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01 06/13/15
Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

Grig Misiona, MD

 Necrosis – type of cell death that occurs after

INTRODUCTION TO PATHOLOGY such abnormal stresses as ischemia and
PATHOLOGY chemical injury; always pathologic 

- The study (logos) of diseases (disease)
- The study of the structural, biochemical, and functional changes  Apoptosis – occurs due to activation of an
in cells, tissues, and organs that underlie the disease internally controlled suicide program;
- Foundation of medical science and practice physiologic and pathologic
- Scientific study of disease
- The study of structural and functional abnormalities that manifest I. CELLULAR ADAPTATION
th
as diseases of organs and organ systems (Rubin’s 7 ed.) - Occurs when excessive physiologic or pathologic stresses result
- The study of injury to cells and organs and of their capacity to in a new but altered steady state
th
adapt to such injury (Rubin’s 7 ed.)
DIVISIONS OF PATHOLOGY
1. General Pathology
o Concerned with the reactions of cells and tissues to
abnormal stimuli and to inherited defects, which are the
main causes of disease
2. Systemic Pathology
o Examines the alterations in specialized organs and
tissues that are responsible for disorders that involve
these organs

FOUR ASPECTS OF A DISEASE PROCESS THAT FORM THE

CORE OF PATHOLOGY
1. Etiology
o The cause of the disease
o 3 types: Fig.1. Schematic Diagram of the Overview of Cellular Response to
 Genetic Injury and Adaptation
 Acquired TYPES OF ADAPTATION
 Combined/Multifactorial 1. Physiologic
2. Pathogenesis o Response of cell to hormones or endogenous influence
o Refers to the sequence of events in the response of o e.g. runners, mountain climbers
cells or tissues to the etiologic agents, from the initial 2. Pathologic
stimulus to the ultimate expression of the disease o Response to injurious stimuli
o Answers the question, “How does the disease o e.g. prolonged hypertension
progress?”
3. Morphologic Changes ADAPTATIONS OF CELLULAR GROWTH AND
o Refer to the structural alterations in cells or tissues that DIFFERENTIATION
are either characteristic of a disease or diagnostic of an 1. HYPERPLASIA
th
etiologic process Rubin’s 7 ed:
o Can be gross or microscopic  An increase in cell number in an organ or tissue usually with
o There are diseases, which do not have pathognomonic increased mass as well
lesions like autoimmune diseases. This is where  May occur in response to an altered endocrine milieu, increased
immunology or molecular pathology comes in. functional demand, or chronic injury
4. Clinical Significance/Manifestation  May occur simultaneously with hypertrophy and are triggered by the
o Functional consequence of the alteration same external stimulus
o The end results of genetic, biochemical, and structural  Takes place if cell is capable of dividing
changes in cells and tissues are functional abnormalities
o What is the impact/effect on the patient?

