PATHOLOGY

HSC 381/581
Pathology Web

INFLAMMATION
and
REPAIR
(Robbins Chapter 2)

1
 Overview of Inflammation
“Inflammation is a protective response to eliminate
the cause of injury and its resultant effect.”
Though connected with healing and repair,
inflammation can have potential to cause harm .
e.g. anaphylactic reactions, rheumatoid arthritis,
atherosclerosis

Inflammation divided into two patterns:

Acute inflammation
– rapid onset, short duration, with fluid and
protein exudation, and leucocyte accumulation,
mainly neutrophils
Chronic inflammation
– slow, longer duration, predominance of
lymphocytes and macrophages, with vascular
proliferation and fibrosis
2
 Steps of Inflammation
The Five R’s:

1. Recognizing the injury causing agent

– by phagocytes and dendritic cells
2. Recruitment of leucocytes (WBCs)
– Neutrophils, monocytes/macrophages, lymphocytes
3. Removal of agent after destroying it
– Phagocytosis, oxidative burst and extrusion
4. Regulation of response, and
– regeneration and repair
5. Resolution (scarring and fibrosis)
– scar formation and remodelling

3
 Causes of inflammation
1. Infection
2. Trauma
3. Physical injury from thermal extremes or from
ionizing radiation
4. Foreign bodies
5. Chemical injury
6. Immunologic injury
7. Tissue death (necrosis) - inflammatory changes
occur in viable tissue adjacent to necrotic
areas

▼
4
 Acute Inflammation
This is the immediate and early response to
injury, lasting from a few minutes to a few
days, to deliver the WBCs and plasma
proteins to the site of injury.

It has 2 major components:

 Vascular changes
– vasodilation and increased permeability
 Cellular events
– recruitment and activation of leukocytes,
accumulation of leukocytes (mainly
neutrophils) at the focus of injury
In addition, there is a local release of
chemical mediators.
5
 Classic signs of acute
inflammation
Calor – Heat (due to increased blood
flow)
Rubor – Redness (due to dilation of
vessels & histamine-mediated reaction)
Tumor – Swelling (due to extravascular
accumulation of fluid)
Dolor – Pain (due to increased pressure
and Bradykinin release)
Functio laesa – Loss of function
6
Five classic signs of acute
inflammation
The
cardinal
signs of
inflammati
on is seen
in this
patient
with acute
cellulitis of
the lower
extremity:
Rubor,
Calor, 7
 Vascular Changes
1. Arteriolar dilation
− Initial vasoconstriction (only a few seconds),
followed by arteriolar dilation; induced by
histamine release
2. Increased vascular permeability
− Vessels become more permeable forcing
movement of protein-rich fluid into
extravascular tissues; induced by histamine,
kinins and other mediators
3. Increased blood viscosity
− blood becomes more concentrated with RBCs,
leading to ‘stasis’ of blood within capillaries.
4. Margination
− Leukocytes, mainly neutrophils adhere along
endothelial surface of vessels
5. Transmigration
– They then migrate/squeeze (Diapedesis)
Diapedesis through
the vessel wall into the interstitial tissue. 8
Acute Inflammation
 The major local
manifestations of
acute
inflammation:
 vascular dilation
(causing erythema
and warmth),
 extravasation of
plasma fluid and
proteins (edema),
and
 leukocyte
emigration and
accumulation in
the site of injury 9
9
 Increased Vascular
Permeability
 Increased blood flow ↑’es
intravascular hydrostatic
pressure; causes movement of
protein-rich fluid from capillaries
to interstitium called exudate

 This leads to edema resulting in

decrease in intravascular colloid
osmotic pressure and increase in
interstitial fluid osmotic pressure Fluid and protein
leakage

 Non-inflammatory conditions
however result in edema due to
protein-free transudate, as a
consequence of reduced venous
return leading to ↑’ed
10
intravascular hydrostatic pressure
 Cellular Events
 Margination and Rolling within the lumen:
– as blood flows through the venules, leukocytes are
pushed to the periphery of vessels ( margination);
they tumble and transiently stick to walls of vessels
(rolling) by specific binding receptors called
‘Selectin.’
 Adhesion and Transmigration across
endothelium:
– leukocytes firmly attach to endothelium (mediated by
integrins & ligands) and slowly squeeze themselves
between cells into extravascular space ( diapedesis)
Diapedesis predominantly occurs in the venules
 Migration in interstitium: Chemotaxis
– eventually leukocytes move towards sites of injury
along a chemical gradient
11
 Cellular Events

