INFLAMMATION

Definition: Inflammation is a response of living, vascularized tissues to injury.

It is a body defense reaction in order to eliminate or limit the spread (isolation) of injurious agent.
Causes of Inflammation
1. Infective agents: bacteria, viruses, fungi, parasites.
2. Necrotic tissue.
3. Immunological agents ( hypersensitivity , autoimmune)
4. Physical agents: heat, cold, radiation, mechanical trauma.
5. Chemical agents: organic and inorganic poisons/ toxins.
6. Foreign bodies (splinters, dirt, sutures)
Fundamental properties
1. Events in inflammatory response.
2. Harmful consequences of inflammation.
3. Local and systemic inflammation.
4. Mediators of inflammation.
5. Acute and chronic inflammation.
6. Termination of inflammation and initiation of tissue repair.
Events in inflammation:
The major Components à blood vessels and leukocytes
Alteration in vascular caliber.
Vascular dilationà to slow down blood flow
Increased permeability à leakage of proteins& leukocytes.
Changes in endothelium à adherence and migration of leukocytes.
Emigration of Leukocytes à accumulation and activationà ingestion and killing of microbes, dead cells and
foreign bodies.
Harmful consequences of inflammation
Inflammation is usually accompanied by local tissue damage
Inflammation may become potentially harmful, leading to life threatening diseases. (autoimmune diseases,
allergies).
Because the stimuli cannot be eliminated
Such harmful consequences of inflammation are referred as “SILENT KILLER.
Local and systemic inflammation:
Local inflammation:
Tissue reaction Feature Acute Chronic and damage is
largely confined inflammation inflammation to the site of
infection or Onset The initial and rapid Gradual damage.
Systemic Minutes or hours Days to weeks. inflammation:
Inflammatory Duration Short duration, Longer duration reaction is
systemic e.g. lasting for several disseminated
bacterial hours or a few days infections called
sepsis. Main Exudation: (edema) Mononuclear cells,
characteristics and emigration of proliferation of
leukocytes. blood vessels, and
deposition of
connective tissue
Cellular Mainly neutrophils Monocytes/
infiltrate macrophages and
lymphocytes
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Tissue injury Mild and self limited More tissue
and fibrosis destruction
Type of host Innate immunity, Adaptive immunity
defense
Local and Prominent Less
systemic signs
4.

Termination Of Inflammation And Initiation Of Tissue Repai r

1. Elimination of offenders.
2. Breakdown of mediators and leukocytes.
3. Activation of antiinflammatory mechanisms to prevent
excessive damage to the host.
Tissue repair
Repair is a series of events that heal damaged tissue.
1. Regeneration: Injured tissue is replaced by healthy tissue.
2. Scarring : Filling of residual defects with connective tissue
Cardinal Signs Of Inflammation
1. Rubor (redness)
2. Tumor (swelling)
3. Calor (heat)
4. Dolor (pain)
5. functio laesa (loss of function)
The steps in series inflammatory reaction
1. Recognition of offender by host cells and molecules.
2. Recruitment of leukocytes and plasma proteins from Circulation.
3. Activation of leukocytes and proteins to destroy and eliminate the
stimulus.
4. Termination of the reaction.
5. Tissue repair
Components Of Acute Inflammation
Three major components:
(1) Dilation of small vesselsà to increase in blood flow.
(2) Increased permeability of microvasculature à leakage of plasma
proteins and leukocytes recruitment.
(3) Emigration, accumulation and activation of leukocytes to eliminate the
offending agent
Release of mediators at the site of injury à efflux of plasma and leukocytes
recruitmentà recognized by phagocytesà liberation of cytokines and
mediatorsà inflammationà elimination of offender

Hemodynamic Changes: Changes in Vascular Flow and Caliber

Begin immediately after injury.
Earliest features
Vasodilatation à by the action of several mediators (histamine, on vascular
smooth muscle)
First involves the arterioles and then leads to opening of new capillary beds in the area.The result is increased
blood flow, which is the cause of heat and redness (erythema) at the site of inflammation.

Sequence of Changes in Vascular Flow and Caliber

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Transient vasoconstriction of arterioles: Immediate vascular response for few seconds.
Persistent progressive vasodilatation: Vasodilation follows, to increase flow (heat and redness) Vasodilatation
à increased blood volume in microvascular bed àredness and warmth
Progressive vasodilatationà elevation of local hydrostatic pressure à transudation of fluid into the
extracellular spaceà swelling
Stasis of flow Loss of fluid and vasodilationàslower blood flow à increased blood viscosity
Leucocytic margination
As stasis develops peripheral orientation of leucocytes (mainly neutrophils)

Lewis experiment of ‘Triple response’