CELLULAR RESPONSES TO STRESS AND NOXIOUS STIMULI

STAGES OR CELLULAR RESPONSE TO STRESS AND
INJURIOUS STIMULI
a. Cellular Adaptation
o Reversible functional and structural responses to more
severe physiologic stresses and some pathologic
stimuli, during which new but altered steady state are
achieved, allowing to cell to survive
b. Cell Injury
o Results when cells are stressed so severely they are no
longer able to adapt
o Or when cells are exposed to inherently damaging
agents or suffer from intrinsic abnormalities
o When environmental changes exceed the cell’s capacity
th
to maintain normal homeostasis (Rubin’s 7 ed.)
o Reversible Cell Injury
 When the stimulus is removed, the changes may
revert back to normal
 For mild types of injury
o Irreversible Cell Injury
 Permanent changes
 Will eventually cause cell death with certainty
 There is failure of adaptive mechanism
c. Cell Death
o The end result of progressive cell injury
o One of the most crucial events in the evolution of
disease in any tissue or organ
o A normal and essential process in embryogenesis, the
development of organs, and the maintenance of
homeostasis
TRANSCRIBERS: Espinosa, Elvambuena, Manching, Miniano
Fig.2. Comparison of a Normal Bone Marrow(Left) with a
hyperplastic Bone Marrow (Right)
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TYPES OF HYPERPLASIA (Robbins, 9 ed.)
a. Physiologic
o Hormonal
 increases the functional capacity of a tissue when
needed
 e.g. proliferation of the glandular epithelium of the
female breast at puberty and during pregnancy;
hyperplasia of endometrial glands
o Compensatory
 Increases tissue mass after damage or partial
resection
 e.g. liver cells after hepatectomy
th
o Increased Functional Demand (Rubin’s 7 ed.)
 Increased physiological requirements may result to
hyperplasia
 E.g. high altitudes, low oxygen tension causes
hyperplasia of erythroid precurors in the bone
marrow and increased blood erythrocytes
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 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death
b. Pathologic
o Caused by excesses of hormones or growth factors acting
on target cells (e.g. endometrial and prostatic hyperplasia)
o Also a characteristic response to certain viral infections
(e.g. papillomaviruses)
o May give rise to neoplasms
o e.g. endometrial hyperplasia - balance between estrogen
and progesterone is disturbed → results in increase amount
of estrogen → hyperplasia of endometrial glands → causes
abnormal menstrual bleeding; benign prostatic hyperplasia
th
o Chronic Injury(Rubin’s 7 ed.)
 Persistent injury may result to hyperplasia
 Long standing inflammation of physical or chemical
injury is often accompanied by a hyperplastic
response
 E.g. pressure from ill-fitting shoes causes
hyperplasia of the skin of the foot, so-called corns
and calluses
Fig.3. Comparison of (Left) Normal Epidermis and
(Right) Thickened Epidermis due to Increased number of
th
squamous cells (Rubin’s 7 ed.)
MECHANISMS OF HYPERPLASIA
1. Result of growth factor-driven proliferation of mature cells
2. By increased output of new cells from tissue stem cells
↑ local production of growth factors (GF)
↓ -
↑ GF receptors on responding cells
↓
Activation of particular intracellular signaling pathway
↓
↑ Activation of transcription factors
↓
Turn on many cellular genes (including genes encoding growth
factors, receptors for growth factors and cell cycle regulators)
↓
CELLULAR PROLIFERATION
2. HYPERTROPHY
- Increase in the size of cells due to the synthesis of more
structural components
- Leads to an increase in size of the organ
- Occurs in non-dividing cells (e.g. muscle cells)
- ***muscle cells may have a potential to divide in certain situations
TWO TYPES OF HYPERTROPHY
1. Physiologic Hypertrophy
o Caused by increased functional demand
 e.g. endurance athletes, basketball players
o Caused by specific hormonal stimulation (Inc Trophic
Signals)
 Hypertrophy of breast in response to estrogen
and progestins
 Uterine hypertrophy during pregnancy
o Puberty
 Just as aging is associated with atrophy, the
onset of puberty especially in males leads to
greater muscle mass
2. Pathologic Hypertrophy
o Hypertrophy in hypertension (barado yung ugat/volume
overload -> excessive pumping of the heart -> increase in
muscle fibers/myosin to compensate)
o Heart may lose capacity to adapt -> heart failure
TRANSCRIBERS: Espinosa, Elvambuena, Manching, Miniano
MECHANISM OF HYPERTROPHY
1. The result of increased production of cellular proteins
2. Two main biochemical pathways involved in muscle hypertrophy:
a. Phosphoinositide 3-kinase/Akt pathway
b. Signaling downsteam of G protein-coupled receptors
3. Hypertrophy may also b associated with a switch of contractile
proteins from adult to fetal or neonatal forms
4. Some genes expressed only during early development are re-
expressed during hypertrophy and the products of these genes
participate in the cellular response to stress
5. In the heart, there at least two groups of signals to trigger gene
expression:
 Mechanical triggers – stretch
 Trophic triggers – polypeptide growth factors (IGF-1) and
vasoactive agents (angiotensin II, α-adrenergic agonists)
th
Rubin’s 7 ed.:
o Growth Factor Stimulation: some growth factors are key
initiators of hypertrophy (e.g. IGF-1)
o Neuroendocrine Stimulation: in some tissues, adrenergic
signaling may be important in initiating or facilitating
hypertrophy
o Ion Channels: ion fluxes may activate adaptation to
increased demand
o Other Chemical Mediators: NO, angiotensin II, and
bradykinin
o Oxygen Supply: ↑ functional demand requires ↑ energy
supply. Angiogenesis with oxygen delivery is stimulated if
tissue oxygen deficit is sensed, a key component in adaptive
hypertrophy
o Hypertrophy Antagonists: ANF and ↑ concentration of NO
brake or prevent adaptation by hypertrophy
MYOCARDIAL HYPERTROPHY
- Associated with reinduction of ANF gene expression
- Mechanical sensors appear to be the major triggers for
physiologic hypertrophy
Agonists and growth factors may be more important in pathologic
states (e.g. ANF, IGF-1)
Fig.4. Diagrammatic representation of the general mechanism for
myocardial hypertrophy
SELECTIVE HYPERTROPHY
- Hypertrophy prefers to increase size of cells and tissues but
Sometimes, a subcellular organelle may undergo selective
hypertrophy
- e.g. barbiturates cause hypertrophy of the sER in hepatocytes
th
EFFECTOR PATWAYS OF HYPERTROPHY (Rubin’s, 7 ed.)
o Increase Protein Degradation: ubiquitin-proteasome system,
activation of intracellular proteases and autophagy
o Increased Protein Translation: increased translational efficiency
without changes in RNA levels
o Increased Gene Expression: concentration of key proteins are also
elevated by upreglation of their genes; increased gene transcription
of growth-promoting factors (Fos and Myc)
o Survival: Stimulation of specific receptors activates several
enzymes that promote cell survival, inhibiting cell death
o Remodelling Extracellular Matrix
o Recruitement of Satellite Cells
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 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

