CHAPTER I

CELLULAR RESPONSES TO STRESS AND TOXIC INSULTS: ADAPTATION, INJURY and DEATH
1


INTRODUCTION TO PATHOLOGY
Pathology
o study of disease
o Devoted to the study of structural, biochemical and functional
changes in cells, tissues and organs that underlie the disease.
o Attempts to explain the whys and wherefores of the signs and
symptoms manifested by patients while providing a rational basis for
clinical care and therapy.
o serves as bridge between the basic sciences and clinical medicine
o Scientific foundation for all of medicine.
o The study of pathology is divided into:
1. General Pathology
- Concerned with the:
a. reactions of the cells and tissues to abnormal
stimuli and
b. to inherited defects, which are the main
causes of disease.
2. Systemic Pathology
- Examines the alterations in specialized organs and tissues
that are responsible for disorders that involve in these
organs.

FOUR ASPECTS OF DISEASE
o forms the core of pathology
1. Etiology - cause of disease
2. Pathogenesis - mechanisms of its development
3. Molecular and Morphological Changes - the biochemical and
structural alterations induced in the cells and organs of the
body
4. Clinical Manifestations - functional consequences of the
different changes
Etiology
o two major classes of etiologic factors:
1. genetic (inherited mutations and disease associated gene
variants or polymorphisms)
2. acquired (infectious, nutritional, chemical, physical)
o The idea that one etiologic agent is the cause of one disease is not
applicable to majority of disease is not applicable.
o Most of the common afflictions are multifactorial and arise from the
effects of various external triggers on a genetically susceptible
individual.
o The relative contribution of inherited susceptibility and external
influences varies in different disease.
Pathogenesis
o Pathogenesis refers to the sequence of events in the response of
cells or tissues to etiologic agent,
o from the initial stimulus to the ultimate expression of the disease.
Molecular and Morphologic Changes
o Morphologic changes refer to the structural alterations in cells or
tissues that are either characteristic of a disease or diagnostic of an
etiologic process.
o Diagnostic pathology is devoted to identifying the nature and
progression of disease by studying morphologic changes in tissues
and chemical alterations in patients.
o Molecular analysis by techniques such as DNA microarrays has begun
to reveal genetic differences that predict the behavior of the tumors
as well as their responsiveness to different therapies.

Functional Derangement and Clinical Manifestation
o End result of genetic, biochemical and structural changes in cells and
tissues are functional abnormalities, which lead to the clinical
manifestations of disease as well as its progress.
o All forms of disease start with molecular or structural alterations in
cells.
o Injury to cells and to the extracellular matrix ultimately leads to
tissue and organ injury, which determine the morphologic and clinical
patterns of disease.


OVERVIEW: CELLULAR RESPONSES TO STRESS AND NOXIOUS STIMULI

The normal cell is confined to a fairly narrow range of function and
structure:
- by its state of metabolism, differentiation and
specialization
- by constraints of neighboring cells
- by availability of metabolic substrates
The normal cell can handle physiologic demands, maintaining a
steady state called homeostasis.
Adaptations
Are reversible functional and structural responses to more
physiologic stress and some pathologic stimuli.
new but altered steady states are achieved
Allows the cell to survive and continue to function.
the adaptive response may consist of:
a. increase in size of cells (hypertrophy) and functional
activity
b. increase in number of cells (hyperplasia)
c. decrease in the size and metabolic activity of the cells
(atrophy) or
d. a change in the phenotype of the cell (metaplasia)
When the stress is eliminated, the cell can recover to its original state
without having suffered any harmful consequences.

CELLULAR RESPONSES TO INJURY
Nature of Injurious Stimulus Cellular Response
Altered Physiological Stimuli; Some
Nonlethal injurious Stimuli
Cellular Adaptations
increased demand, increased stimulation
(GF,Hormomes)
decreased nutriets, decreased stimulation
Chronic irritation
Hyperplasia, hypertrophy

Atrophy
Metaplasia
Reduced Oxygen Supply, Chemical
Injury, Microbial Infection
Cell Injury
Acute and transient


Progressive and severe


Acute reversible injury,
cellular swelling fatty
change
irreversible injury cell
death, necrosis, apoptosis
Metabolic alterations, genetic or
acquired; chronic injury
Intracellular
accumulations,
calcification
Cumulative sublethal injry over long life
span
Cellular aging


CELL INJURY
Cell injury occurs :
a. if the limits of adaptive responses are exceeded
b. if the cells are exposed to injurious agents or stress
c. if the cell is deprived of essential nutrients
d. if the cell becomes compromised by mutations that affect
essential cellular constituents
Cell injury is reversible up to a certain point.
If the stress or noxious stimuli persists, or it is severe enough from
the beginning, the cell suffers irreversible injury and ultimately cell
death.
Adaptation, reversible cell injury and cell death may be the stages of
progressive impairment following different types of insults.
CELL DEATH
Cell death
the end result of progressive cell injury
Most crucial events in the evolution of disease in any tissue or
organ.
Results from diverse causes including ischemia (reduced blood
flow), infection and toxins.
Is a normal and essential process in embryogenesis, the
development of organs and maintenance of homeostasis.
there are two principal pathway for cell death:
1. Necrosis
2. Apoptosis

Nutrient deprivation triggers an adaptive cellular response call
autophagy and may also culminate in cell death
Stresses of different types may induce changes in cells and tissues
other than typical adaptations, cell injury and cell death:
Metabolic derangements in cells and sub lethal, chronic
injury may be associated with intracellular accumulations
of a number of substances, including proteins, lipids and
carbohydrates
Calcium is often deposited at the sites of cell death
resulting in pathologic calcification
Aging is accompanied by characteristic morphologic and
functional changes in the cell.
Three other processes that affect cells and tissues are
1. intracellular accumulations
2. pathologic calcification
3. Cell Aging

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CELLULAR RESPONSES TO STRESS AND TOXIC INSULTS: ADAPTATION, INJURY and DEATH
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ADAPTATION OF CELLULAR GROWTH AND DIFFERENTIATION

Adaptations are reversible changes in the number, size, phenotype,
metabolic activity, or functions of cells in response to changes in their
environment.
Physiologic adaptations
Usually represent responses of cells to normal
stimulation by hormones or endogenous chemical
mediators (e.g., the hormone-induced enlargement
of the breast and uterus during pregnancy).
Pathologic adaptations
Are responses to stress that allow cells to modulate
their structure and function and thus escape injury.
Such adaptations can take several distinct forms

HYPERTROPHY
O HYPERTROPHY
- refers to an increase in the size of cells
- results in an increase in the size of the organ
O the hypertrophied organ has no new cells, just larger cells
O Increased size
due to the synthesis of more structural components of
the cells.
O Cells capable of division may respond to stress by undergoing both
hyperplasia and hypertrophy
O Nondividing cells (myocardial fibers) increased tissue mass is due to
hypertrophy
O hypertrophy and hyperplasia may coexist and contribute to increased
sized
O Hypertrophy can be physiologic or pathologic and is caused by
increased functional demand or by stimulation by hormones and
growth factors.
- striated muscle cells in the heart and skeletal muscles
have only a limited capacity for division and respond to
increased metabolic demands mainly by undergoing
hypertrophy
O The most common stimulus for hypertrophy of muscle is increased
workload.
- In the heart, the stimulus for hypertrophy is usually
chronic hemodynamic overload, resulting from either
hypertension or faulty valves.
O In both the heart and muscle fiber tissues, the muscle cells
synthesize more proteins and the number of myofilaments increase.
this increases the amount of force each myocyte can generate
and thus increases the strength and work capacity of the
muscle as a whole.

Physiologic Hypertrophy
o massive physiologic growth of the uterus during pregnancy is a good
example of hormone-induced increase in the size of an organ that
results mainly from hypertrophy of muscle fibers.
the cellular enlargement is stimulated by estrogenic hormones
acting on smooth muscle estrogen receptors
results in increased synthesis of smooth muscle proteins and an
increase in cell size.