capillary walls
neutrophils

12
 Chemotax
is
Chemotaxis is the
process by which
leukocytes are
attracted to and move
toward an injury site.
 It is mediated by
diffusible chemical
agents; movement of
leukocytes occurs
along a chemical
gradient.
 The chemotactic
 Leukocytes move
factors also induce
leukocyte activation by
extending
pseudopods 13
 Chemotaxis – Contd…
Chemotactic factors, produced at the site of
injury include:
 Products from bacteria
 Complement components (mainly C5a)
 Arachidonic acid metabolites (leukotrienes)
 Cytokines
These factors are produced endogenously in
response to infections/tissue damage
Neutrophils predominate in first 6-24
hours; replaced by monocytes in
24-48 hours
Exceptions occur – e.g. pseudomonas,
viral infections, allergic
reactions
14
 Phagocytosis and
Degranulation
Leukocytes are activated; they remove bacteria by
phagocytosis
This occurs in 3 distinct steps:
 Recognition and attachment of offending particle to
leukocyte
 Engulfment forming a phagocytic vacuole
 Killing and degradation of ingested material
Recognition and attachment is facilitated by serum
proteins called Opsonins.
Opsonins Coating the microbe by
opsonins for recognition is called Opsonization.
Leukocytes have specific surface receptors for these
opsonins.
Important opsonins are:
Antibodies, especially Immunoglobulin G (IgG) – most important
Complement proteins (of C3b)
Collectins
15
Phagocytosis and Degranulation
– Contd.
 Phagocytosis is characterized by internalization of
opsonized particle by pseudopodial extensions from
the surface of leukocytes, enclosing the foreign
particle (engulfment), and forming an internal
vacuole, the phagosome.

 Phagosomes fuse with cytoplasmic lysosomes

forming phagolysosomes,
phagolysosomes releasing lysosomal
enzymes into it

The final step is killing and degradation of microbes

within phagolysosomes, accomplished by lysosomal
enzymes and by reactive oxygen species (ROS) that
are generated by an oxidative burst (sudden increased
oxygen consumption, glycogenolysis, glucose oxidation and
16
ROS production).
Phagocytosi  Phagocytosis occurs in
s specialized cells called
phagocytes, which
include macrophages,
neutrophils, and other
white blood cells;
 Invagination produces a
vesicle called a phago-
some, which usually
fuses with one or more
lyso-somes containing
hydro-lytic enzymes;
 Materials in the phago-
some are broken down
by these enzymes and
de-graded;
Phagocytosis and
Degranulation
Phagocytosis of a particle
(bacterium) involves:
1)attachment and binding of
Opsonized microbe (Collectins
or C3b compliment or
immunoglobulin G) to receptors
on leukocyte surface, followed
by
2)engulfment and
3)fusion of the phagocytic
vacuole with granules of
lysosomes, degranulation,
and killing of microbe.

18
 Realtime Phagocytosis

• http://highered.mcgraw-hill.
com/olc/dl/120067/bio01.swf
• (please copy and paste this
link to see the video)
 Intracellular Microbial
Killing
Oxygen-dependent microbial killing
It is the most important intracellular microbicidal
process.
Important microbicidal agents are ROS (Reactive
Oxygen Species) and lysosomal enzymes
Steps:
1.Phagocytosis initiates an oxidative burst (↑’ed O2,
glycogenolysis, ↑’ed glucose oxidation and generation of
ROS).
– Leucocyte enzyme NADPH oxidase is activated
that oxidizes NADPH in phagosomal membrane.

20
Oxygen-dependent microbial
killing – Contd.
2. Oxygen is converted to superoxide anion (ROS) in
the reaction, which is further converted into
hydrogen peroxide (H2O2) by dismutation. But H2O2
is not a powerful microbicidal agent

3. However, in the presence of the lysosomal enzyme

myeloperoxidase and a halide ion (chloride), H2O2
is converted to HOCL (hypochlorous radical) which
disrupts cell walls of bacteria killing them. This
process is referred to as the myeloperoxidase-
halide system of bacterial killing.

The dead bacteria is then degraded by lysosomal

enzymes called hydrolases (esp. elastase). 21
Intracellular Microbial Killing
– Contd.
Oxygen-independent
microbial killing

 Is much less effective that O2-dependent

killing.
 Is mediated by proteins such as
lysozyme, major basic proteins,
defensins, arginase, and lactoferrin.

22
 Types of inflammatory cells
1. Neutrophils
- Most prominent inflammatory cells in acute
inflammation during the first several hours (6-24
hrs); short-lived; mobilized from storage pool of
neutrophils in bone marrow by the action of IL-1 and
TNF.
2. Monocytes-macrophages
- After 1-2 days, neutrophils are replaced largely by
monocytes that transform into macrophages, which
on activation can engulf larger particles; live longer
than neutrophils.
- Macrophages are present in other organs: in liver
(Kupffer cells), spleen, lymph nodes (sinus
histiocytes), CNS (microglial cells), lungs (alveolar
macrophages)
23
Types of inflammatory cells
– Contd.
3. Lymphocytes
- T and B lymphocytes are the most prominent
inflammatory cells in many viral infections, and
along with monocytes-macrophages and plasma
cells, are involved in chronic inflammation.

