Acute inflammation and chemical

mediators of inflammation

Pooja Sharma

Moderator: Dr Biman saikia

 INFLAMMATION

 Is fundamentally a protective mechanism

designed to rid the organism of both the
initial cause of cell injury (microbes, toxins)
and the consequences of such injury
(necrotic cells, tissues).

 Without inflammation
 infections would go unchecked
 wounds would never heal
 injured organs might remain permanent festering
sores.
Inflammation…
 Inflammation and repair may be potentially
harmful, however.
 Life-threatening hypersensitivity reactions to
insect bites, drugs and toxins
 Chronic diseases- rheumatoid arthritis,
atherosclerosis and lung fibrosis.

 The major causes of inflammation are:

 Trauma ( sprain, strain, contusion, etc.)
 Chemical agents ( poisons, stings, etc.)
 Thermal extremes of heat or cold (burns)
 Pathogenic organisms ( infections )
 two types of inflammation…

Inflammation
Acute Chronic

 short duration-few  days to years

minutes to days  mainly macrophages
 protein exudate and lymphocytes
 neutrophils  Proliferation of blood
predominate vessels, fibrosis and
tissue necrosis
 fewer neutrophils
Acute versus chronic inflammation are distinguished by the duration and the type of infiltrating inflammatory cells
The components of acute and chronic inflammatory responses:
circulating cells and proteins, cells of blood vessels, and cells
and proteins of the extracellular matrix.

Adhesive glycoproteins:
(Fibronectin and laminin)

Structural Fibrous proteins

 SIGNS AND SYMPTOMS OF
INFLAMMATION
 The inflammatory response can be either acute or
chronic, but the local reactions are described as
the cardinal signs and symptoms of inflammation:

LOSS OF
HEAT REDNESS SWELLING PAIN FUNCTION
Functio
Calor Rubor Tumor Dolor laesa
 The nomenclature used to describe
inflammation in different tissues employs
the tissue name and the suffix “-itis”
e.g
pancreatitis
meningitis
pericarditis
arthritis
 Acute inflammation involves:

alteration of vascular caliber

(vasodilation leads to increased blood flow)

changes of microvasculature
(increased permeability for plasma proteins and cells)

emigration of leukocytes from microcirculation

(leukocyte activation leads to elimination of offending agent)
Vascular changes play an important role during acute inflammation
(begin early after injury and depends upon the severity of the injury)

 Vasodilation, leads to
increased blood flow causing
redness and warmth (rubor and
calor)

 Increased Permeability,
leads to exudation of protein rich
fluid into the extravascular space
causing swelling (tumor)

 Loss of fluid from the vessels

leads to Concentration of red
cells resulting in decreased
velocity and stasis of the blood
flow

 Leukocyte rolling, adhesion

and migration leads to the
accumulation of inflammatory
cells
 Increased vascular permeability and edema:
a hallmark of acute inflammation

 loss of protein from plasma leads to

edema
 due to reduced osmotic pressure in
the vasculature
 and increased osmotic pressure in
the interstitium

Normal fluid exchange and vascular permeability depends upon intact endothelium

Proposed mechanisms for how the endothelium becomes leaky?

 Leakage is restricted to venules of

20-60mm in diameter
 caused by endothelial gaps
 usually an immediate and transient
response (30 min.)

 Gaps occur due to contraction of e.g.

myosin and shortening of the
individual endothelial cell
  direct endothelial injury causing
necrotic cell death will result in
leakage from all levels of
microcirculation (venules,
capillaries and arterioles)
 reaction is immediate
and sustained

 Delayed prolonged leakage

begins after 2-12 hours and can
last several days occur due to
thermal-, x-ray or ultraviolet
radiation (sunburn) and involves
venules and capillaries

 Transcytosis occurs across

channels consisting of
interconnected, uncoated
vesicles and vacuoles called
vesiculovacuolar organelle.
Certain factors like VEGF
increases number and size of
these channels.

 during tissue repair - new blood

vessels (angiogenesis) – remain
leaky until intercellular junctions
are formed.

All these described mechanisms may occur in one wound (e.g burns) and can be life threatening
 A critical function of the vascular inflammatory response (stasis and
vascular permeability) is to deliver leukocytes to the site of injury in
order to clear injurious agents

Neutrophils are commonly the first inflammatory cells (first 6-24 hours) recruited to a
site of inflammation.
Extravasation of leukocytes is a coordinated event of:
margination
rolling,
adhesion,
transmigration (diapedesis)
migration.
 Laminar blood flow maintains the leukocytes
against the venular wall
 In normal flowing blood erythrocytes are confined to a
central axial column, displacing leukocytes towards the
wall of vessel.

 As blood flow slows in inflammation more white cells

assumes peripheral position along the endothelial surface.
 This process of leukocyte accumulation is called
margination
 The multistep process of leukocyte migration through blood vessels.

