Inflammation: Acute, Chronic and Systemic Design a System Recognize injury promptly & properly Eliminate invaders &

p; debris Communicate & continuously adjust to changing conditions Continue the response as long as needed Prepare for rebuilding Sources of Injury Traumatic Infectious Chemical Immune reactions (hypersensitivity) Immune system response begins with platelets and neutrophils or mast cells Neoplastic Inflammation Every person, every disease Destroy, dilute or wall off the injurious agent A closely regulated protective reaction Relies on vascularized tissue Learning Objectives 1. Acute and chronic inflammation features 2. 3 components of the inflammatory system 3. Steps of leukocyte emigration, chemotaxis and phagocytosis 4. Nine mediator classes 5. How inhibitors regulate & cytokines transition to chronic phase 6. Four causes of chronic inflammation 7. Cardinal signs of acute inflammation

Mon. 08/23/10

1. Acute and chronic inflammation features: Acute vs Chronic Inflammation: Acute Immediate Transient (does not last long) Edema Neutrophils Fibrin Necrosis (cell death cleaned up fast)
FIGURE 27A Nature of leukocyte infiltrates in inflammatory reactions. The photomicrographs are representative of the early (neutrophilic) (A) and later (mononuclear) cellular infiltrates (B) seen in an inflammatory reaction in the myocardium following ischemic necrosis (infarction). The kinetics of edema and cellular infiltration (C) are approximations.

Test q: Which of the following is a marker of chronic inflammation? Capillary formation.

Chronic Gradual Prolonged (persistence of injury-causing agent) Fibrosis & vessels (change in architecture) Blood vessels derive from preexisting blood vessels (angiogenesis) Essential for normal wound healing Mononuclear cells (monocytes, macrophages, lymphocytes, plasma cells) Collagen Resolution of necrosis (takes a long time to clean up debris)

Test q: A 20y/o college student comes to your office w/vague complaints of fatigue and right upper quadrant fullness. His liver enzymes are elevated and he has a family history of primary biliary cirrhosis, so you request a liver biopsy. When you review the slides w/the pathologist, he points out prominent periportal lymphocytic infiltration w/germinal centers and scattered fibroblasts in the interlobular zone. The most likely pathologic diagnosis is: chronic inflammation.

Figure: Histology of Acute Inflammation FIGURE 217A The characteristic histopathology of acute inflammation. A, Normal lung shows thin (virtually invisible) blood vessels in the alveolar walls and no cells in the alveoli. B, The vascular component of acute inflammation is manifested by congested blood vessels (packed with erythrocytes), resulting from stasis. C, The cellular component of the response is manifested by large numbers of leukocytes (neutrophils) in the alveoli. Acute inflammation- dilation of blood vessels, neutrophils come in.

2. 3 Components of the Inflammatory System: 1. Vessels Arterioles Venules Lymphatics 2. Leukocytes 3. Soluble mediators: many produced by cell and effective in neighborhood around cell. Some in serum but only activated in location of acute inflammatory response. Paracrine Serum enzyme Cytokines Proteins produced by many cell types (activated lymphocytes and macrophages; endothelial, epithelial, connective tissue) TNF + IL-1: produced by macrophages (activated) Endothelial activation: endothelial adhesion; chemical mediators Vascular and Cellular Responses Increased blood flow to tissue (vasodilation) Increased vascular permeability (leakage) only certain vessels. Arterioles dilate and let in more blood, venules become more leaky. Migration of leukocytes out of the blood vessels (chemotaxis) FIGURE 22 Formation of transudates and exudates. A, Normal hydrostatic pressure (blue arrows) is about 32 mm Hg at the arterial end of a capillary bed and 12 mm Hg at the venous end; the mean colloid osmotic pressure of tissues is approximately 25 mm Hg (green arrows), which is equal to the mean capillary pressure. Therefore, the net flow of fluid across the vascular bed is almost nil. B, A transudate is formed when fluid leaks out because of increased hydrostatic pressure or decreased osmotic pressure. C, An exudate is formed in inflammation, because vascular permeability increases as a result of increased interendothelial spaces. Normal: slight leakage out of vessel Congestive heart failure, fluid overload: increased hydrostatic pressure fluid leaks out more. Transudate: fluid with low protein content, little or no cellular material, low specific gravity. Ultrafiltrate of blood plasma that results from osmotic or hydrostatic imbalance across vessel wall without an increase in vascular permeability. Exudate: escape of fluid, proteins, blood cells from vascular system into interstitial tissue or body cavities. Increase in normal permeability of small blood vessels due to injury inflammation. Blood flow slows down in acute inflammatory vessels. Have extravascular fluid with high protein concentration, cellular debris, high specific gravity.

Test q: In acute inflammation, the most significant increase in vascular permeability occurs in: Post-capillary venules.

Figure: Capillaries dilate with increased pressure due to dilation of arterioles. Venules get leaky. Vascular Changes: Transient Vasoconstriction Hemostasis: slow moving red cells (b/c vasodilation follows transient vasoconstriction) Vasodilation (biggest effect) Mediated by prostaglandins and Nitric oxide Arteriole smooth muscle relaxes Relax vessels allow more blood flow Increased Permeability (leakage) Transient, sustained or delayed

Normal: Capillary has only 1 endothelial cell around vessel. Venules has ~3.

