CHAPTER 2: CELLULAR RESPONSES TO STRESS AND TOXIC
INSULTS: ADAPTATION, INJURY, AND DEATH
INTRODUCTION TO PATHOLOGY
 Pathology – devoted to the study of the structural, biochemical, and functional
changes in cells, tissues, and organs that underlie disease
o Explain whys and whereof of the signs and symptoms manifested by
patients; provide rational basis for clinical care and therapy
o Serves as the bridge between the basic sciences and clinical medicine
o Scientific foundation for all of medicine
 General pathology – concerned with the common reactions of cells and tissues to
injurious stimuli
OVERVIEW: CELLULAR RESPONSE TO STRESS AND NOXIOUS STIMULI
o Such reactions are not tissue specific (thus acute inflammation is response
to bacterial infections produces same reactions in most tissues)
 Systemic pathology – examines the alterations and underlying mechanisms in
organ specific diseases such as ischemic heart disease
 Four aspects of disease process that form the core of pathology:
Etiology or Cause
 Cause of the disease
 Can be grouped into two classes:
 Genetic – inherited mutations, disease-associated gene variants, polymorphisms
 Acquired – infectious, nutritional, chemical, physical
 The idea that one etiologic agent is the cause of a disease is from the study of
infections and inherited disorders caused by single genes
o Idea is not applicable to majority of diseases (e.g., atherosclerosis and
cancer  multifactorial and cause by various external triggers)
Pathogenesis
 biochemical and molecular mechanisms of its development
 Refers to the sequence of cellular, biochemical, and molecular events that
follow the exposure of cells or tissues to an injurious agent
o How mutations induced disease
 Even when initial cause is known, it is many steps removed from expression of disease
o Example: to understand cystic fibrosis it is essential to know the defective
gene product and the biochemical and morphological events leading to
formation of cysts and fibrosis in lungs, pancreas, etc.
Morphologic Changes
 structural alterations induced in the cells and organs of the body
 Refer to the structural alterations in cells or tissues that are either
characteristic of a disease or diagnostic of an etiologic process
 Morphology – determine the nature of the disease and to follow its progression;
diagnostic cornerstone
 Limitations: morphologically identical lesions may arise by distinct molecular
mechanisms
o E.g., tumors  breast cancers that are indistinguishable morphologically
may have widely different courses, therapeutic responses, and prognosis
 Molecular analysis (e.g., next generation sequencing) – reveal genetic differences
that predict the behaviour of tumor and responses
Functional Derangements and Clinical Manifestations
 functional consequences of these changes
 Functional abnormalities – the end results of genetic, biochemical, and structural
changes in cells and tissues are functional abnormalities
o Lead to clinical manifestations (symptoms and signs) of disease, as well
as its progress (clinical course and outcome)
 Clinicopathologic correlations are very important in the study of the disease
 All forms of disease start with molecular or structural alterations in cells
 Rudolph Virchow – father of modern pathology; developed the concept of cellular
basis of disease
 Cell and ECM injury leads to tissue and organ injury which determines the
morphologic and clinical patterns of disease
 Normal cell is confined to narrow range of function and structure by its state of
metabolism, differentiation, and specialization; by constraints of neighboring cells; and
by the availability of metabolic substrates
o Homeostasis – steady state
 Adaptations – reversible functional and structural responses to changes in
physiologic states (e.g., pregnancy) and some pathologic stimuli (new and altered
steady states are achieved to allow the cell survival and functioning)
 Adaptive response may consist of:
o Hypertrophy – increase in size and function
o Hyperplasia – increase in number of cells
o Atrophy – decrease in size and metabolic activity
o Metaplasia – change in the phenotype of cells
 When the stress is eliminated, the cell can recover to its original state without
consequences
If the limits of adaptive responses are exceeded or if cells are exposed to
injurious agents or stress, deprived of essential nutrients, or become
compromised by mutations that affect essential cellular constituents, a
sequence of events follows that is termed cell injury.
 Cell injury is reversible upto certain point  but if the stimulus persists or is severe
enough from the beginning  may lead to irreversible injury and ultimately cell
death
 Stages of progressive impairment following different types of insults:
o Adaptation
o Reversible injury
o Cell death
 Example: ↑ hemodynamics  enlargement of heart muscle (adaptation)  may then
become injured (if blood supply to myocardium is not enough, heart muscle suffers
reversible injury and eventually irreversible injury and cell death)
 Cell death – the end result of progressive cell injury; one of the most crucial events
in the evolution of disease in any tissue or organ
o Results from diverse causes (ischemia, infection, toxins)
 Cell death is also a normal and essential process in embryogenesis, the development
of organs, and the maintenance of homeostasis
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  Two principal pathways of cell death:  Striated cells (heart and skeletal muscles) have limited capacity for division 
o Necrosis respond to increased metabolic demands mainly by undergoing hypertrophy
o Apoptosis o Stimulus for hypertrophy in heart is usually chronic hemodynamic overload
 Autophagy – adaptive cellular response triggered by nutrient deprivation; may also (may result from hypertension or faulty valves)
culminate in death o Cells synthesize more proteins and number of myofilaments increases 
 Metabolic derangements in cells and sublethal, chronic injury may be associated with increase strength and work capacity
intracellular accumulations of a number of substances, including proteins, lipids, and  Most common stimulus for hypertrophy of muscle is increased workload (e.g., body
carbohydrates builders)
 Calcium – often deposited at sites of cell death, resulting in pathologic calcification  Pregnancy  massive physiologic growth of uterus
 Aging is also accompanied by characteristic morphologic and functional changes in o Hormone-induced enlargement of organ mainly from hypertrophy of muscle
cells o Uterine hypertrophy is stimulated by estrogenic hormones acting on smooth
 Three other processes that affect cells and tissues: muscle  ↑ synthesis of smooth muscle proteins and an increase in cell size
o Intracellular accumulations
o Pathologic calcifications Mechanisms of Hypertrophy
o Cell aging
 Hypertrophy is the result of increased production of cellular proteins
 Hypertrophy of the heart may become mal-adaptive and can lead to heart failure,
arrhythmias, and sudden death.

Three basic steps in the molecular pathogenesis of cardiac hypertrophy:

 The actions of mechanical sensors (triggered by ↑ workload), growth factors
(TGF-B. IGF-1, FGF) and vasoactive agents (a-adrenergic agonist, endothelin
1, ANG II). Mechanical sensors induce production of growth factors and agonist.
 Signals from cell membrane activate a complex of signal transduction
pathways. Two biochemical pathways are involved in muscle hypertrophy
o PI3K/AKT pathway – most important in physiologic hypertrophy
o Signaling downstream of GPCRs – induced by many growth factors
and vasoactive agents; though to be more important in pathologic
hypertrophy
 Signalling pathways activate transcription factors such as GATA4, NFAT, and
MEF2. These transcription factors work co-ordinately to increase the synthesis of
muscle proteins that are responsible for hypertrophy

ADAPTATIONS OF CELLULAR GROWTH AND DIFFERENTIATION

 Hypertrophy is also asso. w/ a switch of contractile proteins from adult to fetal
 Adaptations – reversible changes in the size, number, phenotype metabolic neonatal forms
activity, or functions of cells in response to changes in their environment
o During muscle hypertrophy, the alpha isoform of heavy chain is replaced by
the beta isoform  has slower, more energetically economical contraction
HYPERTROPHY
 Some genes expressed only during early development are reexpressed in hypertrophic
cells, and the products participate in the cellular response to stress
 Hypertrophy refers to an increase in the size of the cells, that results in an
o E.g.,gene for ANF is expressed in both the atrium and the ventricle in the
increase in the size of the affected organ
embryonic heart. Cardiac hypertrophy is associated with ↑ ANF gene
o Organ has no new cells, only larger cells
o ANF – peptide hormone that causes salt secretion by the kidney, decreases
 Due to synthesis and assembly of additional intracellular structural components
blood volume and pressure  serves to reduce hemodynamic load
 Cells capable of division may respond to stress by undergoing both hyperplasia and
 Cardiac hypertrophy reaches a limit  enlargement is unable to cope with
hypertrophy
enlargement  regressive changes (lysis and loss of myofribrillar contractile
o Non dividing (e.g., myocardial fibers) increased tissue mass is due to
elements)  myocyte death  net result: cardiac failure (if stress is not relieved)
hypertrophy
o To prevent such consequences, several drugs that inhibit key signaling
o Hypertrophy and hyperplasia may coexist and contribute to increase size
pathways involving NFAT, GATA4, and MEF2 genes are in clinical trials
 Hypertrophy can be physiologic or pathologic
o Physiologic – caused by increased functional demand or by stimulation by
hormones and growth factors