3. ATROPHY
- Shrinkage or reduction in the size of the cell due to decrease in 4. INADEQUATE NUTRITION
cell size and number - E.g. marasmus –assoc. w/ use of skeletal muscle as energy
source when adipose stores have been depleted) -> muscle
TYPES OF ATROPHY wasting
I. Physiologic Atrophy - Cachexia
- Common during normal development
- E.g. embryonic structures undergo atrophy during fetal 5. LOSS OF ENDOCRINE STIMULATION
development and uterus decreases in size shortly after parturition - Hormone-responsive tissues are dependent on endocrine
stimulation
II. Pathologic Atrophy - E.g. loss of estrogen stimulation after menopause -> physiologic
- Depends on underlying cause atrophy of endometrium, vaginal epithelium, breast
- Can be local or generalized
6. AGING
- Diminished body movement

7. PRESSURE
- Tissue compression for any length of time -> atrophy
- E.g. enlarging benign tumor -> atrophy of surrounding tissues
(ischemic changes caused by compromise of the blood supply
by the pressure exerted by the expanding mass)

Table 1.

Fig.5. Normal uterus of a reproductive age woman revelas thick endometrium

composed of proliferative glands in abundant stroma

Fig. 6.The endometrium of a 75yr old woman is thin and contains only a few
atrophic and cystic glands

COMMON CAUSES OF ATROPHY

- The fundamental cellular changes in atrophy are the same:
Initial response (decrease in cell size and organelles)
↓
Reduced metabolic needs of the cell
↓
Cell function will be diminished but not dead, however gradual
reduction of blood supply
↓
Irreversible injury MECHANISM OF ATROPHY
↓
1. ↓Protein synthesis
Death (often by apoptosis) 2. ↑Protein degradation thru the ubiquitin proteosome pathway
Ubiquitin- Proteosome Pathway:
1. DECREASED WORKLOAD (ATROPHY OF DISUSE)
- Reversible once activity is resumed but prolonged disuse ->
apoptosis -> bone resorption -> osteoporosis of disuse
- E.g. Muscle atrophy due to immobilized fractured bone in a
plaster cast or bedrest