Injury: Stimulate endothelial cells to contract and release tight junctions bt cells increased interendothelial spaces.

3. Emigration, chemotaxis and phagocytosis: Leukocyte Extravasation Margination Leukocytes approach endothelium RBCs aggregate in venules Neutrophils pushed from central to periphery Rolling Mediated by selectin Weak bonding bt cell and endothelium Activation of selectin adhesion molecules on surface of neutrophils and endothelial cells Neutrophils loosely bind selectins and roll along endothelium Adhesion (pavementing) Tight integrin (2) binding Communication in cytoplasm, rearrangement of cytosol Adhesion molecules firmly bind neutrophils to endothelial cells Catecholamine, corticosteroids, and lithium inhibit activation of adhesion molecules Transmigration (Diapedesis) Integrin Find a hole neutrophils dissolve basement membrane and enter interstitial tissue Functions of exudate: (1) dilutes bacterial toxins (2) provides opsonins Chemotaxis Neutrophils follow chemical gradients that lead to the infection site Chemotactic mediators bind to neutrophil receptors; binding causes release of calcium which increases neutrophil motility

Above: Arrow = arteriole. Rabbit injected with carbon black pigment. Histamine put in area. Venules more leaky due to dilated vessels. Contraction of endothelial cells and increased interendothelial spaces is elicited by histamine.

Test q: During acute inflammation, neutrophils migrate through the walls of the venules. This migration requires integrins and selectins. Test q: A 6y/o child has a history of recurrent infections w/pyogenic bacteria, including Staph aureus and Strep pneumoniae. The infections are accompanied by a neutrophilic leukocytosis. Microscopic exam of a biopsy specimen obtained from an area of soft tissue necrosis shows microbial organisms but very few neutrophils. An analysis of neutrophil function shows a defect in rolling. This childs increased susceptibility to infection is most likely caused by a defect in which of the following molecules? Selectins. Test q: In the acute inflammatory reaction, the principal function of selectins and integrins is to enhance leukocyte binding to the endothelium.

FIGURE 24 The multistep process of leukocyte migration through blood vessels, shown here for neutrophils. The leukocytes first roll, then become activated and adhere to endothelium, then transmigrate across the endothelium, pierce the basement membrane, and migrate toward chemoattractants emanating from the source of injury. Different molecules play predominant roles in different steps of this processselectins in rolling; chemokines (usually displayed bound to proteoglycans) in activating the neutrophils to increase avidity of integrins; integrins in firm adhesion; and CD31 (PECAM-1) in transmigration. Neutrophils express low levels of L-selectin; they bind to endothelial cells predominantly via Pand E-selectins. ICAM-1, intercellular adhesion molecule 1; TNF, tumor necrosis factor.

TNF and IL-1--released by macrophages--act on endothelial of post-capillary venules and induce expression of adhesion molecules. Adhesion Molecule Expression: FIGURE 25: Regulation of expression of endothelial and leukocyte adhesion molecules. A, Redistribution of Pselectin from intracellular stores to the cell surface. B, Increased surface expression of selectins and ligands for integrins upon cytokine activation of endothelium. C, Increased binding avidity of integrins induced by chemokines. Clustering of integrins contributes to their increased binding avidity (not shown). IL-1, interleukin-1; TNF, tumor necrosis factor. Weibel-Palade bodies: endothelial granules that store P-selectin; redistribution of P-selectin in W-P bodies to surface. Chemokines produced at injury site enter blood vessel and bind to endothelial cell proteoglycans; induced expression of integrin ligands on endothelium and activation of integrins to high affinity state on leukocytes A

Figure: Migration to extracellular space. High response of inflammatory substance at core of inflammation. Chemotaxis attacts leukocyte by having extracellular matrix attachment sites.

Chemotaxis: a family of 40 peptides that attract inflammatory cells. Increasing chemical gradient Exogenous agents Bacterial N-formyl-methionine peptides Endogenous products Complement (C3a & C5a) Lipoxygenase products (LTB4) Cytokines (TNF, IL-1) - IL-1 is produced by macrophages. Macrophages release it once theyre at inflammatory site. Chemokines (IL-8, ,,) Phagocytosis: Neutrophil has to recognize that material is foreign. Recognition and attachment - Opsonins: IgG-Fc, C3b, iC3b, collectins - attach to bacteria (or foreign bodies) - Neutrophils have receptors for IgG and C3b - Enhances neutrophil recognition and attachment to foreign bodies - Leukocyte receptors: FcR, CR1/2 Engulfment: phagocytose; phagocytic vacuoles Killing and degradation: - Oxidative burst - Enzyme digestion

Figure: macrophage SEM. Scanning electron micrograph of a moving leukocyte in culture showing a filopodium (upper left) and a trailing tail. Figure: Pseudopod toward attractant. Project cytoplasm in direction that has most chemotaxis