MECHANISM OF HYPERTROPHY

o Hypertrophy is the result of increased production of cellular proteins.;
understanding is based on the studies of the heart.
o Hypertrophy can be induced by the linked actions of
a. mechanical sensors (triggered by increased workload)
b. growth factors (TGF-, insulin-like growth factor-1 [IGF-1],
fibroblast growth factor)
c. vasoactive agents (-adrenergic agonist, endothelin-1, and
angiotensin II)
o Mechanical sensors induce production of growth factors and agonist
these stimuli work coordinately to increase the synthesis of
muscle proteins that are responsible for hypertrophy.
o 2 main biochemical pathways involved in muscle hypertrophy:
1. Phosphoinositide 3-kinase/Akt pathway
- most important in physiologic hypertrophy such as
exercise-induced hypertrophy
2. signaling downstream of G-protein coupled receptors.
- induced by many GF and vasoactive agents
- more important in pathologic hypertrophy.
o Hypertrophy may also be associated with a switch of contractile
proteins from adult to fetal or neonatal forms.
E.g. during muscle hypertrophy, the isoform of myosin heavy
chain is replaced by the isoform which has a slower, more
energetically economical contractions.
genes that are expressed only during early development are re
expressed in hypertrophic cells and the products of these genes
participate in the cellular response to stress.
- gene for Atrial Natriuretic Factor (ANF) is expressed in
both the atrium and ventricle in the embryonic heart, but
is down regulated after birth.
- Cardiac hypertrophy is associated with reinduction of ANF
gene expression.
- ANF
peptide hormone that causes
a. salt secretion by the kidney
b. decreases blood volume and pressure
c. serves to reduce hemodynamic load.
o Cardiac hypertrophy eventually reaches a limit beyond which
enlargement of muscle mass is no longer able to compensate for the
increase burden.
- Several regressive changes occur in the myocardial fiber
but the most important are
a. lysis
b. loss of myofibrillar contractile elements.
- extreme cases: myocyte death can occur by either
apoptosis or necrosis.
- net result: CARDIAC FAILURE, a sequence of events that
illustrates how an adaptation to stress can progress to
functionally significant cell injury if stress is not relieved.
o A subcellular organelle may also undergo selective hypertrophy.
hypertrophy of the smooth endoplasmic reticulum in
hepatocytes for patients treated with barbiturates.
- adaptive response that increases the amount of enzymes
(cytochrome P40 mixed function oxidase) available to
detoxify the drugs.
- patient respond less to drug because of this adaptation.

HYPERPLASIA

Hyperplasia
- increase in the number of cell in an organ or tissue
- usually resulting in an increased mass of the organ tissue
- hyperplasia and hypertrophy frequently occur together, and may be
triggered by the same stimulus.
- Hyperplasia takes place if the cell population is capable of dividing and
thus, increasing the number of cells.
- can by physiologic or pathologic.

PHYSIOLOGIC HYPERPLASIA - divided into
1. hormonal hyperplasia
increases the functional capacity of the tissue when needed
well illustrated by the proliferation of the glandular epithelium
of the female breast at puberty and during pregnancy, usually
accompanied by enlargement of the glandular epithelial cells.
2. compensatory hyperplasia
- increases tissue mass after damage or partial resection.
- e.g. in individuals who donate one lobe of the liver for
transplantation, the remaining cells proliferate so that the
organ soon grows back to its original size.
PATHOLOGIC HYPERPLASIA
- most forms are caused by excesses of hormones or growth factors acting
on target cells.
- Endometrial hyperplasia is an example of abnormal hormone-induced
hyperplasia.
the balance between estrogen and progesterone is disturbed
results in absolute or relative increases in the amount of
estrogen, with consequent hyperplasia of the endometrial
glands.
this form of hyperplasia is a common cause of abnormal
menstrual bleeding.
- benign prostatic hyperplasia
induced by androgens.
- Benign prostatic hyperplasia and endometrial hyperplasia are abnormal
but the process remains controlled because there are no mutations in
genes that regulate cell division and the hyperplasia regress if the
hormonal stimulation is eliminated.
- Hyperplasia is a characteristic response to certain viral infections such as
papillomaviruses which causes skin warts and several mucosal lesions
composed of masses of hyperplastic epithelium.
growth factors produced by viral genes or by infected cells may
stimulate cellular proliferation.
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CELLULAR RESPONSES TO STRESS AND TOXIC INSULTS: ADAPTATION, INJURY and DEATH
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MECHANISM OF HYPERPLASIA
o a result of growth factor-driven proliferation of mature cells and, in
some cases, by increased output of new cells from tissue stem cells.
E.g. after partial hepatectomy, growth factors are produced in
the liver that engage receptors in the surviving cells and
activate signaling pathways that stimulate cell proliferation.
If the proliferative capacity of the liver cells is compromised,
hepatocytes can regenerate from intrahepatic stem cells.

ATROPHY

- reduced size of an organ or tissue
- resulting from a decrease in cell size and number
- can be physiologic or pathologic.

PHYSIOLOGIC ATROPHY
o common during normal development
o embryonic structures such as notochord and thyroglossal duct
undergo atrophy during fetal development.
o uterus decrease in size shorty after parturition

PATHOLOGIC ATROPHY
o depends on the underlying cause and can be local or generalized.
o common causes of atrophy are the following:
Decreased workload (atrophy of disuse)
- when a fractured bone is immobilized in a plaster cast or
when a patient is restricted to complete bed rest, skeletal
muscle atrophy rapidly ensues.
- initial decrease in cell size is reversible once activity is
resumed.
- with more prolonged disuse, skeletal muscle fibers
decrease in number as well as in size. (this atrophy can
be accompanied by increase bone resorption, leading to
osteoporosis of disuse)
loss of innervation (denervation atrophy)
- normal metabolism and function of skeletal muscle are
dependent on its nerve supply.
- Damage to nerves leads to atrophy of the muscle fibers
supplied by those nerves.
diminished blood supply
- decrease in blood supply to a tissue as a result of slowly
developing arterial occlusive disease results in atrophy of
the tissue.
- in late adult life, brain may undergo progressive atrophy
because of reduced blood supply as a result of
atherosclerosis. (senile atrophy, affects the heart)
inadequate nutrition
- profound protein-calorie malnutrition (marasmus) is
associated with the use of skeletal muscle as a source of
energy after other reserves such as adipose stores have
been depleted.
results in marked muscle wasting (cachexia)
- Cachexia is also seen in patients with chronic
inflammatory diseases and cancer.
In CID, chronic overproduction of the inflammatory
cytokine tumor necrosis factor is responsible for
appetite suppression and lipid depletion,
culminating in muscle atrophy.
loss of endocrine stimulation
- hormone responsive tissues, such as breast and
reproductive organs, are dependent on endocrine
stimulation for normal metabolism and function.
- loss of estrogen stimulation after menopause results in
physiologic atrophy of the endometrium, vaginal
epithelium and breast.
pressure
- tissue compression for any length of time can cause
atrophy.
- enlarging benign tumor can cause atrophy in the
surrounding, uninvolved tissues.
atrophy results of ischemic changes caused by
compromise of the blood supply by the pressure
exerted by the expanding mass.
o Fundamental cellular changes associated with atrophy are identical in
all pathologic settings.
o Initial response is a decrease in cell size and organelles, which may
reduce the metabolic needs of the cell sufficiently to permit its
survival.
o In atrophic muscle:
- cells contain fewer mitochondria and myofilaments
- reduced amount of rough ER

MECHANISMS OF ATROPHY
o atrophy results from:
a. decreased protein synthesis
- protein synthesis decrease because of reduced metabolic
activity.
b. increased protein degradation in cells
- degradation of cellular proteins occurs mainly by the
ubiquitin-proteasome pathway.
o Ubiquitin-proteasome pathway
- nutrient deficiency and disuse may activate ubiquitin
ligases, which attach the small peptide ubiquitin to
cellular proteins and target these proteins for degradation
in proteasomes.
- also thought to be responsible for the accelerated
proteolysis seen in a variety of catabolic conditions,
including cancer cachexia.
o atrophy is usually accompanied by increased autophagy with
resulting increases in the number of autophagic vacuoles.
Autophagy
- self-eating
- process in which starved cell eats its own component in
an attempt to find nutrients and survive.
autophagic vacuole
- membrane bound vacuoles that contain fragments of cell
components
- fuse with lysosomes and their contents are digested by
lysosome enzymes.
some of the cell debris within the autophagic vacuole may
resist digestion and persist as membrane bound residual bodies
that may remain as sarcophagus in the cytoplasm.
- example of residual bodies is the lipofuscin granules.
when present in sufficient amounts, they impart a
brown discoloration to the tissues.


