body tissues. Those immune-mediated
reactions that DO damage normal tissues are called Hypersensitivity Reactions. There are four
basic types. In reality, many reactions are combinations of two or more types with one type
predominating.
Type I - Anaphylactic or allergic hypersensitivity
These reactions include allergic reactions,

anaphylaxis, and atopy. Type I reactions can be
localized allergy. Or generalized anaphylaxis,
which can kill you. The reaction is mediated by
production of IgE by plasma cells in response to
certain antigens. IgE binds to mast cell and
basophil Fc receptors. These cells are now
specifically sensitized to a given antigen, and
upon re-exposure to the antigen, IgE binds the
antigen causing immediate degranulation and
synthesis of inflammatory mediators by mast
cell.
Examples of Type I hypersensitivity:

hay fever, urticaria, atopy, anaphylaxis
Histamine, heparin and serotonin are preformed in mast cell granules. Therefore, they are
released immediately upon degranulation causing vasodilation and increased vascular
permeability. Uh oh, lots of edema.
First exposure to antigen causes plasma cells to produce IgE that binds to Fc receptors on mast
cells and basophils. You have to see it once in order to be RE-exposed, which is the time when
the hypersensitivity reaction kicks in.
51
Arachidonic acid metabolites are synthesized by mast cells de novo at the time of degranulation.
Vasoactive products include leukotrienes (LT) and prostaglandins (PG). LTB4 is chemotactic for
neutrophils, and LTD4 and LTC4 cause smooth muscle contraction (bronchospasm - in asthma).
Why do some individuals develop allergies and others don’t?

It’s simple. Those who are allergy-prone make more IgE than what is useful. Normal
individuals synthesize only small amounts of IgE when exposed to the antigens and higher
amounts of IgG and IgM.
Anaphylaxis
Systemic anaphylaxis occurs when antigen is systemically distributed in a highly sensitized
individual. It is a generalized reaction mediated by mast cell and basophil granule release.
Principal mediators include histamine and leukotrienes. The reaction is characterized by smooth
muscle contraction in lungs and gut, vasodilation, increased vascular permeability, hypotension,
vasomotor collapse, and pooling of blood in shock organs. Basically, death. Domestic animals
are less susceptible to anaphylactic shock compared to humans.
52
Special cases of type I reactions in veterinary medicine:
- Milk allergy in Jersey cattle - Due to missed milking, milk proteins (alpha casein) get into
circulation and act as antigens causing an allergic reaction. There is urticaria and sometimes
life threatening anaphylaxis.
- Allergies to vaccines and drugs are not uncommon. Dachshunds especially are susceptible
to developing urticaria after routine vaccinations.
- Inhaled allergens can cause atopic dermatitis in dogs.
- Chronic obstructive pulmonary disease (COPD, also known as heaves) happens in some
horses that inhale fungal allergens from dusty hay.
- Warble fly larvae in cattle - Hypoderma bovis pupae develop under skin after larvae migrate
from heel to back. If pupae rupture an anaphylactic response can occur.
- Fly bite allergy - Horses may also develop type I allergies to Culicoides and Simulium (black
fly) bites.
Type II - Cytotoxic Hypersensitivity

These reactions are also called cytotoxic or cytolytic because host cells are killed or undergo
lysis after reacting with antibody. This type of hypersensitivity depends on the abnormal
production of IgG or IgM directed against tissue antigens or a normal reaction to foreign
antigens expressed on host cells. There are 3 main mechanisms of injury in Type II reactions:
* Complement is activated and forms

MAC (membrane attack complex)
resulting in lysis of the target cell, or
antibody and complement opsonize
target cell so that neutrophils or
macrophages phagocytose target
cells and destroy them.
* ADCC (antibody-dependent cell
mediated cytotoxicity) - neutrophils,
macrophages, or lymphocytes (null
cells) bind to antibody and destroy
the target cell without phagocytosis,
through secretion of cytotoxic
compounds.
* Antibody binds to and inactivates or
down regulates a biologically active
molecule. An example is antibody
produced against acetylcholine
receptors in myasthenia gravis
resulting in subsequent muscular
weakness.
53
Examples of Type II hypersensitivity are neonatal isoerythrolysis,
transfusion reactions, and autoimmune hemolytic anemia.
Type III - Immune-complex hypersensitivity