Demonstrates hemodynamic changes
Elicited by firm stroking of skin of forearm with a pencil.
Reaction shows
i. Red line à local vasodilatation
ii. Flare à bright reddish appearance surrounding the red line.
iii. Wheal à swelling due to transudation of fluid
Increased Permeability Of The Microvasculature
Follow Vasodilation
Outpouring of protein-rich fluid into the extravascular tissues.
Normal fluid exchange depends on the starling law and intact endothelium
Starling law maintains the normal fluid balance between two forces
Forces that cause outward movement of fluid from microcirculation are intravascular
a. Hydrostatic pressure
b. Colloid osmotic pressure of interstitial fluid.
Forces that cause inward movement of interstitial fluid into circulation are
a. Intravascular colloid osmotic pressure
b. Hydrostatic pressure of interstitial fluid.
Normally endothelial layer is non-permeable
Several mechanisms are responsible for the increased permeability of postcapillary venules, a Hallmark of acute
inflammation.
1.Endothelial cell contraction in venules
2.Retraction of endothelial cells
3.Direct Endothelial injury,
4.Leukocyte mediated endothelkial injury
5.Leakiness in neovascularisation

Endothelial Cell Contraction In Venules (Immediate Transient Response )

Most common mechanism of vascular leakage.
Widening of intercellular junction (temporary gaps )
Mediators
Histamine ,Bradykinin, Leukotrienes And other chemical mediators
It occurs rapidly and is usually short-lived (15 to 30 minutes).
Example: thermal injury of forearm.
Retraction of endothelial cells
Reorganization of cytoskeleton and junctionà reversible retraction at the intercellular junctions à delayed
prolonged leakage.
Mediators (TNF)-α and IL-1.
Onset takes 4-6 hours after injury and lasts for 2-4 hours or more e.g. : burns, irradiation or ultraviolet radiation,
bacterial toxins, Late-appearing sunburn is a good example

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Direct Endothelial injury
Direct injury à endothelial cell necrosis and detachmentà physical gaps.
Affects all levels of microvasculature
May appear immediately after injury and last for
several hours or days
Leukocyte mediated endothelial injury
Adherence of leucocytes to the endotheliumà
activation of leucocytes à release of proteolytic
enzymes and toxic oxygen species à endothelial
injuryà increased vascular leakiness.
Affects mostly venules
Late response
Increased Transcytosis
Across the endothelium cytoplasm via
Intracellular channels (VEGF) promote vascular
leakage
Leakiness in neovascularisation
Leakage from regenerating capillaries
During healing the new capillary spouts are leaky

Cellular Events In Acute Inflammation

Important component of inflammation.
Purpose is to deliver leukocytes at the site of injury.
The most important leukocytes are phagocytes (neutrophils and macrophages)
They ingest and destroy bacteria ,necrotic tissue and foreign
The cellular phase of inflammation consists of 2 processes
1. Extravasation of leucocytes
2. Phagocytosis.
Extravasation: Leukocyte Recruitment to Sites of
inflammation
3. Extravasation:
The escape of leucocytes from the lumen of
microvasculature to the interstitial tissue.
Steps in extravasation:
1. Margination, rolling and adhesion of leukocytes in the
leumen.
2. Transmigration (diapedesis) across the endothelium.
3. Migration in interstitial tissue towards the chemotactic stimulus.

Margination

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Leukocyte rolling and Adhesion to Endothelium
After margination leukocytes adhere transiently to the endothelium, detach and bind again,
thus rolling on the vessel wall.
The cells finally adhere firmly (resembling pebbles over which a stream runs without
disturbing them) called pavementation.
Adhesion Of Leukocytes
The protein molecules involved in leukocyte adhesion and migration are
1. Selectins
2. Immunoglobulin Gene Superfamily Adhesion Molecule
3. Integrins, and their ligands
Selectins
The initial rolling interactions are mediated by selectins expressed on
1. Leukocytes (L-selectin)à homing of leukocytes.
2. Endothelium (E-selectin)à rolling and adhesion
3. Platelets and on endothelium (P-selectin)à rolling
P-selectin is preformed in endothelial Weible-Palade bodies.
Ligands for selectins: sialylated oligosaccharides bound to glycoprotein
backbones (s-Lewis X molecule)
The expression of selectins and their ligands is regulated by cytokines
including (TNF), IL-1, and chemokines.
Immunoglobulin Gene Superfamily Adhesion Molecule
Allow a tighter adhesion and stabilise the interaction between
leucocytes and endothelial cells.
Intercellular adhesion molecule-1 (ICAM-1).
Vascular cell adhesion molecule-1 (VCAM-1)
Platelet-endothelial cell adhesion molecule- 1 (PECAM-1) or CD31
( adhesion and migration)
Integrins
Function as receptor.
Provide firm adhesion between leukocytes and endothelium.
Activate during rolling, meanwhile receptors for integrins on the neutrophils are also stimulated
Within 1 to 2 hours endothelial expresses E-selectin and ligands for L-selectin.
Histamine and thrombin redistribute P-selectin from Weibel-Palade bodies
Leukocytes express L-selectin at the tips of their microvilli and also express ligands for E- and P-selectins.
The low-affinity interactions are at fast off rate, and can easily disrupt by the flowing blood.
As a result, the bound leukocytes bind, detach, and bind again, and thus begin to roll along the endothelial surface
Firm adhesion is mediated by integrins
TNF and IL-1 induce endothelial expression of ligands for integrins
VCAM-1, the ligand for the β1 integrin VLA-4

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ICAM-1, the ligand for the β2 integrins LFA-1 and Mac-1.
Chemokines bind to endothelial cell, and are displayed on the surface.
These chemokines bind to and activate the rolling leukocytes.