Test q: A 10y/o boy suffers recurring infections due to Strep pneumoniae. He is found to have an inherited disorder of a complement factor such that phagocytosis is deficient. This factor is most likely: C3b. Test q: Phagocytosis of bacteria by neutrophils or other bactericidal cells is greatly facilitated by coating the foreign organisms w/substances recognized by the phagocytes. These attachment-promoting substances, called opsonin, are present in the ECF of inflamed tissue. One example of an opsonin is: Fc fragments of IgG. REPEATED TWICE (but on 2005 answer key, says answer is C5a even though Fc fragments of IgG is a choicetypo?) Test q: The oxidative burst of leukocytes produces a substance which is the most potent bactericidal product of the cell. This substance is called: Hypochlorous acid (HOCl). (Other choices: Bacterial permeability increasing protein (BPI); Major basic protein (MBP); Lactoferrin; Lysozyme)

Phagocytosis & Oxidative Burst:

FIGURE 29 Phagocytosis and intracellular destruction of microbes. Phagocytosis of a particle (e.g., bacterium) involves binding to receptors on the leukocyte membrane, engulfment, and fusion of lysosomes with phagocytic vacuoles. This is followed by destruction of ingested particles within the phagolysosomes by lysosomal enzymes and by reactive oxygen and nitrogen species. The microbicidal products generated from superoxide are hypochlorite (HOCl) and hydroxyl radical (OH), and from nitric oxide (NO) it is peroxynitrite (OONO). During phagocytosis, granule contents may be released into extracellular tissues (not shown). MPO, myeloperoxidase; iNOS, inducible NO synthase.

Reactive Oxygen Species: Respiratory burst: oxidizes NADPH and in process, reduces oxygen superoxide anion, which is converted to H2O2 Occurs in lysosome H2O2 not able to efficiently kill microbes; enzyme myeloperoxidase in neutrophil granules converts H2O2 to hypochlorite. Neutrophil Granules Specific (secondary) Smaller, fuse with plasmalemma Lysozyme: hydrolyzes muramic acid-N-acetylglucosamine bond, found in glycopeptide coat of all bacteria Collagenase IV Azurophil (primary) Fusion with phagosome Myeloperoxidase, NADPH oxidase Acid & neutral protease

4. Nine mediator classes: Soluble Factor Overview Paracrine cell products Nitric Oxide (NO) Vasoactive amines (Histamine) Arachidonic acid metabolites (COX,LOX) Platelet Activating Factor (PAF) Neuropeptides (SP) Plasma protease systems Bradykinin, Kallekrein Complement cascade Clotting products and enzymes

Test q: A clever pharmaceutical rep is telling you about how his companys amazing drug counteracts all of the soluble mediators of acute inflammation. He describes how this drug counteracts the effects of plasma protease products, arachidonic acid metabolites, histamine, platelet activating factor, and even neuropeptides. You, however, know something about acute inflammatory mediators. Noticing that he has left something out, you ask him what his drug does for: Nitric oxide.

Nitric Oxide Vasodilates Produced by endothelium and macrophages From L-arginine, O2, NADPH, cofactors NO synthesized from L-arginine via nitric oxide synthase (NOS) Nitric Oxide Synthase Endothelial, neuronal, inducible on macrophages Inhibits rolling, adhesion of leukocytes (thought to control inflammatory response) Three types of NOS: eNOS (endothelial), nNOS (neuronal), iNOS (inducible) Antimicrobial free radicals released (NO is microbicidal) Vasoactive Amines Histamine Stored in granules of mast cells and basophils Granules released into surrounding inflammatory tissue by allergen binding multiple IgE molecules on mast cell
Test q: In acute inflammation, arterioles dilate and venules become more permeable (leaky). These changes occur when mast cells release Histamine. Test q: A woman who is allergic to cats visits a neighbor who has several cats. During the visit, she inhales cat dander and within minutes, she develops nasal congestion w/abundant nasal secretions. Which of the following substances is most likely to produce these findings? Histamine. Test q: A man w/a mold allergy returns to his recently flooded home in New Orleans. During the visit, he develops nasal congestion w/abundant nasal secretions. Which of the following substances is most likely to produce these findings? Histamine. Test q: Of those listed, the earliest chemical mediator of inflammation is: histamine. (Other choices: Hageman factor, Bradykinin, serotonin, Kallikrein)

Serotonin (5-HT) Stored in granules of platelets and enterochromaffin cells Released when platelets aggregate Vasodilate and increase permeability
FIGURE 211 Generation of arachidonic acid metabolites and their roles in inflammation. The molecular targets of action of some anti-inflammatory drugs are indicated by a red X. Not shown are agents that inhibit leukotriene production by inhibition of 5-lipoxygenase (e.g., Zileuton) or block leukotriene receptors (e.g., Montelukast). COX, cyclooxygenase; HETE, hydroxyeicosatetraenoic acid; HPETE, hydroperoxyeicosatetraenoic acid.

