Dyah Fauziah, M.

D
Deparment of Anatomical Pathology
Faculty of Medicine, Universitas Airlangga, Surabaya
References:
— Kumar V, Abbas AK, Aster JC; Robbins Basic
Pathology, 9th.
Topics:
— Overview of cell injury & cell death
— Causes of cell injury
— Mechanism of cell injury
— Cellular adaptation to injury
— Reversible & irreversible cell injury
— Program cell death – apoptosis
Overview of Cell Injury & Cell Death
— Cell death:
— Necrosis
— Pattern of cell death after pathologic stimuli
(abnormal stress).
— Characterized by cellular swelling, protein
denaturation, & organellar breakdown.
— Always pathologic.

— Apoptosis
— Internally controlled “suicide” program.
— Occurs in physiologic & pathologic state.
— Cell degeneration
— Nonlethal injury to cell --- cell degeneration
— Manifested as some abnormality of biochemical
function or structural abnormality or combined of
biochemical and structural abnormality
— Reversible
— May progress to necrosis if injury persist
Causes of Cell Injury
— Oxygen deprivation
— Hypoxia : oxygen deficiency
— Ischemia : loss of blood supply in a tissue due to
impeded arterial flow or reduced venous drainage.
Ischemia is the most common cause of hypoxia.
Injury due to ischemia more rapid & severe than
hypoxia.
— Inadequate oxygenation (e.c. cardiorespiratory failure)
— Oxygen carrying capacity < (e.c. anemia, CO poisoning)
— Chemical agents
— Any chemical substance can cause injury.
— Poisons --- alter membrane permeability, osmotic
homeostasis, or integrity of an enzyme --- cell death.
— Infectious agents
— Submicroscopic viruses to meter-long tapeworms.
— Physical agents
— Trauma, extremes of temperatures, radiation, electric
shock, & sudden changes in atmospheric pressure.
— Immunologic reaction
— Anaphylaxis
— Autoimmune disease
— Genetic defect
— Nutritional imbalance
— Nutritional deficiencies
— Excesses of nutrition
— Aging
 CHAPTER 2 Cell Injury, Cell Death, and Adaptations

Hypoxia, Multiple Mutations, cell Radiation, Infections,

ischemia injurious stimuli stress, infections other insults immunologic disorders

ATP ROS Accumulation of

misfolded proteins DNA damage Inflammation

Energy- Damage to ER Nucleus

dependent lipids, proteins,
functions nucleic acids Toxic molecules

Cell injury Apoptosis Apoptosis Necrosis or

apoptosis
Necrosis
Fig. 2.15 The principal biochemical mechanisms and sites of damage in cell injury. Note that causes and mechanisms of cell death by necrosis and apoptosis
are shown as being independent but there may be overlap; for instance, both may contribute to cell death caused by ischemia, oxidative stress, or radiation
ATP, Adenosine triphosphate; ROS, reactive oxygen species.

in hypoxia and ischemia) primarily impairs energy- are induced by transcription factors of the hypoxia-
dependent cellular functions, culminating in necrosis, inducible factor 1 (HIF-1) family. HIF-1 simulates the syn-
whereas damage to proteins and DNA triggers apop- thesis of several proteins that help the cell to survive in the
tosis. However, it should be emphasized that the very face of low oxygen. Some of these proteins, such as vascu-
Mechanism of Cell Injury
— Various causes of cell injury --- many different ways to
induce injury.
— General principles:
— The cellular response to injurious stimuli depends on
the type of injury, its duration, & its severity.
— The consequences of an injurious stimulus depend on
the type, status, adaptability & genetic makeup of the
injured cells.
— Four intracellular systems are particularly
vulnerable: (1) cell membrane integrity, (2) ATP
generation, (3) protein synthesis, (4) the
integrity of genetic apparatus.
— The structural & biochemical components of a
cell are integrally connected --- initial locus of
injury cause multiple secondary effects.
— Cellular function is lost far before cell death
occurs, & the morphologic changes of cell injury
(or death) lag far behind both.
 mentioned earlier, injury to lysosomal membranes results discus
in the enzymatic dissolution of the injured cell, which is oxidat
the culmination of injury progressing to necrosis. (ROS)
Schematic Asdiagram demonstrating
mentioned theinjurious
earlier, different relationship between
stimuli may have
induce
cellular deathcell
function, by necrosis
death &ormorphologic
apoptosis (Fig. 1–6 andof
changes Table
cell handl
injury. nobar
may e
seizur
Reversible Irreversible induc
cell injury cell injury Ultrastructural Light
changes microscopic
changes
Cell Cell death
function M
Gross Cell
EFFECT