• Slowly move along the endothelium and adhere transiently (process called rolling) finally they come to rest at some point - adhere
firmly.
• After adhesion they insert there pseudopods into endothelial cell junction and squeeze through this layer into the extarvascular space.
• The process of adhesion and transmigration is determined by binding of adhesion molecules on leukocytes and endothelial cells.
Four families of adhesion molecules are involved in leukocyte
migration

Immunoglobulin family
Selectins
ICAM-1 (intercellular adhesion
E-selectin (endothelium) molecule 1)
P-selectin (endothelium & platelets) VCAM-1 (vascular adhesion
L-selectin (leukocytes) molecule 1)
Ligands are sialylated glycoproteins Are expressed on activated
(e.g Sialylated Lewis X) which are linked endothelium
to mucin-like glycoproteins:PSGL- Ligands are integrins on
1,GlyCAM-1, ESL-1, CD34 leukocytes

Integrins (a + b chain) Mucin-like glycoproteins

Heterodimeric molecules Heparan sulfate (endothelium)
VLA-4 (b1 integrin) binds to Ligands for CD44 on leukocytes
VCAM-1
LFA1 and MAC1 (CD11/CD18) =
b2 integrin bind to ICAM
Expressed on leukocytes
 Regulation of endothelial and leukocyte
adhesion molecules.

Intracytoplasmic endothelial granules

P-selectins – bind leukocytes
Role – leukocyte rolling

Induces expression of E-sectins, ICAM-1

and VCAM-1 in endothelial cells

LFA-1 (leukocytes) – low to high affinity by

chemokines secreted by endothelial cells
Leukocyte activation..
 Leukocytes follow towards the site of injury
in the tissue along a chemical gradient of
chemo-attractants in a process called
chemotaxis.
Exogenous and endogenous stimuli can act as
chemoattractants

Exogenous: bacterial product (e.g N-

formyl-methionyl peptides
Endogenous: anaphylatoxins (C5a),
leukotrienes (LTB4),
chemokines (e.g IL-8)

Most chemotactic agents signal via G-protein-coupled 7 transmembrane

receptors leading to the activation of phospholipase C resulting in intracellular
Ca2+ release and activation of small GTPases (Rac,Rho, cdc42). This leads to
actin/myosin polymerization and a morphological response with directional
filopodia formation
Rac, Rho and cdc42 and the morphological
response
 While signaling of chemo-attractants induces a morphological
response and locomotion of neutrophils, pattern recognition
receptors or opsonin receptors induce neutrophil and macrophage
effector functions

Pattern recognition receptors recognize

CD14
Toll-like receptor
Mannose receptor
Scavenger receptors
LPS
endotoxins, CpG, dsRNA,
bacterial proteoglycans
bacterial carbohydrates
lipids

Opsonin-receptors recognize
CR1 complement product C3b
Fcg receptor IgG coated pathogens
Neutrophil and macrophage effector functions serve
to eliminate pathogens and noxious substances

 Phagocytosis of pathogens and

noxious agents

 Release of bactericidal and cytoxic

molecules
Phagocytosis and its outcome involves three distinct steps

 Recognition and attachment

 Engulfment and fusion of phagosome

and lysosome

 Killing and degradation mainly

through the generation of oxygen
radicals and their halogenation
Phagocytosis of a particle (e.g., bacterium) involves attachment and
binding of Fc and C3b to receptors on the leukocyte membrane,
engulfment, and fusion of lysosomes with phagocytic vacuoles, followed
by destruction of ingested particles within the phagolysosomes.
Killing and degradation
1. Oxygen dependent mechanism

2. Oxygen independent mechanism

occur through the action of substances in leukocyte granules
e.g. BPI (bactericidal permeability increasing proteins),
Lysozymes, Lactoferrins, major basic proteins and endotoxins
Systemic effects of acute inflammation
acute phase response

 Fever (temperature > 37.8oC or >100 F)

 Increased pulse, blood pressure
 Chills
 Anorexia
 Leukocytosis
 neutrophilia and left shift of neutrophils points
to bacterial infection
 Lymphocytosis points to viral infection
 Eosinophilia point to allergy or parasitic
infection
 Acute phase protein production in liver
 fibrinogen, CRP,SAA leads to increased ESR
 Increased Erythrocyte Sedimentation Rate as a result of the
presence of acute phase reactants

ESR = rate at which erythrocytes settle

out of unclotted blood in one hour
Normally, Erythrocytes are very
buoyant and settle slowly
Erythrocytes are negatively charged
and repel each other (no aggregation
occurs)
In presence of acute phase reactants
(fibrinogen) erythrocytes aggregate
due to loss of their negative charge
resulting in increased sedimentation