4. Eosinophils
- Predominant inflammatory cells in allergic
reactions and parasitic infestations, and some
forms of chronic inflammation. Their granules
contain major basic protein , a eosinophil
cationic protein that is highly toxic to parasites
and tissue cells.

24
 Types of inflammatory cells –
Contd.
5. Mast cells:
- They participate in both acute and
chronic inflammations. Mast cells with
IgE antibodies are the main cells
involved in allergic reactions, esp.
anaphylactic shock

6. Plasma cells:
– Develop from activated B-lymphocytes
– They produce antibodies against the
antigen.

25
Mixed Inflammatory Infiltrate
Eosinophils

Neutrophils
Plasma cells

Macrophages

26
Chemical Mediators of
Inflammation

27
Cell-Derived Chemical Mediators
Amines
Histamine:
– Preformed, present in mast cells,
circulating basophils and platelets; released
in response to stimulus.
– Causes arteriolar dilation, increased
vascular permeability
– It is immediately inactivated by histaminase.

Serotonin: (5 HT)
– Preformed and found within platelets
– Induces vasoconstriction during clotting
– Released during platelet aggregation.
28
 Neuropeptides
– These are small proteins (Substance P),
they initiate inflammatory responses,
– Transmit pain signals, regulate vessel
tone, increase vascular permeability
– Secreted from nerves (in lung, GI tract)

Platelet-Activating Factor (PAF)

– Generated from membrane
phospholipids of leukocytes,
endothelium and platelets
– Stimulates platelets to aggregate,
induces broncho-constriction, 100 to
1000 times more potent than histamine
in vasodilation and increasing
permeability of vessel wall 29
 Arachidonic Acid Metabolites
(Eicosanoids):
Prostaglandins, Leukotrienes, and
Lipoxins
 AA is a polyunsaturated fatty acid and is present
in membrane phospholipids
 Their metabolites act at all steps of inflammation
 They are produced by mast cells, leukocytes,
endothelial cells and platelets
 Agents that inhibit them also decrease
inflammation
 AA metabolism proceeds along 2 pathways:
1. Cyclogenase pathway
2. Lipogenase pathway

30
 Cyclogenase pathway
– stimulates synthesis of prostaglandins
(PGE2, PGD2), prostacyclin (PGI2) and
thromboxane A2 (TXA2) (vasoconstriction)
 Prostaglandins cause vasodilation, edema
and are involved in pathogenesis of pain and
fever
 Thromboxane A2 causes platelet aggregation
and vasoconstriction, while PGI2 inhibits it
 Lipogenase pathway
– synthesize leukotrienes (chemotactic
agent; also cause vasocontriction and
bronchospasm) and lipoxins. Lipoxins
function mainly as inhibitors of
inflammation.
Aspirin and NSAIDs block eicosanoid synthesis
31
32
Role of Prostaglandin Inhibitors
Asprin and NSAIDs (Ibuprofen) inhibit
cyclooxygenase pathway and block Prostaglandin
systhesis

Two forms of cyclooxygenase enzymes are present

– COX-1 and COX-2. Prostaglandin generated by
COX-1 in gastric mucosa, has protective action
against acid-induced damage.

Asprin and NSAIDs inhibit both COX-1 and COX-2

reducing inflammation but predisposing to
gastric ulceration. Highly selective COX-2
inhibitors are now available that do not hurt
gastric mucosa. However, they lead to greater
incidence of acute coronary artery disease
because of prostacylin (PGI 2) synthesis
inhibition.
One consequence of acute inflammation is drug-induced
ulceration on epithelial surfaces. The gastric mucosa above
has been lost due to ulceration. A larger ulcer & several
adjacent smaller ones with surrounding erythema appear at
the left of center. 34
Chemical Mediators – Contd.