morphologic almo
changes that
but i
Whe
(as a
and
may
repr
DURATION OF INJURY plasm
General biochemical mechanisms
— ATP depletion Ischemia and
ph
• Th
ATP --- source of wh
int
energy for every Mitochondrion
cus

process in the cell. Influx

Oxidative phosphorylation
The im
Loss of ATP synthesis - ATP
exper
delay
-- impede most critical toxins
ATP-d
Na+ pump Anaerobic glycolysis Detachment
homeostatic pathways. of ribosomes much
cellul
Influx of Ca2+
H2O, and Na+ Lactic
drial a
Glycogen pH Protein
acid synthesis increa
Efflux of K+ of rel
result
ER swelling
brane
Clumping of
Cellular swelling nuclear with
Loss of microvilli chromatin These
Blebs memb
memb
(whic
Figure 1–15 The functional and morphologic consequences of deple- tion),
tion of intracellular adenosine triphosphate (ATP). ER, endoplasmic hasten
reticulum.
— Oxygen deprivation or generation of reactive oxygen
species.
— Oxygen deprivation --- ischemic cell injury
— Reactive oxygen species (free radicals) ---- important
mediators of cell death.
free radical lipid peroxidation.
 14 C H A P T E R 1 Cell Injury, Cell Death, and Adaptations

Ca2+ Extracellular Accu

Ca2+
(Oxi
Injurious agent
Free
electr
— Loss of calsium extre
inorg
homeostasis. Mitochondrion Smooth ER they
lular
react
— Cell injury Ca2+ Ca2+ Ca2+
are th
there
Increased cytosolic Ca2+ Re
deriv
intracellular Ca Activation of
lished
by f
cellular enzymes
Ca2+ reper
injury
Mitochondrial micro
deleterious effects Phospho-
lipase
Protease Endo- ATPase
nuclease permeability cause
transition Th
Phospho- Disruption by tw
lipids of membrane • RO
and cytoskeletal
proteins du
du
tio
red
MEMBRANE NUCLEAR tro
ATP
DAMAGE DAMAGE
ho
sh
ox
Figure 1–17 Sources and consequences of increased cytosolic calcium inc
in cell injury. ATP, adenosine triphosphate; ATPase, adenosine ge

• Lipid breakdown products. These include unesterified
— Defects in membrane
permeability.
— Primary: toxin bacteria,
viral protein, component
Activation of proteases by increased cytosolic Ca may
cause damage to elements of the cytoskeleton, leading w
to membrane damage. g
in
th
free fatty acids, acyl carnitine, and lysophospholip-
ids, all of which accumulate in injured cells as a result
of phospholipid degradation. These catabolic products
have a detergent effect on membranes. They may also
either insert into the lipid bilayer of the membrane or
exchange with membrane phospholipids, causing
changes in permeability and electrophysiologic
alterations.
O2 Cytosolic Ca2+

complement, etc. Reactive ATP

oxygen Phospholipase Protease

— Secondary: species activation activation

Lipid Phospholipid Phospholipid Cytoskeletal

loss of ATP synthesis, peroxidation reacylation/
synthesis
degradation damage

phospholipase activity. Phospholipid Lipid

loss breakdown
products

MEMBRANE DAMAGE

Figure 1–20 Mechanisms of membrane damage in cell injury. Decreased

O2 and increased cytosolic Ca2+ typically are seen in ischemia but may T
accompany other forms of cell injury. Reactive oxygen species, which ce
often are produced on reperfusion of ischemic tissues, also cause mem- co
brane damage (not shown). a

