Slide No. M-10-15 Acute Appendicitis (vascular and early leukocytic phases).

1. Pathogenesis of vascular dilatation and congestion

Upon the damage of an area or tissue, substances (inflammatory mediators such as histamine, leukotriene, nitric
oxide, prostaglandin, etc.) will cause the vascular dilatation and increase vascular permeability of the blood vessels
supplying the area. This happens because the dilatation and increase in permeability will initiate and immune
response to rid the area of the microorganisms invading and at the same time help in repairing the damage on the
tissue to restore function lost. The inflammatory respoinse is initiated by either tissue necrosis (which may have
happened to the appendix of this slide), infection (also a possibility), foreign bodies, and hypersensitivity reactions.

2. Role of red blood cells during the vascular phase of acute inflammation

Inflammation increases the blood volume along the site of injury. The red blood cells along the area provide the
necessary nutrients (such as glucose) and oxygen for the leukocytes in order for them to function properly. Also,
the red blood cells in the area may have several fibroblastic functions important in tissue remodelling. The dead
and dying cells contribute to pus formation. Red blood cells may likewise help in clot formation through the
delivery of fibrinogen and fibronectin along the area with haemorrhage.

3. Pathogenesis of rolling, margination, pavementing, and emigration of leukocytes

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

In normally flowing blood in venules, red cells are confined to a central axial column, displacing the leukocytes
toward the wall of the vessel. Because blood flow slows early in inflammation (stasis), hemodynamic conditions
change (wall shear stress decreases), and more white cells assume a peripheral position along the endothelial
surface. This process of leukocyte redistribution is called margination. Subsequently, individual and then rows of
leukocytes adhere transiently to the endothelium, detach and bind again, thus rolling on the vessel wall. The cells
finally come to rest at some point where they adhere firmly (resembling pebbles over which a stream runs without
disturbing them

Slide No. M-10-22 Acute Appendicitis with Liquefactive Necrosis (Suppurative Appendicitis)
1. Pathogenesis of liquefactive necrosis

Liquefactive necrosis (or colliquative necrosis) is a type of necrosis which is characteristic of focal bacterial or
fungal infections. In liquefactive necrosis, the affected cell is completely digested by hydrolytic enzymes, resulting in
a soft, circumscribed lesion consisting of pus and the fluid remains of necrotic tissue. After the removal of cell
debris by white blood cells, a fluid filled space is left. It is generally associated with abscess formation and is
commonly found in the central nervous system.
 2. Pathogenesis of fibrin thrombi

Thrombi formation or thrombosis is the formation of ante mortem clots within the blood vessels, it is a solid
mass of blood constituents, platelets, red cells, fibrin and white cells formed in the circulating blood stream.
Rupture of the atherosclerotic plaque exposes the subendothelial collagen to the bloodstreamon contact
with collagen, platelets become activated. Platelets adhere to exposed subendothelium through interaction
with a variety of platelet surface receptors, the most important of which is GP-Ib.Thrombi may occur anywhere
in the cardiovascular system. When thrombi are formed within a cardiac chamber or the aorta they often have
apparent laminations called the lines of Zahn. These are produced by alternating layers of paler platelets
admixed with fibrin, separated by darker layers containing more red blood cells. Thrombus formation may be
caused by predisposing factors such as hypercoagulability, injury to the endothelium, and stasis of blood
(virchows triad)

3. Relationship between the fibrin thrombi and extensive necrosis of mucosa .

This is due to excessive consumption of coagulation factors and subsequent activation of fibrinolysis using
all of the body's available platelets and clotting factors. The end result is hemorrhaging and ischaemic necrosis
of tissue/organs.

Acute appendicitis seems to be the end result of a primary obstruction of the appendix lumen. Once this
obstruction occurs the appendix subsequently becomes filled with mucus and swells, increasing pressures
within the lumen and the walls of the appendix, resulting in thrombosis and occlusion of the small vessels, and
stasis of lymphatic flow. Rarely, spontaneous recovery can occur at this point. As the former progresses, the
appendix becomes ischemic and then necrotic. As bacteria begin to leak out through the dying walls, pus forms
within and around the appendix (suppuration). The end result of this cascade is appendiceal rupture (a 'burst
appendix') causing peritonitis, which may lead to septicemia and eventually death.