Cytokines
 They are polypeptides involved in
early inflammatory reactions and in
later adaptive immune responses
 Some stimulate bone marrow
precursors to produce more
leukocytes
 Their secretion is typically transient
and tightly regulated.
 Important cytokines are:
Interleukins, Tumor necrosing factor
(TNF), chemokines, and interferons 35
36
 Reactive Oxygen Species
(ROS)
 These oxygen-derived free radicals are
synthesized via NADPH pathway within
neutrophils and macrophages

 They destroy microbes and necrotic cells and

increase production of cytokines at low levels

 At high levels they cause tissue injury

themselves

 Fortunately, they are controlled by several

antioxidant protective mechanisms (catalase,
superoxide dismutase, glutathione) within
tissues and blood
37
 Nitric Oxide
 Important mediator in several physiologic and
pathologic states. It is a short-lived (half-life
measured in seconds) free radical gas,
synthesized de novo and has many functions.
– It regulates neurotransmitter release and
blood flow in brain
– It kills microbes and tumor cells
– It causes vascular smooth muscle
relaxation (vasodilation)
– It is antagonistic to all stages of platelet
activation.
– It reduces leukocytes recruitment at
inflammatory sites 38
 Lysosomal Constituents

 Present mainly in neutrophils and macrophages

 Composed mainly of enzymes like acid proteases

(act within phagolysomes) and neutral proteases
(act in ECM)

 They digest phagocytosed microbes

 Their potentially damaging effects are controlled

by antiproteases (α1-antitrypsin) in serum and
tissue fluids

 Deficiencies of these inhibitors result in tissue

destruction e.g. α1-antitrypsin deficiency causes
panacinar emphysema 39
 Plasma-derived mediators
Plasma Proteases

Three systems involved: Kinin, Clotting and Compliment

systems
The first two below are released by initial activation of
Hageman factor (Factor XII).

Kinin system
– Leads to formation of bradykinin which increases
vascular permeability, arteriolar dilation, and
bronchial smooth muscle constriction; and
kallikrein which activates factor XII. Their actions
are short-lived.
Clotting system
– Causes thrombin activation which reacts with
fibrinogen to form fibrin clot. Thrombin enhances
leukocyte adhesion to endothelium, increases
permeability and is chemotactic; it also activates
fibrinolytic system 40
 Compliment system

 Plays an important role in immunity and

inflammation. Compliment proteins opsonize
particles for phagocytosis, increase vascular
permeability and chemotaxis
Components C1 to C9 present as inactive forms
in plasma; upon activation become proteolytic
and set up an enzymatic cascade (by 3 pathways –
classical, alternative and lectin)
Fragments C3a and C5a (anaphylotoxins)
increase vascular permeability and vasodilation
in anaphylaxis, and C3b act as opsonins
It punches holes in membrane of invading
microbe and kills them (MAC).
Their activation is tightly regulated by regulatory
proteins
 Effects of Inflammation and
Their Major Mediators
Vasodilation
– Prostaglandins
– Nitric oxide
– Histamine
Increased Vascular Permeability
– Vasoactive amines (histamine, serotonin)
– C3a and C5a (by inducing release of
vasoactive amines)
– Bradykinin
– Leukotrienes C4, D4, E4
– Platelet-activating factor; Substance P
Chemotaxis, Leukocyte Activation
– C3a, C5a
– Leukotriene B4
– Bacterial products 42
 Effects of Inflammation and
their Major Mediators – Contd.
Fever
– IL-l, IL-6, tumor necrosis factor (TNF)
– Prostaglandins
Pain
– Prostaglandins
– Bradykinin
Tissue Damage
– Neutrophil and macrophage lysosomal enzymes
– Oxygen metabolites (ROS)
– Nitric oxide

43
 Systemic Effects of
Inflammation
Acute-phase reactions mediated by cytokines TNF, IL-1,
IL-6
– Fever (Cytokines acting on the thermoregulatory
center of the hypothalamus via PGE2); caused by
pyrogens
– ↑’es HR (heart rate), ↑’es BP, ↓’es sweating, rigors,
chills
– Somnolence
– Malaise
– Anorexia; cachexia
– In sepsis – DIC, acidosis, hypotension (Septic shock)
– Accelerated degradation of skeletal muscle proteins
– ↑’es hepatic synthesis of a variety of proteins – CRP,
Fibrinogen, serum amyloid A proteins
(elevated fibrinogen levels  increased ESR)
– Causes alterations in circulating white blood cell pool
44
 Some blood cell count values
 Leukocytosis (esp. those induced by bacterial
infection)
– Increases to 15,000 or 20,000 cells/micro liter
(normal 4000-10,000 cells/µL)
– It may climb as high as 40,000 to 100,000
(Leukemoid reaction)
reaction
 Neutrophilia
– Increased polymorphonuclear cells – esp. in acute
bacterial infections
 Eosinophilia
– Increased Eosinophils– parasitic infestations, allergy
 Lymphocytosis
– Increased lymphocytes– in infectious mononucleosis,
mumps, rubella (viral infections); chronic infections
 Leucopenia
– Decreased leukocytes– in some viral infections,
rickettsia, protozoal infections, typhoid