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HYPERPLASIA
 Hyperplasia is defined as an increase in the number of cells in an organ or
tissue in response to a stimulus
 Hyperplasia can only take place if the tissue contains cells capable of
dividing  increase number of cells; can be physiologic or pathologic
Physiologic Hyperplasia
 Physiologic hyperplasia due to the action of hormones or growth factors occurs in
several circumstances:
o When there is a need to increase functional capacity of hormone
sensitive organs
o When there is need for compensatory increase after damage or
resection
 Hormonal hyperplasia – eg, proliferation of glandular epithelium of female breast
and enlargement (hypertrophy) of glandular epithelial cells
 Compensatory hyperplasia – eg, liver regeneration (proliferation to its normal size)
 Marrow undergo rapid hyperplasia in response to a deficiency of terminally
differentiated blood cells
o Example: acute bleed or hemolysis  EPO are activated to stimulate RBC
progenitors  ↑ RBC production upto 8x
Pathologic Hyperplasia
 Most forms of pathologic hyperplasia are caused by excessive or
inappropriate actions of hormones or growth factors acting on target cells
 Endometrial hyperplasia – example of abnormal hormone-induced hyperplasia
o Disturbed balance between estrogen and progesterone  ↑ estrogen 
hyperplasia of endometrial glands
o Common cause of abnormal menstrual bleeding
 Benign prostatic hyperplasia – pathologic hyperplasia induced by androgens
 These pathologic hyperplasia remains controlled; hyperplasia regresses if hormonal
stimulation is eliminated
 Pathologic hyperplasia constitutes a fertile soil for cancer
 Hyperplasia is a characteristic response to certain viral infections
o HPV – may cause skin warts & several mucosal lesions composed of
masses of hyperplastic epithelium
Mechanisms of Hyperplasia
 Hyperplasia is the result of growth factor-driven proliferation of mature
cells and, in some cases, by increased output of new cells from tissue stem
cells
 Example: after partial hepatectomy growth factors are produced in the liver that
engage receptors on surviving cells and activate cell proliferation
o If proliferative capacity of liver is compromised (e.g., hepatitis) hepatocytes
can instead regenerate from intrahepatic stem cells
ATROPHY
 Atrophy is defined as a reduction in the size of an organ or tissue due to a
decrease in cell size and number; physiologic or pathologic
Physiologic Atrophy
 Common during normal development
 Example: notochord and thryoglossal duct  atrophy during fetal development
 Uterus  decrease in size after parturition
Pathologic Atrophy
 Has several causes and can be: local or generalized
Common Causes of Atrophy
Decreased - Atrophy of disuse
workload - Example: immobilized fractured bone in a cast or complete bed rest
- Initial decrease in cell size is reversible once activity is resumed
- Prolonged disuse  skeletal muscle fibers ↓ in size
- Muscle atrophy can be accompanied by ↑ bone resorption  lead to
osteoporosis of disuse
Loss of - Denervation atrophy
inervation - Normal metabolism and function is dependent on nerve supply
- Damage to nerves  atrophy of the muscle fibers supplied
Diminished - Ischemia (↓ blood supply; e.g., occlusion)
blood supply - Brain may go progressive atrophy in late adult life  due to ↓ blood
supply from atherosclerosis  senile atrophy (also affect heart)
Inadequate - Marasmus (profound protein calorie malnutrition) – asso. w/
nutrition utilization of skeletal muscle proteins as a source of energy (other
reserves like adipose tissue has already been depleted)  results in
cachexia (marked muscle wasting)
- Cachexia – also seen in patients w/ chronic inflammatory disease
(CID) and cancer
- In CID, TNF is overproduced and is responsible for appetite
suppression and lipid depletion  ends in muscle atrophy
Loss of - Hormone responsive tissue (e.g., breast and reproductive
endocrine organs) are dependent on endocrine stimulation for normal function
stimulation - Loss of estrogen stimulation after menopause results in physiologic
atrophy of endometrium, vaginal epithelium, and breast
Pressure - Tissue compression can cause atrophy
- Enlarging benign tumor  atrophy in surrounding uninvolved tissue
- This atrophy is due to ischemic changes caused by compromise of
the blood supply by the pressure exerted by the expanding mass
 Fundamental cellular changes asso. w/ atrophy are identical in all of these settings
o Initial response  decrease in cell size and organelles, which ↓ the
metabolic needs of the cell for its survival
 In atropic muscle, cells contain fewer mitochondria and myofilaments and a reduced
amount of RER
o New equilibrium is achieved  balance of metabolic demands, low levels of
blood supply, nutrition or trophic stimulation
 Atrophy caused by gradually reduced blood supply  progress to irreversible injury
and death of cells (apoptosis)
o cell death by apoptosis contributes to the atrophy of endocrine organs after
hormonal withdrawal
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Mechanism of Atrophy
 Atrophy results from decreased protein synthesis and increased protein
degradation in cells
o Protein synthesis decreases because of reduced metabolic activity
 The degradation of cellular proteins occurs mainly by the ubiquitin-
proteasome pathway
o Nutrient deficiency and disuse  activate ubiquitin ligase  attach ubiquitin
to cellular proteins  target proteins for degradation in proteasome
o This pathway is responsible for the accelerated proteolysis in catabolic
conditions (e.g., cancer cachexia)
 Atrophy is also accompany by autophagy, marked by appearance of ↑ #s of
autophagic vacuoles
o Autophagy (“self-eating”) – process where starved cells eat its own
components to reduced nutrient demand to match the supply
o Some cell debris resist digestion and seen in cytoplasm as membrane-bound
residual bodies (e.g., lipofuscin granules  brown atrophy)
METAPLASIA
 Metaplasia is reversible change in which one differentiated cell type
(epithelial or mesenchymal) is replaced by another cell type
 Often represents as an adaptive response  “one cell type that is sensitive to a
particular stress is replaced by another cell type that is better able to withstand the
adverse environment”
 Most common epithelial metaplasia is columnar to squamous (occurs in respiratory
tract in response to chronic irritation)
o Habitual cigar smoker’s trachea and bronci: ciliated columnar is replaced by
stratified squamous cells
o Secretory columnar epithelium (salivary gland, pancreas, bile duct) is
replaced by stratified squamous epithelium (squamous metaplasia)
o Vitamin A deficiency induces squamous metaplasia in the respiratory
epithelium
 Stratified squamous is able to survive under circumstances than columnar cells
o However, important mechanisms of protection against infection are lost
(e.g., mucus secretion and ciliary action)
 Epithelial metaplasia is “double-edged sword”
 The influences that predispose to metaplasia, if persistent, can initiate malignant
transformation in metaplastic epithelium (common cause of cancer in respiratory tract
is compose of squamous cells)
 Metaplasia from squamous to columnar type also occur in Barrett esophagus 
squamous is replaced by columnar cells under the influence of refluxed gastric acid
o Cancer may arise in this areas and are typically glandular
 Connective tissue metaplasia – formation of cartilage, bone, or adipose tissue
(mesenchymal tissues) in tissues that do not contain these elements
o Example: myositis ossificans – bone formation in muscle; occur after
intramuscular hemorrhage; seen as adaptive response from cell or tissue
injury
Mechanisms of Metaplasia
 Metaplasia does not result from a change in the phenotype of an already
differentiated cell type; instead it is the result of a reprogramming of stem
cells that are known to exist in normal tissues, or of undifferentiated
mesenchymal xells present in connective tissue
o Precursor cells differentiate in a new pathway or lineage by signals from
cytokines, growth factors, and ECM components in the cell’s environment
 Direct link between transcription factor dysregulation and metaplasia is seen with
vitamin A (retinoic acid) deficiency or excess (both may cause metaplasia)
o Retinoic acid regulates gene transcription directly through nuclear retinoid
receptors  influence differentiation of progenitors derived from tissue
stem cells
KEY CONCEPTS: Cellular Adaptation to Stress
Hypertrophy - Increased cell and organ size in response to increased workload
- Induced by growth factors produced in response to mechanical
stress or other stimuli
- Occurs in tissues incapable of cell division
Hyperplasia - Increased cell numbers in response to hormones ad ther growth
factors
- Occurs in tissues whose cells are able to divide or contain
abundant tissue stem cells
Atrophy - Decreased cell and organ size as a result of decreased nutrient
supply or disuse
- Asso. w/ decreased synthesis of cellular building blocks and
increased breakdown of cellular organelles
Metaplasia - Change in phenotype of differentiated cells, often in response to
chronic irritation, that makes cells better able to withstand the
stress
- Usually induced by altered differentiation pathway of tissue stem
cells
- May result in reduced functions or increased propensity for
malignant transformation
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OVERVIEW OF CELL INJURY AND DEATH
 Cell injury results when cells are severely stressed and no longer able to adapt or
when cells are exposed to inherently damaging agents or from intrinsic abnormalities
 Injury may progress through a reversible stage and culminate in cell death
Reversible Cell Injury
 Changes are reversible in early or mild forms if damaging stimulus are removed
 Hallmarks of reversible injury:
o Reduced oxidative phosphorylation with resultant depletion of energy stored
in the form of ATP and;
o Cellular swelling caused by changes in ion concentration and water influx
 Intracellular organelles (mitochondria and cytoskeleton) may show alterations
Cell Death
 Injury becomes irreversible with continuous damage  cell cannot recover and dies
 Two principal types of cell death: necrosis and apoptosis
- “accidental” and unregulated form of cell death due to damage
to cell membranes and loss of ion hemostasis
- When membrane damage is severe  lysosomal enzymes
enter the cytoplasma and digest the cell  give rise to
Necrosis morphologic changes or necrosis
- Cellular contents leak through the damaged plasma membrane
into extracellular space where they elicit reaction 
inflammation
- Necrosis is the pathway of cell death in many commonly
encountered injuries (e.g., resulting from ischemia, exposure
to toxins, various infections, trauma)
- When the cell’s DNA or proteins are damaged beyond repair,
cell kill itself by apoptosis
- Characterized by:
Apoptosis o Nuclear dissolution
o Fragmentation of cell w/o complete loss of
membrane integrity
o Rapid removal of the cellular debris
- Cellular contents do not leak out  no inflammatory
reaction
- Highly regulated process driven by a series of genetic
pathways
- “programmed cell death”
 Whereas necrosis is always pathologic process, apoptosis serves many normal
functions and is not necessarily associated with cell injury
 Necrosis in some cases is also a form of programmed cell death  necroptosis
CAUSES OF CELL INJURY
 May range from physical trauma to subtle cellular abnormalities such as mutation
(e.g., lack of enzyme that impairs normal function)
 Most injurious stimuli can be grouped into the following broad categories:
- Hypoxia – deficiency of oxygen; causes cell injury by
reducing aerobic oxidative respiration
- Hypoxia is an extremely important and common cause of
cell injury and cell death
Oxygen Deprivation - Causes of hypoxia:
o Ischemia (reduced blood flow)
o Inadequate oxygenation of the blood due to
cardiorespiratory failure
o Decreased oxygen-carrying capacity of blood (as
in anemia or carbon monoxide poisoning or after
severe blood loss)
- Trauma, extremes of temperature (burns and deep cold),
Physical agents sudden changes in atmospheric pressure, radiation,
electric shock
- Simple chemicals (glucose or salt) in hypertonic
concentrations may cause cell injury directly or by
deranging electrolyte balance in cells
- Oxygen at high concentration is toxic
Chemical agents and - Poisons (arsenic, cyanide or mercuric salts) in trace
drugs amounts may damage cells to cause death
- Daily companions: environmental and air pollutants,
insecticides, herbicides
- Industrial/Occupational hazards: carbon monoxide,
asbestos
- Recreational drugs (alcohol) and ever-increasing variety of
therapeutic drugs
Infectious agents - Range from viruses to tapeworms
- Rickettsiae, bacteria, fungi, and parasites
Immunologic - Immune system serves an essential function in defense
reactions against pathogens but may also cause cell injury
- Autoimmune diseases
- Genetic defects may cause cell injury due to deficiency of
functional proteins
o Enzyme defects in inborn errors of metabolis
Genetic o Accumulation of damaged DNA or misfolded
derangements proteins
o Both trigger cell death when damage is beyond
repair
- Polymorphism (DNA sequence variants) can also influence
the susceptibility of cell to injury by chemicals and
environmental insults
- Major cause of cell injury
Nutritional - Protein-calorie deficiencies cause number of deaths
imbalances (among under privileged populations)
- Can be self-imposed (anorexia nervosa)
- Nutritional excess also cause cell injury (atherosclerosis
and obesity)
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MORPHOLOGIC ALTERATIONS IN CELL INJURY REVERSIBLE INJURY

