Forms of Cell Damage: Irreversible

Cell Injury and Cell Death

Dilip K. Das, MBBS, MD, PhD, DSc, FRCPath
Department of Pathology,
Faculty of Medicine
Kuwait University
 States of Progressive Encroachment on the
Cell’s Normal Function and Structure: Cellular
Adaptation, Cell Injury and Cell Death

• Normal homeostasis.
• Cellular adaptations.
• Cell injury:
 Reversible cell injury.
 Irreversible cell injury.
• Cell death:
 Necrosis.
 Apoptosis
 Cell Injury and Cell Death
• Cell injury: Occurs, if the limits of adaptive response to a
stimulus are exceeded or in certain instances when adaptation is not
possible.
• Reversible cell injury: Cell injury is reversible up to a certain
point.
• Irreversible cell injury: If the stimulus persists or is severe
enough from the beginning, the cell reaches the point of no return and
suffers irreversible cell injury and cell death.
• Cell death: The ultimate result of cell injury, has two principal
patterns: (1) necrosis; (2) apoptosis.
• Necrosis (when a group of cells die in continuity with living)
is the cell death after exogenous stimuli such as ischemia and
chemical injury.
• Apoptosis occurs when a cell dies through an internally controlled
suicide program.
Irreversible Cell Injury due to Ischemia/Hypoxia
• Inability to reverse mitochondrial dysfunction causes marked
ATP depletion, which contributes to the functional and
structural consequences of ischemia.
• Membrane damage which is a central factor in the
pathogenesis of irreversible cell injury, is caused by several
factors such as mitochondrial dysfunction, loss of membrane
phospholipids, cytoskeletal abnormalities, reactive oxygen
species, lipid break down products, and loss of intracellular
aminoacids.
• Massive influx of calcium into the cell then occurs. There is
continued loss of proteins, enzymes, coenzymes, ribonucleic
acids from the hyperpermeable membrane.
• Injury to lysosomal membrane is followed by leakage of their
enzymes into the cytoplasm and activation of their acid
hydrolases (RNAses, DNases, and proteases, etc.) leading to
digestion of cell components.
 Irreversible Cell Injury due to
Ischemia/Hypoxia
• Irreversible injury is associated
morphologically with severe
swelling of mitochondria,
extensive damage to plasma
membrane, and swelling of
lysosomes. Clumping of
nuclear chromatin is followed
by nuclear pyknosis,
karyorrhexis, and karyolysis.
• After cell death cell components
are progressively degraded
leading to necrosis or
apoptosis.
• If restoration of blood flow
follows, there is infiltration of
leukocytes, and perfusion injury
by oxygen free radicals and
reactive oxygen species.
Schematic representation of normal cell (A), and ultrastructural
changes in reversible (B), and irreversible (C) cell injury
 Changes Following Cell Death
• Changes following cell death differ according to whether or not
the dead tissue remains an integral part of a living organism.
• Cellular or tissue changes occurring during the period
following death of the organism: Post-mortem change
• When dead tissue is an integral part of living organism:
Necrosis or apoptosis.
Post-mortem change
• In a dying cell glycolysis proceeds for a while and results in a
drop of pH due to production of lactic acid. Enzymes active at
low pH, i.e., proteases, lipases, deoxyribonucleases,
ribonucleases, etc, cause self-digestion, or autolysis.