METAPLASIA

Metaplasia
- Reversible change in which one differentiated cell type (epithelial or
mesenchymal) is replaced by another cell type.
- represent an adaptive substitution of cells that are sensitive to stress by
cell types better able to withstand the adverse environment.

columnar to squamous epithelial metaplasia
occurs in the RT in response to chronic irritation.
habitual cigarette smoker: normal ciliated columnar epithelial cells of
the trachea and bronchi are often replaced by stratified squamous
epithelial cells
stones in the excretory duct of the salivary gland, pancreas or bile
ducts may also cause replacement of the normal secretory columnar
epithelium by stratified squamous.
deficiency in vitamin A (retinoic acid) induces squamous metaplasia
in the respiratory epithelium.
the more rugged stratified squamous epithelium is able to survive
under circumstances in which the more fragile specialized columnar
cells might have succumbed.
Although the epithelial lining becomes tough, important mechanism
of protection against infection (mucus secretion, and the ciliary action
of the columnar epithelium) are lost.
metaplasia from squamous to columnar
Barrett esophagus in which the esophageal squamous epithelium is
replaced by intestinal-like columnar cells under the influence of
refluxed gastric acid.
Connective tissue metaplasia
formation of cartilage, bone or adipose tissues in tissues that
normally dont contain these elements.
Myositis ossificans
bone formation in the muscle
occurs after intramuscular hemorrhage.
may be a result of cell or tissue injury

MECHANISMS OF METAPLASIA
o does not result from a change in the phenotype of an already
differentiated cell type
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o result of a reprogramming of stem cells that are known to exist in
normal tissues or of undifferentiated mesenchymal cells present in
connective tissues.
o in a metaplastic change, these precursor cells differentiate along a
new pathway.
o differentiation of stem cells to a particular lineage is brought about by
signals generated by cytokines, growth factors and ECM components
of the cells environment.
o Retinoic acid regulates gene transcription directly through nuclear
retinoid receptors which can influence the differentiation of
progenitors derived from tissue stem cells.

OVERVIEW OF CELL INJURY AND CELL DEATH

REVERSIBLE CELL INJURY
o in early stages or mild forms of injury, the functional and
morphologic changes are reversible if the damaging stimulus is
removed.
o hallmarks of a reversible cell injury are:
a. reduced oxidative phosphorylation with resultant depletion of
energy stores in the form of ATP
b. cellular swelling caused by changes in ion concentrations and
water influx.
o various intracellular organelles (mitochondria and cytoskeleton) may
also show alteration.
CELL DEATH
o continuing damage
o injury becomes irreversible
o cell cannot recover and eventually dies
o two principal type of cell death:
1. Necrosis
2. Apoptosis
Necrosis
damage to membrane is severe, lysosome enzymes
enter the cytoplasm and digest the cell
cellular contents leak out
Apoptosis
cells DNA or protein are damaged beyond repair,
the cell kills itself.
form of cell death that is characterized by
a. nuclear dissolution
b. fragmentation of the cell without complete
loss of membrane integrity
c. rapid removal of cellular debris

o Necrosis is always pathologic, apoptosis serves many normal
function and is not necessarily associated with cell injury.
o Cell death is also sometimes the end result of autophagy.
o Apoptosis can progress to necrosis
o Cell death during autophagy may show many of the biochemical
characteristics of apoptosis.

FEATURES OF NECROSIS AND APOPTOSIS

Feature

Necrosis

Apoptosis
Cell size Enlarged (swelling) Reduced (shrinkage)
Nucleus
Pyknosis karyorrhexis
karyolysis
Fragmentation into
nucleosome-size fragments
Plasma
membrane
Disrupted
Intact; altered structure,
especially orientation of lipids
Cellular contents
Enzymatic digestion; may
leak out of cell
Intact; may be released in
apoptotic bodies
Adjacent
inflammation
Frequent No
Physiologic or
pathologic role
Invariably pathologic
(culmination of irreversible
cell injury)
Often physiologic, means of
eliminating unwanted cells;
may be pathologic after some
forms of cell injury, especially
DNA damage

CAUSES OF CELL INJURY

OXYGEN DEPRIVATION
o Hypoxia
- deficiency of oxygen
- causes cell injury by reducing aerobic oxidative respiration.
- extremely important and common cause of cell injury and cell
death.
- causes of hypoxia:
a. reduced blood flow (ischemia)
b. inadequate oxygenation of the blood due to cardiorespiratory failure
c. decreased oxygen-carrying capacity
- anemia or
- carbon monoxide poisoning (producing a stable carbon
monoxyhemoglobin that blocks oxygen carriage)
- after severe blood loss
PHYSICAL AGENTS
o physical agents capable of causing cell injury include:
a. mechanical trauma
b. extremes of temperature (burns and deep cold)
c. sudden changes in atmospheric pressure
d. radiation
e. electric shock
CHEMICAL AGENTS AND DRUGS
o simple chemicals such as glucose or salt in hypertonic
concentration may cause cell injury directly or by deranging
electrolyte balance in cells.
o Oxygen at high concentration is toxic
INFECTIOUS AGENTS
IMMUNOLOGIC REACTIONS
o injurious reactions to endogenous self-antigens are responsible for
several autoimmune diseases.
o immune reactions to many external agents, such as microbes and
environmental substances are also important causes of cell and tissue
injury.
GENETIC DERANGMENTS
o may result in a defect as severe as congenital malformations
associated with Down syndrome caused by chromosomal anomaly or
as subtle as the decreased life span of RBC caused by a single amino
acid substitution in hemoglobin in sickle cell anemia.
o Genetic defects may cause injury because of
a. deficiency in functional proteins, such as enzyme defects in
inborn errors of metabolism or
b. accumulation of damaged DNA or misfolded proteins
both of which trigger cell death when they are beyond repair.
NUTRITIONAL IMBALANCES
o major cause of cell injury
o protein-calorie deficiencies cause death esp. in under privileged
population


MORPHOLOGIC ALTERATIONS IN CELL INJURY

- All stresses and noxious influences exert their effects first at the molecular
or biochemical level.
- the morphologic manifestation of necrosis take more time to develop than
those of reversible damage.
E.g. in ischemia of myocardium, cell swelling is a reversible
morphologic change that may occur in a matter of minutes and
may progress to irreversibility within an hour or two.
Light microscopic of cell death may not be seen until 4 to 12
hours after total ischemia.
- Reversible injury is characterized by:
a. generalized swelling of the cell and its organelles
b. blebbing of the plasma membrane
c. detachment of the ribosomes from the ER
d. clumping of nuclear chromatin
these morphologic changes are associated with:
decreased generation of ATP
loss of cell membrane integrity
defects in protein synthesis
cytoskeletal damage
DNA damage
- Irreversible injury and cell death occurs if the injurious stimulus becomes
persistent or in case of excessive injury.
injurious stimuli that induces death associated with necrosis
are:
a. severe mitochondrial damage with depletion of ATP
b. rupture of lysosome and plasma membrane
- Necrosis is the principal outcome in many commonly encountered injuries.

REVERSIBLE INJURY

o Two features of reversible injury:
1. Cellular swelling
2. Fatty change
o Cellular swelling
- appears whenever cells are incapable of maintaining ionic and
fluid homeostasis
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- result of failure of energy-dependent ion pumps in the plasma
membrane
o Fatty change
- occurs in hypoxic injury and various forms of toxic or metabolic
injury.
- manifested by the appearance of lipid vacuoles in the
cytoplasm.
- seen mainly in cells involved in and dependent on fat
metabolism such as hepatocytes and myocardial cells.