 All stresses and noxious influences exert their effects first at the molecular or  Two features of reversible cell injury can be recognized under the light
biochemcical level microscope:
 There is a time lag between stress and morphologic changes of cell injury or death o Cellular swelling
o The duration of this delay may vary with the sensitivity of methods used to o Fatty change
detect changes  Cellular swelling – appears when cells are incapable of maintaining ionic
 Histochemical or Ultrastructural techniques  changes may be seen in minutes to homeostasis; result of failure of energy-dependent ion pumps in the plasma
hours after injury membrane
 Light microscopy or gross examination – changes take longer time (hours to days) to  Fatty change – occurs in hypoxic injury and various forms of toxic or metabolic
be seen injury
 Morphologic manifestations of necrosis take more time to develop than those or o Manifested by the appearance of lipid vacuoles in the cytoplasm
reversible damage (Example: ischemia  cell swelling occur in minutes  progress to o Seen mainly in cells involved in and dependent on fat metabolism, such as
irreversibility within an hour or two) hepatocytes and myocardial cells
 Light microscopic changes of cell death may not be seen until 4 to 12 hours after
onset of ischemia MORPHOLOGY
 FIGURE 2-8 (sequential changes in cell injury to cell death) Cellular swelling – first manifestation of almost all forms of injury to cells
 Difficult to see in LM; more apparent at the level of whole organ
Features of Necrosis and Apoptosis  When it affects many cells, it causes pallor, increased turgor, increased weight of the
organ; Swelling of cells is reversible
Feature Necrosis Apoptosis
 On microscopic exam: small clear vacuoles may be seen in cytoplasm  represent
Cell size Enlarged (swelling) Reduced (shrinkage)
distended and pinched-off segments of the ER
Nucleus Pyknosis  karyorrhexis  Fragmentation into nucleosome-size
o This pattern of non lethal injury is called hydropic change or vacuolar
karyolysis fragments
degeneration
Plasma Disrupted Intact; altered structure (orientation of  Cells may also increased eosinophilic staining  becomes more pronounced with
membrane lipids) progression to necrosis
 Ultractructural changes of reversible injury include:
Cellular Enzymatic digestion; may leak out Intact; may be released in apoptotic 1. Plasma membrane alterations  blebbing, blunting, and loss of microvilli
contents of cell bodies 2. Mitochondrial changes  including swelling anf the appearance of small
Adjacent Frequent No amorphous densities
inflammation 3. Dilation of the ER with detachment of polysomes; intracytoplasmic myelin
Physiologic or Invariably pathologic (culmination Often physiologic, means of figures may be present
pathologic of irreversible cell injury) eliminating unwanted cells; may be 4. Nuclear alterations  disaggregation of granular and fibrillar elements
role pathologic after injury (DNA damage)

 Reversible injury is characterized by: NECROSIS

o Generalized swelling of cell and organelles
o Blebbing of the plasma membrane  The morphologic appearance of necrosis as well as necroptosis is the result
o Detachment of ribosomes from the ER of denaturation of intracellular proteins and enzymatic digestion of the
o Clumping of nuclear chromatin lethally injured cell
 These morphologic changes are associated with:  Necrotic cells are unable to maintain membrane integrity and their contents leak out
o Decreased generation of ATP  cause inflammation
o Loss of cell membrane integrity  Enzymes that digest necrotic cells are derived from the lysosomes of the dying cells
o Defects in protein synthesis themselves and from the lysosomes of leukocytes
o Cytoskeletal damage  Digestion of cellular contents and response take hours to develop
o DNA damage o No detectable changes if myocardial infarct caused sudden death
 Persistent of excessive injury  “point of no return” ; irreversible injury and death o Earliest histologic evidence of myocardial necrosis does not become
 Severe mitochondrial damage with depletion of ATP and rupture of lysosomal and apparent until 4-12 hours later
plasma membranes are associated with necrosis  Because of the loss of plasma membrane integrity, cardiac-specific enzymes and
 Necrosis also occur in: proteins are rapidly released from necrotic muscle and can be detected in the blood as
o Ischemia; Exposure to toxins early as 2 hours after myocardial necrosis
o Various infections; Trauma