Slide No. M-10-19 Chronic Inflammation of Skin with Granulation Tissue Formation

1. Roles of lymphocytes and macrophages in the acute and chronic phases of inflammation

Acute inflammation

Macrophage- recognizes microbial products and secretes most of the cytokines important for acute
inflammation

TNF and IL-1 are two of the major cytokines that mediate inflammation

Effects:

1. Acute phase reaction- fever, sleep, appetite, acute phase proteins, shock,
neutrophilia
2. Endothelial effects- leukocyte adherence, PGI synthesis, procoagulant activity,
anticoagulant activity, IL-1,6,8 & PDGF
3. Fibroblast effects- proliferation, collagen synthesis, collagenase, protease, PGE
synthesis
4. Leukocyte effects- cytokine secretion IL-1,6
Chronic Inflammation
-Macrophages display antigens to T cells, and produce membrane molecules (costimulators) and cytokines (notably
IL-12) that stimulate T-cell responses

-Activated T lymphocytes produce cytokines, and one of these, IFN-y, is a major activator of macrophages

-Plasma cells develop from activated B lymphocytes and produce antibody directed either against persistent
antigen in the inflammatory site or against altered tissue components.

2. Pathogenesis by which these roles are effected

After digesting a pathogen, a macrophage will present the antigen (a molecule, most often a protein found on the
surface of the pathogen, used by the immune system for identification) of the pathogen to the corresponding
helper T cell. The presentation is done by integrating it into the cell membrane and displaying it attached to an
MHC class II molecule, indicating to other white blood cells that the macrophage is not a pathogen, despite having
antigens on its surface.

Eventually, the antigen presentation results in the production of antibodies that attach to the antigens of
pathogens, making them easier for macrophages to adhere to with their cell membrane and phagocytose. In some
cases, pathogens are very resistant to adhesion by the macrophages.

The antigen presentation on the surface of infected macrophages (in the context of MHC class II) in a lymph node
stimulates TH1 (type 1 helper T cells) to proliferate (mainly due to IL-12 secretion from the macrophage). When a
B-cell in the lymph node recognizes the same unprocessed surface antigen on the bacterium with its surface bound
antibody, the antigen is endocytosed and processed. The processed antigen is then presented in MHCII on the
surface of the B-cell. TH1 receptor that has proliferated recognizes the antigen-MHCII complex (with co-stimulatory
factors- CD40 and CD40L) and causes the B-cell to produce antibodies that help opsonisation of the antigen so that
the bacteria can be better cleared by phagocytes.

Macrophages provide yet another line of defense against tumor cells and somatic cells infected with fungus or
parasites. Once a T cell has recognized its particular antigen on the surface of an aberrant cell, the T cell becomes
an activated effector cell, chemical mediators known as lymphokines that stimulate macrophages into a more
aggressive form. These activated macrophages can then engulf and digest affected cells much more readily. The
macrophage does not generate a response specific for an antigen, but attacks the cells present in the local area in
which it was activated.

3. Roles of fibroblasts and endothelial cells in chronic inflammation and healing

Endothelial cells for angiogenesis

Fibroblast- proliferation and migration into the granulation tissue framework of new blood vessels and loose ECM
that initially forms at the repair site

- Fibroblasts progressively deposit increased amounts of ECM. Fibrillar collagens form a major portion of
the connective tissue in repair sites and are important for the development of strength in healing wounds
4. Factors that determine the transformation of an acute to a chronic inflammatory response.

Persistent infections, prolonged exposure to potentially toxic agents either exogenous or endogenous

