Inflammation

Marc Imhotep Cray, M.D. Basic Medical Sciences Teacher

http://www.imhotepvirtualmedsch.com/

Companion Inflammation Notes

Inflammation

Inflammation
Definition
EVOLUTION OF INFLAMMATION Inflammation is a complex reaction of a tissue and its microcirculation to a Engulfment/entrapment pathogenic insult. It is characterized Neutralization of irritant by the generation of inflammatory mediators and movement of fluid & Elimination of injurious agent leukocytes from the blood into extravascular tissues.

The inflammatory response:

Is fundamentally a protective/defensive response Persists until the inciting stimulus is removed and the mediators are dissipated or inhibited Can be potentially harmful: Anaphylactic shock (peanut allergy) Systemic inflammatory response syndrome (SIRS) Is closely intertwined with repair Therapeutic strategies target critical control points in inflammatory pathways
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Acute Inflammation: major components

Vascular changes:
Vasodilation and increased blood flow Increased vascular permeability

Cellular events:
Leucocyte transmigration Phagocytosis

Chemical mediators (acute & chronic)

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Inflammation: the players

Cardinal Signs
(Celsus, 2 AD)

Redness (rubor) Swelling (tumor) Heat (calor) Pain (dolor) Loss of function (functio laesa)
(the fifth cardinal sign added by Virchow)
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Inflammation
Cardinal Signs
Patient with a Methicillin-resistant Staphylococcus aureus wound infection, and classic signs of inflammation.

Inflammation
Cardinal Signs
X-ray of previous patient showing non-union of fracture. Holes are from orthopedic screws.

Inflammation
Cardinal Signs
Bone scan of same patient, showing uptake in area of active inflammation.

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Acute Inflammation: 1. Vasodilation/increased blood flow

2. Deposition of fibrin and other plasma proteins (exudate) 3. Transmigration and accumulation of neutrophils
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Vasodilation
Slowing of circulation Stasis and margination

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Inflammation
Stasis and Margination
Polymorphs at margin of a vessel in acutely inflamed tissue.

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Vascular Leakage:
Transudate: (edema) specific gravity <1.015 and protein content low Exudate: (inflammation) specific gravity >1.015 and protein content high

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Vascular Leakage (cont.)

Rat model: only venules leak and deposit carbon

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Leukocyte Extravasation and Phagocytosis

Margination, rolling, activation and adhesion
Transmigration (diapedesis) Migration toward the site of injury along a chemokine gradient
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Adhesion Molecule Modulation

P-selectin is redistributed to the cell surface from the Weibel-Palade bodies due to stimulation by thrombin, histamine, and Platelet Activating Factor (PAF)

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Adhesion Molecule Modulation

Induction of E-selectin on endothelium by IL1 and TNF Increased avidity of binding of integrins (conformational change)

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Endothelial/Leukocyte Adhesion Molecules: Summary

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Animation

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Sequence following acute injury:

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Mechanisms of Inflammatory Cell Function

The formation of a ligand-receptor complex leads to activation of a specific phospho-diesterase (phospholipase C) in the plasma membrane (stimulusresponse coupling)

Increased phospholipid metabolism Increased intracellular calcium Activation of protein kinases and phosphatases
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Biochemical Events in Leucocyte Activation

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Chemotaxis
Locomotion along a chemical gradient Chemoattractants: Exogenous (from bacteria) Endogenous (from mediators)

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Chemotaxis
Exogenous mediators, e.g.:
N-formyl methionine terminal amino acids from bacteria Lipids from destroyed or damaged membranes (including LPS)

Endogenous mediators, e.g.:

Complement proteins (C5a) Chemokines, particularly IL-8 Arachidonic acid products (LTB4)
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Phagocytosis
Recognition and attachment Engulfment Degradation (killing)

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Bactericidal activity

Activated oxygen species

Superoxide (.O2) - formed via NADPH oxidase Hydrogen peroxide (H2O2) - formed via spontaneous dismutation of superoxide) Hypochlorous acid (HOCl) (Myeloperoxidase)

Probably the primary bactericidal agent in neutrophils Myeloperoxidase converts H2O2 into HOCl. . Hydroxl radical ( OH)
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Bactericidal activity

Non-oxidative bacterial killing

Lysosomal hydrolases (1o and 2o granules) Bactericidal/permeability-increasing protein (1o granules - affects Gram-negatives) Defensins (1o granules) Lactoferrin (2o granules - chelates iron) Lysozyme (1o and 2o granules, lysosomes) Bactericidal proteins of eosinophils
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Tissue Injury by Inflammatory Cells