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Fibrinoid
necrosis
Patterns of Tissue Necrosis
 When large number of cells die the tissue or organ is said to be necrotic
 Necrosis of tissue has severe distinct morphological patterns  important to recognize
because they provide clues about the underlying cause
KEY CONCEPTS: Morphologic Alterations in Injured Cells and Tissues
Coagulative - Architecture of dead tissues is preserved for a span of some days
necrosis - Affected tissue exhibit a firm texture
- The injury denatures not only structural proteins but also enzymes
and so blocks the proteolysis of the dead cells  as a result,
eosinophilic, anucleate cells may persist for days or weeks
- Ultimately the necrotic cells are removed by phagocytois of the
cellular debris by infiltrating leukocytes and by digestion of dead
cells by lysosomal enzymes of leukocytes
- Ischemia caused by obstruction in a vessel may lead to coagulative
necrosis of the supplied tissue in all organs except the brain
- A localized area of coagulative necrosis is called an infarct
Liquefactive - Characterized by digestion of the dead cells  results in
necrosis transformation of the tissue into a liquid viscous mass
- Seen in focal bacterial or fungal infections because microbes
stimulate the accumulation of leukocytes and the liberation of
enzymes from these cells
Gangrenous - Not a specific pattern of cell death
necrosis - Usually applied to a limb that has lost its blood supply and has
undergone necrosis (coagulative necrosis) involving multiple tissue
planes
- When bacterial infection is superimposed there is more liquefactive
necrosis because of the actions of degradative enzymes in the
bacteria and the attracted leukocytes  give rise to wet gangrene
Caseous - Encountered most often in foci of tuberculosis infection
necrosis - “caseous” (cheese-like) derived from the friable white appearance
of the area of necrosis
- Microscopic exam: necrotic area appears as a structureless collection
of fragmented or lysed cells and amorphous granular debris
enclosed within a distinctive inflammatory border  this appearance
is characteristic of a focus of inflammation known as granuloma
Fat necrosis - Does not denote a specific pattern of necrosis
- Refers to focal areas of fat destruction, typically resulting from
release of activated pancreatic lipase into pancreas and peritoneal
cavity
- Occurs in the calamitous abdominal emergency known as acute
pancreatitis  pancreatic enzymes leak out of acinar cells and
liquefy the membranes of fat cells in the peritoneum  released
lipase split the triglyceride esters within fat cells
- Fatty acids combine with calcium to produce chalky-white areas
(fat saponification)
- Histologic exam: necrosis takes the form of foci shadowy outlines of
necrotic fat cells, with basophilic calcium deposits, surrounded
by an inflammatory reaction
- Special form of necrosis usually seen in immune reactions involving
blood vessels
- Occurs when complexes of antigens and antibodies are deposited in
the wallsof arteries
- Deposits of “immune complexes” together with fibrin result in a
bright pink and amorphous appearance in H&E  called “fibrinoid”
(fibrin-like)
 Most necrotic cells disappear due to enzymatic digestion and phagocytosis by WBC
 If not destroyed  they provide a nidus for deposition of calcium and become
calcified  dystrophic calcification
 Reversible cell injury: cellular swelling, fatty change, PM blebbing and loss of
microvilli, mitochondrial swelling, ER dilation, eosinophilia (↓ cytoplasmic RNA)
 Necrosis: ↑ eosinophilia, nuclear shrinkage, fragmentation, dissolution; breakdown of
PM and organelle membranes; abundant myelin figures; leakage and enzymatic
digestion of cellular contents
 Pattern of tissue necrosis: under different conditions, necrosis in tissues may assume
specific patterns: coagulative, liquefactive, gangrenous, casseous, fat, fibrinoid
MECHANISMS OF CELL INJURY
 Several principles that are relevant to most forms of cells injury:
 The cellular response to injurious stimuli depends on the nature of the
injury, its duration, and its severity
o Small doses of chemical toxin or brief period of ischemia may induce
reversible injury
 The consequence of cell injury depend on the type, state, and adaptability
of the injured cell
o Nutritional and hormonal status and metabolic needs  important in
response to injury
o Striated muscle in leg can be placed at rest and preserved when deprived of
its blood supply; not so the striated muscle of the heart
o Exposure of two individual cells to a toxin may have no effect in one cell
and cell death in another  due to polymorphism
 Cell injury results from different biochemical mechanisms acting on several
essential cellular components (Figure 2-16)
o Cellular components that are most frequently damaged by injurious stimuli
include: mitochondria, cell membranes, the machinery of protein synthesis
and packaging, and DNA
o Any injurious stimulus may simultaneously trigger multiple interconnected
mechanisms that damage cells  difficult to ascribe cell injury to a single
biochemical derangement
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DEPLETION OF ATP
 Reduction in ATP levels is fundamental cause of necrotic cell death
 ATP depletion and decreased ATP synthesis  asso. w/ hypoxic and chemical (toxic)
injury
 ATP is produced in two ways:
o Major pathway is oxidative phosphorylation of ADP  results in
reduction of oxygen by the electron transfer system of mitochondria
o Glycolytic pathway  can generate ATP in the absence of oxygen using
glucose derived from body fluids or from hydrolysis of glycogen
 Major causes of ATP depletion are:
o Reduced supply of oxygen and nutrients
o Mitochondrial damage
o Actions of some toxins (e.g., cyanide)
 High energy phosphate in the form of ATP is required for virtually all synthetis and
degradative processes within the cell (e.g., membrane transport, protein synthesis,
lipogenesis, deacylation-reacylation reaction for phospholipid turnover)
 Depletion of ATP to 5%-10% of normal levels has widespread effects on many critical
cellular systems:
 Activity of the plasma membrane energy-dependent Na-pump is reduced
o Failure of this active transport system causes Na to enter and
accumulate inside cells and K to diffuse out (SIPO)
o Net gain of solute = isosmotic gain of water  cell swelling and
dilation of ER
 Cellular energy ,metabolism is altered
o If supply of oxygen is reduced = oxidative phosphorylation ceases
 ↓ ATP and ↑ AMP
o Changes stimulate phosphofructokinase and phosphorylase
activities  lead to ↑ anaerobic glycolysis (generate ATP from
glycogen)  rapid ↓ glycogen stores
o Anaerobic glycolysis causes accumulation of lactic acid and
inorganic phosphates  ↓ intracellular pH  ↓ cellular enzymes
activity
 Failure of Ca2+ pump leads to influx of Ca2+  has damaging effects
 Prolonged depletion of ATP  structural disruption of the protein synthetic
apparatus occurs  manifested as detachment of ribosomes and
dissociation of polysomes with reduction in protein synthesis
 In cells deprived of oxygen or glucose, proteins become misfolded
o Accumulation of misfolded proteins in ER triggers a cellular
reaction called “unfolded protein response” that may
accumulate in cell inury and even death
 Ultimately, there is irreversible damage to mitochondrial and lysosomal
membranes, and the cell undergoes necrosis
MITOCHONDRIAL DAMAGE
 Mitochondria are critical players in cell injury and cell death by all pathways
o They supply life-sustaining energy by producing ATP
 Mitochondria can be damaged by : (they are sensitive to hypoxia and toxins)
o Increases of cytosolic Ca2+
o Reactive oxygen species
o Oxygen deprivation
 Mutations in mitochondrial genes are the cause of some inherited diseases
 Three major consequence of mitochondrial damage:
 Formation of a high-conductance channel in the mitochondrial membrane called
mitochondrial permeability transition pore
o Opening of channel leads to the loss of mitochondrial membrane potential
 leads to failure of oxidative phosphorylation and progressive ↓ of ATP 
ends in cell death
o Cyclophilin D – one of the structural components of mitochondrial
permeability transition pore (MPTP)
 Targeted by cyclosporine (immunsuppressive drug)
 Cyclosporine reduces injury by preventing opening of the MPTP
 Abnormal oxidative phosphorylation also leads to the formation of ROS which have
many deleterious effect
 Mitochondria produce several proteins capable of activating apoptotic pathways
o Includes cytochrome c and proteins that indirectly activate apoptosis-
inducing enzymes called caspases
o Increased permeability of outer membrane results in leakage of these
proteins in the cytosol and death by apoptosis
INFLUX OF CALCIUM AND LOSS OF CALCIUM HOMEOSTASIS
 Calcium ions are important mediators or cell injury
 Depleting calcium protects cells from injury induced by harmful stimuli
 Cytosolic calcium – maintained at 0.1umol
 Extracellular levels 0 1.3 mmol
 Most intracellular calcium is sequestered in mitochondria and ER
 Ischemia and certain toxins cause an increase in cytosolic calcium concentration
o Initially due to release of Ca2+ from intracellular stores and later due to
increased influx across the plasma membrane
 Increased intracellular Ca2+ causes cell injury by several mechanisms:
o Accumulation of Ca2+ in mitochondria  opens MPTP and fails production
of ATP
o ↑ cytosolic calcium activates enzymes with harmful effects on cells
 Phospholipase – cause membrane damage
 Proteases – breakdown both membrane and cytoskeletal proteins
 Endonuclease – responsible for DNA and chromatin fragmentation
 ATPase – hastening ATP depletion
o ↑ intracellular Ca2+ levels result in the induction of apoptosis by direct
activation of caspases and by increasing mitochondrial permeability
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ACCUMULATION OF OXYGEN-DERIVED FREE RADICALS (OXIDATIVE STRESS)
 Cell injury induced by free radicals, particularly ROS, is an important
mechanism of cell damage in many pathologic conditions, such as:
o chemical and radiation injury,
o ischemia-reperfusion injury (induced by restoration of blood flow in
ischemic tissue)
o cellular aging and microbial killing phagocytes
 Free radicals – chemical species that have single unpaired electron in outer orbit
o Unpaired electrons are highly reactive; “attack” and modify adjacent
molecules (inorganic or organic chemicals – CHON, CHO, Lipids, nucleic
acids)
o Some reactions are catalytic  molecules that react with free radicals are
themselves converted to free radicals
 Reactive oxygen species (ROS) – type of oxygen-derived free radicals
o Produced normally inc ells during mitochondrial respiration and energy
generation  degraded and removed by cellular defense system
o Do not cause damage at low concentrations
o ↑ production or ↓ scavenging of ROS  cause oxidative stress
o Oxidative stress – cell injury, cancer, aging and degenerative diseases
o ROS are also produced by leukocytes (neutrophils and macrophage)
Generation of Free Radicals
Free radicals may be generated within cells in several ways
 The reduction-oxidation reactions that occur during normal metabolic processes
 Absorption of radiant energy
 Rapid bursts of ROS are produced in activated leukocytes during inflammation
 Transition metals (iron and copper) donate or accept free electrons during intracellular
and catalyze free electrons during intracellular reactions and catalyze free radical
formation (Fenton Reaction)
 Nitric Oxide – important chemical mediator generated by endothelial cells,
macropahges, neurons and other cell types
o Act as free radical and can also be converted to highly reactive peroxynitrite
anion as well as NO2 and NO3
Removal of Free Radicals
Free radicals are unstable and decay spontaneously. Mechanisms to remove free radicals and
minimize injury:
 Antioxidants – block or inactivate free radicals
o Ex: vitamin E and A; ascorbic acid; glutathione in cytosol
 Free iron and copper can catalyze formation of ROS
o Reactivity of these metals is minimized by their binding to storage and
transport proteins (e.g., transferrin, lactoferrin, ferritin, ceruloplasmin) 
prevents these metals from participating in reactions that generate ROS
 Series of enzymes acts as free radical-scavenging systems (breaks down H2O2 and
O2-); these enzymes are located near the sites of generation of the oxidants and
includes:
o Catalase – present in peroxisomes; decomposes H2O2
o Superoxide dismutase (SOD) – found in many cell types; convert O2- to
H2O2
 Includes manganese SODs (mitochondria)
 Copper-zinc SODs (cytosol)
 Glutathione peroxidise – protects against injury by catalyzing free radical
breakdown
o Intracellular ration of oxidized glutathione (GSSG) to reduced glutathione
(GSH) is a reflection of the oxidative state of the cell and is an important
indicator of the cell’s ability to detoxify ROS
Pathologic Effects of Free Radicals
Effects of ROS and other free radicals are wide-ranging. Three actions relevant to cell injury:
 Lipid peroxidation in membranes
o Presence of O2  peroxidation of lipids
o Oxidative damage is initiated when the double bonds in unsaturated fatty
acids of membrane lipids are attacked by O2 derived free radicals (.OH)
o Lipid free radical interactions yield peroxides  unstable and reactive 
autocatalytic chain reactions ensues (called propagation) extensive
membrane damage
 Oxidative modification of proteins
o Free radicals promote oxidation of amino acid side chains, formation of
covalent protein-protein cross –lins and oxidation of the protein backbones
o Oxidative modification of proteins damages the active sites of enzymes,
disrupt the conformation of structural proteins, and enhance the
proteasomal degradation of unfolded or misfolded proteins
 Lesions in DNA
o Free radicals are capable of causing single and double-strand breaks in
DNA, cross-linking of DNA strands. And formation of adducts
o Oxidative DNA damage has been implicated in cell aging and in malignant
transformation of cells
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DEFECTS IN MEMBRANE PERMEABILITY Reversible vs. Irreversible Injury

 Early loss of selective membrane permeability, leading ultimately to overt
membrane damage, is a consisitent feature of most forms of cell injury
(except apoptosis)
 Mechanisms and pathologic consequences of membrane damage:
Mechanisms of Membrane Damage
In ischemic cells, membrane defects may be result of : ↓ ATP and calcium-mediated activation of
phospholipases. Plasma membrane can also be damages by: bacterial and viral toxins, lytic
complement components, physical and chemical agents.
 “point of no return” – damage becomes irreversible
 Two phenomena consistently characterized irreversibility
o the inability to reverse mitochondrial dysfunction – lack of oxidative
phosphorylation and ATP generation
o profound disturbances in membrane function
 Injury to lysosomal membranes results in the enzymatic dissolution of the injured cell
that is characteristic of necrosis
 Leakage of intracellular proteins through the damage cell membrane and ultimately
into the circulation provides a means of detecting tissue-specific cellular injury and
necrosis using serum samples

ROS - Cause injury to cell membranes by lipid peroxidation Mechanisms of Cell Injury
↓ Phospholipid - Consequence of defective mitochondrial function or hypoxia   ATP depletion: failure of energy-dependent functions  reversible injury  necrosis
Synthesis both decrease the production of ATP  Mitochondrial damage: ATP depletion  failure of energy-dependent cellular
- Affect cellular membranes and mitochondria functions  ultimately, necrosis; under some conditions, leakge of mitochondrial
↑ Phospholipid - Due to activation of Ca-dependent phospholipases by ↑ levels proteins that cause apoptosis
Breakdown of cytosolic and mitochondrial Ca2+  Influx of calcium: activation of enzymes that damage cellular components and may
- Phospholipid breakdown  lead to accumulation of lipid also trigger apoptosis
breakdown products (FFA, acyl carnitine, lysosphospholipids   Accumulation of ROS: covalent modification of cellular proteins, lipids, nucleic acids
detergent effect on membranes)  Increased permeability of cellular membranes: may affect plasma membrane,
- May also insert in lipid bilayer  changes in permeability and lysosomal membranes, mitochondrial membranes; typically culminates in necrosis
electrophysiologic alterations  Accumulation of damaged DNA and misfolded proteins: triggers apoptosis
Cytoskeletal - Activation of protease  damage in cytoskeleton
abnormalities
CLINICOPATHOLOGIC CORRELATIONS: SELECTED EXAMPLES OF CELL INJURY AND
Consequences of Membrane Damage NECROSIS