MORPHOLOGY OF REVERSIBLE CELL INJURY
cellular swelling is the first manifestation of almost all forms of injury
to cells.
- more apparent at the level of the whole organ
- when it affects many cells, it causes some pallor, increased
turgor and increase weight in organ
On microscopic examination, small, clear vacuoles may be seen
within the cytoplasm.
represent distended and pinched off segments of the ER.
hydropic change or vacuolar degeneration.
Swelling is reversible.
Cells may show increased eosinophilic staining which becomes more
pronounced with progression to necrosis.
Ultrastructural changes of reversible cell injury include:
1. Plasma membrane alterations
- blebbing, blunting, loss of microvilli
2. Mitochondrial changes
- swelling and appearance of amorphous densities
3. dilation of the ER
- with detachment of polysomes
- intracytoplasmic figures may be present
4. nuclear alterations
- disaggregation of granular and fibrillar elements.

NECROSIS
o Morphologic appearance of necrosis is the result of:
1. denaturation of intracellular proteins
2. enzymatic digestion of lethally injured cells
o Necrotic cells are
- unable to maintain membrane integrity and
- their contents often leak out, a process that may elicit
inflammation in the surrounding tissue.
o Enzymes that digest the necrotic cells are derived from
a. the lysosomes of the dying cells themselves ]
b. the lysosomes of the leukocytes that are called in as part of the
inflammatory reaction.

MORPHOLOGY OF NECROTIC CELLS
Necrotic cells show increased eosinophilia
- attributable in part to the loss of cytoplasmic RNA and in part to
the denatured cytoplasmic
Necrotic cell may have a more glassy, homogenous appearance than
do normal cells, mainly as a result of the loss of glycogen particles.
When enzymes have digested the cytoplasmic organelles, the
cytoplasm becomes vacuolated and appears moth eaten.
Dead cells may be replaced by large, whorled, phospholipid masses
called myelin figures that are derived from damaged cell membranes.
- phospholipid precipitates are either phagocytized by other cells
or further degraded into fatty acids.
In EM, necrotic cells are characterized by
a. discontinuities in plasma and organelle membranes
b. marked dilation of the mitochondria with the appearance of
large amorphous densities
c. intracytoplasmic myelin figures
d. amorphous debris
e. aggregates of fluffy material probably representing denatured
protein.
Nuclear changes appear in one of the three patterns, all due to
nonspecific breakdown of DNA:
1. KARYOLYSIS
- the basophilia of the chromatin may fade
- change that presumably reflects loss of DNA because of
enzymatic degradation by endonucleases
2. PYKNOSIS
- seen in apoptotic cell death
- characterized by nuclear shrinkage and increased basophilia.
- chromatin condenses into a solid, shrunken basophilic mass
3. KARYORHEXIS
- pyknotic nucleus undergoes fragmentation.

PATTERNS OF TISSUE NECROSIS
Morphology

1. COAGULATIVE NECROSIS
- architecture of dead tissues is preserved for a span of at least
some days
- affective tissues exhibit a firm texture
- injury denatures not only on structural proteins but also in
enzymes and so blocks proteolysis of dead cells
- eosinophilic, anucleate cells persist for days or weeks.
- E.g. ischemia caused by obstruction in a vessel may lead to
coagulative necrosis of the supplied tissue in all organs except
the brain.
- Infarct
a localized area of coagulative necrosis

2. LIQUEFACTIVE NECROSIS
- characterized by digestion of the dead cells, resulting in
transformation of the tissues into a liquid, viscous mass.
- seen in focal bacteria, fungal infections
- necrotic material is creamy yellow because of the presence of
the dead leukocytes and is called pus.
- E.g., hypoxic death of cells within the central nervous system
often manifests as liquefactive necrosis.


3. GANGRENOUS NECROSIS
- usually applied to a limb, generally the lower leg that has lost
its blood supply and has undergone necrosis.
- when bacterial infection is superimposed, there is more
liquefactive necrosis because of the actions of degradative
enzymes in the bacteria and the attracted leukocytes
wet gangrene
4. CASEOUS NECROSIS
- encountered most often in the foci of tuberculosis infection.
- caseous (cheese-like)
- friable white appearance of the area of necrosis,
- necrotic area appears as a collection of fragmented or lysed
cells and amorphous granular debris enclosed within a
distinctive inflammatory border.
- appearance is characteristic of a focus of inflammation known
as granuloma.
5. FAT NECROSIS
- refers to focal areas of fat destruction, resulting from release of
activated pancreatic lipases into the substance of the pancreas
and the peritoneal cavity.
- occurs in acute pancreatitis.
- necrosis takes the form of foci of shadowy outlines of necrotic
fat cells with basophilic calcium deposits, surrounded by an
inflammatory reaction.
6. FIBRINOID NECROSIS
- usually seen in immune reactions involving blood vessels.
- occurs when complexes of antigens and antibodies are
deposited in the walls of arteries.
- deposits of these immune complexes, together with fibrin that
has leaked out of vessels, result in a bright pink and
amorphous appearance in H&E stains called fibrinoid

O Most necrotic cells and their contents disappear by phagocytosis of
the debris and enzymatic digestion by the leukocytes.
O Dystrophic calcification
- if necrotic cells and cellular debris are not promptly destroyed
and reabsorbed, they tend to attract calcium salts and other
minerals and to become calcified.

MECHANISM OF CELL INJURY

principles that are relevant to most forms of cell injury:
1. Cellular response to injurious stimuli depends on the nature of the
injury, its duration and its severity.
2. Consequence of cell injury depend on the type, state and adaptability
of the injured cell.
- cells nutritional and hormonal status and its metabolic needs
are important in its response to injury.
3. Cell injury results from different biochemical mechanisms acting on
several essential cellular components.
- cell components that are most frequently damaged by
injurious stimuli are include
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mitochondria
cell membrane
machinery of protein synthesis and packaging
DNA nuclei

4. Any injurious stimulus may simultaneously trigger multiple
interconnected mechanisms that damage cells.

DEPLETION OF ATP

o ATP depletion and decreased ATP synthesis are frequently associated
with both hypoxic and chemical injury.
o ATP is produced in 2 ways:
1. major pathway: oxidative phosphorylation of adenosine
diphosphate
reaction that results in the reduction of O2 by the electron
transfer system of mitochondria.
2. glycolytic pathway
can generate ATP in the absence of O2 using glucose derived
from either body fluids or from the hydrolysis of O2.
o the major causes of ATP depletion are
a. reduced supply of oxygen and nutrients
b. mitochondrial damage
c. actions of some toxins (e.g. cyanide)
o Tissues with greater glycolytic capacity (e.g. liver) are able to survive
loss of O2 and decreased oxidative phosphorylation better than are
tissues with limited capacity for glycolysis. (e.g. brain)
o synthetic and degradative processes within the cell that require high
energy phosphate in the form of ATP are:
membrane transport
protein synthesis
lipogenesis
deacylation-reacylation reactions for phospholipid
turnover
o Depletion of ATP to 5% to 10% of normal levels has widespread
effects on many critical cellular systems:

a. Activity of the plasma membrane energy dependent
sodium pump (ouabain-sensitive Na,K-atpase) is reduce
failure of this active transport system causes:
Na to enter and accumulate inside the cell
K to diffuse out of the cell
Net gain of solute is accompanied by isosmotic gain of water,
causing cell swelling and dilation of the ER

b. Cellular energy metabolism is altered
if supply of O2 to cells is reduced (as in ischemia),
a. oxidative phosphorylation ceases
b. decrease in cellular ATP
c. associated increase in adenosine monophosphate.
these changes stimulate phosphofructokinase and
phosphorylase -> increased rate of anaerobic glycolysis
Anaerobic glycolysis
designed to maintain the cells energy sources by
generating ATP through metabolism of glucose
derived from glycogen
glycogen stores are depleted
results in the accumulation of lactic acid and
inorganic phosphates
reduces the intracellular pH
decreased activity of many cellular
enzymes.
c. Failure of the Ca pump leads to influx of Ca with
damaging effects on numerous cell components
d. With prolonged or worsening of ATP depletion, structural
disruption of protein synthetic apparatus occurs
manifested as detachment of ribosomes from rough ER and
dissociation of polysomes
consequent reduction in protein synthesis.

e. in cells deprived of O2 or glucose, proteins may become
misfolded.
misfolded proteins trigger a cellular reaction called unfolded
protein response
f. irreversible damage to mitochondrial and lysosome membranes
and the cell undergoes necrosis.