• The microscopic changes affects the whole cell: the cytoplasm
becomes homogeneous and brightly eosinophilic. Later on
cellular and nuclear details become lost.
• The post-mortem changes can be distinguished from those
occurring during life by the complete absence of any
surrounding inflammatory cells (‘vital reaction’).
 Necrosis
• Necrosis refers to a spectrum of morphologic changes that
follow cell death in living tissue, largely resulting from the
progressive degradative action of enzymes on the lethally
injured cell.
• The dead cells do not show changes immediately. Within a few
hours, however, autolysis (digestion of cell by its own catalytic
lysosomal enzymes) or heterolysis (enzymatic digestion by
lysosomes of immigrant leukocytes) occurs and the cells show
morphological changes by which cell death can be recognized.
• The morphologic appearance of necrosis is the result of two
essentially concurrent processes: (1) enzyme digestion of the
cell and (2) denaturation of proteins.
• Following cell death both cytoplasmic and nuclear changes
occur but the autolytic changes of nucleus are regarded as
pathognomonic of necrosis.
 Nuclear Changes of Necrosis
1. Pyknosis.
2. Karyorrhexis.
3. Karyolysis.
• Margination of the chromatin adjacent to the nuclear envelope is an
early change. The chromatin loses its fine reticular pattern and
becomes clumped. The nucleus becomes smaller.
• As the DNA is broken down by endonucleases, short
oligonucleotide fragments are formed and phosphoric acid groups
become available for binding to basic dyes such as hematoxylin.
The shrunken nucleus therefore becomes acidic and stains deeply:
a process termed pyknosis.
• The nucleus either beaks into fragments (karyorrhexis), or its
outline becomes indistinct as the nuclear material is broken down
to mononucleotide, the phosphoric acid groups are split off, and
they easily leach (percolate) from the cell.
• Hence the basophilia of the nucleic acids diminish, and the cell
becomes an eosinophilic ghost of itself. The process is termed
karyolysis.
 Types of Necrosis
• Coagulative necrosis: When denaturation
of protein is the primary pattern.
• Colliquative or liquafactive necrosis:
Enzyme digestion is dominant.
• Caseous necrosis: A distinct form of
coagulative necrosis.
• Gangrene: Necrosis with putrefaction.
• Necrosis in a specialized tissue: E. g. , Fat
necrosis, fibrinoid necrosis.
 Coagulative Necrosis
• Important change: preservation of the general architecture of the
tissue despite the death of its constituent cells.
• Implies preservation of the basic outline of the coagulated cell
(structured necrosis) for a span of at least some days.
• Denaturation of protein makes the tissue opaque as does an egg on
boiling.
• Hypoxic death of cells in all tissues except brain can cause
coagulative necrosis but infarction of heart and kidney are good
examples.
• The necrotic tissue becomes more reactive and binds eosin more
avidly than normal tissue and tends to calcify.
• The increased eosinophilic staining of heart muscle fibers is an early
sign of necrosis.
• The nuclear changes (pyknosis, karyorrhexis, and karyolysis) follows.
• An inflammatory reaction develops.
• Ultimately the necrotic cells are removed by fragmentation and
phagocytosis of cellular debris by scavenger white cells and by the
action of their proteolytic lysosomal enzymes.
Coagulative necrosis: Myocardial infarction
 Colliquative necrosis