2. LOSS OF INNERVATION (DENERVATION ATROPHY)

- Nerve damage -> atrophy of muscles supplied by these nerves
- Normal metabolism and function is compromised
3. ↑Autophagy
3. DIMINISHED BLOOD SUPPLY (ISCHEMIA) - Number of Autophagic vacuoles and lysosomes
- Result of slowly developing arterial occlusive disease -> atrophy - Residual bodies – cell debris within the autophagic vacuoles that
of ischemic tissue resist digestion
- Senile atrophy – reduced blood supply of brain as a result of .4. ↓ Energy Utilization
atherosclerosis -> progressive atrophy of the brain among adults - A selective decrease in the use of free fatty acids as an energy
and also affects the heart source for muscle in response to unloading

BROWN ATROPHY
- Atrophy is often accompanied by increased autophagy ->
increased number of autophagic vacuoles (causes accumulation
of sarcophagus like lipofuscin granules, sufficient amounts will
impart brown discoloration to tissue)

Fig.7. Comparison of a Normal Brain (A) and an Ischemic one (B)

TRANSCRIBERS: Espinosa, Elvambuena, Manching, Miniano Page 3 of 19

 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

Fig.11.

-
-

MECHANISM OF METAPLASIA
- Result of a reprogramming of stem cells that are known to exist
in normal tissues or of undifferentiated mesenchymal cells
present in connective tissue
- Signals generated by cytokines, growth factors, ECM
components -> differentiation of stem cells to a particular
lineage
- Vitamin A (rRtionoic acid)
Fig. 9.
o Directly regulates gene transcription through nuclear
retinoid receptors; so deficiency or excess of which can
influence the differentiation of progenitors derived from
tissue stem cells
- Other external stimulus – exact mechanism is unknown but may
also alterFig.12.
the activity of transcription factors that regulate
differentiation
4. METAPLASIA 5. DYSPLASIA
- Reversible change in which one differentiated cell type
(epithelial or mesenchymal) is replaced by another cell type
- E.g. ni Doc: parang mga homosexuals 
- May represent an adaptive substitution of cells that are sensitive
to stress by cell types better able to withstand the adverse
environment
- Most common: columnar to squamous (in the respiratory tract
due to chronic irritation)

Fig.13.Nondysplastic Cervical Epithelium. No mitotic activity above

most basal layer cells but rather shows epithelial maturation with
flattening of cells and progressive dimunition of nuclei
Fig.10. Histologic specimen that shows the columnar to squamous hyperplasia

- E.g. secretory columnar epithelium in excretory ducts of the

salivary glands, pancreas, or bile ducts is replaced by stratified
squamous epithelium because of stones present in them
- E.g. respiratory epithelium becomes squamous due to vitamin A
(retinoic acid) deficiency
o In the case of respiratory epithelium, the mucus
secretion and ciliary action is lost and renders the body
more susceptible to infections
- Persistent predisposition to metaplasia may initiate malignant
transformation
- Another example: squamous to columnar (in Barrett’s
esophagus, due to refluxed gastric acid, glandular
(adeno)carcinoma may arise)

Fig.14. Dysplastic Epithelium of uterine cervix lacks normal polarity,

and individual cells show hyperchromatic nuclei and a greater than
normal nucleus-to-cytoplasm ratio