The third type of immunologic injury is also called immune-complex mediated hypersensitivity.
At the center of the pathogenesis is an antigen that won’t go away or can’t be neutralized, so
there are beaucoup (too many) antigen-antibody complexes in the circulation. Immune complex
disease is seen in persistent infectious diseases and autoimmune disease can also cause this. In
both cases, antigenemia is persistent and the animal suffers from immune complex disease.
There is deposition of the antigen-antibody complexes at various sites in the body. Afterwards,
there is fixation of complement to the immune complexes, causing chemotaxis of neutrophils.
C5a and C3a cause more mast cell degranulation and increased vascular permeability.
Neutrophils try to phagocytose the immune complexes, but cannot because the complexes are
bound to matrix. They do, however, spill their enzymes into vascular walls and cause tissue
injury. Oops.
Rules of engagement for Type III:

1. Exposure to antigen causes plasma cells to produce IgG or IgM.
2. In conditions of persistent antigenemia and slight antigen excess, soluble antigen-antibody
complexes form.
54
3. Increased vascular permeability allows antigen-antibody complexes to deposit in vessels, or
form de novo in vascular basement membranes.
4. Deposition can be generalized (i.e. acute serum sickness) or localized (i.e.,
glomerulonephritis, Arthus reaction, which occurs in the joints).
5. Deposited complexes activate complement and complement components C5a and C3a cause
mast cell degranulation and C5a attracts neutrophils.
6. Complexes are bound to matrix or are too large to be phagocytosed by neutrophils, so they
release their contents, destroying normal tissues and often resulting in fibrinoid necrosis of
vascular walls.
7. Examples include hypersensitivity pneumonia and immune complex glomerulonephritis.
Organs with fenestrated endothelium are particularly susceptible. Examples include the
glomerulus, synovium, and uvea.
Examples of Type III hypersensitivity:

FIP, rheumatoid arthritis, membranous glomerulonephritis
When there are so many ag-

ab complexes circulating,
some get “stuck” in the
glomerulus. This disrupts
the membrane structure of
the glomerulus and makes it
leaky. Normally proteins
don’t pass through the
glomerulus into the urine but
when the membrane is all
disrupted, they can. So,
animals with membranous
glomerulonephritis often are
losing plenty of ample
protein into the urine. What
gets lost first? –
Antithrombin III!
Type IV - Cell-mediated (or delayed) Hypersensitivity
Also known as cell-mediated hypersensitivity (remember the other three are due to antibodies),
this form is a common response to many intracellular pathogens and to large or complex
infectious agents.
Type IV cell-mediated hypersensitivity is initiated by T lymphocytes specifically sensitized to

locally deposited antigen. The two effector mechanisms, (1) delayed-type and (2) direct
55
cytotoxicity, are mediated by 2 different sub-populations of T cells. CD4 cells mediate delayed-
type reactions and CD8 cells cause direct cytotoxicity.
Delayed-type reaction – CD4 cells

1. T lymphocytes bind specific antigen in
conjunction with MHC II on antigen presenting
cells.
2. T cells - release chemokines to attract
macrophages and more lymphocytes to the area.
3. Activated macrophages can cause destruction of
normal adjacent tissues by release of nasty
enzymes and oxygen radicals (delayed type
hypersensitivity).
Delayed-type hypersensitivity reactions are initiated

by actively sensitized Tcells, but only about 10% of
the mononuclear cell infiltrate in a delayed-
hypersensitivity reaction are specifically sensitized
T cells. The other 90% are non-sensitized
lymphocytes and macrophages attracted by
chemokines from sensitized T cells to amplify the
reaction.
T Cell mediated cytotoxicity – CD8 cells

If antigen is bound to a target cell in conjunction with MHC I molecules, T cells (cytotoxic T
cells) may bind to this antigen and release perforins and granzymes to directly kill the target cell
(direct cytotoxicity). Direct cytotoxicity may also occur by binding between T cell and target
cell.
Both delayed-type hypersensitivity (CD4-mediated) and direct T cell-mediated (CD8-mediated)

cytotoxicity are necessary immunologic reactions, but can cause extensive tissue damage in
some instances.
Examples - Dermal reaction to poison ivy (cytotoxic, type IV),

positive tuberculin skin test (DTH, type IV).
56
57
Chronic Inflammation
Definition:
Host response to an inciting stimulus that goes on for weeks or months
Characteristics:
Not usually red or hot (unlike acute inflammation)
Do not “ooze”
Productive or proliferative
Often present in infections with higher order organisms (mycobacteria, fungi, metazoan
parasites) and in many autoimmune diseases
Histologic appearance:
Primarily mononuclear cells involved
Fibroblasts and new blood vessels, together called “granulation tissue”
Granulomatous inflammation
Is always chronic
Is composed predominantly of macrophages
May have multinucleate giant cells – macrophages fuse
           