MITOCHONDRIAL DAMAGE
o Mitochondria can be damaged by:
a. increases of cytosolic Ca
b. reactive oxygen species
c. oxygen deprivation
o two major consequences of mitochondrial damage:

a. Mitochondrial damage often results in the formation of a high
conductance channel in the mitochondrial membrane called
mitochondrial permeability transition pore
opening of tis conductance channel leads to:
loss of mitochondrial membrane potential resulting
in depletion of ATP.
cyclophilin D
component of MPTP
target of cyclosporine
b. Mitochondria sequester between the outer and inner membrane
several proteins that are capable of activating apoptotic pathways
includes cytochrome c and proteins
indirectly activate apoptosis inducing enzymes
called caspase.
increase permeability of the outer mitochondrial membrane
may result in leakage of these proteins into the cytosol, and
death by apoptosis.

INFLUX OF CALCIUM AND LOSS OF CALCIUM HOMEOSTASIS

o Cytosolic free Ca (0.1 umol) is maintained at low concentrations,
while extracellular levels of 1.3 nmol
o most intracellular calcium is sequestered in mitochondria and ER.
o Ischemia and certain toxins can cause an increase in cytosolic Ca
concentration because of release of Ca from intracellular stores
resulting from increased influx of Ca across the plasma
membrane
o Increased intracellular Ca causes cell injury by several mechanisms:

a. accumulation of Ca results in the opening of the mitochondrial
permeability transition pore, and failure of ATP generation
b. increased cytosolic Ca activates a number of enzymes that has
deleterious cellular effects:
phospholipase - cause membrane damage
protease - breaks down both membrane and cytoskeletal
proteins
endonuclease - DNA and chromatin fragmentation
ATPase - hastening ATP depletion
c. Increase cytosolic Ca levels result in the induction of apoptosis by
direct activation of caspases and by increasing mitochondrial
permeability

ACCUMULATION OF OXYGEN DERIVED FREE RADICALS (OXIDATIVE
STRESS)
o Free radicals
chemical species that have a single unpaired electron in an
outer orbit.
energy is released through reactions with adjacent molecules
(inorganic and organic compounds)
initiate autocatalytic reactions
o Reactive oxygen species (ROS)
type of oxygen derived free radical
produced normally in cells during mitochondrial respiration and
energy generation
degraded and removed by cellular defense system.
produced in large amounts by leukocytes (neutrophils and
macrophages) as mediators for destroying microns, dead
tissues and other unwanted substances.
injury caused by ROS often accompanies inflammatory
reactions during which leukocytes are recruited and activated.
o cells are able to maintain a steady state in which free radicals are
present transiently at lower concentrations but do not cause damage.
o When production of ROS increases or scavenging systems are
ineffective, result is an excess of free radicals leading to oxidative
stress
o Oxidative stress
implicated in cell injury, cancer, aging and Alzheimer disease.

GENERATION OF FREE RADICALS
1. Reduction-Oxidation reactions that occur during normal metabolic
process
- different number of electrons have been transferred from O2.
- includes
Superoxide
Hydrogen peroxide
hydroxyl ions
2. Absorption of radiant energy
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- E.g. ionizing radiation can hydrolyze water into hydroxyl ions
and hydrogen free radicals
3. Inflammation
- rapid bursts of ROS are produced in activated leukocytes during
inflammations
- reaction in plasma membrane multiprotein complex that uses
NADPH oxidase for redox reaction.
- Intracellular oxidase (e.g. xanthane oxidase) generate
superoxide
4. Enzymatic metabolism of exogenous chemicals or drugs can generate
free radicals that are not ROS but have similar effects
5. Transition metals such as iron and copper donate or accept free
electrons during intracellular reactions and catalyze free radical
formation
6. Nitric oxide
- important chemical mediator generated by endothelial cells,
macrophages, neurons and other cell types
- can act as free radical
- can be converted to peroxynitrite anion


REMOVAL OF FREE RADICALS
1. Antioxidants
- block the initiation of free radicals formation or inactivate free
radicals.
- E.g. lipid soluble vitamin E and A as well as ascorbic acid and
glutathione in the cytosol
2. Iron and Copper
3. Enzymes
Catalase
present in peroxisomes, decomposes
H202
Superoxide dismutase (SODs)
convert superoxide to hydrogen
peroxide
includes both manganese SOD, localized
in the mitochondria
copper-zinc-SOD, found in the cytosol
Glutathione peroxides
catalyzing free radical breakdown
PATHOLOGIC EFFECTS OF FREE RADICALS
o Lipid Peroxidation in membranes
- in the presence of O2, free radicals may cause lipid
peroxidation within the plasma and organelle or membranes
- Oxidative damage is initiated when the double bonds in
unsaturated fatty acids of membrane lipids are attacked by O2
derived free radicals, particularly by hydroxyl ions
- Propagation (autocatalytic chain reaction) occurs which can
result to extensive membrane damage.
o Oxidative modification of proteins
- free radicals promote
a. oxidation of amino acid side chains,
b. formation of protein-protein cross linkages
c. oxidation of protein backbone
- oxidative modification of proteins may:
a. damage the active sites of enzymes
b. disrupt the conformation of structural proteins
c. enhance proteosomal degradation of unfolded or
misfolded proteins
o Lesions in DNA
- free radicals cause:
a. single and double strand breaks in DNA
b. cross linking of DNA strands
c. formation of adducts

DEFECTS IN MEMBRANE PERMEABILITY

o Early loss of selective membrane permeability leading ultimately to
overt membrane damage is a consistent feature of most forms of cell
injury (except apoptosis)

MECHANISM OF MEMBRANE DAMAGE
o in ischemic cells, membrane defects may be the result of ATP
depletion and calcium mediated activation of phospholipase.
o toxins, viral proteins, lytic complement components, physical and
chemical agents
o Some biochemical mechanisms contribute to membrane damage:
a. ROS
b. decreased phospholipid synthesis
c. increased phospholipid breakdown
d. Cytoskeletal abnormalities

CONSEQUENCES OF MEMBRANE DAMAGE
o the most important sites of membrane damage during cell injury are
the mitochondrial membrane, plasma membrane and membranes of
lysosomes.

a. Mitochondrial membrane Damage
opening of the MPTP
decreased ATP
release of proteins that trigger apoptotic death
b. Plasma Membrane Damage
loss of osmotic balance and influx of fluids and ions
loss of cellular contents.
cells leak metabolites that are vital for the
reconstitution of ATP, further depleting energy
stores
c. Injury to lysosome membranes
results in leakage of enzymes into the cytoplasm
activation of the acid hydrolase in then acidic
intracellular pH of the injured cell.
cells die by necrosis.

DAMAGE TO DNA AND PROTEINS

o Two phenomena consistently characterize irreversibility:
1. inability to reverse mitochondria dysfunction
2. profound disturbances in membrane function.

EXAMPLES OF CELL INJRY AND NECROSIS

A. ISCHEMIC AND HYPOXIC INJURY
o most common type of cell injury.
o Hypoxia
- reduced oxygen availability
- energy production by anaerobic glycolysis can continue
o Ischemia
- the supply of oxygen and nutrients is decreased because of
reduced blood flow as a consequence of
a. a mechanical obstruction in the arterial system.
b. by reduced venous drainage
- ischemia compromises the delivery of the substrates for
glycolysis
- aerobic metabolism is compromised
- anaerobic energy generation also stops after glycolytic
substrate are exhausted or glycolysis is inhibited by the
accumulation of metabolites that would have been removed
otherwise by blood flow.
- tends to cause more rapid and sever cell and tissue injury than
does hypoxia in the absence of ischemia.