"Our arsenals for fighting off bacteria are so powerful, and involve so many different defense mechanisms, that we are more in danger from them than from the invaders. We live in the midst of explosive devices; we are mined."
Lewis Thomas

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Tissue Injury by Inflammatory Cells

Activated oxygen species

Can migrate through intact plasma membranes Initiate lipid peroxidation React with DNA Oxidize sulfhydryl groups of proteins Degrade extracellular matrix components

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Tissue Injury by Inflammatory Cells

Lysosomal enzymes

Since these enzymes are used to degrade microorganisms in lysosomes, obviously they could damage tissue in the extracellular environment Usually protease activity is controlled by a variety of anti-proteases present in plasma (a1-anti-trypsin, a2-macroglobulin, etc.)
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Tissue Injury by Inflammatory Cells

Phagocytic cell adherence

Adherence to basement membranes, other components of the extracellular matrix and other cells by phagocytes enhances the damage caused by reactive oxygen species and lysozyme, because normal inhibitors present in plasma cannot gain access to that space by virtue of the phagocytic cell adherence
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Tissue Injury by Inflammatory Cells

Abscess, formed via liquifactive necrosis, primarily due to the action of neutrophils.

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Tissue Injury by Inflammatory Cells

Normal glomerulus, containing 50-100 nuclei.

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Tissue Injury by Inflammatory Cells

Post-streptococcal glomerulonephritis, showing a hypercellular glomerulus. Most of the extra cells are neutrophils, reacting with immune complexes in the glomerular basement membrane. This is a very bad thing for the glomerulus, and it is usually destroyed and heals with a hyaline scar.

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Clinical examples of leukocyte-induced injury

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Defects in Phagocytosis

Congenital

Chediak-Higashi Syndrome (autosomal recessive)

Defective intracellular transport protein, inability to lyse bacteria

Job Syndrome (Hyper IgE) Chronic granulomatous disease (x-linked)

No oxidative burst

Myeloperoxidase deficiency

Acquired

Iatrogenic immunosuppression (most common) Overwhelming infections Severe trauma or burn Diabetes mellitus Chronic debilitating disease

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Summary of Acute Inflammation

What You MUST Know

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Chemical Mediators of Inflammation

Originate from either plasma or cells Bind to specific cellular receptors, have direct enzymatic activity or mediate oxidative damage One mediator can stimulate release of additional mediators (amplification) Effects on multiple cell types, varying effects on different cells Once activated and released are short-lived Have potential to cause harmful effects

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Sources of Inflammatory Mediators

Cell-derived:
Proteins sequestered in granules Membrane phospholipids (via arachidonic acid metabolism) Vasoactive amines (mast cells and platelets)

Inactive precursors in plasma:

Complement proteins (C3a, C5a) Coagulation proteins initiated by Hageman factor (FDPs)
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Chemical mediators of inflammation

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Chemical mediators of inflammation

Vasoactive amines:
Histamine Serotonin

Plasma proteases:
Complement system Kinin system Coagulation system

Arachidonic acid metabolites:

Prostaglandins Leukotrienes Lipoxins

Platelet activating factor Cytokines and chemokines Nitric oxide Leucocyte lysosomal consituents Oxygen-derived free radicals Neuropeptides

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Vasoactive Amines
Histamine: Source = mast cell granules Wide distribution around vessels Main action is vasodilation and increased vascular permeability Released by trauma, heat or cold, complement, cytokines G-protein-coupled receptor

Serotonin (5-hydroxytryptamine): Source = platelet granules Actions similar to histamine Released by platelet aggregation (collagen, thrombin, ADP, PAF from mast cells G-protein-coupled receptor
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Plasma Protease Systems

Complement, coagulation, fibrinolytic and kinin systems All zymogen-based proteolytic cascades with great amplification characteristics Generate pro-inflammatory by-products Mutual interactions between systems

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Chemical Mediators: proteases

Complement cascade system Classic and alternative pathways C3 is the critical control point, and interacts with both pathways C3a and C5a are known as anaphylatoxins, and are capable of releasing histamine from mast cells, along with potent chemotactic abilities (C5a) Membrane attack complex (MAC) is the active agent of complement lysis and consists of C5-9

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Biologic effects of complement fragments

Vascular phenomena:
Increase vascular permeability Vasodilation

Leucocyte adhesion, chemotaxis: C5a Phagocytosis: C3b and C3bi

Opsonins
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Complement: regulatory mechanisms