45
 Outcomes of Acute
AcuteInflammation
inflammation has
one of three outcomes:

1) Resolution
– when injury is
limited with
minimal damage;
returns to
normalcy

2) Progression to 3) Tissue destruction,

Chronic Scarring
Inflammation
– follows when
or Fibrosis
offending agent is – results from extensive
not eliminated; tissue destruction, and
could end in fibrinous exudates that
restoration of are organized with
normal structure resultant fibrosis or 46
or in scarring
abscess formation and
 Chronic Inflammation
 Inflammation of prolonged duration (weeks
to years) in which active inflammation,
tissue injury, and healing proceed
simultaneously
It is characterized by:
– Infiltration with macrophages,
lymphocytes and plasma cells
– Tissue destruction due to products of
inflammatory cells
– Repair with angiogenesis (new vessel
proliferation) and fibrosis
Acute inflammation may progress to chronic
inflammation when not resolved
47
Reasons for Acute
Progressing to Chronic
Inflammation

When the inciting

injury/microbe is persistent or
Secondary syphilis
recurring
When the normal healing
process is interfered with
When inflammatory reaction is
not sufficient to completely
degrade the agent (bacteria,
tissue debris, foreign bodies)
Rheumatoid arthritis
Some forms of injury involves
chronic inflammation
essentially from the beginning
e.g. viral infections
Prolonged exposure to
potentially toxic agents Silicosis 48
Chronic Inflammation
A, Chronic inflammation in the lung,
showing the characteristic histologic
features: collection of chronic
inflammatory cells (asterisk),
destruction of parenchyma (normal
alveoli are replaced by spaces lined
by cuboidal epithelium,
arrowheads), and replacement by
connective tissue (fibrosis, arrows).

B, By contrast, in acute
inflammation of the lung (acute
bronchopneumonia), neutrophils
fill the alveolar spaces and blood
vessels are congested. 49
 Acute Chronic
Inflammation
Many forms of chronic
inflammations
continue to show
extensive neutrophilic
infiltration due to
persistent microbes
or necrotic cells or
mediators released by
macrophages or Crohn's disease. The mucosa shows
crypt architectural distortion and an
necrotic cells. increased amount of acute and chronic
inflammation in the lamina propria. The
Such responses are inflammation extends into the deep
called acute chronic mucosa and superficial submucosa.
Non-necrotizing granulomas are
inflammation. present both in the superficial mucosa
50
and in the submucosa.
 Granulomatous Inflammation
 Distinct type of chronic
inflammation
 Shows activated macrophages
assuming a squamous cell-like
(epithelioid) appearance.
 Diagnostic lesions in
Tuberculosis and Syphilis.
 Also develop in response to
inert foreign bodies (suture,
splint, breast implants) forming
foreign body granulomas.
 They “wall off” the offending
agent without necessarily
killing it and is a useful defense
mechanism.
51
Lymphatics and Lymph Nodes in
Inflammation
 Represent a secondary line of defense with the
mononuclear phagocyte system.
 Help to drain the edema fluid ( with leukocytes
and cell debris) from the extravascular space.
 Sometimes they become secondarily inflamed
due to drained microbes (lymphangitis),
lymphangitis
leading to inflamed nodes
(reactive/inflammatory lymphadenitis).
lymphadenitis
 Liver, spleen, and bone marrow form the next
line of defense
 But massive infections overcome these and
implant on heart valves (endocarditis),
meninges (meningitis), kidneys (renal
abscesses) and joints (septic arthritis) 52
LYMPHANGITIS

LYMPHADENITIS

53
 Morphological Types of Acute
and Chronic Inflammations
Serous Inflammation:
– Characterized by watery, protein-poor fluid
(effusion)
effusion from the peritoneum, pleura,
pericardium or skin. e.g. blisters from burns,
scalds.

Fibrinous Inflammation:
– Extravascular fluid accumulates as fibrin
threads or coagulum. e.g. meninges, pleura,
pericardium
– They are degraded by fibrinolysis resulting in
resolution or scarring (organization)
organization restricting
function of organ. e.g. Pericardial exudates
forming fibrinous pericarditis 54
Effusion
Massive left sided pleural
effusion (excess
collection of fluid
between pleural space
due to inflammation).

Impression: Large left

pleural effusion with LLL
atelectasis (lung collapse).