Figure 1–15 The functional and morphologic consequences of deple-
tion of intracellular adenosine triphosphate (ATP). ER, endoplasmic
reticulum.
(which are responsible for DNA and chromatin fragmenta-
tion), and adenosine triphosphatases (ATPases) (thereby
hastening ATP depletion). Increased intracellular Ca2+
levels may also induce apoptosis, by direct activation of
caspases and by increasing mitochondrial permeability.

• Prolonged or worsening depletion of ATP causes

structural disruption of the protein synthetic apparatus,
manifested as detachment of ribosomes from the rough
— Mitochondrial damage
ER (RER) and dissociation of polysomes into mono- O2 supply Survival signals
somes, with a consequent reduction in protein synthesis. Toxins DNA, protein
Ultimately, Mitochondrial integrity is
— there is irreversible damage to mitochon- Radiation damage
drial and lysosomal membranes, and the cell undergoes
necrosis. critical for cell survival.
Pro-apototic proteins
— Mitochondria,
Mitochondrial Damage and Dysfunctiondirectly / Anti-apoptotic proteins

Mitochondriaindirectly
may be viewed ---as targets of that
“mini-factories”
produce life-sustaining energy in the form of ATP. Not
surprisingly, most
therefore,types of critical
they are also injury.players in cell Mitochondrial damage
injury and death (Fig. 1–16). Mitochondria are sensitive to or dysfunction
many types of injurious stimuli, including hypoxia, chemi-
cal toxins, and radiation. Mitochondrial damage may result
in several biochemical abnormalities: ATP Production
• Failure of oxidative phosphorylation leads to progres- generation of ROS Leakage of
mitochondrial
sive depletion of ATP, culminating in necrosis of the cell,
proteins
as described earlier.
• Abnormal oxidative phosphorylation also leads to the Multiple cellular abnormalities
formation of reactive oxygen species, which have many
deleterious effects, described below. NECROSIS APOPTOSIS
• Damage to mitochondria is often associated with the
Figure 1–16 Role of mitochondria in cell injury and death. Mitochondria
formation of a high-conductance channel in the mito- are affected by a variety of injurious stimuli and their abnormalities
chondrial membrane, called the mitochondrial permea- lead to necrosis or apoptosis. This pathway of apoptosis is described in
bility transition pore. The opening of this channel more detail later. ATP, adenosine triphosphate; ROS, reactive oxygen
leads to the loss of mitochondrial membrane potential species.
Cellular Adaptation to Injury
— In normal conditions, cells constantly adapt to changes
in their environment.
— Physiologic adaptations
— Pathologic adaptations
— Cellular adaptation:
— Atrophy
— Hypertrophy
— Hyperplasia
— Metaplasia
Atrophy
— Definition: Shrinkage in the size of the cells by the loss
of cell substance.
— If sufficient number is involved – the entire tissue /
organ becoming atrophic.
— Atrophic cells --- diminished function, but not dead
— Causes of atrophy
— Decreased workload
— Loss of innervation
— Diminished blood supply
— Inadequate nutrition
— Loss of endocrine stimulation
— aging
— Atrophy ---- reduction of the organelles
— Mechanism:
—Not fully understood.
— Affect the balance between synthesis & degradation.
— Mammalian cells --- 2 proteolytic systems:
— Lysosomes: contain protease & other enzymes.
— Ubiquitin-proteosome pathway:
— Degradation of cytosolic & nuclear proteins