Slide No. M-10-09 Chronic Granulomatous Inflammation of Lung

1. Pathogenesis of caseous necrosis.
Caseous necrosis, a distinctive form of coagulative necrosis, is encountered most often in foci of
tuberculous infection. The term caseous is derived from the cheesy white gross appearance of the area of
necrosis. On microscopic examination, the necrotic focus appears as amorphous granular debris seemingly
composed of fragmented, coagulated cells and amorphous granular debris enclosed within a distinctive
inflammatory border known as a granulomatous reaction. Unlike coagulative necrosis, the tissue
architecture is completely obliterated. Granulomatous inflammation is a distinctive pattern of chronic
inflammatory reaction characterized by focal accumulations of active macrophages, which often develop
an epithelial-like appearance. It is encountered in a limited number of immunologically mediated,
infectious, and some non-infectious conditions. Tuberculosis is the prototype of the granulomatous
diseases. Recognition of the granulomatous pattern in a biopsy specimen is important because of the
limited number of possible conditions that cause it and the significance of the diagnoses associated with
the lesions.
2. Reason why granulomas are formed in some conditions of chronic inflammation
A granuloma is a focus of chronic inflammation consisting of a microscopic aggregation of
macrophages that are transformed into epithelium-like (epitheloid) cells surrounded by a collar of
mononuclear leukocytes, principally lymphocytes and occasionally plasma cells. In the usual H&E stained
tissue sections, the epitheloid cells have a pale pink granular cytoplasm with indistinct cell boundaries,
often appearing to merge into one another. The nucleus is less dense than that of a lymphocyte, is oval
and elongate, and may show folding of the nuclear membrane. Older granulomas develop an enclosing
rim of fibroblasts and connective tissue. Frequently, epitheloid cells fuse to form giant cells in the
periphery or sometimes in the center of granulomas. These giant cells may attain diameters of 40 to 50
um. They have a large mass of cytoplasm containing 20 or more small nuclei arranged either peripherally
or haphazardly. There is no known functional difference between these two giant cells.
In countries where bovine tuberculosis and infected milk have been eliminated, pimary
tuberculosis almost always begins in the lungs. Typically, the inhaled bacilli implant in the distal airspaces
of the lower part of the upper lobe of the upper part of the lower lobe, usually close to the pleura. As
sensitization develops, a 1- to 1.5cm area of gray-white consolidation emerges, known as the Ghon focus.
In most cases, the center of this focus undergoes caseous necrosis. Tubercle bacilli, either free or within
phagocytes, drain to the regional nodes, which also often caseate. This combination of parenchymal lung
lesion and nodal involvement is referred to as the Ghon complex. During the first few weeks, there is also
lymphatic and hematogenous dissemination to other pats of the body. In approximately 95% of cases,
development of cell-mediated immunity controls the infection. Hence, the Ghon complex undergoes
progressive fibrosis, often followed by radiologically detectable calcification and despite seeding of other
organs, no lesions develop. Histologically, sites of active involvement are marked by a characteristic
granulomatous inflammatory reaction that forms both caseating and non-caseating tubercles. Individual
granulomas are microscopic; it is only when multiple granulomas coalesce that they become
macroscopically viable. The granulomas are usually enclosed within a fibroblastic rim punctuated by
lymphocytes. Multinucleate giant cells are present in the granulomas. Immunocompromised people do
not form the characteristic granulomas.
 3. Relationship between the epitheloid cells, Langhans giant cells, and lymphocytes; what are these cells
saying to one another and how are they communicating it?
Macroscopically, there is usually no demonstrable alteration, although at times, the coalescence
of granulomas may produce small nodules that are palpable o visible as 1- to 2-cm, noncaseating,
noncavitated consolidations. Histologically, the lesions are distributed primarily along the lymphatics,
around bronchi and blood vessels. Macrophages are the cells that define a ganuloma. They often, but not
invariably, fuse to form giant multinucleated cells. The macrophages in granulomas are epithelial-like thus
often referred to as epitheloid. This term refers to the vague resemblance of these macrophages to
epithelial cells. Epitheloid macrophages differ from ordinary macrophages in that they have elongated
nuclei that often resemble the sole of a slipper of shoe. They also have larger nuclei than ordinary
macrophages and their cytoplasm is typically more pink when stained with eosin. These changes are
thought to be a consequence of the macrophage by the offending antigen.
4. Pathogenesis in the formation of epitheloid and Langhans giant cell
Epithelioid histiocytes (Epithelioid cells) are activated macrophages resembling epithelial cells: elongated
with finely granular, pale eosinophilic (pink) cytoplasm and central, ovoid nucleus(oval or elongate), which
is less dense than that of a lymphocyte. They have indistinct shape contour, often appear to merge into
one another and form aggregates.

Langhans giant cells are large cells found in granulomatous conditions. They are formed by the fusion of
epithelioid cells (macrophages), and contain nuclei arranged in a horseshoe-shaped pattern in the cell
periphery.Although traditionally their presence was associated with tuberculosis, they are not specific for
tuberculosis or even for mycobacterial disease. In fact, they are found in nearly every form of
granulomatous disease, regardless of etiology.

They should not be confused with Langerhans cells, which are mononuclear epidermal dendritic cells
derived (like Langhans cells) from monocytes
5. Healing process of granulomas.

Granulomatous inflammation occurs only in immune-competent host since a cell-mediated immune response is
necessary for granuloma formation. Lymphocytes surround a core of epitheloid cells and macrophages. T4 cells stay
near the granulomas center indicating their role in antigen recognition for the maintenance of the immune
response; T8 cells at the edges. Granuloma formation occurs during chronic inflammation wherein it helps:

Isolate source of injury by fibrosis and intracellular sequestration within epitheloid cells (phagocytosis)
Prevent destructive recurrent acute inflammation due to persistent agent through sustained immune
response
Initiate repair

Slide No. M-10-20 Keloid of Skin (scar)

1. Pathogenesis of the healing process

EARLY 1. Thrombosis: Formation of a growth factor-rich barrier having significant tensile strength
2. Inflammation: Necrotic debris and microorganisms must be removed by neutrophils; the appearance of
macrophages signals and initiates repair
3. Re-epithelialization: Newly formed epithelium establishes a permanent barrier to microorganisms and
fluid
MID 4. Granulation tissue formation and function: This specialized organ of repair is the site of extracellular
matrix and collagen secretion; it is vascular, edematous, insensitive, and resistant to infection
5. Contraction: Fibroblasts and possibly other cells also transform to actin-containing myofibroblasts, link to
each other and collagen, and contract, stimulated by TGF-1 or 2