MECHANISMS OF ISCHEMIC CELL INJURY
o As oxygen tension within the cell decreases, there is
a. loss of oxidative phosphorylation and
b. decreased generation of ATP
results in failure of the sodium pump, loss of potassium, influx
of calcium.
progressive loss of glycogen and decreased protein synthesis.
loss of contractility does not mean cell death

o If hypoxia continues, worsening of ATP depletion causes further
deterioration.
they cytoskeleton disperses
resulting in the loss of Ultrastructural features such
as microvilli and the formation of blebs at the cell
surface.
Myelin figures may be seen within the cytoplasm or
extracellularly.
Mitochondria are swollen as a result of loss of volume control
ER remains dilated
entire cell is markedly swollen with
a. increased concentrations of water, Na and Cl
b. decreased concentration of K.
- IF O2 is restored, all of these disturbances are reversible

o If ischemia persists, irreversible injury and necrosis ensue.
Irreversible injury is associated morphologically with
a. severe swelling of mitochondria
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b. extensive damage to plasma membranes (giving rise to
myelin figures)
c. swelling of lysosomes
d. large, flocculent, amorphous densities develop in the
mitochondrial matrix.
in the myocardium, the alterations are indications of irreversible
injury and can be seen as early as 30 to 40 minutes after
ischemia.
Massive influx of Ca into the cell occurs
Death is mainly by necrosis but apoptosis also contributes.
Apoptotic pathway is activated by release of
proapoptotic molecules from leaky mitochondria.
Dead cells may become replaced by large masses
composed of phospholipids in the form of myelin
figures.
Myelin figures are phagocytized or degraded into
fatty acids.
Calcification of fatty acid residues may occur with
the formation of Ca soaps.

o Leakage of intracellular enzymes and other proteins across the
abnormally permeable plasma membrane and into the blood provides
important clinical indicators of cell death
Creatine Kinase MB and troponin are early signs of MI and may
be seen before the infarct is detectable morphologically.

o Mammalian cells have developed protective responses to hypoxic
stress.
Hypoxia-inducible factor-1
- promotes new blood vessel formation
- stimulate cell survival pathway
- enhances anaerobic glycolysis.
o The strategy that is most useful in ischemic brain and SC injury is the
transient induction of hypothermia (reducing the core body temp to
92F)
this treatment:
a. reduces the metabolic demands of the stressed cells
b. decrease cell swelling
c. suppress the formation of free radicals
d. inhibits host inflammatory response

B. ISCHEMIA-REPERFUSION INJURY

o When blood flow is restored to cells that have been ischemic but
have not died, injury is paradoxically exacerbated and proceed at an
accelerated phase.
As a consequence, reperfused tissue may sustain loss of cells
in addition to cells that are irreversible damaged at the end of
ischemia
o Ischemia-reperfusion injury
- contributes to tissue damage during myocardial and cerebral
infarction
- occurs when new damaging processes are set in motion during
reperfusion, causing the death of cells that might have
recovered.
- the mechanisms are as follows:
a. mew damage may be initiated during reoxygenation by
increased generation of reactive oxygen and nitrogen
species from parenchymal and endothelial cells and from
infiltrating leukocytes.
b. ischemic injury associated with inflammation as a result
of production of cytokines and increased expression of
adhesion molecules by hypoxic parenchymal and
endothelial cells.
c. Activation of the complement system
IgM antibodies have a propensity to deposit in
ischemic tissues.
When blood flow is resumed, complement
proteins bind to deposited anitbodies, are
activated and cause more cell injury and
inflammation.

C. CHEMICAL (TOXIC) INJURY
o major limitation to drug therapy.
o chemicals induce cell injury by one of two general mechanisms:
1. Chemicals injure cells directly by combining with critical
molecular components.
2. Most toxic chemicals are not biologically active in their native
form but must be converted to reactive toxic metabolites, which
them act on target molecules.
This modification is accomplished by cytochrome P-450 mixed
function oxidases in the smooth ER of the liver and other
organs.
the toxic metabolites that cause membrane damage and cell
injury mainly by:
a. formation of free radicals
b. subsequent lipid peroxidation
c. direct covalent binding to membrane proteins and lipids
may also contribute.


APOPTOSIS
o Apoptosis
- is a pathway of cell death that is induced by a tightly regulated
suicide program
- cells destined to die activated enzymes that degrade the cells
own nuclear DNA and nuclear and cytoplasmic proteins.
o Apoptotic cells break up into fragments called apoptotic bodies.
contain portions of cytoplasm and nucleus
plasma membrane remains intact
structure is altered to become tasty targets for phagocytes.
o dead cells and fragments are devoured before the contents have
leaked out.
o Cell death by this pathway does not elicit an inflammatory reaction in
the host.
o Apoptosis induced by pathologic stimuli may progress to necrosis.

CAUSES OF APOPTOSIS

APOPTOSIS IN PHYSIOLOGIC CONDITIONS

o Embryogenesis
- including implantation, organogenesis, developmental
involution and metamorphosis
- death of specific cell types at defined times during development
of an organism.
o Involution of hormone dependent tissues upon hormone withdrawal
- endometrial cell breakdown during menstrual cycle
- ovarian follicular atresia in menopause
- regression of lactating breast after weaning
- prostatic atrophy after castration.
o Cell loss in proliferating cell population
- immature lymphocytes in the bone marrow and thymus that fail
to express useful antigen receptors
- B lymphocytes in germinal centers
- epithelial cells in intestinal crypts to maintain a constant
number.

o Elimination of potentially harmful self-reactive lymphocytes
- either before or after they have completed their maturation to
prevent reactions against ones own tissue.
o Death of host cells that have served useful purpose such as:
- neutrophils in an acute inflammatory response
- lymphocytes ate the end of an immune response
cells undergo apoptosis because they are deprived of essential
survival signals such as GFs.

APOPTOSIS IN PATHOLOGIC CONDITIONS
- eliminates cells that are injured beyond repair without eliciting
a host reaction, thus limiting collateral tissue damage.
o DNA Damage
- radiation, cytotoxic anticancer drugs, hypoxia
- elimination of cells may be a better alternative than risking
mutations in damaged DNA which may result to malignant
transformation.
- larger doses may result in necrotic cell death
o Accumulation of misfolded proteins
- improperly folded proteins arise because of mutations in the
genes encoding thee proteins.
- ER Stress
Excessive accumulations of misfolded proteins in the ER
culminates in apoptotic cell death
- degenerative diseases of the CNS and other organs
o cell death in certain infection
- viral infections
- loss of infected cells is due to apoptosis that may be induced by
the virus or by the host immune response.
o Pathologic atrophy in parenchymal organs after the duct obstruction

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MORPHOLOGIC AND BIOCHEMICAL CHANGES IN APOPTOSIS

MORPHOLOGY
a. Cell shrinkage
- cell is smaller
- cytoplasm is dense
- organelles are normal but more tightly packed.
b. Chromatin condensation
- most characteristic feature of apoptosis
- chromatin aggregates peripherally
- nucleus may break up, producing two or more fragments
c. Formation of cytoplasmic blebs and apoptotic bodies
- first show extensive surface blebs
- undergoes fragmentation
d. Phagocytosis of apoptotic cells or cell bodies usually by macrophage

o Plasma membranes are thought to remain intact during apoptosis
until the last stages when they become permeable to normally
retained solutes.
o Apoptosis does not elicit inflammation.
BIOCHEMICAL FEATURES OF APOPTOSIS
1. Activation of Caspases
- Caspases
c refers to cysteine protease
aspase refers to unique ability of the enzymes to cleave after
aspartic acid residues.
can be divided into 2 groups:
a. initiator
include caspase 8 and caspase 8
b. executioner
caspase 3 and caspase 6
exist as inactive pro-enzymes or zymogens
must undergo enzymatic cleavage to become active
presence of cleaved, active caspase is a marker for cells
undergoing apoptosis.
2. DNA and protein breakdown
3. Membrane alteration and Recognition by Phagocytes
- movement of some phospholipids (phosphatidylserene) from
the inner leaflet to the outer leaflet of the membrane.
- annexin V