Arachidonic acid - when inflammatory stimulation, may be further metabolised by Cycloxygenase pathway or Lipoxygenase pathway (produce lipoxins- inhibitors of inflammatory response and also chemotaxins important in asthma response) Cyclooxygenase pathway - balance between prostacyclin and thromboxane
Test q: We now believe that many of the anti-inflammatory effects of glucocorticoid hormone-related drugs are caused by boosting of cytoplasmic calcium-dependent phospholipid-binding proteins called lipocortin. Since lipcortin-1 inhibits phospholipase A2, glucocorticoid indirectly decreases the level of free arachidonic acid by cells receiving inflammatory stimuli. One consequence of decreased free arachidonic acid is decreased vasodilation by products of: the cyclooxygenase pathway.

Simplified AA Metabolism:
Membrane Phospholipids Phospholipase A 2 Arachidonic Acid

Phopholipase A2: primary enzyme that releases arachidonic acid from membrane phospholipids. AA-derived mediators--aka eicosanoids--synthesized by two major classes of enzymes: 1. Cyclooxygenase: generate prostaglandins 2. Lipoxygenase: Leukotriense and lipoxins

Cyclooxygenase Pathway

Lipoxygenase Pathway

Prostaglandins vasodil Thromboxane clot Prostacyclin unclot

Leukotrienes incr perm Lipoxins oppose inflam

Platelet Activating Factor (PAF) paracrine substance produced at inflammation site Vasodilates and increases permeability 100 to10,000 times more potent than histamine also adhesion, chemotaxis, oxidative burst Fatty acid on middle C of PC replaced by product of phospholipase A2 From endothelial cells, platelets Synthesized at site of inflammation PAF-specific acetylhydrolase inactivates Test q: The major sources of PAF are: Platelets and endothelium. Neuropeptides Substance P (most widely known neuropeptide) is the prototype Tachykinin family of peptides CNS & PNS Multiple effects Vasodilate Increase permeability Pain mediation (most important function) Capsaicin in hot peppers Hageman Factor XII: protein synthesized by liver that circulates in inactive form. Inflammation and blood clotting are intertwined, with each promoting the other. Anytime clotting promoted, you also get fibrinolysis. Deposition and degradation balance. Plasmin: activates fibrinolysis and complement. Kallikrein: enzyme that cleaves precursor to bradykinin Bradykinin: Increase permeability Contraction of smooth muscle Vasodilation Pain

Fibrin clot formation also occurs with fibrinolysis (cleaves fibrin, solubilize clot) Plasmin also cleaves complement protein C3 to produce C3 fragment C3a + C5a: increase vascular permeability C5a: chemotaxis

FIGURE 214 The activation and functions of the complement system. Activation of complement by different pathways leads to cleavage of C3. The functions of the complement system are mediated by breakdown products of C3 and other complement proteins, and by the membrane attack complex (MAC).
Test q: A 20y/o male presents w/acute abdominal pain. Phys exam reveals rebound tenderness indicating peritonitis. The discomfort experienced by the young patient is mediated primarily by: Bradykinin.

Mediator Functions: Nitric oxide Histamine Serotonin Cyclooxygenase Vasodilates, inflammation control, defense Vasodilation, permeability Vasodilation, permeability Prostaglandins: vasodilation Thromboxane: clot Prostacylin: unclot Leukotrienes: permeability Lipoxygenase: X inflammation Vasodilation, permeability Vasodilation, permeability, pain Vasodilation, permeability, smooth muscle contraction, pain C3a: permeability C5a: permeability, vasodilate Vasodilate, cleave fibrin,solubilize clot
Test q: Nitric oxide is an important mediatior of: vasodilation. REPEATED TWICE.

Lipoxygenase PAF Neuropeptide Substance P Bradykinin Complement Clotting

Vasodilate Increase Permeability Chemotaxis Pain

Clotting

5. How inhibitors regulate & cytokines transition to chronic phase Complement Because of the destructive effects of lysosomal enzymes, the initial leukocytic infiltration if unchecked can potentiate further inflammation and tissue damage. Harmful proteases are kept in check by antiproteases in serum and tissue fluids.

Kinins

Antiprotease Antioxidant Found in serum Scavenge 1 - antitrypsin O2 , H2O2, HO Inhibits neutrophil NO2 , OONO , RSNO elastase Extracellular Alveoli rupture/coalesce Ceruloplasmin pulmonary emphysema Transferrin No alpha-1-antitrypsin = Intracellular neutrophil elastase is not Superoxide dismutase inhibited (sustained action Catalase of leukocyte proteases) Glutathione peroxidase 2 macroglobulin - In both serum and secretions

Test q: If acute inflammatory responses were to proceed w/o inhibition, they would cause considerable tissue destruction and permanent loss of function of inflamed organs. Once important regulator of acute inflammation is the substance: alpha-1-antitrypsin.

Cyclooxygenase Lipoxygenase Histamine

} AA

Test q: Examples of two plasma proteins that limit, control, and regulate the potentially destructive products of the acute inflammatory response: -1-antitrypsin and ceruloplasmin.

Nitric Oxide PAF

Test q: Which of the following cellular enzymes are produced by polymorphonuclear cells in acute inflammatory responses to protect against toxic byproducts? Superoxidase. Test q: Which of the following is assocd w/prevention of damage to human tissue by free radicals? Glutathione peroxidase.