The most important part of membrane damage during cell injury are: mitochondrial membrane,
plasma membrane, membranes of lysosomes.
Mitochondrial - Results in opening of MPTP  lead to ↓ ATP generation and
membrane damage release of proteins that trigger apoptotic death
Plasma membrane - Results in loss of osmotic balance and influx of fluids and
damage ions, as well as loss of cellular components
- Cells may also leak metabolites vital for reconstitution of ATP
furthering the depletion of energy stores
Injury to lysosomal - Results in leakage of enzymes into cytoplasma
membranes - Activates the acid hydrolase in the acidic intracellular pH of
injured cell
- Lysosomes contain RNAses, DNAses, proteases,
phosphatises, glucosidases  activation leads to digestion of
proteins, RNA, DNA, glycogen and cells die by necrosis
DAMAGE TO DNA AND PROTEINS
 Cells have mechanisms that repair damage to DNA, but if DNA damage is
too seveer to be corrected (e.g., after exposure to DNA damaging drugs,
radiation, or oxidative stress), the cell initiates a suicide program that
results in death by apoptosis
Common and clinically significant forms of cell injury that culminate in necrosis:
ISCHEMIC AND HYPOXIC INJURY
 Ischemia is the most common type of cell injury in clinical medicine and it
results from hypoxia induced by reduced blood flow, most commonly due to
a mechanical arterial obstruction (also venous drainage)
 Anaerobic glycolysis continue and exhaust glycolytic substrates  stops anaerobic
energy generation
 Glycolysis is inhibited by accumulation of metabolites that would be washed out by
flowing blood
 Ischemia tends to cause more rapid and severe cell and tissue injury than does
hypoxia in the absence of ischemia
 Ischemia – deficient blood supply
 Hypoxia – deficient oxygen supply
Mechanisms of Ischemic Cell Injury
 ↓ oxygen tension in cells  ↓ oxidative phosphorylation; ↓ATP generation
 ↓ ATP  failure of Na-pump  K out; Na and water in  cell swelling
 Influx of calcium  harmful effects  loss of glycogen and ↓ protein synthesis
 If oxygen is restored, all of these disturbances are reversible
 If ischemia persists, irreversible injury and necrosis ensue
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  Irreversible injury is associated with:
o Severe swelling of mitochondria
o Extensive damage to plasma membrane (give rise to myelin figures)
o Swelling of lysosomes
 Large, flocculent, amorphous densities develop in the mitochondrial matrix 
indications of irreversible injury in the myocardium; seen 30-40mins after ischemia
 Massive influx of calcium then occurs if ischemic zone is reperfused
 Death is mainly by necrosis, but apoptosis also contributes
o Apoptotic pathway is activated by the release of pro-apoptotic molecules
from leaky mitochondria
 Cell’s components are degraded  widespread leakage of cellular enzymes in the
extracellular space and there is entry of extracellular molecules from the interstitial
cells into the dying cells
 Finally, dead cells become replaced by large masses composed of phospholipids in the
form of myelin figures
o Phagocytosed by WBC or degraded further into fatty acids
o Calcification of fatty acids  calcium soaps
 Leakage on intracellular enzymes  important clinical indicators of cell death
 Hypoxia-inducible factor-1  promotes new blood vessels, stimulates cell survival
pathways, and enhance anaerobic glycolysis
ISCHEMIA-REPERFUSION INJURY
 Restoration of blood flow to ischemic tissues can promote recovery of cells
if they are reversibly injured, but can also paradoxically exacerbate the
injury and cause cell death
 Ischemia-reperfusion injury – process where reperfused tissues sustain loss of
cells in addition to the cells that are irreversibly damaged at the end of ischemia
o Clinically important: contributes to tissue damage during myocardial and
cerebral infarction and following therapies to restore blood flow
o Reperfusion injury occurs when new damaging processes happen during
reperfusion , causing death of cells that might have recovered otherwise.
 Several mechanisms:
Oxidative stress - New damage may be initiated during reoxygenation by ↑ ROS
- Free radicals may be produced in reperfused tissue as a result of
incomplete reduction of oxygen by damaged mitochondria, or
because of action of oxidases from leukocytes, endothelial or
parenchymal cells
- Cellular antioxidant defense mechanism may be compromised by
ischemia  favors accumulation of free radicals
Intracellular - Intracellular and mitochondrial calcium overload begins during
Ca2+ overload acute ischemia  exacerbated during perfusion due to influx of
calcium resulting from cell membrane damage and ROS
mediated injury to SR
- Ca2+ overload favors opening of the MPTP with resultant
depletion of ATP  furthers cell injury
Inflammation - Result of: “dangers signals” released from dead cells, cytokines
released by macrophages; increased expression of adhesion
molecules by hypoxic parenchymal and endothelial cells 
recruit circulating to reperfused tissue
- Inflammation causes additional tissue injury
Activation of - Contribute to ischemia-reperfusion injury
Complement - IgM  deposit in ischemic tissues and when blood flow is
System resumed, complement proteins bind to the deposited antibodies
 activated and cause cell injury and inflammation
CHEMICAL (TOXIC) INJURY
 Chemical injury remains a frequent problem in clinical medicine and is a
major limitation to drug therapy
 Liver – frequent target of drug toxicity
o Toxic liver injury – most frequent reason for terminating drug use
 Chemicals induce cell injury by one of two general mechanisms
Direct Toxicity
 Some chemicals can injure cells directly by combining with critical molecular
components
 Ex: mercuric chloride poisoning  mercury binds with sulfhydryl groups  cause ↑
membrane permeability and inhibition of ion transport
o Greatest damage is usually to the cells that use, absorb, excrete, or
concentrate the chemicals (GIT and kidney)
 Cyanide – poisons mitochondrial cytochrome oxidase  inhibits oxidative
phosphorylation
 Antineoplastic chemo agents and antibiotics  induce cell damge by direct cytotoxic
effects
Conversion to Toxic Metabolites
 Most toxic chemicals are not biologically active in their native form
o Converted to reactive toxic metabolites and act on target molecules
o Modification is usually accomplished by cytochrome P-450 mixed-function
oxidases in the sER of liver and other organs
 Toxic metabolites cause membrane damage and cell injury mainly by formation of free
radicals and subsequent lipid peroxidation, also direct covalent binding
 Ex: CCL4  converted to highly reactive free radical CCL3 by cyt450
o Causes lipid peroxidation and damages many cellular structure
 Ex: Acetaminophen  analgesic; converted to a toxic product in the liver  cause cell
injury
KEY CONCEPTS: Ischemic and Toxic Injury
 Mild Ischemia: ↓ oxidative phoaphorylation  ↓ ATP generation  failure of Na pump
 influx of Na and H2O  organelle and cellular swelling (reversible)
 Severe/prolonged ischemia: severe swelling of mitochondria, Ca influx into
mitochondria and into cell w/ rupture of lysosomes and PM. Death by necrosis and
apoptosis due to release of cytC from mitochondria
 Reperfusions injury follows blood flow into ischemic area is due to oxidative sress by
the release of free radicals from WBC and endothelial cells. Blood brings Ca that
overloads reversibly injured cells with mitochondrial injury. Influx of WBC generated
free radicals and cytokines. Local activation of complement by IgM deposited in
ischemic tissues
 Chemicals may cause injury directly or by conversion to toxic metabolites. Direct
injury to critical organelles such as mitochondria or indirect injury from free radicals
generated from chemicals/toxins involved
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APOPTOSIS
 Apoptosis is a pathway of cell death that is induced by a tightly regulated
suicide program in which cells destined to die activate intrinsic enzymes
that degrade the cell’s own nuclear DNA and nuclear and cytoplasmic
proteins
 Apoptotic bodies – fragmented apoptotic cells
o Contain portions of the cytoplasma and nucleus
o Plasma membrane is intact but they become “tasty” targets for phagocytes
o Rapidly devoured before contents have leaked out  cell death does not
elicit inflammation
 Apoptosis – programmed cell death; characterized by:
o Loss of membrane integrity
o Enzymatic digestion of cells
o Leakage of cellular components
o Host reaction
CAUSE OF APOPTOSIS
Apoptosis – serves to remove unwanted, aged, or potentially harmful cells; also a
pathologic event when diseased cells become damaged beyond repair
Apoptosis in Physiologic Situations
 Death by apoptosis is a normal phenomenon that serves to eliminate cells that are no
longer needed, and to maintain a steady number of various cell populations in tissues.
 It is important in following physiologic situations:
 The destruction of cells during embryogenesis
o implantation, organogenesis, developmental involution, metamorphosis
 Involution of hormone-dependent tissues upon hormone withdrawal
o Endometrial cell breakdown during menstrual cycle, ovarian follicular atresia
in menopause, prostatic atrophy after castration
 Cell loss in proliferating cell populations
o Immature lymphocytes in bone marrow, thymus, B lymphocytes in germinal
centers, epithelial cells in intestinal crypts  to maintain homeostasis
 Elimination of potentially harmful self-reactive lymphocytes
 Death of host cells that have served their purpose
o Neutrophils in acute response, lymphocytes at the end of immune response
 deprived of growth factors
Apoptosis in Pathologic Conditions
 Apoptosis eliminates cells that are injured beyond repair without eliciting a host
reaction  limit tissue damage
 Death by apoptosis is responsible for loss of cells in a variety of pathologic states:
 DNA damage
o Radiation, cytotoxic anticancer drugs, hypoxia  damage DNA directly or
via free radicals
 Accumulation of misfolded proteins
o May arise because of mutations in genes or because of extrinsic factors
o Excessive accumulation in ER leads to ER stress  ends in apoptotic cell
death
o Apoptosis by accumulation of misfolded proteins  basis of several
degenerative diseases of the CNS and other organs
 Cell death in certain infections (particularly viral infections)
o Adenovirus, HIV or viral hepatitis
o Important host response  cytotoxic T cells  induce apoptosis of infected
cells  eliminate reservoir of infection
o Cytotoxic T cells also responsible for cell death in tumors and cellular
rejection of transplants
 Pathologic atrophy in parenchymal organs after duct obstruction
o Pancreas, parotid glands, kidney
MORPHOLOGIC AND BIOCHEMICAL CHANGES IN APOPTOSIS
 Best seen in electron microscope
Cell shrinkage - Cell is smaller in size; cytoplasm is dense; organelles
are tightly packed
Chromatin condensation - Most characteristic feature of apoptosis
- Chromatin aggregates peripherally,under the nuclear
membrane, into dense masses of shapes and sizes
- Nucleus fragmentation
Blebbing and apoptotic - Apoptotic cell first shows extensive surface blebbing,
bodies then undergo fragmentation into membrane-bound
apoptotic bodies (w/ or w/o nuclear fragments
Phagocytosis of apoptotic - Apoptotic bodies are rapidly ingested by phagocytes
cells or cell bodies, usually and degraded by the phagocytes lysosomal ezymes
by macrophages
 Plasma membranes are thought to remain intact during apoptosis until the last stages
when they become permeable
 H & E: apoptotic cell appears as round or oval mass of intensely eosinophilic
cytoplasm with fragments of dense nuclear chromatin
 Apoptosis does not elicit inflammation  difficult to detect histologically
Mechanisms of Apoptosis
 Apoptosis results from the activation of enzymes called caspases (cysteine
proteases that cleave proteins after aspartic residues)
 Presence of cleaved, active caspases is a marker for cells undergoing apoptosis
 Process of apoptosis may be divided into:
o Initiation phase – where caspases become active
o Execution phase – other caspases trigger the degradation of critical
cellular components
 Two distinct pathways converge on caspase activation:
o Mitochondrial pathway
o Death receptor pathway
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Intrinsic or Mitochondrial Pathway of Apoptosis
 The mitochondrial pathway is the major mechanism of apoptosis in all
mammalian cells
 Results from increased permeability of mitochondrial outer membrane with release of
pro-apoptotic molecules from the mitochondrial intermembrane space into cytoplasm
 Mitochondria are remarkable organelles  they contain cytochrome c which is
essential for life
o Release of cytochrome c  indication that the cell is not healthy  initiate
the suicide program of apoptosis
 BCL2 – controls the release of mitochondrial pro-apoptotic proteins
Anti- - BCL2, BCL-XL, MCL1
apoptotic - Possess four BH domains (BH1-4)
- Reside in the outer mitochondrial membranes as well as the
cytosol and ER membranes
- Prevent leakage of cytochrome c and other death-inducing
proteins into the cytosol by keeping the mitochondrial outer
membrane impermeable
Pro- - BAX and BAK (they also have four BH domains)
apoptotic - Upon activation, they oligomerize w/in the outer mitochondrial
protein and promote permeability
- They form a channel in the outer mitochondrial membrane 
allow leakage of cytochrome c from the intermembranous space
Sensors - BAD, BIM, BID, Puma, Noxa
- Contain only one BH (3rd of the four BH domains; hence they are
called BH3-only proteins)
- BH3-only proteins – acts as sensors of cellular stress and
damage; regulate balance between the other two groups  thus
acting as arbiters of apoptosis
 Growth factors and other survival signals stimulate the production of anti-apoptotic
proteins such as BCL2  prevent leakage of deatg-inducing proteins fron the outer
mitochondrial membrane
 When cells are deprived of survival or their DNA is damaged, or misfolded proteins
induce ER stress  BH3-only proteins “sense” such damage and are activated
o Sensors activate pro-apoptotic effectors (BAX and BAK)  allow leakage of
proteins
 BH3-only proteins may also bind to and block the function of BCL2 and BCL-XL 
BCL2 and BCL-XL may decline
 BAX-BAK activation  activate caspase cascade and release cytochrome c  cyt c
binds to APAF-1 (forms wheel-like hexamer called apoptosome)  complex is able to
bind to caspase-9
 Caspase-9  critical initiator caspase of the mitochondrial pathway  set up an
autoamplification process
 Cleavage activates caspase-9  triggers other pro-caspases  mediate the execution
phase of apoptosis
 Smac/Diablo – enter the cytoplasm and bind to and neutralize cytoplasmic proteins
that function as physiologic inhibitors of apoptosis  called IAPs
 IAPs – block the activation of caspases, including executioners like caspase-3 and
keep cells alive
o Neutrlaization of IAPs permits the initiation of a caspase cascade
Extrinsic or Death Receptor-Initiated Pathway of Apoptosis
 This pathway is initiated by engagement of plasma membrane death
receptors on a variety of cells
 Death receptors (members of TNF receptor family)
o Contain death domain protein-protein interaction; essential for
delivering apoptotic signals
o TNFR1 & CD95
o Mechanism of apoptosis is induced by Fas (death receptor in many cel
types)
 FasL – ligand for Fas; expressed on T-cells that recognize self-antigens and cytotoxic
T cells
o FasL + FAS = FADD
o FADD attached to death receptors binds an inactive form of caspase-8 or 10
via death domain  cleave to form active caspase 8
 This pathway of apoptosis can be inhibited by FLIP  binds to pro-caspase 8but
cannot cleave and activate the caspase because it lacks a protease domain
o Inhibits FAS-mediated apoptosis
The Execution Phase of Apoptosis
 The two initiating pathways converge to a cascade of caspase activation,
which mediates the final phase of apoptosis
 Mitochondrial pathway leads to activation of the initiator caspase 9
 Death receptor pathway leads to activation of caspases-8 and -10
 After initiator caspase is cleaved to active form  sequential activation of executioner
caspase (caspase-3 and -6)
o Ex: caspase 3 and 6 cleave DNAse inhibitor  makes DNAse active 
induce DNA cleavage
 Caspase also degrade structural components and promote fragmentation of nuclei
Removal of Dead Cells
 Formation of apoptotic bodies breaks cells up into “bite-sized” fragments that are
edible for phagocytes
 Phosphatidylserine – present on the inner leaflet of plasma membrane of a healthy
cell
o Flips out and expressed on the outer layer of membrane in apoptotic cells
 recognize by macrophage receptors
 Dying cells by apoptosis secrete soluble factors that recruit phagocytes  target for
engulfment; “eat me” signal
o E.g., thrombospondin; C1q
 This process is efficient that dead cells disappear within minutes without a trace 
inflammation is absent even in the face of extensive apoptosis
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CLINICOPATHOLOGIC CORRELATIONS: APOPTOSIS IN HEALTH AND DISEASE SELECTED DISEASES CAUSED BY MISFOLDED PROTEINS
Disease Affected Protein Disease
Examples of Apoptosis Cystic fibrosis CFTR Loss of CTFRdefect in chloride transport
Growth Factor - Hormone-sensitive cells, lymphocyte and neurons die by Familial LDL receptor Loss of LDL
Deprivation apoptosis if deprived by their growth factor hypercholesterolemia receptorhypercholesterolemia
- Apoptosis is triggered by the intrinsic (mitochondrial) Tay-Sachs disease Hexosaminidase β Loss of lysosomal enzyme storage of GM,
pathway  attributed by the ↓ synthesis of BCL2 and subunit gangliosides in neurons
BCL-XL and activation of BIM and other pro-apoptotic Alpha-1 antitrypsin A1-antitrypsin Storage of non-functional protein in
members of the BCL2 family deficiency hepatocytes cause apoptosis; absence of
DNA Damage - Exposure to radiation or chemotherapeutic agents  enzymatic activity in lungs causes
initiated by DNA damage or genotoxic stress  involves destruction in elastic tissue giving rise to
TP53 (tumor-suppressor gene) emphysema
- P53 accumulates in cells when DNA is damaged  Creutzfeldt-Jacob Prions Abnormal folding of PrPsc causes neuronal
arrest G1 phase of cell cycle to allow time for repair disease cell death
- If damage is too great  P53 triggers apoptosis Alzheimer disease Aβ peptide Abnormal folding of Aβ peptide causes
- If TP53 is mutated or absent (cancers)  cells with aggregation w/in neurons and apoptosis
damaged DNA fail to undergo p53-mediated apoptosis
and survive  may cause mutations and neoplastic
transformations Disorders Associated with Dysregulated Apoptosis (“too little or too much”)
- P53 serves as a critical “life or death” switch ff Disorders associated - Incorrect low rate of apoptosis  permit survival or
genotoxic stress with defective abnormal cells
o Triggers the distal death effector machinery; apoptosis and - E.g., TP53 mutations cause accumulation of defective
o Involve its function as a DNA-binding increased cell DNA repair  give rise to cancer
transcription factor survival - Defective apoptosis results in failure to eliminate harmful
o BAX, BAK, BH3-only proteins cells (e.g., self Ags)  basis of autoimmune disease
Protein Misfolding - Ubiquitinated and targeted for proteolysis in Disorders associated - Diseases characterized by loss of cells and include:
proteasomes with increased - (1) Neurodegenerative diseases – manifested by loss
- Accumulation of un/misfolded proteins  trigger apoptosis and of specific neurons (apoptosis caused by mutations and
“unfolded protein response”  activates signalling excessive cell death misfolded proteins)
pathways to ↑ production of chaperones  enhance - (2) Ischemic injury – e.g., myocardial infarction and
proteasomal degradation and slow protein translation  stroke
reduce load of misfolded proteins in cell - (3) death of virus-infected cells – e.g., viral infections
- If unable to cope with accumulation  induces
apoptosis called “ER stress”
- Alzheimer, Huntington, Parkinson Disease, Type 2 DM –
neurodegenerative diseases caused by intracellular KEY CONCEPTS: Apoptosis
accumulation of abnormally folded proteins  Regulated mechanism of cell death that serves to eliminate unwanted and irreparably
- Deprivation of glucose and oxygen, and stress (e.g., damaged cells, w/ the least possible host reaction
heat) – also result in protein misfolding  Cxd by enzymatic degradation of proteins and DNA, initiated by caspases; and by
Apoptosis Induced by - FasL on T cells binds to Fas on the same or neighboring recognition and removal of dead cells by phagocytosis
TNF Receptor Family lymphocytes  Initiated by two major pathways:
- Plays a role in the elimination of lymphocytes that Mitochondrial  Triggered by loss of survival signals, DNA damage, and
recognize self Ags, and mutations affecting Fas or FasL (intrinsic) accumulation of misfolded proteins (ER stress)
result in autoimmune diseases in humans and mice pathway  Asso. w/ leakage of pro-apoptotic proteins from mitochondrial
Cytotoxic T - CTL (cytotoxic T-lymphocytes) recognize foreign Ags on membrane into cytoplasm, where they activated caspases
Lymphocyte-Mediated the surface of host cells  Inhibited by anti-apoptotic members of BCL2 family (induced
Apoptosis - Activated CTLs secrete perforin – transmembrane pore- by survival signals; GF)
forming molecule  promotes entry of granzymes Death  Responsible for elimination of self-reactive lymphocytes and
- Granzymes – cleave proteins at aspartate residues receptor damaged cytotoxic T-lymphocytes
- CTL kills target cells by directly inducing the effector (extrinsic)  Initiated by engagement of death receptors (TNF receptor
phase of apoptosis pathway family) by ligand on adjacent cells