MECHANISMS OF APOPTOSIS
o The basic mechanisms of apoptosis are conserved in multicellular
organisms.
o The process of apoptosis may be divided into
a. initiation phase
- caspases becomes catalytically active
- occurs principally by signals from two distinct pathways:
intrinsic or mitochondrial pathway
extrinsic or death receptor-initiated
pathway
b. execution phase
- other caspase trigger the degradation of critical cellular
components.
Initiation Phase
INTRINSIC (MITOCHONDRIAL PATHWAY

o major mechanism
o result of increased mitochondrial permeability and release of pro
apoptotic molecule into the cytoplasm
o cytochrome c
- proteins that when released into the cytoplasm, initiate a
suicide program of apoptosis.
- release of these proteins is controlled by balance between pro
and anti-apoptotic members of the Bcl family.
Growth factors are other survival signals stimulate production
of anti-apoptotic proteins , the main ones are:
a. Bcl-2
b. Bcl-x
c. Mcl-1
these proteins reside in cytoplasm and
mitochondrial membranes
control mitochondrial proteins that have the
ability to trigger cell death
o When cells are deprived of survival signals, or their DNA is damaged,
or misfolded proteins induce ER stress, sensors of damage or stress
are activated
these sensors are members of the Bcl family and include
a. Bim
b. Bid
c. Bad
EXTRINSIC (DEATH RECEPTOR-INTIATED) PATHWAY OF APOPTOSIS

O pathway is initiated by engagement of plasma membrane death
receptors on a variety of cells.
O Death receptors are members of the TNF receptor family that contain
a cytoplasmic domain called death domain because it is essential for
delivering apoptotic signals.
the best known death receptors are
a. the type 1 TNF receptor
b. Fas (CD95)

Execution Phase of Apoptosis
O Two initiating pathways converge to a cascade of caspase activation,
which mediates the final phase of apoptosis.
O the mitochondrial pathway leads to activation of caspase 9.; the
death receptor pathway to caspase 8 and 10.
O After the initiator caspase is cleaved to generate its active form, the
enzymatic death program is set in motion by activation of executioner
caspase:
Caspase 3 and 6
- act on many cellular components
- once activated, cleave an inhibitor of a cytoplasmic DNase and
make DNase active.
- degrade structural components
- promote fragmentation of nuclei.

REMOVAL OF DEAD CELLS
o in healthy cells, phosphatidylserene is present on the inner leaflet of
the membrane
o in apoptotic cells, phosphatidylserene flips out and is expressed on
the outer layer of the membrane, where it is recognized by several
macrophage receptors.
o Cells that are dying by apoptosis secrete soluble factors that recruit
phagocytes
thrombospondin
- adhesive glycoprotein
- recognized by phagocytes
C1q
- natural antibodies
- proteins of complement system

CLINICOPATHOLOGIC CORRELATIONS: APOPTOSIS IN HEALTH AND
DISEASE
1. Growth Factor deprivation
2. DNA damage
3. Protein misfolding
4. Apoptosis induced by the TNF receptor family
5. Cytotoxic T Lymphocyte Mediated Apoptosis
- Granzymes
ability to cleave protein at aspartate resides
activate a variety of cellular caspases
kills target cells by directly inducing the effector phase of
apoptosis

Disorders Associated with Dysregulated Apoptosis
A. Defective Apoptosis and Increased Cell Survival
- low rate of apoptosis permit the survival of abnormal cells
- defective apoptosis: autoimmune disorder
B. Increased Apoptosis and Excessive Cell Death
- diseases characterized by a loss of cells
- include:
1. neurodegenerative diseases
2. ischemic injury
3. death of virus-infected cells

AUTOPHAGY
o Autophagy
- cell eats its own content
- survival mechanism in times of nutrient deprivation
o intracellular organelles and portions of cytosol are first sequestered
from the cytoplasm in an autophagic vacuole.
o AV fuses with lysosomes to form autophagolysosomes, and the
cellular components are digested by lysosome enzymes
o Regulated by Autophagy genes (Atgs)

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INTRACELLULAR ACCUMULATIONS

o One manifestations of metabolic derangements in cells is the
intracellular accumulation of abnormal amounts of various
substances.
o stockpiled substances fall into two categories
1. normal cellular constituent that accumulate in excess
- water
- lipids
- proteins
- carbohydrates
2. abnormal substance
o substances may be located in either the cytoplasm
(phagolysosomes) or nucleus
o most accumulations are attributable to four types of abnormalities:

a. a normal endogenous substance is produced at a normal or
increased rate, but the rate of metabolism is inadequate to
remove it
- fatty change in the liver
- reabsorption protein droplets in the kidney tubules

b. abnormal endogenous substance (product of mutated gene )
accumulates because of
defects in protein folding and transport
inability to degrade the abnormal protein efficiently
- E.g. accumulation of mutated alpha1-antitrypsin in liver cells

c. normal endogenous substance accumulates because of defects
in enzymes that are required for the metabolism
d. abnormal exogenous substance is deposited and accumulates
because cell has neither the
ability to transport
enzymatic machinery to degrade the substance

LIPIDS
- triglycerides
- cholesterol/cholesterol esters
- phospholipids
o Phospholipids - components of myelin figures found in necrotic cells.
o Abnormal complexes of lipids and carbohydrates accumulate in the
lysosome storage disease.
o TG and cholesterol accumulation

STEATOSIS (FATTY CHANGE)
o abnormal accumulations of TGs within parenchymal cells.
o often seen in the liver because it is the major organ involved in fat
metabolism.
o also occurs in heart, muscle and kidney.
o causes include:
a. toxins
b. protein malnutrition
c. DM
d. obesity
e. anoxia
o Mechanism may be that:
free fatty acids from adipose tissue or ingested food are
normally transported into hepatocytes
in the liver:
esterified to Tgs
converted into cholesterol or phospholipid
oxidized to ketone bodies
some are synthesized as acetate as well
Excess accumulation of TGs within the liver may result from
excessive entry or defective metabolism and export of lipids
o induced by alcohol that alters mitochondrial and microsomal function,
leading to increased synthesis and reduced breakdown of lipids
o CCl and protein malnutrition cause fatty change by reducing
synthesis of apoproteins
o hypoxia inhibits fatty acid oxidation
o starvation increases fatty acid mobilization from peripheral stores.


MORPHOLOGY
- often seen in liver and heart
- in all organs: appears as clear vacuoles within parenchymal
cells.
o Liver
- mild fatty change may not affect the gross appearance
- organ enlarges
- becomes increasingly yellow
- in extreme cases, liver may weigh two to four times and
transformed into a bright yellow, soft, greasy organ.
- fatty change begins with the development of minute membrane
bound inclusions closely applied to the ER.
o Heart
- lipid is found in cardiac muscle in the form of small droplets
occurring in two patterns
1. prolonged moderate hypoxia causes intracellular deposits
of fat
creates grossly apparent bands of yellowed
myocardium
alternating with bands of darker red brown,
uninvolved myocardium (tigered effect)
2. other pattern of fatty change is produced by more
profound hypoxia or by some forms of myocarditis
shows more uniformly affected myocytes

CHOLESTEROL AND CHOLESTEROL ESTERS
a. Atherosclerosis
- smooth muscle cells within the intimal layer of the aorta and
large arteries are filled with lipid vacuoles,
- most are made up of cholesterol and cholesterol esters.
- foamy appearance ; intima: yellow cholesterol-laden atheromas
- EC cholesterol esters may crystalize in the shape of long
needles, producing quite distinctive clefts in tissue sections
b. Xanthomas
- intracellular accumulation of cholesterol within macrophages is
characteristic of acquired and hereditary hyperlipidemic states
- clusters of foamy cells in subepithelial connective tissues of the
skin and tendons

c. Cholesterolosis
- focal accumulations of cholesterol-laden macrophages in the
lamina propria of the gallbladder.
- unknown mechanism of accumulation
d. Niemann-Pick Disease, type C
- caused by mutations affecting an enzyme involved in
cholesterol trafficking = cholesterol accumulation in multiple
organs