55
Fibrinous inflammation
When the
inflammatory exudate
contains plentiful
fibrinogen, this
polymerises into a
thick fibrin coating.
This is often seen in
acute pericarditis and
gives the parietal and
visceral pericardium a
'bread and butter'
appearance

56
Morphological Types of Acute
and Chronic Inflammations –
Contd.
Suppurative (Purulent) Inflammation:
– Contains purulent exudates (pus)
pus consisting
of neutrophils, necrotic cells and edema fluid.
e.g. abcesses
Ulceration
– Refers to sites of inflammation where an
epithelial surface becomes eroded or necrotic
due to injury (peptic ulcer) or vascular
compromise (foot ulcers).
– It could be with neutrophilic infiltration and
vasodilation as in acute ulcers or with
fibroblastic proliferation, scarring and chronic
inflammatory cells as in chronic ulcers.
57
Suppurative (Purulent)
Acute ulcer
Inflammation
Purulent Leptomeningitis

Chronic Ulcer

58
Necrotising (gangrenous)
inflammation
High tissue pressure
due to oedema may
lead to vascular
occlusion and
thrombosis, which
may result in
widespread septic
necrosis of the
organ. The
combination of
necrosis and
bacterial
putrefaction is
gangrene.
59
 TISSUE REPAIR: REGENERATION &
FIBROSIS
 Repair (healing) means restoration of tissue
structure and function after an injury.
 Begins very early in the process of inflammation.
It involves 2 types:
 Regeneration by parenchymal cells of same type,
when restitution is possible
 Healing and scar formation – by replacement
with connective tissue (fibrous), when severe
damage occurs
 Provides structural stability without lessening
function
An extensive deposition of collagen leads to fibrosis;
fibrosis
may affect function
If fibrosis occurs within an inflammatory exudate it is
called organization (e.g. pneumonia) 60
 Mechanisms of
tissue repair
In this example, injury
to liver is repaired:
a) by regeneration of
cells if only
hepatocytes are
damaged, or
b) by laying down of
fibrous tissue if
matrix is also
injured.

Repair involves:
a) Proliferation of 61
 Cell Proliferation
Normal cell population is
balanced by:
 Cell proliferation
 Cell death or
 Cell differentiation

Cell proliferation is
stimulated by proteins
called growth factors

Normal cell proliferation

occurs through a series
of phases known as the
“Cell Cycle.”

62
 Normal Cell Proliferation

The Cell Cycle

Proliferation occurs by DNA replication and mitosis
and the events that control these two process is
known as Cell Cycle
The cell cycle consists of 4 phases:
1. Presynthetic growth phase 1 (G1)
2. DNA-synthetic phase (S)
3. Premitotic growth phase 2 (G2)
4. Mitotic phase (M)
In addition, there are Quiescent Cells that are in an
arrested state or exit the cycle, known as G0
phase.
Throughout the process, the cell cycle has multiple
controls that regulate the entire process 63
 The Cell
Checkpoint controls transiently stop cell
cycle to allow DNA repair or eliminate
irreversibly damaged cells
Cycle
During S phase, cell is
replicated and progresses
through G2 and mitosis

Progression is
regulated by
Cyclins and CDKs

Growth Factors

CDKs are suppressed

Exposure to growth factors during G1 by multiple
promote G0/G1 transition mechanisms. Growth
factors release the
suppression of CDKs
64
 Cyclins
 They control the progression of cells through
cell cycle.

 Cyclin levels increase at specific stages of

cell cycle; they are degraded as cell moves
forward in cycle.

 Cyclins combine with cycline-dependent

kinases (CDKs) and undergo
phosphorylation, forming complexes

 CDKs are suppressed during G1 phase, and

growth factors release this suppression 65
Cycline-dependent kinases
(CDKs)
 The Cyclin- CDK complexes are regulated by
CDK inhibitors which are important in
regulating cell cycle checkpoints.
 At these checkpoints, the cell takes stock of its
DNA replication and all mistakes are corrected
before progressing further.
 Failure to adequately monitor the correctness
of DNA replication leads to accumulations of
mutations and possible malignant
transformations.
 If the DNA damage is too extensive the cell is
convinced to commit suicide.
 After mitosis, cyclins dissociate from CDK and
are degraded, leaving behind the inactive CDK66
 Types of Proliferative Cells

Proliferative cell types are classified

by their regenerative capacity and
their relationship to the cell cycle
into:

– Labile Cells
– Stable Cells
– Permanent Cells

67
 Labile Cells

 Develop from a population of Stem cells

 Capable of continuously dividing and
dying (hence labile)
Examples:
 hematopoietic cells of bone marrow
 squamous epithelia of skin, oral cavity,
vagina, cervix
 cuboidal epithelia lining ducts of exocrine
glands;
 columnar epithelium of GI tract, uterus,
fallopian tubes,
 transitional epithelia of urinary tract
68
 Stable Cells
 They are quiescent (in G0 stage) with minimal
replication in their normal state
 They divide rapidly in response to injury
– e.g. parenchymal cells of liver, kidney,
pancreas; endothelial cells lining blood
vessels; fibroblasts, and smooth muscle cells;
have limitations to regenerate (except lever).