Substance P

Cytokines: transition from acute to chronic/reparative response Interleukins Monokines IL-1 Lymphokines IL-2 Macrophage activators IFN (most important activator of macrophages), TNF , TNF , IL-5, IL-10, IL-12 Hematopoietic growth factors c-kit ligand, GMCSF, MCSF, G-CSF, stem cell factor Chemokines chemotactic attract other inflammatory cells Cytokines: Acute Inflammation: Cytokine TNF IL-1 IL-6 Chemokines Principal Sources Macrophages, mast cells, T lymphocytes Macrophages, endothelial cells, some epithelial cells Macrophages, other cells Macrophages, endothelial cells, T lymphocytes, mast cells, other cell types Principal Actions in Inflammation Stimulates expression of endothelial adhesion molecules and secretion of other cytokines; systemic effects Similar to TNF; greater role in fever Systemic effects (acute-phase response) Recruitment of leukocytes to sites of inflammation; migration of cells to normal tissues

Cytokines: Chronic Inflammation: Cytokine IL-12 IFN- IL-17 Principal Sources Dendritic cells, macrophages T lymphocytes, NK cells T lymphocytes Principal Actions in Inflammation Increased production of IFN- Activation of macrophages (increased ability to kill microbes and tumor cells) Recruitment of neutrophils and monocytes

FIGURE 225 Macrophage-lymphocyte interactions in chronic inflammation. Activated T cells produce cytokines that recruit macrophages (TNF, IL-17, chemokines) and others that activate macrophages (IFN). Different subsets of T cells (called TH1 and TH17) may produce different sets of cytokines; these are described in Chapter 6. Activated macrophages in turn stimulate T cells by presenting antigens and via cytokines (such as IL-12). IFN- activates more macrophages.

Outcome of Acute Inflammation: Resolution (regeneration) No functional or histologic change Progression Chronic inflammation Granuloma Abscess formation Abcess or granuloma chronic inflammation response Healing (reconstitution) Collagen binder or filler Fibrosis (replacement by scar)

Acute versus Chronic Lung Inflammation

A Chronic inflammatory response- change in architecture

FIGURE 222A A, Chronic inflammation in the lung, showing all three characteristic histologic features: (1) collection of chronic inflammatory cells (*), (2) destruction of parenchyma (normal alveoli are replaced by spaces lined by cuboidal epithelium, arrowheads), and (3) 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.

6. Four Causes of Chronic Inflammation: Persistent infection Persistent injurious agent Interference with healing Autoimmunity May begin with minimal acute phase Rheumatoid arthritis Atherosclerosis Tuberculosis Serous & Fibrinous Inflammation (Figures) FIGURE 218 Serous inflammation (top). Low-power view of a cross-section of a skin blister showing the epidermis separated from the dermis by a focal collection of serous effusion. FIGURE 219A Fibrinous pericarditis (bottom). A, Deposits of fibrin on the pericardium. B, A pink meshwork of fibrin exudate (F) overlies the pericardial surface (P). Bread and butter pericarditis

Serous Inflammation (skin blister):

Fibrinous Inflammation (fibrinous pericarditis):

Test q: A 53y/o male develops pericarditis after a bacterial pneumonia and dies. At autopsy, the pericardium is coated w/acellular pink (smudgy) material. Fibroblasts and capillaries are not present. The best description is: fibrinous pericarditis.

FIGURE 220A (left) Purulent inflammation. A, Multiple bacterial abscesses in the lung, in a case of bronchopneumonia. B, The abscess contains neutrophils and cellular debris, and is surrounded by congested blood vessels. FIGURE 221A (right) The morphology of an ulcer. A, A chronic duodenal ulcer. B, Low-power cross-section of a duodenal ulcer crater with an acute inflammatory exudate in the base.
Test q: A 75y/o female develops a cough and fever of 103F. Chest x-ray shows a virtual white-out of the left upper lobe. If the area of involvement were biopsied, you would expect to see: Gram-positive diplococci and neutrophils. (indicating Strep pneumo)

Test q: A 70y/o woman has worsening shortness of breath. Her temp is 38.3*C. On percussion, there is fullness over the left lung fields. Thoracentesis yields 800mL of cloudy yellow fluid from the left pleural cavity. Analysis of the fluid reveals a WBC count of 2500/mm3 w/98% neutrophils and 2% lymphocytes. A gram stain of the fluid shows gram-positive cocci in clusters. Which of the following terms best describes the process occurring in the left pleural cavity? Purulent exudates. (Other choices were Abscess, Chronic inflammation, Transudate, and Fibrinous inflammation)

FIGURE 223 Maturation of mononuclear phagocytes:

Granuloma: Disease Tuberculosis Leprosy Syphilis Cause M. tuberculosis M. leprae Treponema pallidum Tissue Reaction Caseating granuloma (tubercle) Noncaseating granulomas Acid-fast bacilli in macrophages Gumma: plasma cell infiltrate; central cells necrotic without loss of cellular outline Stellate granuloma with neutrophils; giant cells uncommon Noncaseating granulomas with abundant activated macrophages Noncaseating granulomas intestine wall, transmural inflammatory infiltrate