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NECROPTOSIS
 Form of cell death with aspects of both necrosis and apoptosis
 Characterization of necroptosis:
 Morphologicallyand biochemically, resemples necrosis
o Cxd by loss of ATP
o Swelling of cell and organelles
o Generation of ROS
o Release of lysosomal enxymes
o Rupture of the plasma membrane
 Mechanistically, it is triggered by genetically programmed signal transduction that
culminate in cell death  resembles programmed cell death (hallmark of apoptosis)
 Necroptosis aka “programmed necrosis” or “ caspase-independent programmed cell
death”
 In sharp contrast to apoptosis, the genetic program that drives necroptosis does not
result in caspase activation  “ caspase-independent programmed cell death”
 Initiation of necroptosis is similar with extrinsic form of apoptosis  by ligation of a
receptor by its ligand (TNFR1)
o TNF can cause both apoptosis and necroptosis
 Necoptosis involves two unique kinases: RIP1 and RIP3
o Ligation of TNFR1 recuits RIP1 and RIP3 into a multiprotein complex that
contains caspase-8
o Unlike apoptosis, caspases are not activated
o Like in necrosis, terminal events include permeabilization of lysosomal
membranes, generation of ROS, damage to mitochondria, and ↓ ATP levels
o This explains the morphologic similarity of necroptosis with necrosis initiated
by other injuries
 Necroptosis – important death pathway in physiologic and pathologic conditions
o E.g., necroptosis occurs in mammalian growth plate, cell death in
steatohepatitis, acute pancreatitis, reperfusion injury and neurodegenerative
diseases (ex, Parkinson)
o Acts as a back up mechanism in host defense against viruses that encode
caspase inhibitor (ex:CMV)
 Pyroptosis – form of programmed cell death accompanied by the release of fever
inducing cytokine IL-1 and bears some biochemical properties with apoptosis
 Microbial products that infected the cells are recognized by innate immune receptors
 activate multiprotein complex called “inflammasome”
o Inflammasome – activate caspase-1 (aka IL-1b converting enzyme) 
cleaves and activates IL-1
o IL-1 – mediator of leukocyte recruitment and fever
o Caspase-1 and -11  also induce cell death
o This pathway of death is czd by:
 Swelling of cells
 Loss of plasma membrane integrity
 Release of inflammatory mediators
 Pyroptosis results in the death of microbes the enters the cytosol and promotes
release of inflammasome-generated IL-1
KEY CONCEPTS: Necroptosis and Pyroptosis
 Necroptosis resembles necrosis morphologically and apoptosis mechanistically as a
form of programmed cell death
 Necroptosis is triggered by ligation of TNFR1, and viral proteins of RNA and DNA virus
 Necroptosis is caspase-independent but dependent on signalling by RIP1 and RIP3
 RIP1-RIP3 signaling reduces mitochondrial ATP generation, causes production of ROS,
and permeabilizes lysosomal membranes, causing cellular swelling and membrane
damage as well as necrosis
 Release of cellular contents evokes an inflammatory reaction as in necrosis
 Pyroptosis occurs inc ells infected by microbes. It involves activation of caspase-1
which cleaves the precursor form IL-1 to activate it. Caspase-1 along with closely
related caspase-11 also cause of death of the infected cell
AUTOPHAGY
 Autophagy is a process in which a cell eats its own contents
 Involves delivery of cytoplasmic materials to the lysosome for degradation
 Can be categorized into three types:
Chaperone-mediated - Direct translocation across the lysosomal membrane by
autophagy chaperone proteins
Microautophagy - Inward invagination of lysosomal membrane for delivery
Macroautophagy - Referred to as autophagy
- Major form of autophagy involving the sequenstration and
transportation of portions of cytosol in a double-membrane
bound autophagic vacuole
 Autophagy is seen in single-celled organisms as well as mammalian cells
o Survival mechanism in states of nutrient deprivation  starved cell eats
itself and recycles digestive contents
o It is seen in physiologic states (e.g., aging and exercise) and pathologic
processes
o Proceeds through several steps:
 Formation of an isolation membrane (aka phagosphore) and its nucleation; the
isolation membrane is believed to be derived from the ER
 Elongation of the vesicle
 Maturation of the autophagosome, its fusion with lysosomes, and eventual
degradation of the contents
 Starvation or depletion of growth factors activate an initiation complex of four proteins
that stimulates the assembly of a nucleation complex  promotes nucleation of
autophagosomal membrane  surrounds and closes to form autophagosome
o Require LC3
o LC3 – augmented during autophagy; marker for identifying cells in which
autophagy is occurring; “target” protein aggregates and effete organelles
o Newly formed autophagosome fuses with endosome and lysosome to form
autophagolysosome
o Loading of cargo into autophagosome is “selective”
 Autophagy is a survival mechanism that maintains the integrity of the cells by
recycling essential metabolites and clearing cellular debris
o Prominent in atrophic cells exposed to severe nutrient deprivation
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  Autophagy is involved in the turnover of organelles like ER, mitochondria, and LIPIDS
lysosomes and the clearance of intracellular aggregates that accumulate during aging,
stress, and various disease states  All major lipids can accumulate in cells: triglycerides, cholesterol/cholesterol
 Autophagy can trigger cell death if it is inadequate to cope with the stress on the cell esters, phospholipids
 Autophagic vacuolization often precedes or accompanies call death  Phospholipids – components of the myelin figures found in necrotic cells
 Autophagy plays a role in human disease:  Abnormal complexes of lipids and carbohydrates accumulate in the lysosomal storage
diseases
Cancer - Autophagy can both promote cancer growth and act as a
defense against cancers Steatosis - Abnormal accumulations of triglycerides within
Neurodegerative - Associated with dysregulation of autophagy (Fatty parenchymal cells
Diseases - E.g., Alzheimer and Huntington Disease Change) - Fatty change is often seen in the liver because it is the major
Infectious diseases - E.g., mycobacteria, shigella, HSV-1 organ involved in fat metabolism (also occurs in heart, muscle,
Inflammatory bowel - E.g., Crohn disease and ulcerative colitis kidney)
diseases - Causes include: toxins, protein malnutrition, DM, obesity and
anoxia
- In developed nations, the most common cause of fatty change in
Key Concepts: Autophagy liver are alcohol abuse and non-alcoholic fatty liver disease,
associated with diabetes and obesity
 Autophagy involves sequestration of cellular organelles into cytoplasmic autophagic
Cholesterol - Accumulations are seen in several pathologic processes:
vacuoles (aurophagosomes) that fuse with lysosomes and digest the enclosed material
 Autophagy is an adaptive response that is enhanced during nutrient deprivation, and
allowing the cell to cannibalize itself to survive Cholesterol Atherosclerosis - Smooth muscle cells and
Esters macrophages w/in the intimal layer
 Autophagosome formation is regulated by more than an dozen proteins that act in a
coordinated manner of aorta and large arteries are filled
 Dysregulation of autophagy occurs in many diseases states including cancer, with lipid vacuoles, most of which
inflammatory bowel disease, and neurodegenerative disorders. Autophagy play a role are made up of cholesterol and
in host defense against certain microbes cholesterol esters
- Cells have foamy appearance  foam
cells
- Aggregation in intima produces yellow
INTRACELLULAR ACCUMULATIONS cholesterol-laden atheromas
characteristic of the disorder
 One of the manifestations of metabolic derangements - Extracellular cholesterol esters may
 May be located in the cytoplasm, within organelles (usually lysosomes), or in the crystallize in the shape of long needles,
nucleus; may be synthesized by the affected cells or may be produced elsewhere producing quite distinctive clefts in tissue
 Four main pathways of abnormal intracellular accumulations: sections
Xanthomas - Intracellular accumulation of
cholesterol within macrophages is
 Inadequate removal of a normal substance secondary to defects in mechanisms of
also characteristic of acquired and
packaging and transport (e.g., stetaosis) hereditary hyperlipidemic states
 Accumulation of an abnormal endogenous substance as a result of genetic or acquired - Clusters of foamy cells found in
defects: folding, packaging, transport or secretion (e.g., mutated a1-anitrypsin) subepithelial connective tissue of skin
 Failure to degrade a metabolite due to inherited enzyme deficiencies  storage and tendons  produce timorous
diseases masses aka xanthomas
 Deposition and accumulation of an abnormal exogenous substance when the cell has Cholesterolosis - Refers to the focal accumulations of
cholesterol-laden macrophages in lamina
neither the enzymatic machinery to degrade it nor the ability to transport. (e.g.,
propria of gall bladder
accumulation of carbon particles)
Niemann-Pick - Lysosomal storage disease cause by
diseases, type C mutations affecting enzyme involved in
 Accumulation is reversible if overload can be controlled or stopped cholesterol trafficking, resulting in
 Inherited storage disease  accumulation is progressive  overload causes cell injury cholesterol accumulation in multiple
that leads to death of tissue and patient organs