Permanent Cells
 These cells are terminally differentiated and
nonproliferative after birth.
e.g. most neurons and cardiac cells.
 Thus injury is irreversible and results only in
scar. 69
 Stem cells
 Mature labile cells are short-lived and replaced
by differentiated cells from stem cells
(homeostasis)
 Pleuripotent stems cells have capability to
generate multiple lineages
 Embryonic stem cells (ES) are pleuripotent
cells isolated from embryo
 Stem cells capable of generating multiple
lineages are present in adults also – tissue/adult
stem cells e.g. bone marrow
 In the new field of regenerative medicine
damaged organs are regenerated by ES or adult
stem cells – therapeutic cloning (a form of stem
cells therapy)
70
 Therapeutic Cloning

Specific genes having

characteristics of ES
cells are introduced
into fully
differentiated cells,
such as the skin
epithelial cells,
leading to
reprogramming of
the somatic cell
nucleus. These cells
eventually acquire
the properties of ES
Induced Pleuripotent Stem Cells (iPS cells) cells. The ES cells are
then transplanted 71
 Growth Factors
 Cell proliferation is triggered by growth factors,
hormones and cytokines
 Growth factors are numerous and are produced by
recruited leukocytes or parenchymal and stromal
cells
 They promote quiescent cells to enter cell cycle,
release suppression of CDKs, prevent apoptosis, and
increase synthesis of proteins for mitosis
 Growth factors bind to specific receptors on cell
surface and stimulate the function of genes that
help in cell proliferation
 Many of these genes are protooncogenes; mutations
in them lead to unrestrained cell proliferation
(oncogenesis)
 Growth factors also stimulate cell migration, 72
 Extracellular Matrix
 Intact ECM is required for tissue regeneration;
otherwise scar results
 ECM is a dynamic, constantly remodeling complex that
provides turgor to soft tissues and rigidity to bones.

ECM occurs in 2 basic forms:

 Interstitial Matrix
– synthesized by mesenchymal cells (e.g. fibroblasts),
present in spaces between cells in connective tissue,
vascular and smooth muscle structures
 Basement Membrane
– synthesized by epithelium and mesenchymal cells
and lies between both; mainly made up of collagen
and lamina; forms a “chicken-wire” mesh beneath
epithelium

73
 Role of ECM
 Provides mechanical support to tissues by
collagen and elastin

 Provides substrate for cell growth and acts as

filtration apparatus in kidneys (basement
membrane)

 Regulates cell proliferation and differentiation

 Stores growth factors for rapid deployment

after injury or during regeneration

74
75
Extracellular Matrix – Contd.
The components of ECM are:
1) Fibrous structural proteins:
– Collagen – a fibrous structural protein
that confers tensile strength; important
in wound healing; 30 types are identified
– Elastin – helps tissues to recoil and
return to baseline structure e.g. in vessel
walls, uterus, skin
2) Water- hydrated gels:
– Proteoglycans and Hyaluronan – highly
hydrated gel that permit resilience and
lubrication; composed of
glycosaminoglycans and hyaluronic acid
e.g. cartilage in joints 76
3) Adhesive proteins
– Glycoproteins and Integrins – Adhesive proteins that
connect matrix elements one to another, and to ECM;
they include fibronectins, laminin, and integrins
a) Fibronectin – synthesized by fibroblasts,
monocytes and endothelium; binds ECM
components and attach to cell integrins; binds to
fibrin to form blood clot; also plays major role in
wound healing
b) Laminin – present in basement membrane and
connects cell to collagen and heparan sulfate in
ECM; also regulates cell proliferation, cell
differentiation and motility
c) Integrins - found on leukocytes surfaces and help
them to adhere to vessel endothelium; also
present on plasma membrane of other cells except
RBCs

77
 Cell and Tissue Regeneration
 Occurs continuously in labile tissues such as
bone marrow, gut, and skin
 Occurs also in parenchymal organs with stable
cells; limited
 Surgical excision of kidney promotes
contralateral compensatory response with
hypertrophy and hyperplasia in the other
kidney
 Liver unique in that, 40-60% loss is replaced; a
portion of normal liver from donor if
transplanted into recipient, grows into normal
sized liver
Extensive regeneration possible only if residual tissue is intact as in
 Replication
surgical resection;initiated by cytokines
if tissue is extensively (TNFor& IL-6)
damaged by infection
 Progression through
inflammation, regeneration cell cycle
is incomplete with scardependent
formation on78
 Repair By Connective Tissue
(Fibrosis)
 When repair cannot be accomplished by
regeneration of cells alone, it involves
replacement with connective tissue or by
combination of both
 Begins in 24 hours by fibroblasts
 Granulation tissue forms by
proliferation of fibroblasts with
new vessels in a loose ECM;
eventually, scar tissue is formed
Steps in the process:
1) Angiogenesis or Neovascularisation
2) Migration and proliferation of fibroblasts
3) Formation of ECM (leading to scarring)
4) Maturation and remodeling of scar tissue 79
 The Process of Regeneration
 Angiogenesis or Neovascularisation
- the process by which preexisting vessels
send out capillary sprouts (stimulated by
VEGF) to produce new vessels. It is
critical in the development of collateral
circulation at ischemic sites.