Cat-scratch disease Sarcoidosis Crohn disease

Gram-negative bacillus Unknown etiology Intestinal bacteria, self-antigens

Test q: A chest radiograph of an asymptomatic, 37y/o man showed a 3cm nodule in the middle lobe of the right lung. The nodule was excised w/a pulmonary wedge resection, and sectioning showed the nodule to be sharply circumscribed with a soft, white center. Culture of tissue from the nodule grew Mycobacterium tuberculosis. Which of the following pathologic processes has most likely occurred in this nodule? Necrotizing granulomatous inflammation. REPEATED TWICE (once w/o the necrotizing in the answer)

Test q: A 20y/o African American male has bilateral hilar adenopathy, and radiography reveals densities in both lung fields. A bronchoscopic biopsy reveals granulomatous inflammation w/multiple giant cells of the Langhans type and no evidence of necrosis. Routine mycobacterial and fungal cultures are negative. Which of the following is the most likely diagnosis? Sarcoidosis,

FIGURE 213 Principal local and systemic actions of tumor necrosis factor (TNF) and interleukin-1 (IL-1). Prolonged inflammation- cytokines can have systemic effects. Systemic illness: fever (mostly from IL1/TNF)

7. Cardinal Signs of Acute Inflammation: Heat- blood flow Redness- vasodilation Swelling- increased blood flow Pain- due to swelling Loss of function- directly related to core four (above) Learning Objectives (w/answers): 1. Acute and chronic inflammation features AI=PMNs & exudate CI=mononucs & spindle cells 2. 3 components of the inflammatory system Vessels, leukocytes, soluble mediators 3. Steps of leukocyte emigration, chemotaxis and phagocytosis Margination, rolling, adhesion, transmigration, chemotaxis, phagocytosis, oxidative burst 4. Nine mediator classes NO, amines, COX, LOX, PAF, NP, Clot, comp, kinin 5. How inhibitors regulate and cytokines transition to chronic phase Antiprotease, antioxidant; Cyt mitogenic & activate macrophages, chemotactic to endothelial & fibrocytes 6. Four causes of chronic inflammation Persistent infection, insult, healing delay, autoimmune 7. Cardinal signs of acute inflammation BF=rubor,calor (redness, heat), perm=tumor (swelling), cells=dolor (pain), functio laesa (loss of function) Why are the above answers written in Latin?

Repair: Regeneration, Replacement, or Fibrosis Learning Objectives: 1. Regeneration versus replacement 2. 3 Surface receptor types 3. Cell cycle, 4 cyclins, 2 checkpoints 4. 2 unique basement membrane molecules 5. Collagen synthesis & structure 6. 5 Growth factors 7. Wound healing & maturation, zinc function

Tues. 08/24/10

1. Regeneration versus replacement Depends on Matrix preservation Parenchymal cells able to regenerate Cells (stromal & epithelial) must Migrate chemotaxis Proliferate mitogenesis Differentiate angiogenesis, collagen synthesis Intact matrix (BM+ECM) required for all 3 In the interstitial fibrosis (middle) picture, there are neutrophils in the alveoli alveolar lining cells have been able to multiply and restore the normal architecture. In the myocardial fibrosis pic (far right), instead of expanding, the fibrosis contracts down. Myocardial scarring never as big as the original defect.

Replacement Matrix disrupted or permanent cells destroyed Granulation tissue early in process Angiogenesis (and edema) Fibroblasts Evolving inflammation Connective tissue scar end result Replaces granulation tissue by maturation Granulation tissue general term for tissue w/new vessels growing in it (no pericytes) never stays the same. Matures over time and changes its appearance. Looks different in every instance. Wound Healing Can see overlap between inflammation and granulation tissue. Usually, in MI, granulation tissue appears at day 3 (becomes histologically recognizable).

Figure: Cell Cycle. There are two points at which the cell decides whether to proceed: 1. Before it makes the enzymes in G1 phase. 2. Just before the cell enters mitosis

2. 3 Surface receptor types Cell Surface Receptors: Intrinsic kinase activity (IK) Transmembrane with binding and catalytic domains Either Tyrosine kinase or Serine/threonine kinase Mitogenic receptors Cytosol kinase-linked activity (CK) Transmembrane with extracellular and cytosolic enzyme binding Activates cytosoic tyrosine kinase Cytokine receptor superfamily G protein-linked (GPCR) Seven-spanning receptors (serpentine) Intracellular second messenger (cAMP or cGMP) Chemokines, epinephrine, glucagon, drug receptors

FIGURE 39 Overview of the main types of cell surface receptors and their principal signal transduction pathways. Shown are receptors with intrinsic tyrosine kinase activity, seven transmembrane G proteincoupled receptors, and receptors without intrinsic tyrosine kinase activity. cAMP, cyclic adenosine monophosphate: IP3, inositol triphosphate; JAK, Janus kinase; MAP kinase, mitogen-activated protein kinase; PI3 kinase, phosphatidylinositol 3-kinase; PKB, protein kinase B, also known as Akt; PLC-, phospholipase C gamma; STATs, signal transducers and activators of transcription.
Test q: Intrinsic kinase receptors may communicate w/the nucleus by the PI3 kinase pathway, the MAP kinase pathway, or the IP3 pathway. A common ligand for this type of receptor is: Growth factor.