Leukocyte Migration Through Endothelium

Process of leukocyte recruitment is called transmigration or diapedesis.
It occurs mainly in postcapillary venules.
Chemokines stimulate the cells to migrate through interendothelial spaces toward the chemical concentration
gradient (site of injury )where the chemokines are being produced.
Molecules Involved In the Migration Of Leukocytes
Several molecules; A member of the immunoglobulin superfamily called CD31 or PECAM-1
Activated leukocytesà traverse endothelium à pierce
basement membrane (collagenases)àextravasation.
Then cells move toward the chemotactic gradient

Chemotaxis of Leukocytes
Chemotaxis: Locomotion of leukocytes along a chemical gradient. Occurs after transmigration
Substances responsible for chemotaxis are chemoattractants.
Chemotactic agents bind to receptors on leukocytes surface.
1. Exogenous : bacterial products
2. Endogenous
1. Cytokines (chemokine family e.g., IL-8)
2. Complement system Components , particularly C5a; and
3. Arachidonic acid (AA) metabolites, leukotriene B4 (LTB4).
Chemotactic agents bind to receptors on leukocytes surface.

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The Nature Of Leukocyte Infiltrate
• Neutrophils à during the first 6 to 24 hours
• Monocytes replace neutrophils in 24 to 48 hours
WHY neutrophils usually predominate in acute response ?
• More numerous in the blood
• Respond more rapidly to chemokines
• Attach more firmly to endothelial cells.
• Short life span of neutrophils in tissue, disappear within 24 to 48 hours
Monocytes : survive longer and can proliferate in the tissues.
Phagocytosis:
The process of engulfment of solid particulate material by the cells (cell-eating).
The cells performing this function are called phagocytes.
Two main types of phagocytic cells (scavengers)
1. Neutrophils
2. Monocytes and macrophages.
Phagocytes produce several proteolyitc enzyme
Phagocytosis involves three sequential steps
(1) Recognition and attachment of the particle to be ingested by leukocyte
(2) Engulfment with subsequent formation of a phagocytic vacuole
(3) Degradation or Killing of the ingested material.
Recognition of injurious agent occurs via opsonization.
Opsonization : coating of microoraganism with specific factors (Opsonin), for recognition by leukocyte
receptors and to enhance the efficiency of phagocytosis
Major opsonins
1. IgG antibodies
2. C3b
Engulfment
Particle binding to phagocyte receptors-à pseudopods encircle the particle to be ingested
Plasma membrane encloses the particle and form phagosome
Fusion of phagosome with lysosomal granuleà phagolysosome
During this process granule contents may release in tissue.

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 Intracellular Destruction of Microbes and Debris
Final step in the elimination of injurious agents.
Accomplished by
1. Reactive oxygen species (ROS or ROI)
2. Reactive nitrogen species, mainly derived from
NO.
3. Lysosomal enzymes destroy phagocytosed debris.
4. Neutrophil extracellular traps (NETS)
5. All killing mechanisms are sequestered in
lysosomes.

Oxygen Dependant Killing

A phase of increased oxygen consumption in neutrophil
Respiratory burst
ROS are produced by NADPH oxidase (also called
phagocyte oxidase)
Location of NADPH oxidase:
Resting neutrophils: plasma membrane and cytosol.
Activated neutrophils: cytosolic component translocate to
phagolysosomal membrane
ROS are produced within the phagolysosome to avoid
phagocyte damage.
H2O2-MPO-halide system
Most efficient bactericidal system.
Azurophilic granules of neutrophils contain the enzyme
myeloperoxidase
MPOàH2O2 in the presence of halides à hypochlorite (HOCl)
Destroys microbes by halogenation (halide binds covalently to cellular
constituents) or by oxidation of proteins and lipid.
Nitric Oxide
By the action of nitric oxide synthatase (NOS), àarginineàNO
Types of NOS:
1. Endothelial (eNOS)
2. Neuronal (nNOS)
3. Inducible (iNOS). Microbial killing
Activation of phagocytesà NO reacts with superoxide (O2 • ) à highly reactive peroxynitrite (ONOO−)
Attack and damage the lipids, proteins, and nucleic acids of microbes and host cells
Lysosomal Enzymes and Other Lysosomal Proteins
Lysosomal granules àkilling àreleaseà tissue damage.

Neutrophil Extracellular Traps (NETs)

Extracellular fibrillar networks Produced by neutrophils
Trap microbes and prevent spread of infection.
NETS consist of a viscous meshwork of nuclear chromatin (histones and associated DNA )à binds and
concentrates lysosomal granule proteins
During NET formation, nuclei of the neutrophils are lost, leading to cell death.
NETs can be detected in blood during sepsis
GOOD LUCK
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