80
Migration and proliferation of fibroblasts

– Recruitment and stimulation of

fibroblasts by Growth Factors from
activated endothelium and their
proliferation by inflammatory cells (mast
cells, lymphocytes)

Deposition of ECM

– Deposition of ECM by fibroblasts occurs

with accumulation of collagen and
elastin: this is enabled by mediators like
PDGF, TGF-β and cytokines

81
 Deposition of ECM – contd..

 As healing progresses proliferating

fibroblasts and new vessels decrease
with increased deposition of ECM.
 Collagen synthesis by fibroblasts in ECM
strengthens the wound healing site.
 The granulation tissue scaffolding
gradually evolves into a scar composed
of inactive fibroblasts, dense collagen,
elastic tissue and other ECM
components.
 As the scar matures the highly
vascularized granulation tissue becomes
largely avascular.
82
 Maturation and reorganization
of fibrous tissue (remodeling)

 Scar ECM continues to be modified and

remodeled maintaining a balance between
ECM synthesis and degradation.
 Degradation is primarily accomplished by
metalloproteinases (MMPs) and serine
proteinases; dependent on zinc ions
 These proteinases are essential in the
debridement of injured sites and in the
remodeling of the ECM necessary to
repair any tissue defects.

83
 Healing granulation tissue Mature Scar

A, Granulation tissue showing numerous blood vessels, edema, and a

loose ECM containing occasional inflammatory cells. Collagen is stained blue
by the trichrome stain; minimal mature collagen can be seen at this point.
B, Trichrome stain of mature scar, showing dense collagen with only
scattered vascular channels. 84
 Growth Factors In Cell
Regeneration and Fibrosis

Cellular regeneration is mediated by several

growth factors:
– Platelet Derived Growth Factor (PDGF)
– Epidermal Growth Factor (EGF)
– Fibroblast Growth Factors (FGFs)
– Transforming Growth Factors (TGFs)
– Macrophage Derived Growth Factors (IL-
1 and TNF)

85
 Healing of Skin Wounds

Primary Union or Healing by First

Intention:
– Occurs in clean, uninfected, approximated
surgical incisions
– Only focal disruption of BM, continuity present
with minimal destruction of cells
– Incisional space is filled with fibrin clotted
blood, followed by granulation tissue, covered
by new epithelium growing from both sides of
incision
– Epithelial regeneration prominent than fibrosis
– Small scar formed with minimal wound
contraction
– Healing is completed by end of one month. 86
Healing of Skin Wounds – Contd.

Secondary Union or Healing by Second

Intention:
– Occurs when cell or tissue loss is
extensive
– Extensive ingrowth of granulation tissue
from wound margin to bridge the open
wound
– Healing occurs from bottom upward
– Accumulation of ECM and wider scarring
occurs in time
– Wound contraction common due to
myofibroblasts 87
88
Cutaneous Wound Healing
Healing by
First

Intention

Healing by
Second
Intention

89
 Wound Strength

 Sutured wounds have 70% of strength of

unwounded skin
 When sutures are removed after 1 week,
only 10% of strength is present; it increase
rapidly over the next 4 weeks
 During the first 2 months, tensile strength
recovery results from collagen synthesis
that exceeds degradation, followed by
structural modifications of collagen later
 By 3 months, strength reaches 70-80% of
normal; does not improve beyond that.

90
 Pathological Aspects of Repair
Extrinsic and intrinsic factors that affect wound
healing are:
– Infection – it prolongs the inflammation phase;
important cause of delayed wound healing
– Nutrition – ascorbic acid and protein
deficiencies inhibit collagen synthesis; zinc aids
healing
– Glucocorticoids – have anti-inflammatory effects;
result in poor wound strength due to reduced
fibrosis
– Mechanical factors – ↑’ed local pressure, torsion
impair healing
– Poor circulation – due to atherosclerosis,
diabetes, or obstructed venous drainage delay
healing 91
Pathological Aspects of Repair – Contd.

 Foreign bodies – fragments of steel, glass or

bone impede healing
 Type and volume of tissue injured – complete
repair occurs in tissues composed of stable
and labile cells, and wounds of smaller area
 Location of Injury – pleural or peritonial
effusions, healing by resolution
 Aberration of cell growth and ECM
production – e.g. keloids, exuberant
granulation
 Chronic immune/autoimmune reactions –
rheumatoid arthritis, pulmonary fibrosis,
cirrhosis produce disabling fibrosis 92
Keloid After Surgical Wound Healing

93