- Disoredered cellular growth and maturation

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 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death
- Patterns that are exhibited in normal cells are disturbed by (1)
variations in cell size and shape, (2) nuclear enlargement,
irregularity, and hyperchromatism, (3) disorderly arrangement of
cells in epithelium
- Occurs most often in hyperplastic squamous epithelium, and in
areas of squamous metaplasia
- Considered as a preneoplastic lesion and that it is a necessary
stage in the multistep cellular evolution to cancer
It is the morphologic exression of a disturbance in growth regulation,
however, unlike cancer cells, dysplastic cells are not autonomous and
with intervention, the tissue may still revert to normal
II. CELL INJURY
TIMING AND CHANGES IN CELL INJURY
CELL INJURY OCCURS WHEN CELLS:
- Are stressed so severely that they are unable to adapt
- Are exposed to inherently damaging agents
- Suffer from intrinsic abnormalities
REVERSIBLE CELL INJURY
- Functional and morphologic changes are reversible if the
damaging stimulus is removed (early stages, mild forms of
injury)
- Hallmarks of reversible injury:
o ↓Oxidative phosphorylation → depletion of energy stores
(ATP)
o Cellular swelling due to changes in ion concentrations and
water influx
o Alterations in organelles (mitochondria and cytoskeleton)
CELL DEATH
- Point of irreversibility: beyond which the cell cannot recover and
dies
- TWO PRINCIPAL TYPES:
1. NECROSIS
o severe damage to membranes
o Lysosomal enzymes enter the cytoplasm and digest the
cell
o Cellular contents leak out
o Always a pathologic process
2. APOPTOSIS
o Cell’s DNA or proteins are damaged beyond repair
o Nuclear dissolution, fragmentation of the cell without
complete loss of membrane integrity and rapid removal of
the cellular debris
o Serves many normal functions
o Not necessarily associated with cell injury
CAUSES OF CELL INJURY
1. HYPOXIA (OXYGEN DEPRIVATION)
- Deficiency of oxygen
- Most common cause of cell injury and death
- Hypoxia = ↓aerobic oxidative respiration → cell injury
- CAUSES OF HYPOXIA
o Ischemia (↓blood flow)
o Inadequate oxygenation of the blood due to
cardiorespiratory failure
o ↓oxygen-carrying capacity of the blood (anemia, CO
poisoning)
- Cells have varying responses to the severity of the hypoxia:
o Narrowed artery →atrophy of the tissue supplied by the
blood vessel
o More severe or sudden hypoxia  injury and cell death
2. PHYSICAL AGENTS
- Mechanical trauma
- Extremes of temperature (burns and deep cold)
- Sudden changes in atmospheric pressure
- Radiation
- Electric shock
3. CHEMICAL AGENTS AND DRUGS
- Glucose or salt in ↑ concentrations
- O2 at ↑ concentrations
- Trace amounts of arsenic, cyanide or mercuric salts
- Environmental and air pollutants
- Insecticides and herbicides
- Industrial and occupational hazards (CO, asbestos)
TRANSCRIBERS: Espinosa, Elvambuena, Manching, Miniano
- Recreational drugs (alcohol)
- Therapeutic drugs
4. INFECTIOUS AGENTS
- Rickettsiae, Bacteria, Fungi, Higher forms of parasites
5. IMMUNOOGIC REACTIONS
- Autoimmune diseases: d/t injurious reactions to endogenous
self-antigens
- Immune reactions to external agents (microbes and
environmental substances)
6. GENETIC DERANGEMENTS
- Genetic defects may cause cellular injury d/t deficiency of
functional proteins (enzyme defects in inborn errors of
metabolism)
- Accumulation of damaged DNA or misfolded proteins →
triggering of cell death of beyond repair
- Variations in genetic makeup: can influence the susceptibility
of cells to injury by chemicals and other environmental insults
7. NUTRITIONAL IMBALANCES
- Major causes of cell injury
- Protein-calorie deficiencies, deficiencies of specific vitamins
- Anorexia nervosa: self-induced starvation
- ↑↑cholesterol →↑predisposition to atherosclerosis
- Obesity → diabetes and cancer
MECHANISMS OF CELL INJURY
PRINCIPLES RELEVANT TO CELL INJURY
1. Factors that influence the RESPONSE of a cell to injurious stimuli
o NATURE, DURATION AND SEVERITY of the injury
 Small doses of a toxin or brief periods of ischemia 
reversible injury
 Large doses of the same toxin or prolonged ischemia
 instantaneous cell death or slow, irreversible
injury (which also leads to death eventually)
2. Factors that influence the CONSEQUENCES of cell injury
o TYPE, STATE AND ADAPTABILITY of the injured cell
 The nutritional and hormonal status and the
metabolic needs of the cell are important in its
response to injury.
 Striated leg muscles, when deprived of blood supply
can be placed at rest and preserved but the striated
cardiac muscles can not.
 Susceptibility to hypoxia:
 Neurons – very sensitive (mins)
 Myocytes, hepatocytes – intermediate (mins
to hrs)
 Fibroblasts, epidermis, muscle – low (many
hours)
 Two individuals who are exposed to identical toxin
concentrations may produce no effect in one and cell
death in the other
 May be due to genetic variations that affect
hepatic enzyme activity
3. Cell injury results from different biochemical mechanisms acting
on several essential cellular components
4. Any injurious stimulus may simultaneous trigger multiple
interconnected mechanisms that damage cells.
Fig.15. 1 Mechanism that can lead to apoptosis
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 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