Tissue Type Determines Regeneration Capacity Labile epithelia, bone marrow respond promptly Stable glands, mesenchyme G0 recruited to G1 Permanent neurons, striate muscle dont proliferate

3. Cell cycle, 4 cyclins, 2 checkpoints Regulation of Cell Division Checkpoints completion of molecular events G1 checkpoint Rb gene regulates G2M checkpoint p53 gene regulates Protein phosphorylation is Upregulated by cyclins Cyclin D in early G1 Cyclin E in late G1, early S Cyclin A in S, early G2 Cyclin B in late G2, early M Stem Cells Self renewal Asymmetric differentiation Stem cell Progenitor cell Adult Stem Cells Bone Marrow Hematopoietic stem cells (HSC) Mesodermal progenitor cells Multipotent adult progenitor cells (MAPC) Developmental plasticity in culture MAPC similar to ES Tissue stem cell Niche locations Hair follicles, GI crypts, muscle satellite cell, canals of Herring, corneal limbus Figure: Adult Stem Cell Niches
B. Small intestine stem cells located near the base of a crypt, above Paneth cells (stem cells in the small intestine may also be located at the bottom of the crypt). C. Liver stem (progenitor) cells, known as oval cells, are located in the canals of Hering (thick arrow), structures that connect bile ductules (thin arrow) with parenchymal hepatocytes (bile duct and Hering canals are stained for cytokeratin 7). D. Corneal stem cells are located in the limbus region, between the conjunctiva and the cornea.
Test q: The tumor suppressor genes Rb and p53 are found in what cellular location? In the nucleus. Test q: The nuclear proteins Rb and p53 are gene products for: Tumor suppressor genes. REPEATED TWICE.

Embryonic Stem Cells Up to Blastocyst stage (32 cells) Developmental plasticity in culture Chimeras in all organs when reimplanted in another mouse blastocyst Human embryonic stem cells (HES) proliferative over 70 passages in vitro HES do not form teratomas in nude mice No therapeutic uses yet Stem Cell Therapy:
FIGURE 36: Steps involved in stem cell therapy, using embryonic stem (ES) cells or induced pluripotent stem (iPS) cells. Left side, Therapeutic cloning using ES cells. The diploid nucleus of an adult cell from a patient is introduced into an enucleated oocyte. The oocyte is activated, and the zygote divides to become a blastocyst that contains the donor DNA. The blastocyst is dissociated to obtain ES cells. Right side, Stem cell therapy using iPS cells. The cells of a patient are placed in culture and transduced with genes encoding transcription factors, to generate iPS cells. Both ES and iPS cells are capable of differentiating into various cell types. The goal of stem cell therapy is to repopulate damaged organs of a patient or to correct a genetic defect, using the cells of the same patient to avoid immunological rejection.

4. 2 unique basement membrane molecules Extracellular Matrix (ECM) Scaffold and support for cell adherence, migration, proliferation Binds growth factors and factors for cell migration and differentiation Binds water and ions for turgor, mineralization and mechanical properties 3 major components Structural collagen, elastin (lung) Adhesive glycoproteins fibronectin, laminin Stabilizing gel proteoglycans, hyaluronan Figure: ECM components
FIGURE 312 Main components of the extracellular matrix (ECM), including collagens, proteoglycans, and adhesive glycoproteins. Both epithelial and mesenchymal cells (e.g., fibroblasts) interact with ECM via integrins. Basement membranes and interstitial ECM have different architecture and general composition, although there is some overlap in their constituents. For the sake of simplification, many ECM components (e.g., elastin, fibrillin, hyaluronan, and syndecan) are not included.

Collagen Type IV = BM

Basement Membrane (BM) Spreading of epithelial or endothelial cells Collagen type IV Laminin Links cells to BM matrix by collagen IV & heparan Fibronectin Adheres to cells by RGD integrinbinding motif Also attaches to heparan, collagen & fibrin Heparan sulfate Ligand for both laminin and fibronectin Center portion of laminin attaches to base of cell, other parts fold back into BM. Important for attaching epithelial cells. There are also release signals for when cells begin to divide. See various binding domains for ECM (heparan, fibrin, collagen, etc.)

5. Collagen synthesis & structure Collagen Structure Tropocollagen is basic unit (monomer) 3 alpha chains in each unit Triple helix, left handed (DNA is righthanded helix) 27 collagen types determined by 41 genes on 14 chromosomes Fibrillar collagens: I, II, III, V, IX Have 67 nm banding from linking zones Present in tendon, scar, strong connective tissue As a scar matures, type III type I Nonfibrillary collagens: IV, others Amorphous (no banding pattern) Present in interstitium, submucosa, BM Lysine hydroxyl groups form very strong cross-links.
Test q: A 25y/o med student wrecks her bike in a construction zone, resulting in several abrasions to her arms and knees. In a few days, a scab forms which contains: Type III collagen. Test q: A 23y/o woman receiving corticosteroid therapy for an autoimmune disease has an abscess on her upper outer right arm. She undergoes minor surgery to incise and drain the abscess, but the wound heals poorly over the next month. Which of the following aspects of wound healing is most likely to be deficient in this patient? Collagen synthesis.