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PROTEINS
 Intracellular accumulations of proteins usually appear as rounded,
eosinophilic droplets, vacuoles, or aggregates in the cytoplasm
 EM: amorphous, fibrillar, or crystalline appearance
 Amyloidosis – abnormal proteins deposit primarily in extracellular spaces
 Excesses of proteins within the cells sufficient to cause morphologically visible
accumulation have diverse causes:
 Reabsorption droplets in proximal renal tubules are seen in renal diseases associated
with proteinuria
o Small amounts of protein in kidney – absorbed by pinocytosis in PCT
o Heavy protein leakage - ↑ reabsorption into vesicles  proteins appears as
pink hyaline droplets within the cytoplasm of tubular cell
o Process is reversible; if proteinuria diminishes  protein droplets are
metabolized and disappear
 Proteins that accumulate may be normal secreted proteins that are produed in
excessive amounts.
o E.g., active synthesis of Ig
o ER becomes hugely distended  produce large, homogenous eosinophilic
inclusions called Russell bodies
 Defective intracellular transport and secretion of critical proteins
o E.g., a1-antitrypsin deficiency  build-up of partly folded intermediates 
aggregate in liver and not secreted  causes emphysema
 Accumulation of cytoskeletal proteins: microtubules, actin, myosin, intermediate
filaments
o Intermediate filaments: keratin, neurofilaments, vimentin, glial filaments
o Accumulations of keratin and neurofilaments  asso. w/ cell injury
o Alcoholic hyaline – eosinophilic cytoplasmic inclusion in liver cells that is
characteristic of alcoholic liver disease; composed mainly of keratin
intermediate filaments
o Neurofibrillary tangle found in the brain in Alzheimer disease contains
neurofilaments and other proteins
 Aggregation of abnormal proteins
o Abnormal/misfolded proteins may deposit in tissues and interfere with
normal functions
o Deposits can e intracellular, extracellular or both
o Aggregates may either directly or indirectly cause the pathologic changes
o E.g., proteinopathies or protein-aggregation diseases such as amyloidosis
HYALINE CARTILAGE
 Hyaline – refers to an alteration w/in cells or in extracellular space that
gives a homogenous, glassy, pink appearance in routine H&E
 Intracellular accumulation of protein are examples of intracellular hyaline deposits
 Extracellular hyaline (e.g., collagenous fibrous tissue in old scars)
 Hypertension and DM – walls of arterioles (esp kidney) are hyalinized  resulting
from extravasated plasma protein and deposition of basement membrane material
GLYCOGEN
 Glycogen – energy source stored in the cytoplasm of healthy cells.
 Excessive intracellular deposits of glycogen are seen in patients with an
abnormality in either glucose or glycogen metabolism
 Glycogen masses appear as clear vacuoles within the cytoplasm  they dissolve in
aqueous fixatives
o Readily identified when fixed in absolute alcohol
o Best carmine or PAS  rose to violet color
o Diastase digestion before staining serves as a control by hydrolyzing the
glycogen
 Ex: Diabetes mellitus  prime example; glycogen is found in renal tubular epithelial
cells, liver cells, b cells of islets of Langerhans, heart muscle cells
 Glycogen storage disease or glycogenoses – group of genetic disorders where
glycogen accumulates within cells
PIGMENTS
 Pigments – colored substances (normal or abnormal) that accumulate in cells
 Can be exogenous (coming from outside the body) or endogenous (synthesized
within the body itself
Exogenous Pigments
 Most common is carbon (coal dust), a ubiquitous air pollutant in urban
areas
o accumulation of this pigment blacken the tissues of the lungs (anthracosis)
and lymph nodes
o coal worker’s pneumoconiosis
 Tattooing is a form of localized, exogenous pigmentation of the skin
 The pigments do not usually evoke any inflammation
Endogenous Pigments
 Lipofuscin is an insoluble pigment, aka lipochrome or wear-and-tear
pigment
o Composed of polymers of lipids in complex with protein; derived rough lipid
peroxidation of polyunsaturated lipids of subcellular membranes
o Not injurious to cell or function
o Telltale sign of free radical injury and lipid peroxidation
o Appears a yellow-brown, finely granular cytoplasmic, perinuclear pigment
o Seen in cells undergoing slow, regressive changes; prominent in liver and
heart of aging patients or with severe malnutrition and cancer cachexia
 Melanin – endogenous, brown-black, pigment formed when the enzyme tyrosinase
catalyzes the oxidation of tyrosine to DHP in melanocytes; the only endogenous
brown-black pigment
 Homogentisic acid – black pigment that occurs in patients with alkaptonuria;
deposited in the skin, CT, cartilage and the pigmentation is known as ochronosis
 Hemosiderin – Hb-derived, golden yellow-to-brown, granular or crystalline
pigment is one of the major storage forms of iron
o Iron is transported by transferring and stored with apoferritin to form
ferritin micelles
o When there is a local or systemic excess of iron, ferritin forms hemosiderin
granules (seen in LM)
o Hemosiderin represents aggregates of ferritin micelles
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 o BM, spleen, liver  engaged in RBC breakdown
o Local hemosiderosis  e.g., common bruise
o Green bile (biliverdin)  red bile (bilirubin)
 Hemosiderosis – deposition of hemosiderin in organs and tissues when there is
systemic overload: main causes:
o ↑ absorption of dietary iron due to an inborn error of metabolism called
hemochromatosis
o Haemolytic anemias  prematurelysis of RBC lead to abnormal quantities of
iron
o Repeated blood transfusion (transfused RBC – exogenous iron load)
PATHOLOGIC CALCIFICATION
 Pathologic calcification is the abnormal tissue deposition of calcium salts,
together with smaller amounts of iron, magnesium and other mineral salts
 There are two forms:
o Dystrophic calcification – deposition occurs locally in dying tissues;
 it occurs despite normal serum levels of calcium and in the
absence of derangements in calcium metabolism
o Metastatic calcification – deposition of calcium salts in abnormal tissues;
 almost always results from hypercalcemia secondary to some
disturbance in calcium metabolism
Dystrophic Calcification
 Dystrophic calcification is encountered in areas of necrosis, whether they
are of coagulative, caseous, or liquefactive type and in foci on enzymatic
necrosis of fat
 Calcification is almost always present in the atheromas of advanced atherosclerosis
 Commonly develops in aging, damaged heart valves
 Calcium salts appear macroscopically as fine, white granules or clumps, often felt as
gritty deposits (sometimes converted to stone in tuberculous lymph node)
 Dystrophic calcification may simply be a telltale sign of previous cell injury and often
cause of organ dysfunction
 Serum calcium is normal in dystrophic calcification
Metastatic Calcification
 May occur in normal tissues whenever there is hypercalcemia
 Hypercalcemia also accentuates dystrophic calcification
 Four principal causes of hypercalcemia:
o ↑ PTH (hyperparathyroidism, ectopic PTH secretion by malignant tumors)
o Resorption of bone tissue (secondary to primary tumors of BM, or
diffuse skeletal metastasis, accelerated bone turnover, or immobilization)
o Vitamin D-related disorders (vit. D intoxication, sarcoidosis, idiopathic
hypercalcemia of infancy like Williams syndrome, cxd by abnormal
sensitivity to vit D)
o Renal failure (causes retention of phosphate  secondary
hyperparathyroidism)
 Less common causes includes:
o Aluminium intoxication (px w/ chronic renal dialysis)
o Milk-alkali syndrome (excessive ingestion of calcium and absorbable
antacids such as milk or calcium carbonate
 Occur throughout the body but mostly affects interstitial tissues of gastric mucosa,
kidneys, lungs, systemic arteries, pulmonary veins
o Excrete acid  have internal alkaline compartment  predisposes to
metastatic calcification
 May occurs as noncrystalline amorphous deposits or hydrocyapatite crystals
KEY CONCEPTS: Abnormal Intracellular Depositions and Calcifications
 Deposition of lipids
o Fatty change – accumulation of free TAGs in cells from excess intake or
defective transport; manifestation of reversible cell injury
o Cholesterol deposition – result of defective catabolism and excessive
intake; in macrophage and smooth muscle cells of vessel walls in
atherosclerosis
 Deposition of proteins – reabsorbed proteins in kidney tubules; Ig in plasma cells
 Deposition of glycogens – in macrophage of px w/ defects in lysosomal enzymes
that breakdown glycogen (glycogenoses)
 Deposition of pigments – indigestible pigments such as carbon, lipofiscin (product
of lipid peroxidation), or iron (due to overload; hemosiderosis)
 Pathologic calcification
o Dystrophic calcification – deposition of calcium at sites if cell injury and
necrosis
o Metastatic calcification – deposition of calcium in normal tissues, caused
by hypercalcemia (consequence of PTH excess)
CELLULAR AGING
 Cellular aging is the result of a progressive decline in cellular function and
viability caused by genetic abnormalities and the accumulation of cellular
and molecular damage due to the effects of exposure to exogenous
influences
DNA Damage
 Exogenous and endogenous factors threaten the integrity of nuclear and
mitochondrial DNA
 Werner Syndrome – premature aging; DNA helicase is defective (protein involved in
DNA replication and repair
o Defect in DNA helicase causes rapid accumulation of chromosomal damage
that mimic the injury that normally accumulates during cellular aging
 Genetic instability – characteristic of other disorders where px display some of the
manifestations of aging at increased rate
o Bloom syndrome and ataxia telangiectasia  mutated genes encode
proteins involved in repairing double-strand breaks in DNA
Cellular Senescence
 All normal cells have a limited capacity for replication, and after a fixed
number of divisions cells become arrested in a terminally nondividing state,
known as replicative senescence
 Aging is associated with progressive replicative senescence of cells
 Cells from children have the capacity to undergo more rounds of replication than do
cells from older people
 Two mechanisms underlie cellular senescence:
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 Telomere attrition - Progressive shortening of telomeres  results in
cell cycle arrest
- Telomeres – important for ensuring the complete
KEY CONCEPTS: Cellular Aging
replication of chromosome ends and for protecting the
 Cellular aging results from a combination of accumulating cellular damage, reduced
ends from fusion and degradation
capacity to divide (replicative senescence), reduced ability to repair damaged DNA,
- When somatic cells replicate  telomeres are shortened 
and defective protein homeostasis.
ends of chromosomes are not protected and seen as
o Accumulation of DNA damage: defective DNA repair mechanisms;
broken DNA  signals cell cycle arrest
conversely, caloric restriction activates DNA repair and is known to prolong
- Telomere length is maintained by nucleotide addition by
aging in model organisms
telomerase
o Replicative senescence : reduced capacity of cells to divide secondary to
- Immortalized cancer cells – telomerase is reactivated and
progressive shortening of chromosomal ends (telomeres)
telomere length is stabilized  allow proliferation of cells
o Defective protein homeostasis: resulting from impaired chaperone and
Activation of - CDKN2A locus encodes two tumor suppressor proteins,
proteasome functions
tumor suppressor known as p16 or INK4a  correlated with chronologic age
o Nutrient sensing system: caloric restriction increases longevity.
genes - By controlling G1 to S phase progression during the cell
Mediators may be reduced IGF-1 signaling and increase in sirtuins
cycle, p16 protects the cells from uncontrolled mitogenic
signals and pushes cells along the senescence pathway