Regulation of C3 and C5 convertases:
Decay acceleration and proteolysis

Binding of activated complement components:

C1 inhibitor CD59 membrane inhibitor of lysis

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Chemical Mediators: proteases

Kinin system
Vasoactive peptides called kinins are generated by proteases called kallikrein Hageman factor is a potent activator of kallikrein Most important product is bradykinin Pain + vascular dilation

Coagulation/Fibrinolytic pathway
Both systems are induced by activated factor XIIa (Hageman) The coagulation and fibrinolytic systems complement and counterbalance each other Most important molecules are fibrinogen, fibrin, thrombin, plasminogen, and plasmin
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Arachidonic Acid Metabolites

Arachidonic acid (AA) is a 20-C polyunsaturated fatty acid released from membrane phospholipids by phospholipase A2 Mechanical, chemical physical stimuli can activate phospholipase A2 Metabolites of AA are called eicosanoids, and are generated by cyclooxygenases and lipoxygenases Cycloxygensases synthesize prostaglandins and thromboxane Lipoxygenases synthesize leukotrienes and lipoxins Eicosanoid receptors are G-protein-coupled transmembrane proteins Eicosanoids mediate all aspects of inflammation

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Chemical Mediators of Inflammation

Arachidonic acid metabolites Synthesized from cell membrane phospholipids though the action of phospho-lipases (inhibited by corticosteroids) Form leukotrienes via 5-lipoxygenase Form prostaglandins and thromboxane A2 via cyclo-oxygenase (COX-1 inhibited by aspirin and indomethacin, COX-2 inhibitors now coming on the market) 53

Inflammatory Action of Eicosanoids

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Chemical Mediators of Inflammation

Platelet activating factor Numerous effects, including vasodilation and increased vascular permeability, with 100-10,000-fold increased activity, with respect to those actions, when compared to histamine
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Chemical Mediators of Inflammation

Cytokines of importance
Interleukin 1- endothelial cell activation Interleukin 2 (T cell growth factor) Tumor necrosis factor a (cachectin) Tumor necrosis factor b (lymphotoxin) Various colony stimulating factors, named for the stem cell they affect Chemokines important in chemotaxis

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Cytokines mediating inflammation

Tumor necrosis factor Interleukin-1 (IL-1) Chemokines

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Inflammatory Cells and their Chemokines

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Chemical Mediators of Inflammation

Nitric oxide (NO)
Formed by NO synthase (NOS)
Constitutively expressed in endothelial and neuronal cells. May be increased rapidly by calcium influx. Inducible NOS induced in macrophages by TNF-a or IFN-g

Potent vasodilator Involved in the pathogenesis of septic shock

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Inflammation
Neutrophil Granules

Primary - contain serine proteases, lysozyme and phospholipase A2 Secondary - similar to primary, but also contain lactoferrin and collagenase Tertiary - present at the leading edge of migrating PMNs, contain gelatinases that are capable of degrading basement membrane
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Inflammation
Neutrophil Granules

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Mediators of Inflammation

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Mediators of Inflammation

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Outcomes of Acute Inflammation

Resolution (the hoped-for result) Abscess (via liquifactive necrosis) Scar (sometimes occurs even if pathogen is eliminated) Persistent inflammation (chronic inflammation) due to a failure to completely eliminate the pathological insult (injury)

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Resolution of acute inflammation

Return to normal vascular permeability Drainage of edema fluid into lymphatics or pinocytosis into macrophages Phagocytosis of apoptotic neutrophils and necrotic debris by macrophages Disposal of macrophages
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Chronic Inflammation

Inflammation of prolonged duration (weeks, months) Active inflammation, tissue destruction and attempts at repair proceed simultaneously Settings:

Persistent infection Prolonged exposure to toxic agent Autoimmunity

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Chronic Inflammation
Histologic features
Infiltration by mononuclear cells: macrophages, lymphocytes, and plasma cells Tissue destruction by ongoing inflammation Attempts at healing, including angiogenesis, fibroblasts and fibrosis
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Chronic Inflammation: Lung

Collection of chronic inflammatory cells Destruction of parenchyma Replacement by connective tissue (fibrosis)
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Maturation of macrophages

From Abbas et al Cellular and Molecular Immunology 1997

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Macrophage activation
Via cytokines from immune-activated Tcells By non-immunologic stimuli: endotoxin, fibronectin, mediators