— cytosolic & nuclear protein --- conjugated to

ubiquitin --- degraded within proteosome (large
cytoplasmic proteolytic organelle)
— Atrophy --- autophagic vacuoles >> (fusion of
lysosomes with intracellular organelles & cytosol that
allows the catabolism & turnover of self-components
in a given cell)
— Some of the cell debris within the autophagic vacuole
may resist digestion & persist as membrane bound
residual bodies (e.g. lipofuscin).
Hypertrophy
— Definition: increase in the size of cells & consequently
an increase in the size of organ.
— Hypertrophy --- larger cells, no new cells.
— Cause:
— Increased demand
— Hormonal stimulation
— Hypertrophy
— Physiologic
— Pathologic
— Hypertrophy & hyperplasia can occur together,
triggered by the same stimuli.
— Physiologic hypertrophy
— Muscle hypertrophy in weight lifter
— Enlargement of uterus during pregnancy
— Pathologic hypertrophy
— Cardiac enlargement in hypertension or aortic valve
disease.
— Pure hypertrophy occur in cell that cannot divide in
the adult --- skeletal & heart muscle cells.
— Cardiac hypertrophy:
— Mechanical triggers (stretch)
— Trophic triggers (activation of α adrenergic receptor)
Hyperplasia
— Definition: increase number of cells in tissue / organ
— Can occur together with hypertrophy
— Physiologic hyperplasia
— Hormonal hyperplasia
— Compensatory hyperplasia
Hyperplasia is also important in wound healing.
— Pathologic hyperplasia
— Mostly caused by excessive hormonal (e.g endometrial
hyperplasia) or growth factor stimulation.
— Pathologic hyperplasia constitutes a fertile soil in
which cancerous proliferation may eventually arise ---
endometrial hyperplasia will increase risk of
developing endometrial cancer.
Metaplasia
— Definition: reversible change in which one adult cell
type (epithelial or mesenchymal) is replaced by
another adult cell type.
— Metaplasia --- reprogramming of epithelial stem cells
or undifferentiated mesenchymal cells in connective
tissue.
— Examples of metaplasia in epithelial cells:
— ciliated columnar epithelium --- squamous in
respiratory tract of heavy smoker.
— stone in salivary duct, pancreas, & gall bladder:
metaplasia of columnar epithelium --- squamous.
— Chronic gastric reflux: metaplasia of squamous cell in
distal esophagus --- intestine-type columnar epithel.
(Barret esophagus)
Metaplastic epithelium --- has survival advantages but
protective mechanism are lost.
The influences that induce metaplastic transformation, if
persistent may induce cancer transformation.
squamous metaplasia pada endocervix:
Barret esophagus:
Schematic diagram of columnar to squamous metaplasia:
— Metaplasia may also occur in mesenchymal cells.
— Bone & cartilage formation in tissues where they are
normally not encountered.
— Commonly metaplasia in mesenchymal tissue is part of
disease entity (eg. Myositis ossificans) not an adaptive
response.
Reversible & Irreversible Cell Injury