Defective Protein Homeostasis

 Protein homeostasis involves two mechanisms:
o Those that maintain proteins in correct folded forms (mediated by
chaperones)
o Those that degrade misfolded proteins by the autophagy0lysosome system
and ubiquitin-proteasome system
 Normal folding and degradation of misfolded proteins are impaired with aging
 Rapamycin – promotes autophagy

Deregulated Nutrient Sensing

 Eating less increases longevity
 Caloric restriction increases life span in all eukaryotic species
 Two major neurohormonal circuits that regulate metabolism:
o Insulin and IGF-1 signaling pathway – IGF-1 mimics intracellular
signalling of insulin, informs cells of the availability of glucose and promote
anabolic state as well as cell growth and replication. IGF-1 has multiple
downstream targets; AKT and its downstream target mTOR (w/c is inhibited
by rapamycin
o Sirtuins – family of NAD-dependent protein deacetylases. There are seven
types of sirtuins distributed in different cellular compartments and have
nonredundant functions deisgned to adapt body functions to stress (food
deprivation and DNA damage). Sirtuins promote expression of genes whose
products increase longevity. Includes proteins that: inhibit metabolic
activity, reduce apoptosis, stimulate protein folding, and inhibit harmful
effects of oxygen free radicals.
 Sirtuins increase insulin sensitivity and glucose metabolism, (may be target for
treatment of diabetes
 Caloric restriction increases longevity both by reducing the signalling intensity of the
IGF-1 pathway and by increasing sirtuins
 Attenuation of IGF-1 leads to lower rates of cell growth and metabolism reduced
cellular damage  this effect can be mimicked by rapamycin
 Sirtuin-6 serves dual functions:
o Contribute to metabolic adaptations of caloric restriction
o Promote genomic integrity by activating DNA repair enzyme through
deacylation
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