LATE 6. Accretion of final tensile strength results primarily from the cross-linking of collagen
7. Remodeling: The wound site devascularizes and conforms to stress lines in the skin

2. Factors that influences the type of healing in acutely and chronically injured tissues .
Nutrition
Metabolic status
Circulatory status
Hormones glucocoriticoids
Infection
Mechanical factors
Foreign bodies
Location and type of wound

3. Pathogenesis of scar formation

Migration of Fibroblasts and ECM Deposition (scar Formation)

Scar formation builds on the granulation tissue framework of new vessels and loose ECM that develop early at the
repair site. It occurs in two steps: (1) migration and proliferation of fibroblasts into the site of injury and (2)
deposition of ECM by these cells. The recruitment and stimulation of fibroblasts is driven by many growth factors,
including PDGF, FGF-2 (described above), and TGF-. One source of these factors is the activated endothelium, but
more importantly, growth factors are also elaborated by inflammatory cells. Macrophages, in particular, are
important cellular constituents of granulation tissue, and besides clearing extracellular debris and fibrin at the site
of injury, they elaborate a host of mediators that induce fibroblast proliferation and ECM production. Sites of
inflammation are also rich in mast cells, and with the appropriate chemotactic milieu lymphocytes may also be
present. Each of these can contribute directly or indirectly to fibroblast proliferation and activation.
As healing progresses, the number of proliferating fibroblasts and new vessels decreases; however, the fibroblasts
progressively assume a more synthetic phenotype, and hence there is increased deposition of ECM. Collagen
synthesis, in particular, is critical to the development of strength in a healing wound site. As described later,
collagen synthesis by fibroblasts begins early in wound healing (days 3 to 5) and continues for several weeks,
depending on the size of the wound. As described below, many of the same growth factors that regulate fibroblast
proliferation also participate in stimulating ECM synthesis. Net collagen accumulation, however, depends not only
on increased synthesis but also on diminished collagen degradation (discussed later). Ultimately, the granulation
tissue scaffolding evolves into a scar composed of largely inactive, spindle-shaped fibroblasts, dense collagen,
fragments of elastic tissue, and other ECM components. As the scar matures, there is progressive vascular
regression, which eventually transforms the highly vascularized granulation tissue into a pale, largely avascular scar.
.

Growth Factors Involved in ECM Deposition and scar Formation

Many growth factors are involved in these processes, including TGF-, PDGF, and FGF. Because FGF is also involved
in angiogenesis, it was described earlier. Here we briefly describe some properties of TGF- and PDGF.
TGF- belongs to a family of homologous polypeptides (TGF-1, -2, and -3) that includes other members such as
bone morphogenetic proteins, activins, and inhibins. TGF-1 has a widespread distribution and is usually referred
to as TGF-. The active factor binds to two cell surface receptors with serine/threonine kinase activity, triggering
the phosphorylation of transcription factors called smads. TGF- has many and often opposite effects, depending
on the cell type and the metabolic state of the tissue. In the context of inflammation and repair, TGF- has two
main functions:

TGF- is a potent fibrogenic agent. It stimulates the production of collagen, fibronectin, and proteoglycans,
and it inhibits collagen degradation by both decreasing proteinase activity and increasing the activity of
tissue inhibitors of proteinases known as TIMPs. TGF- is involved not only in scar formation after injury
but also in the development of fibrosis in lung, liver, and kidneys that follows chronic inflammation.TGF-
inhibits lymphocyte proliferation and can have a strong anti-inflammatory effect. Mice lacking TGF- have
widespread inflammation and abundant lymphocyte proliferation.

PDGF belongs to a family of closely related proteins, each consisting of two chains, designated A and B. There are
five main PDGF isoforms, designated AA, AB, BB, CC, and DD. PDGFs bind to receptors designated as PDGFR and
PDGFR . PDGF BB is the prototype for the family and is referred to as PDGF. It is stored in platelets and released on
platelet activation, and produced by endothelial cells, activated macrophages, smooth muscle cells, and many
tumor cells. PDGF causes migration and proliferation of fibroblasts, smooth muscle cells, and macrophages.

Cytokines may also function as growth factors and participate in ECM deposition and scar formation. IL-1 and TNF,
for example, induce fibroblast proliferation and can have a fibrogenic effect. They are also chemotactic for
fibroblasts and stimulate the synthesis of collagen and collagenase by these cells.

Slide No. M-10-21 Cirrhosis of the Liver (scar formation)