ESR is a widely performed test to detect occult processes and

monitor inflammatory conditions
 Granulocytosis with “left shift” of neutrophil population are a
good indicator for a severe bacterial infection

• Leukocyte release result from a direct effect of IL-1 and IL-6 on

bone marrow neutrophil stores.
• Exaggeration of this can result in a “Leukemoid reaction” release
of very immature precursors and cell counts >25-30 x 106/ml
 Termination of acute inflammation

 Eradication of an offending agent should lead to

discontinuation of the inflammatory response

 Neutrophils have only a short life span (few hours -1

day)

 Most mediators are very short lived and are degraded

immediately

 Anti-inflammatory cytokines (TGF-beta, and IL-10) can

inhibit the production of pro-inflammatory cytokines
(TNF)

 In Arachidonic acid metabolism, lipoxin and resolvins

are generated that have anti-inflammatory activity
Clinical Examples of Leukocyte-Induced Injury
Examples of acute inflammatory diseases of different origin

 Allergic reaction

 Peptic ulcer

 Bacterial pneumonia

 Sepsis
Allergic Reaction with swelling of the larynx

www.nature.com/.../ images/nature01324-f1.2.jpg
Bacterial pneumonia
Peptic ulcer

An ulcer is a local defect of

mucosal lining produced by
shedding of necrotic tissue
Peptic ulcers are produced by an
imbalance between gastro-
duodenal defense mechanisms
and the damaging force
70% of all ulcers are due to H.
pyolri infection which initiates a
strong inflammatory response
 Septicemia with disseminated intravascular coagulation due to
Meningococcal Infection

Invasion of the bloodstream by Neisseria meningitides leads to

widespread vascular injury with endothelial necrosis, thrombosis
and peri-vascular hemorrhage.
Hemorrhage as it is seen in the skin can occur in all organs
Defects in Leukocyte Functions
Immunodeficiency Diseases caused by deficiencies or defects in
phagocytes (neutrophils and macrophages)

Lack of neutrophil/macrophage numbers or defect of their

function can lead to live threatening infectious diseases,
particularly with bacterial and fungal pathogens

Clinically most common:

bone marrow suppression with decreased cell numbers
(leukopenia) due to tumor infiltrate or chemotherapy resulting in
myelosuppression (>500 neutrophils /ml is considered very
severe)

However, inherited defects of adhesion, phago-lysosome- and

microbicidal functions have been found
 Wiskott-Aldrich Syndrome:
a Trafficking defect of antigen presenting cells

WAS – Syndrome
Recurrent infections Eczema Thrombocytopenia
Leukocyte adhesion deficiency 1 and 2
(LAD1/2)

LAD 1 is a result of a lack of b2 intergrin

expression due to defect of CD18 (LFA-1 and
MAC-1). Interaction with ICAM and VCAM on
endothelium is impaired

LAD 2 results from a lack of sialyl LewisX (defect

of carbohydrate fucosylation). Interaction with
endothelial E-and P-selectins is impaired
 Leukocyte adhesion deficiencies (LAD 1 and 2)

Neutrophils unable to aggregate

Leukocytes unable to leave the circulatory
system
Neutrophil counts are commonly twice
NEJM: Vol. 343: No 23, pp1703-1714

the normal level even without

an ongoing infection
(Leukocytosis)
Clinical findings:
History of delayed separation of umbilical cord
Severe peridontitis
Recurrent bacterial and fungal infections of oral
and genital mucosa (enteric bacteria, staph,
candida, aspergillus)
Infected foci contain few neutrophils (no pus) and
heal poorly
LAD 2 immunodeficiency is less severe, however the defect is associated with
growth retardation, dysmorphy and neurological deficits
Chronic granulomatous disease
(a defect of NADPH oxidase system and therefore inability to undergo
oxidative burst and production of hydrogen peroxide)

 CGD is a heterogeneous
disorder caused by
defects of any of the four
subunits of NADPH
oxidase.
 70% are due to X-linked
defect of gp91 phox
(more severe form)
 Second most due to
autosomal recessive
defect of p47 phox

NEJM: Vol. 343: No 23, pp1703-1714

 Chronic granulomatous disease = defect of NADPH oxidase system

Clinical findings:
Recurrent infections with catalse-positve
microorganisms
(S. aureus, Burgholderia cepacia, aspergillus
spec., nocardia spec., and Serratia
marrcescens)

Recurrent infections of lungs, soft tissue

and other organs (typical is infection of
nares, and gingivitis)

Appearance of fever and clinical signs of

infection may be delayed

Excessive formation of granuloma in all

NEJM: Vol. 343: No 23, pp1703-1714 tissues
 Chediak-Higashi Syndrome

Defect of the formation and function of neutrophil granules

CHS is an autosomal recessive disorder of all lysosomal

granule containing cells with clinical features involving the
hematological and neurological system

 All cells containing lysosomes have giant granules.