58
Chronic Inflammation
Chronic inflammation, like its acute cousin, is a host response to an inciting stimulus. There are,
however, some distinct differences. First and foremost is the time factor. Chronic inflammation
is considered to be inflammation of prolonged duration - weeks to months. Second, rather than
being just exudative, chronic inflammation usually is productive or proliferative. Chronic
inflammation is rarely gooey. Cells in the chronic inflammatory process tend to produce
substances that add new tissue, such as collagen and new blood vessels. Many of these changes
also represent the repair process, and there is a blurry continuum between chronic inflammation
and the whole repair process. In general, chronic inflammation is characterized by inflammation,
tissue destruction, and attempts at repair all happening at once.
Grossly, chronic inflammation does not have as much rubor (redness) or calor (heat) as in the
acute reaction. Also, exudates aren’t so grossly apparent as they are in acute inflammation.
Because of the fibroplasia and neovascularization, areas affected by chronic inflammation tend
to be slightly swollen and firm. If fibrosis is extensive the lesions can be large and disfiguring.
Fibrosis (end result of granulation tissue) is the best indicator that the inflammatory response is
chronic.
59
Chronic inflammation tends to occur under the following conditions:
Infections by organisms which are more resistant to killing and clearing by the body tend to
cause chronic inflammation. Such persistent organisms include some of the higher
bacteria (including mycobacteria), fungi, and quite a few metazoan parasites.
Repeated bouts of acute inflammation can result in a chronic reaction.
Prolonged exposure to toxins can cause chronic inflammation.
Chronic inflammation is a common component in many of the autoimmune diseases. Because
the reaction is against a host epitope, which is always present, the inflammation is by
definition chronic and persistent.
Chronic inflammation doesn’t usually ooze, rather, its exudates tend to be kind of solid and
white or grayish, and it looks the same no matter what the cell types; the only way to add an
exudative moniker is to see the histology. Here are the cell types:
1. The simplest type of chronic inflammation has mostly lymphocytes with lesser numbers of
macrophages. This will occur mostly in viral infections where the virus survives longer than
the acute phase. This is called “lymphocytic” or “lymphohistiocytic”.
2. Chronic active inflammation is the same, but in this one there are still some neutrophils
present, so there are acute things going on inside of the chronicity. This happens in many
bacterial infections that are not due to very pus-producing bacteria.
3. Next is granulomatous - here the cell types are almost all macrophages. Good examples
here are fungal infections or mycobacteria.
4. Some people use a term pyogranulomatous - which means granulomatous but within the
macrophages are pockets of neutrophils. The most common disease causing this is FIP.
5. Granulomas occur when the inciting cause stimulates macrophages but the agents are
contained within an organized, focal aggregation of macrophages. Think TB. Think
Blastomyces. Think foreign body.
But with all of these types, there is evidence of fibroblasts moving in and some new blood
vessels.
If plasma cells are present in the inflammation, you know two

things. First, it is a chronic problem, because it takes a good 2-4
weeks to generate plasma cells. Second, there must be some
persistent antigen in there, because plasma cells indicate the
body needs plenty of antibody at the site.
60
Granulomatous inflammation
There is one specific subset of chronic inflammation that deserves special attention, and that is
granulomatous inflammation. Histologically, it is very characteristic and is described below.
Granulomatous inflammation is any inflammatory response consisting predominantly of

macrophages.
Macrophages often differentiate into cells called epithelioid macrophages, and these cells are
found within granulomatous infiltrates. Their cytoplasm is abundant and finely granular, with
indistinct cell boundaries, so that they resemble epithelial cells more than macrophages (hence
the name - epitheliOID). Ultrastructurally, these cells contain abundant rough endoplasmic
reticulum and a prominent Golgi apparatus but are poor at phagocytosis. Consequently, their
role is believed to be biosynthesis and protein secretion.
61
A granuloma is a focally discrete chronic inflammatory reaction comprised
predominantly of epithelioid macrophages that are organized or aggregated in closely
packed collections. There is often a central core of caseous debris at the center of the
granuloma surrounded by macrophages that in turn are encircled by a ring of
lymphocytes and organizing fibroblasts.
Other cell types unique to granulomatous inflammation include the multinucleate giant cells,
sometimes called Langhans cells. These are cells formed by the fusion of macrophages and they
can look pretty spectacular under the microscope. But they are poorly phagocytic. Seeing giant
cells means – hey, our regular old standard issue macrophages couldn’t take care of this problem,
so we had to join forces. Very often it is a big old problem, too large to phagocytose, like a
foreign body, or a fungus.
Slide #1564, dog kidney. This dog was infected with Aspergillus, a
fungus that the acute response just couldn’t take care of and it progressed to
granulomatous inflammation. Can you identify some granulomas and also some
Langhans giant cells?
62
Healing and Repair
Repair by regeneration
This is when an organ can make new cells, like the liver!
Repair by replacement
This is when an organ can’t make new cells and the repair is through fibrous tissue (scar),
like the heart.
Wound healing (all soft tissues):