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Macrophage accumulation

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Chronic Inflammation
Monocyte/Macrophages
Key cell in chronic and granulomatous inflammation Reproduce locally, at the site of injury Produce numerous cytokines, which continue to recruit additional cells, including more macrophages May present antigen to T-cells, producing specific hypersensitivity reactions
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Chronic Inflammation
Products released from macrophages

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Lymphocyte-macrophage interactions
Activated lymphocytes and macrophages influence each other Release mediators that affect other cells

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Chronic Inflammation: other cells

Plasma cells

(lymphocytes)

Mast cells
Eosinophils
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Granulomatous Inflammation

Distinct pattern of chronic inflammation in which the chief reactive cell is an activated macrophage Destruction of tissue is primarily via the action of killer T cells (CD8+), directed by macrophages Hence, the old term for tuberculosis was consumption, for good reason
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Examples of Granulomatous Inflammation

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Granulomatous Inflammation

Tuberculous lung, showing massive destruction by granulomatous inflammation. This type of response is simply the best the body can do, since the inciting organism cannot be removed. Mycobacteria may live for years, perhaps even a 80 lifetime, within granulomas.

Granulomatous Inflammation
Characteristic arrangement of cells in a granuloma. The extracellular matrix is active in orchestrating the precise alignment of cells. Granulomas often form when indigestible substances are present, such as foreign bodies, or Mycobacteria, which are resistant to oxidative killing.

Fibroblasts

Lymphocytes

Macrophages, Epithelioid Cells, and Giant Cells

Caseous Necrosis

Non-caseating Granuloma

Caseating Granuloma
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Granulomatous Inflammation

Granuloma, H&E, showing Langhans giant cells. These multinucleated cells have macrophage markers on their cell surface, and are apparently the result of fusion of individual macrophages. While useful in diagnosing a granuloma, they are not considered the characteristic cell. That honor belongs to the epitheliod histiocyte, which also has macrophage cell surface markers.

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Granulomatous Inflammation
Granuloma, H&E, showing Langhans giant cells. These multinucleated cells have macrophage markers on their cell surface, and are apparently the result of fusion of individual macrophages. While useful in diagnosing a granuloma, they are not considered the characteristic cell. That honor belongs to the epitheliod histiocyte, which also has macrophage cell surface markers.
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Tissue morphology: serous inflammation

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Tissue morphology: fibrinous inflammation

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Tissue morphology: suppurative inflammation

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Tissue morphology: inflammation exudative peptic ulceration

Esophagus

Stomach
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Systemic Manifestations of Inflammation

Systemic effects can be seen in setting of acute or chronic inflammation Largely mediated by cytokines Fever - clinical hallmark of inflammation Endogenous pyrogens: IL-1 and TNF-a Leukocytosis:
neutrophils bacterial (pneumonia) lymphocytes viral (infectious mono) eosinophils parasites, allergy

Acute phase reactants - non-specific elevation of many serum proteins - will markedly increase the sed rate
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Acute phase response

Acute phase proteins: a group of proteins - CRP, mannose-binding protein, SAA, that modulate inflammation (complement cascade, stimulate chemotaxis of phagocytes) Inflammatory cytokines (TNF, IL-1, ) stimulate liver cells to sythesize acute phase proteins Acute phase response provides an early defense before full activation of immune responses 89

Acute phase reaction

Endocrine/metabolic: C-reactive protein (CRP) Serum amyloid A (SAA) Serum amyloid P (SAP) Autonomic: blood flow Physiologic/behavioral (shivering)
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Systemic Manifestations of Inflammation

Shock most common in Gram-negative septicemia (bacteria in the bloodstream), although it can occur with Gram-positive bacteremia

Lipopolysaccharide (LPS or endotoxin) of Gram-negatives can produce symptoms of shock when injected into animals TNF-a can produce a similar syndrome
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Systemic Manifestations of Inflammation

Therapy for fever and inflammation targets arachidonic acid metabolism (aspirin) Therapy for shock focuses on fluid resuscitation, and proper selection of antibiotics (more to come later) Experimental therapy for shock using anti-TNF-a, and other antibodies directed against cytokines, has, so far, failed to improve survival
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THE END THANK YOU

Reference: Kumar et al. Robbins and Cotrans Pathological Basis of Disease 8th edition, Elsevier 2010 Learn more, WebPath Inflammation: 75 Images Patterns of cellular and tissue injury with inflammation, including acute, chronic, and granulomatous inflammation. Medical Pathology - What's an Acute Inflammation? (National Institute of Health) Video
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