• Necrosis with softening.

• Liquefaction completely
digests the dead cells and
transforms the tissue into a
liquid viscous mass.
• Occurs typically in infarction
of the central nervous
system.
• Liquefaction may occur in an
area of coagulative necrosis
as a result of secondary
changes, e.g. suppuration
(bacterial action) in septic
infarction and liquefaction of
caseous material.
 Caseous Necrosis
• A distinct form of coagulative
necrosis in which the necrotic
tissue resembles cheese and
contains a mixture of protein
and fat.
• The dead tissue has no residual
structure , i.e., architecture is
completely obliterated
(structureless necrosis).
• It is well seen in necrosis of
tuberculosis.
• Gross: Firm, dry, white, and
cheesy.
• Micro: Necrotic focus appears
as amorphous granular debris,
composed of fragmented,
coagulated cells. Has
inflammatory boarder known as
granulomatous reaction
 Fat necrosis
• An example of necrosis in special sites.
• Occurs following direct trauma to adipose tissue or
as a result of release of pancreatic lipase in acute
pancreatitis.
• Gross: Fatty acids released from fat cells combine
with calcium to produce chalky white areas (fat
saponification).
• Micro: Degenerated fat cells and inflammatory cells.
 Gangrene
• Necrosis with putrefaction of the tissues due to
certain bacteria such as clostridia. Appears black
due deposition of iron sulphide from degraded
hemoglobin.
• Wet gangrene: Follows action of clostridia on
necrosed intestine as a complication of appendicitis
or incarceration of a hernia.
• Dry gangrene: Ischemic necrosis of distal part of a
limb (e. g. toe) as a result of gradual arterial or small
vessel obstruction in atherosclerosis or diabetes
mellitus and subsequent infection by appropriate
organism.
• Gas gangrene: Result of infection by Clostridium
perfringens.
 Diagnosis of Necrosis by Biochemical
Reaction
Principle:
• Many soluble substances like potassium, protein break down products
and enzymes diffuse out of the cells following their death. The last are
absorbed into the blood stream, and their presence can be utilized in
the diagnosis.
Examples:
• Glutamate oxaloacetate transaminases and other enzymes from
infarcted heart muscle.
• Glutamate-pyruvate transaminases in liver necrosis.
• Creatine phosphokinase (CPK) in skeletal muscle damage.
• It is possible to separate these enzymes into components or fractions
called isoenzymes: e.g. MB fraction of CPK is virtually diagnostic of
myocardial damage.
Advantages: E.g. The earliest histologic evidence myocardial
necrosis does not become manifest until 4 to 12 hours later but loss
of cardiac-specific enzymes and proteins can be detected in the blood
stream as early as 2 hours after myocardial death.
 Apoptosis (Greek: Falling Off)
Definition: It is a distinctive form of cell death designed to
eliminate unwanted cells through activation of a coordinated,
internally programmed series of events by a dedicated set of
gene products (Programmed cell death).
General setting of apoptosis: (1) during development;
(2) as a homeostatic mechanism to maintain cell population in
the tissue; (3) when cells are damaged by disease or noxious
agents; (4) as a defense mechanism such as in immune
reactions; and (5) Cell death in tumors, and (6) in aging.
Mechanism of Apoptosis:
• Apoptosis is the end point of an energy-dependent cascade of
molecular events, initiated by certain stimuli.
• Apoptosis results from activation of caspases triggered either
by BCl-2 family or by the binding of Fas ligands to its receptor
(CD 95) called death receptor.
Schematic representation
of apoptotic events
 Apoptosis: Morphology and Dysregulated
Forms
Morphology:
• Apoptosis usually involves single cells.
• Cell shrinkage, chromatin condensation, formation of cytoplasmic
blebs and apoptotic bodies. The apoptotic cell appears as a round or
oval mass of intensely eosinophilic cytoplasm with dense nuclear
chromatin fragments.
• Plasma membrane appear to remain intact during apoptosis.
• Phagocytosis of apoptotic cells by neighbouring cells.
• But apoptosis-in contrast to necrosis- does not elicit inflammation.
Dysregulated apoptosis (“too little or too much”):
• Disorders associated inhibited apoptosis and increased
survival: (1) Cancers, such as breast, prostate, and ovarian
tumors; (2) autoimmune disorders.
• Disorders associated with increased apoptosis and excessive
cell death: (1) Virus-induced lymphocyte depletion (AIDS). (2)
Ischemic injury;
 Comparison of Cell Death by Apoptosis and Necrosis
Feature Apoptosis Necrosis
Induction May be induced by Invariably due to
physiological or pathological pathological stimuli
stimuli
Extent Single cells Cell groups
Biochemical events Energy-dependent Impairment or cessation of
fragmentation of DNA by ion homeostasis
endogenous endonucleases. Lysosomes leak lytic
Lysosomes intact enzymes
Cell membrane Maintained Lost
integrity
Morphology Cell shrinkage and Cell swelling and lysis
fragmentation to form
apoptotic bodies with dense
chromatin
Inflammatory None Usual
response
Fate of dead cells Ingested (phagocytosed) by Ingested (phagocytosed)
neighbouring cells by neutrophil polymorphs
and macrophages
Thank You