PROTEINS
o appear as rounded, eosinophilic droplets, vacuoles or aggregates in
the cytoplasm
o can be amorphous, fibrillar or crystalline in appearance
o Amyloidosis: abnormal proteins deposit primarily in the extracellular
spaces
o causes:
1. reabsorption droplets in proximal renal tubules: renal disease
with proteinuria
2. Proteins that accumulate may be normal secreted proteins that
are produced in excessive amounts, (plasma cells engaged in
active synthesis of immunoglobulins.):
ER becomes distended
Russel bodies - large, homogenous, eosinophilic
inclusions called Russell bodies.
3. Defective intracellular transport and secretion of critical proteins
4. Accumulation of cytoskeletal proteins
- cytoskeletal proteins include:
microtubules (20-25 nm)
thin actin filaments (6-8 nm)
thick myosin filaments (15 nm)
intermediate filaments (10 nm)
IF provide a flexible intracellular scaffold that
organize the cytoplasm and resist forces
applied to the cell
divided into 5 classes:
1. keratin filaments - epithelial cells
2. neurofilaments - neurons
3. desmin filaments - muscle cells
4. vimentin filaments - connective tissue
cells
5. glial cells - astrocytes; Neurofibrillary
tangle found in the brain in Alzheimer
disease contains neurofilaments and
other proteins
5. Aggregation of abnormal proteins - Proteinopathies
Amyloidosis
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- abnormal or misfolded proteins deposit in
tissues and interfere with normal
funcitons
- deposits can be extracellular , or both
- aggregates may either directly or
indirectly cause pathological changess

HYALINE CHANGE
o Hyaline
refers to an alteration within cells or in the extracellular space
homogenous, glassy pink
o hyaline change is produced by a variety of alterations
o does not represent a specific pattern of accumulation.
o Extracellular hyaline

GLYCOGEN
o Glycogen - readily available energy source stored in the cytoplasm of
healthy cells.
o excessive intracellular deposits of glycogen are seen in patients with
an abnormality in either glucose or glycogen metabolism.
o glycogen masses appear as clear vacuoles within the cytoplasm.
o DM
- prime example of glucose metabolism disorder.
- glycogen is found in renal tubular epithelial cells, within liver
cells, beta cells of islet of Langerhans, and heart muscle cells
o Glycogen storage disease/ glycogenoses
- enzymatic defects in the synthesis or breakdown of glycogen
result in massive accumulation, causing cell death

PIGMENTS

o Pigments are colored substances

EXOGENOUS PIGMENTS
o most common is carbon (coal dust).
o when inhaled, it is picked up by macrophages within the alveoli ->
transported through lymphatic channels to the regional lymph nodes
in the tracheobronchial region
o Anthracosis
- accumulation of pigment blacken the tissues of the lungs
o Coal workers pneumoconiosis
- aggregates of carbon dust may induce a fibroblastic reaction or
even emphysema.
o Tattooing - form of localized exogenous pigmentation

ENDOGENOUS PIGMENTS
o Lipofuscin
- insoluble pigment
- also known as lipochrome or wear and tear pigment
- composed of polymers of lipid and phospholipid in complex with
protein
- sign of free radical injury and lipid peroxidation
- appears as yellow brown, finely granular cytoplasmic, often
perinuclear pigment.
- seen in cells undergoing slow, regressive changes
- prominent in liver and heart of aging patients or px with severe
malnutrition and cancer cachexia
o Melanin
- endogenous, non-hemoglobin derived
- brown black pigment
- formed when enzyme tyrosinase catalyzes the oxidation of
tyrosine to dihydroxyphenylalanine in melanocytes
o Hemosiderin
- hemoglobin derived, golden yellow to brown
- granular or crystalline pigment
- major storage form of iron
- iron is:
transported by transferrins
stored by apoferritin, to form ferritin micelles.
Ferritin is a consistent of most cell types.
- When there is local or systemic excess in iron, ferritin forms
hemosiderin granules.
- hemosiderin represents aggregates of ferritin micelles.
- Local excess results from hemorrhage in tissues
heme moiety is converted to biliverdin then to
bilirubin
- Systemic overload : hemosiderosis; caused by:
a. increased absorption of dietary iron
b. hemolytic anemia
c. repeated blood transfusions

MORPHOLOGY
o iron pigment appears as a coarse, golden, granular pigment lying
within the cells cytoplasm
o Colorless potassium ferrocyanide converted by iron to blue black
ferrocyanide.
o underlying cause is the localized breakdown of red cells: hemosiderin
is only found initially in the phagocytes in the area
o Systemic hemosiderosis
- hemosiderin is found at first in the mononuclear phagocytes on
the liver, bone marrow, spleen and lymph nodes and in the
scattered macrophages throughout other organs such as skin,
pancreas, and kidneys
o Bilirubin
- normal major pigment found in bile.
- derived from hemoglobin but contains no iron

PATHOLOGIC CALCIFICATION

o abnormal tissue deposition of Ca salts, together with small amounts
of iron, magnesium and other mineral salts.
o 2 forms of pathologic calcification:
1. dystrophic calcification
- deposition occurs locally in dying tissues
- occurs despite normal serum levels of Ca and in the absence of
derangements in Ca metabolism.
2. metastatic calcification
- deposition of Ca in normal tissues
- almost always results from hypercalcemia secondary to some
disturbance in Ca metabolism.
Dystrophic Calcification
o encountered in area of necrosis
o almost always present in the atheromas of advanced atherosclerosis
o commonly developed in damaged or aging heart valves
o Appear macroscopically as fine, white granules or clumps, often felt
as gritty deposits.
o tueberculous lymph node is converted to stone

MORPHOLOGY: DYSTROPHIC CALCIFICATION
- Ca salts have a basophilic, amorphous, granular, clumped
appearance.
- heterotrophic bone may be formed in the focus of calcification.
- single necrotic cells may constitute seed crystals that become
encrusted by mineral deposits.
- psammoma bodies
lamellated configurations caused by progressive
acquisition of outer layers
resembling grain of sands
PATHOGENESIS
- Final common pathway is the formation of crystalline Ca
phosphate mineral in the form of apatite similar to that
hydroxyapatite of bone.
- Ca is concentrated in vesicles
- steps:
1. Ca binds to phospholipids present in vesicle membranes
2. Phosphatases associated with the membrane generate
phosphate groups which bind to the Ca
3. cycle of Ca and phosphate binding is repeated -> raising
the local concentrations
4. structural change occurs in the arrangement of Ca and
phosphate group, generating a microcrystal which can
propagate and lead to Ca deposition.
Metastatic Calcification
o may occur in normal tissues whenever there is hypercalcemia.
o Hypercalcemia accentuates dystrophic calcification.
o four principal causes:
1. increased PTH with subsequent bone resorption
(hyperparathyroidism)
2. destruction of bone tissue secondary to primary tumors or
diffuse skeletal metastasis
3. vitamin D related disorders
4. renal failure
o may occur widely throughout the body but principally affects the
interstitial tissues of the gastric mucosa, kidneys, lungs, systemic
arteries and pulmonary veins.

CELLULAR AGING
CHAPTER I
CELLULAR RESPONSES TO STRESS AND TOXIC INSULTS: ADAPTATION, INJURY and DEATH
12

o result of a progressive decline in cellular function and viability caused
by genetic abnormalities
o the known changes that contribute to cellular aging include:
1. Decreased cellular replication
concept that most normal cells have a limited
capacity for replication was developed from a simple
experimental model for aging.
senescence
Werner syndrome - rare disease; characterized by
symptom of premature aging; defective in DNA
replication
2. Accumulation of metabolic and genetic change
o Sirtuins - histone deacetylase activity; thought to promote the
expression of several genes whose products increase longevity














gssabidomd2
If any of you lacks wisdom, he should ask God, who gives generously to all
without finding fault, and it will be given to him
James 1:5