— There are 4 cell systems

that particularly
vulnerable to injury
— Persistent / excessive
injury --- irreversible
Mechanism of irreversible injury
— Two phenomena characterize irreversibility:
— Inability to reserve mitochondrial dysfunction
— Profound disturbances in membrane damage
— Membrane damage is a central factor in the
pathogenesis of irreversible injury
— Causes of membrane damage:
— Progressive loss of membrane phospholipids
— Cytosceletal abnormalities
— Toxic oxygen radicals
— Lipid breakdown product
Morphology of reversible cell injury
— Ultrastructural changes:
— Plasma membrane
alteration
— Mitochondrial change
— Dilatasion of the ER
— Nuclear alteration
— 2 morphologic patterns:
— Cellular swelling
— Fatty change
— Cellular swelling:
— First manifestation of almost form of injury to cell
— Cells are incapable of maintaning ionic & fluid homeostasis
— Gross: pallor, turgor >, weight >.
— Microscopic: small & clear vacuole in cytoplasm --- hydropic
change
Hydropic Change:
— Fatty change
— Occur in hypoxic & toxic /
metabolic injury
— Manifestation: lipid
vacuoles in cytoplasm.
— Principally encountered in
cells participating in fat
metabolism (hepatocytes
& myocardial cells)
Morphology of irreversible cell injury-necrosis
— Necrosis: a sequence of morphologic changes that
follow cell death in living tissue.
— The morphologic appearance of necrosis is the result
of 2 essentially concurrent processes:
— Enzymatic digestion of the cell
— Autolysis (lysosomes from dying cells)
— heterolysis (lysosomes from leukocytes)
— Denaturation of proteins
— Morphology:
— > eosinophilia
— > glassy homogenous appearance
— vacuolated cytoplasm
— Nuclear changes: karyolisis, pyknosis, karyorhexis
normal nuclei (left) & picnotic nuclei (right).
Karyorrhexis & karyolisis:
— Types of necrosis:
— Coagulative Necrosis
— Liquefactive Necrosis
— Caseous Necrosis
— Fat Necrosis
— Fibrinoid necrosis
— Coagulative Necrosis
— denaturation proteins is the primary pattern
— Preservation of the basic architecture of the tissue.
— Occur in all organs except the brain.
— Liquefactive necrosis
— enzymatic digestion is
prominent
— Occur in:
— bacterial / fungal Infection
— brain
— Completely digest the dead
cells.
— Gangrenous necrosis
— Is not a distinctive form of
necrosis.
— Clinical term --- refers to
ischemic coagulative
necrosis (frequently of a
limb).
— When there is
superimposed infection
with liquefactive
component --- called wet
gangrene
— Caseous Necrosis
— Distinctive form of
necrosis encountered in
tuberculous infection
— Gross: Cheesy, white
appearance of the central
necrotic area
— Microscopic: necrotic
focus is composed of
structureless, amorphous
granular debris enclosed
within a distinctive ring of
granulomatous
inflammation.
— Fat necrosis
— not specific pattern of
necrosis.
— Describes focal area of fat
destruction, typically
occurring after pancreatic
injury (acute pancreatitis),
as a result from release of
pancreatic enzymes into
peritoneal cavity --- fat
saponification.
— Fibrinoid necrosis
— Special form of necrosis, usually occurs in immune
reaction
— Deposit complex of Ag and Ab, produce a bright pink
amorphous appearance on H&E --- called fibrinoid
— Occurs in immune-mediated disease (e.g polyarteritis
nodosa) Mechanisms of Cell Injury 11

Figure 1–13 Fibrinoid necrosis in an artery in a patient with polyarteritis

— Necrosis --- damage of cellular membrane --- leakage of
cellular enzymes --- digest the cell --- elicits local host
reaction: inflammation --- repair process

— Necrosis --- damaged cell membrane --- leakage of

intracellular proteins into circulation --- tissue-specific
necrosis can be detected using blood / serum samples
— Cardiac muscle: enzyme creatin kinase, contractile protein
troponin
— Hepatocytes: transaminase
— Hepatic bile duct epithelium: enzyme alkaline phosphatase
Program Cell Death - Apoptosis
— Cell death that is triggered by cell’s internal control ---
programmed cell death.
— Apoptosis ≠ necrosis --- (suicide><homicide), but can
be triggered by the same stimulus.
— Apoptosis in physiologic conditions:
— The programmed destruction of cells during embryogenesis
— Hormone-dependent involution in the adult
— Cell deletion in proliferating cell populations
— Deletion of autoreactive T cells in the thymus.
— Cell death induced by cytotoxic T-cells
— Apoptosis in pathologic conditions:
— Cell death due to mild injurious stimuli
examples: radiation & anticancer drugs ---
damage DNA --- irreparable DNA damage ---
cells undergo suicide (apoptosis).
— Certain viral infection (hepatitis virus).
— Cell death in tumors.
ell Death, and Adaptations