First intention:
Edges have to be close; within 24h, there are neutrophils and exudates; within 2-3
days, fibroblasts are in there making collagen; by 7 days, plenty of collagen;
epithelium grows together again; contraction via myofibroblats. Minimal scar.
Second intention:
Edges are further apart; much more fibrous tissue; big scar can result
Mediators in soft tissue healing:
All of the following promote fibrosis: PDGF; TGFβ; FGF; EGF; IGF; IL-1; TNF
Inhibits healing: IFNγ
Special considerations in repair:

Bone has a system all its own.
Nervous tissue cannot regenerate - take care of your neurons!
Heart myofiber regeneration just don’t happen. You only get a scar.
           
63
Healing and Repair
Inflammation and repair should be viewed as two parts of a single vital function, the physiologic
response to tissue injury, the objective of which is restoration of normal structure and function.
Up until now we have focused on the inflammation portion, but it is good to remember that
repair starts pretty soon after inflammation does and then continues during and beyond the
inflammatory phase.
Perfect restoration of function is dependent upon the regeneration of lost cells by similar cells
(repair by regeneration), and the orderly arrangement of these new cells in relation to
preexisting cells so that tissue functions are restored.
If the original cells cannot be replaced by their own kind then they are replaced by other cell
types (repair by replacement), usually by fibrous connective tissue. If necrosis is extensive,
even tissues that are capable of regeneration are replaced by fibrous connective tissue.
There are three cell types based on ability to regenerate:

permanent cells ( almost never divide) -
nerve cell bodies, cardiac myocytes, cells of the lens
stable cells (will divide if stimulated) -
fibroblasts, osteoblasts, parenchyma of liver, kidney, pancreas and
endocrine glands, smooth muscle, vascular endothelium
labile cells (multiply through life) -
epithelial cells of surfaces or linings of ducts and hollow viscera,
lymphoid and hematopoietic cells
64
Wound healing is typically divided into two types: first intention (primary union) and second
intention (secondary union). It should be remembered, however, that all wounds heal in roughly
the same way; new cells are formed from preexisting cells where possible, and these then fill in
the area of tissue loss. All wounds contain a certain amount of connective tissue replacement
depending on the degree of injury and stromal damage and the tissue’s ability to regenerate itself.
First intention healing occurs in wounds that are closely approximated and not infected. Ideally,
most surgical wounds would fit into this category. To illustrate the normal sequence of repair,
let’s use the classic example of a sterile surgical incision.
First, the incision causes hemorrhage and death of a limited number of epithelial cells
and dermal elements. Once the incision is closed, the narrow space is filled with a
fibrin clot that temporarily seals the defect. Fibrin is derived from fibrinogen, a plasma protein,
and has no tensile strength.
A typical acute inflammatory response ensues. Within 24 hours, neutrophils and