 In neutrophils large granules result from abnormal fusion of

azurophilic and specific granules and delayed fusion with
phagosomes.

 Neutrophils of CHS patients fail to orient themselves during

chemotaxis resulting in delayed diapedesis

 Mutated gene: LYST = protein involved in vacuolar formation

and transport of proteins
 Defect of the formation and function of neutrophil granules
Chediak-Higashi Syndrome
Clinical features:
recurrent bacterial infections
with S. aureus and beta hemolytic
streptoc.;

Normal PMN Abnormal PMN

Peripheral nerve defects (nystagmus
and neuropathy)

Mild mental retardation and partial

ocular and cutaneous albinism

Platelet dysfunction and severe

NEJM: Vol. 343: No 23, pp1703-1714 peridonatal disease

Mild neutropenia and normal

immunoglobulins
 Myeloperoxidase deficiency

 Most common inherited

disorder of neutrophils

 Catalyzes the generation

of hypochlorous acid
(HOCL)

 A deficiency is not
generally associated with
disease(!!!!)

 Except in patients with

diabetes mellitus, who
are susceptible to
disseminated Candidiasis
Outcomes of acute inflammation:
resolution, healing by fibrosis, or
chronic inflammation
 Chemical mediators of inflammation

 Perform biological activity by binding to specific receptors on target

cells
 Some have direct enzymatic activity (lysosomal proteases) or
mediate oxidative damage (oxygen metabolites).
 Once activated and released from cell, most of these are short lived-
quickly decay, inactivated or inhibited.
 Preformed chemical mediators

Histamine and Serotonin induce vasodilation and increased vascular permeability

Mast cell :
• richest source of histamine
• located in connective tissue
• adjacent to blood vessels
• Degranulation through receptors for IgE-,
IgG, histamine releasing protein, bacterial
products and anaphylatoxin C3a, C5a,
physical injury, cold, heat
• Mast cells are very important effector cells
in hypersensitivity reactions (anaphylactic
reactions)
Platelets :
• release of PAF (platelet activating
factor) leads to serotonin release
from activated platelets
 Newly synthesized chemical mediators
Generation of arachidonic acid metabolites (eicosanoids)
and their roles in acute inflammation.
Mechanical, physical or chemical stimuli
Or mediators like C5a

 The molecular targets of action of some anti-inflammatory drugs are indicated by a

red X.
 COX, cyclooxygenase; HETE, hydroxyeicosatetraenoic acid; HPETE,
hydroperoxyeicosatetraenoic acid.
Biosynthesis of leukotrienes and
lipoxins by cell-cell interaction.
o AA products can pass from one cell
type to another, and different cell types
can co-operate with each other to
generate eicosanoids (transcellular
biosynthesis).

o Activated neutrophils generate LTB4

from arachidonic acid-derived LTA4 by
the action of 5-lipoxygenase, but they do
not possess LTC4 -synthase activity and
consequently do not produce LTC4.

o In contrast, platelets cannot form

LTC4 from endogenous substrates, but
they can generate LTC4 and lipoxins from
neutrophil-derived LTA4
 Eicosanoids can mediate virtually every step of
inflammation

Action Metabolite

Vasoconstriction Thromboxane A2,

Leukotrien C4, D4, E4

Vasodilation PGI2, PGE1, PGE2, PGD2

Increased vascul. permeab. LTC4, LTD4, LTE4

Chemotaxis, leuko. adhesion LTB4, 5-HETE, lipoxins

Bronchospasm Leukotriene C4, D4, E4

 Plasma Derived mediators
The activation and functions of the complement system in inflammation.

• The most critical step is the activation of third component of complement i.e. C3.
The cleavage of C3 can be brought abought by the classical, alternative or lectic pathway.
• Classical pathway - fixation of C1 to Ab (IgM or IgG) combined with Ag.
• Alternative pathway - the microbial surfaces (endotoxins).
• Lectin pathway - collectins bind to the carbohydrate containing proteins on bacteria and
viruses and activates complement.
• C3 convertase splits C3 into C3a and C3b.
Kinin-Bradykinin System

(HMWK)

Bradykinin increases vascular permeability, contraction of smooth

muscles, vasodilation and pain
Kallikrein is a potent activator of factor XII, is chemotactic and can
directly convert C5 to C5a
 Interrelationships between the four plasma mediator
systems triggered by activation of factor XII (Hageman
factor).

 Note that thrombin induces inflammation by binding to protease-activated receptors

(principally PAR-1) on platelets, endothelium, smooth muscle cells, and other cells
Major effects of interleukin-1 (IL-1) and tumor
necrosis factor (TNF) in inflammation
 Functions of nitric oxide (NO) in blood
vessels and macrophages, produced by two
NO synthase enzymes.

NO causes vasodilation, and NO free radicals are toxic to microbial and mammalian cells.