Table 2.2 Physiologic and Pathologic Conditions Associated

With Apoptosis
Condition Mechanism of Apoptosis
Physiologic
NORMAL During embryogenesis Loss of growth factor signaling
CELL (presumed mechanism)
Turnover of proliferative tissues Loss of growth factor signaling
(e.g., intestinal epithelium, (presumed mechanism)
lymphocytes in bone marrow,
and thymus)
Involution of hormone- Decreased hormone levels lead
dependent tissues (e.g., to reduced survival signals
Condensation endometrium)
of chromatin Decline of leukocyte numbers Loss of survival signals as
at the end of immune and stimulus for leukocyte
inflammatory responses activation is eliminated
Membrane blebs Elimination of potentially Strong recognition of self
harmful self-reactive antigens induces apoptosis by
lymphocytes both the mitochondrial and
death receptor pathways
Pathologic
DNA damage Activation of proapoptotic
proteins by BH3-only sensors
Accumulation of misfolded Activation of proapoptotic
Cellular proteins proteins by BH3-only sensors,
fragmentation possibly direct activation of
caspases
Infections, especially certain Activation of the mitochondrial
viral infections pathway by viral proteins
Killing of infected cells by
APOPTOSIS cytotoxic T lymphocytes, which
activate caspases
— Morphology (EM):
— Cell shrinkage
— Chromatin condensation
— Formation of cytoplasmic blebs & apoptotic
bodies
— Phagocytosis of apoptotic cells
— Apoptosis --- intact cytoplasm --- no enzymatic
leakage --- no inflammatory reaction.
38 CHAPTER 2 Cell Injury, Cell Death, and Adaptations

Table 2.2 Physiologic and Pathologic Conditions Asso

With Apoptosis
Condition Mechanism of Apop
Physiologic
NORMAL During embryogenesis Loss of growth factor si
CELL (presumed mechanism
Turnover of proliferative tissues Loss of growth factor si
(e.g., intestinal epithelium, (presumed mechanism
lymphocytes in bone marrow,
and thymus)
Involution of hormone- Decreased hormone lev
dependent tissues (e.g., to reduced survival si
Condensation endometrium)
of chromatin Decline of leukocyte numbers Loss of survival signals a
at the end of immune and stimulus for leukocyte
inflammatory responses activation is eliminated
Membrane blebs Elimination of potentially Strong recognition of se
harmful self-reactive antigens induces apop
lymphocytes both the mitochondri
death receptor pathw
Pathologic
DNA damage Activation of proapopto
proteins by BH3-only
Accumulation of misfolded Activation of proapopto
Cellular proteins proteins by BH3-only
fragmentation possibly direct activat
caspases
Infections, especially certain Activation of the mitoch
viral infections pathway by viral prote
Killing of infected cells b
APOPTOSIS cytotoxic T lymphocyt
Apoptotic activate caspases
body

poptosis in pathologic conditions. Apoptosis el

Phagocytosis cells that are damaged beyond repair. This is se
Phagocyte of apoptotic cells there is severe DNA damage, for example, af
and fragments sure to radiation and cytotoxic drugs. The accu
of misfolded proteins also triggers apoptotic d
underlying mechanisms of this cause of cell d
its significance in disease are discussed late
context of ER stress. Certain infectious agents,
Fig. 2.11 Apoptosis. The cellular alterations in apoptosis are illustrated.
— Histologic feature (H&E):
— Apoptotic cell appear as round / oval mass with intensely
eosinophilic cytoplasm & condensed fragment of nuclear
chromatin.
Mechanism of apoptotic
— Four basic process:
— Signaling
— Intrinsic (mitochondrial) pathway
— withdrawal of growth factors / hormones
— DNA damage by radiation, toxins, free radicals
— Protein missfolding
— Extrinsic (death receptor-initiated) pathway --- specific receptor-
ligand interactions (Fas, TNF receptors)
— Release granzymes from cytotoxic T cell
— Control & integration
— Adapter protein
— Regulation protein (BCL-2 family of proteins)

— Execution
— Removal of dead cells
— Phagocytosis by neighboring cell or macrophage
Mechanism of apoptotic