lesser numbers of lymphocytes and macrophages are present along with fluid exudate
in the margins of the incision. Edema and exudate can accumulate so it’s a good thing you left
those sutures just a little loose! The dead cells and all other debris resulting from the injury are
removed by the phagocytic cells of the inflammatory response.
As the defect is colonized by the various proliferating cells, the inflammatory exudate and fibrin
are progressively digested and removed by neutrophils and macrophages.
Fibroblasts from the margin of the wound begin proliferation and migration using the fibrin
strands as a foundation. At the same time, endothelial cells from injured capillaries and
lymphatics proliferate into the clot as solid cords of cells that eventually form a lumen.
Epithelial cells of the epidermis begin proliferation at the edge of the wound.
65
In 2-3 days, fibroblasts have bridged the wound and the endothelial cords have
canalized (formed a lumen) and anastomosed to permit the flow of blood from one
margin of the wound to the other. Also epithelial cells grow across the incision in a single layer
to meet in 2-3 days.
The highly vascular connective tissue, with a small component of acute inflammatory exudate
that now populates the wound, is known as granulation tissue. This is minimal in first intention
healing. Fibroblasts begin deposition of collagen. Although collagen production begins early,
deposition of significant amounts (as related to wound strength) begins at 4-5 days. Considerable
collagenous support is present within 7-8 days.
By two weeks the wound has gained almost as much tensile strength as the normal tissue.
Continued production of collagen, and its shrinkage, leads to compression of capillaries, and in
the course of weeks and months leads to the production of an avascular, collagenous
connective tissue scar. Scarring will be minimal in first intention healing.
Thin layers of elastic fibers are formed, thus making the wound capable of some stretching.
Adnexal elements are usually not regenerated. That means no new hair or sweat or sebaceous
glands. Nerves grow slowly into the new connective tissue and are mainly vasomotor.
Granulation tissue (= vascular fibrous connective tissue)
The term “granulation tissue” is derived from its pink soft granular appearance on the surface of
wounds. It looks all pink and pebbly because fibroblasts and capillaries are busy doing their
thing. Granulation tissue is recognized histologically by the presence of newly formed fibrous
tissue and numerous small blood vessels.
66
The new capillaries most commonly run in a
perpendicular direction to the outer surface of the
wound since their function is to carry supplies to
the free surface, while fibroblasts tend to grow in
from the side of the defect to bridge the gap. This
often produces a histological picture of capillaries
running at right angles to the direction of the
fibroblasts. The formation of new capillaries is
termed angiogenesis or neovascularization.
It is important to distinguish the term granulation from granulomatous

inflammation. Although they sound similar, they are really quite different. As
different as fibrinous is from fibrous (know that distinction too). Both of these
sound-alikes are frequent traps that students fall into. Sorry about that.
Remember, granulation tissue is part of the repair process and consists of proliferating fibrous
tissue, and granulomatous refers to inflammatory infiltrates characterized by macrophages.
And sometimes granulation tissue doesn’t know when to quit growing and start turning into the
permanent scar it is supposed to form. Think “exuberant granulation tissue” in horses, also
known as “proud flesh.” Healing process that got stuck and can’t move on.
67
Second intention healing is the term used to designate what happens when there is a wide gap to
bridge and also what happens when there is impairment of healing following infection or the
accumulation of fluids that require surgical drainage. The healing process is similar to first
intention healing, but differs in the following respects:
 greater tissue defect, thus a larger area for granulation tissue to fill
 larger amounts of dead cells, tissue debris, exudate, or foreign material are all in the way
 inflammation is prolonged and healing is therefore slower
 residual fibrosis (scarring) is more prominent, impairing return to function
If the process continues too long, granulation tissue will accumulate in excessive amounts and
bulge above the surface, causing severe disfigurement of the structure. This excessive
granulation tissue is termed “proud flesh” or “exuberant granulation.” Exuberant granulation
tissue is a common complication to flesh wounds in the horse. To obtain healing, this excessive
growth has to be removed by excision or cautery.
68
All this healing takes energy and if an animal is in a compromised state, the repair will take a
whole lot longer.
Mediators
Recently our understanding of all of the mediators involved in tissue repair has expanded.
69
Below is a list of some of these factors that are responsible for growth and healing. YOU ARE
NOT RESPONSIBLE FOR KNOWING THE DETAILS OF ANY OF THESE. JUST
BE AWARE THAT IT IS ALL ORCHESTRATED BY THESE MEDIATORS THAT
COME FROM A VARIETY OF CELLS.
Mediator Source Function