6. 5 Growth factors Stages of Repair Angiogenesis Fibroblast invasion and proliferation Collagen and ECM synthesis Granulation tissue into scar Tissue Remodeling

Five key Growth Factors: Symbol EGF Source Platelets, macrophages, saliva, urine, milk, plasma Platelets, T-cells, endoth., macrophages, sm ms, FB Many types of cells Platelets, macrophages, endothelial cells, keratinocytes, smooth muscle cells Functions Mitogenic: keratinocytes (aka squamous epithelial cells) and fibroblasts; keratinocyte migration Chemotactic inflam., FB, sm ms; scar, angiogenic, MMP, epith. prolif. vascular permeability; mitogenic: endothelial cells; angiogenic Chemotactic: phagocytes, fibroblasts, sm.ms; Activates: phagocytes, fibroblasts; Mitogenic: fibroblasts, endothelial, sm.muscle cells; MMPs, fibronectin, MPS, angiogenesis and wound contraction Chemotactic: fibroblasts; Mitogenic: fibroblasts, epith. cells; keratinocyte migration, angiogenesis, wound contraction, and matrix deposition

TGF- VEGF PDGF

FGF

Macrophages, mast cells, T lymphocytes, endothelial cells, fibroblasts

Principal Mediators of Repair Function Monocyte chemotaxis Fibroblast migration/replication Keratinocyte replication Angiogenesis Collagen synthesis Collagenase secretion Growth Factors and Cytokines Chemokines, PDGF, FGF, TGF-, TNF PDGF, EGF, FGF, TGF-, TNF, IL-1 HB-EGF, KGF, HGF, EGF VEGF, FGF, angiopoietins TGF-, PDGF PDGF, FGF, TNF; TGF- inhibits
Test q: Basic Fibroblast Growth Factor is known to promote new vessel formation in granulation tissue. Another prominent growth factor responsible for angiogenesis is: VEGF. Test q: A 50y/o male is involved in a motor vehicle accident w/liver and spleen trauma. Surgery requires splenectomy and partial hepatectomy. Two years later the liver has regenerated to almost normal size. The hepatocytes will end regeneration with secretion of: TGF- .

TGF- can be an off signal inhibits secretion and remodeling of collagen in mature scars.

Figure: different signals for each stage/zone. Angiogenic Factors: VEGF (vascular endothelial growth factor) Receptors have intrinsic tyrosine kinase activity VEGF-R2 for proliferation VEGF-R1 for tube formation bFGF also angiogenic Stimulates other non-endothelial mesenchymal cells, too (ex: pericytes) Angiopoietins turn off vascular proliferation Ang1 binds endothelial Tie2 receptor to recruit pericytes Endostatin (breakdown product) Collagen fragment that inhibits angiogenesis
Test q: Many researchers have produced anti-angiogenic cancer drugs. A compound normally found in the body that inhibits angiogenesis is: Endostatin.

Fibroplasia Factors Fibrinogen, plasma fibronectin Chemotactic mediators from leaky new vessels PDGF, EGF, FGF From platelets, epithelia & histiocytes Fibroblast migration & proliferation IL-1, TNF- Fibrogenic cytokines Induce PDGF, bFGF, TGF from macrophages Induce collagen and collagenase in fibroblasts TGF- most pleotrophic fibrogenic mediator All of the above plus inhibit collagenase secretion (off signal) Fibroblasts have some phagocytic capability can clean up debris as they migrate.

7. Wound healing & maturation, zinc function Surgical Wound Healing A model for dealing with other wound types Primary intention Clean, closely approximated margins Minimal clot/granulation tissue, motion, bacteria Secondary intention Large tissue defect or reopened surgical wound Greater inflammation and granulation tissue Healing time depends on size of defect Wound contraction up to 95% at 6 weeks (Gpig, rabbit) Myofibroblasts Elastin remodeling Fresh Wound (gray = clot w/inflammatory cells in it) Clean incision Limit motion No infection Minimal foreign material Adequate nutrition and circulation Granulation Tissue Replacement of Injury Collagen accumulation is dynamic Depends on both synthesis and degradation Metalloproteinases require zinc ions (so An important for a person with healing wounds) Serine proteases form leaky vessels Cause continual turnover of ECM in granulation tissue Granulation Tissue Thin wall vessels Edematous/disorganized stroma Fibroblasts Decreasing inflammation Type III collagen (wiggly lines) Reepithelialization

Test q: As granulation tissue matures, collage type III is replaced by collagen type I, the wound contracts and blood vessels appear to dissipate from the reparative tissue. This process of wound tissue remodeling requires a special class of protease that requires: Zinc. Test q: A 58y/o physician experiences poor healing of a foot laceration. He decides to take a supplement of __ to enhance metalloproteinase activity. Zinc.