platelet derived growth platelets  chemotactic for fibroblasts,
factor macrophages macrophages, smooth muscle
(PDGF) endothelium  mitogenic for fibroblasts
transforming growth factor platelets  chemotactic for fibroblasts, leukocytes
beta (TGFβ) T cells  stimulates proliferation of fibroblasts,
macrophages extracellular matrix
fibroblast growth factors many cell types  stimulates angiogenesis
(FGF)  mitogenic for endothelium, smooth
muscle, fibroblasts
epidermal growth factor platelets  induces proliferation of epithelium,
(EGF) macrophages endothelium, fibroblasts
 increases production of
glycosaminoglycans
insulin-like growth factors fibroblasts  mitogenic for fibroblasts
(IGF) hepatocytes
interleukin-1 macrophages  chemotactic for leukocytes
(IL-1) endothelium  stimulates proliferation of
keratinocytes, fibroblasts, endothelium
tumor necrosis factor alpha macrophages  mitogenic for fibroblasts
(TNFα)  angiogenic
interferon gamma lymphocytes  inhibits fibroblast proliferation
(IFNγ)  inhibits collagen synthesis
70
Repair of bone
Repair of bone is a specialized category of healing and repair and deserves individual
attention. Immediately following fracture of bone, blood flows out of the broken vessels
into the gap between the broken ends of bone and displaced or disrupted periosteum, and
into the surrounding soft tissue. A big callus forms with fibrovascular tissue. The
osteoprogenitor cells eventually invade into this callus and slowly new bone is formed
and then remodeled. Don’t worry about knowing this now, there will be more detail at
the appropriate moment (Systemic Pathology I in the spring).
Repair of Nervous Tissue
Repair in the central nervous system (CNS) is very limited because mature neurons do
not divide. When damage occurs in the CNS, neurons and their processes are lost forever;
they cannot be regenerated. Take care of your neurons! In the peripheral nervous system
(PNS), injury to the nerves may be followed by regeneration if the nerve cell body
remains alive. This type of regeneration is more common in the PNS than in the CNS
where injury to axons is more likely to result in death of the neuron cell body rather than
regeneration.
Repair of the Myocardium
Myocardial cells have very poor regenerative capacity. When they die, as in a heart
attack, they are usually gone forever and repair can only take place by fibrosis. This
replacement by fibrosis decreases myocardial contractility. Oops.
71

Inflammation and Repair

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Inflammation and Repair

Uploaded by

Copyright:

Available Formats

INFLAMMATION AND REPAIR

Objectives - We expect you to:

1. Recognize and describe lesions of inflammation

DEFINITION AND CARDINAL FEATURES

Some general characteristics of inflammation are as follows:

1. The inflammatory process is redundant and complex. This makes it a challenging

The four principal effects of inflammation (rubor, tumor,

Beneficial effects of inflammation Harmful effects of inflammation

Systemic Effects of Inflammation

COMPONENTS OF A MORPHOLOGIC DIAGNOSIS FOR INFLAMMATION:

A morphologic diagnosis is the way we describe and communicate about lesions. A

KNOW THIS TABLE:

S SEVERITY How bad is it? Mild or moderate or marked/severe?

T TIME COURSE Is it peracute, acute, subacute or chronic?

D DISTRIBUTION Is it focal, multifocal, locally extensive, or diffuse?

E What is the character of the inflammatory material –

So, every inflammatory lesion could consist of FIVE WORDS.

2. Time course designation for inflammation

Peracute  Acute  Subacute  Chronic

What does catarrhal exudate

Purulent exudate is PUS. Pus is an accumulation of dead neutrophils. Neutrophils have

Oops – hard to treat!

Guinea pig abscess (left) and

What is the outcome of hemorrhagic inflammation? Often guarded.

5. Designation of organ or location

COMMONLY USED ANATOMIC PREFIXES FOR INFLAMMATION (-itis)

Arter ............................................... artery Mening ..................................... meninges

Inflammation has VASCULAR and CELLULAR events:

1. changes in vessel caliber and, consequently, blood flow (hemodynamics)

1. Changes in Vessel Caliber

2. Increased vascular permeability

There are two mechanisms –

Although vascular leakage in inflammation is continuous, it can be divided by mechanism into 3

The increased vascular permeability means that larger

Leukocyte- Endothelial Interactions

3. Formation of the Cellular Exudate

The normally inactive endothelium has to be activated to allow adhesion of neutrophils.

Well, this is great – WBCs are on the endothelium, now

Important neutrophil chemotactic factors

Important eosinophil chemotactic factors

Important monocyte chemotactic factors

Microbicidal Activity of Leukocytes

Leukocytes’ adhesion to micro-organisms

Leukocytes and phagocytosis

The Complement System

What is Complement for? What does Complement do?

1. Classical Pathway Activation

3. Alternative Pathway Activation

The Big MAC

Other Functions of Complement: What else does it do?- A number of well-defined

The Kinin System

Kallikrein, which gets activated by Hageman factor, works

LIPID MEDIATORS - all come from cell membranes

CHEMOKINES = chemotactic cytokines, all are small

YOU KNOW THESE ALREADY – WE COVERED THEM IN THE DISTURBANCES

Histamine is the primary mediator of

Serotonin is another vasoactive amine. It is

2. Lipid mediators - all come from the cell membranes

Arachidonic acid metabolites

Arachidonic acid is acted upon by one of

1. Cyclooxygenases (COX1 and COX2)

2. 5-lipoxygenase produces leukotrienes,

What are prostaglandins?