↓ O2 supply (i.e. ischemia)

↓
↓ Oxidative phosphorylation
↓
↓Cellular ATP, ↑ AMP
↓
Stimulation of PFK and phosphorylase activity
↓
↑ Anaerobic glycolysis
2+
6. Fig.16.The mechanisms of increased Calcium and o Failure of Ca pump which leads to its influx and may
th ROS that can lead to cell lysis damage the mitochondria (explained later).
o Disruption of the protein synthesis apparatus which
manifests as ribosome detachment from the rER and
polysome dissociation = ↓protein synthesis
o Depletion of O2 and glucose may result to protein
misfolding which may trigger an unfolded protein response
(may cause injury or death).
o Irreversible damage to mitochondrial and lysosomal
membranes, leading to cell necrosis.

II. ACCUMULATION OF O2-DERIVED FREE RADICALS

(OXIDATIVE STRESS)
Fig.17.Mechanisms of membrane damage and
CHON misfolding which leads to cell lysis - Important in pathologic conditions such as:
o Chemical and radiation injury
I. ATP DEPLETION o Ischemia-reperfusion injury
- Frequently associated with hypoxic and chemical (toxic) injury o Cellular aging
- ATP is produced in two ways: o Microbial killing by phagocytes
o Oxidative phosphorylation of ADP (aerobic; efficient; major - FREE RADICALS
pathway) o Unstable, partially reduced molecules with unpaired
o Glycolytic pathway (anaerobic; inefficient) electrons in outer orbitals that make them particularly
- The MAJOR causes of ATP depletion are: reactive with other molecules
o ↓ O2 and nutrient supply o These free radicals damage:
o Mitochondrial damage  Lipids by peroxidizing double bonds—causing
o Toxins (e.g. cyanide) chain breakage
- Tissues with ↑glycolytic capacity are able to survive loss of  Proteins by oxidizing and fragmenting peptide
oxygen and decreased oxidative phosphorylation better than bonds
tissues with limited glycolytic capacity (e.g. liver vs. brain)  Nucleic acids by causing single strand breaks
- OXYGEN-DERIVED FREE RADICALS (ROS)
o Are the most common form of free radivals in biological
systems
o Major forms include:
-
 Superoxide anion (O2 )
o Produced mainly by leaks in
mitochondrial electron transport or as
part of inflammatory processes
 Hydrogen peroxide (H2O2)
-
o Formed from the conversion of (O2 )
by superoxide dismutase (SOD)
o Normally not injurious and can be
metabolized to HxO by catalase
o When produced in excess, it is
converted to highly reactive Hydroxyl
radical
o In neutrophils, it is converted by
myeloperoxidase to hypochlorite
which can kill cells if released
extracelllularly
o Reduced to HxO by (1) catalase and
Fig. 18. Mechanism of Ischemia which leads (2) Glutathione Peroxidase which
to cell lysis uses reduced glutathione (GSH) as a
- ATP is necessary for the following: cofactor, yielding oxidized
o Membrane transport glutathione (GSSG)
o Protein synthesis  Hydroxyl ions (OH)
o Lipogenesis o Most reactive ROS
o Deacylation-reacylation reactions for phospholipid turnover o Formed by:
- ATP depletion of 5% to 10% the normal levels have the  Radiolysis of water
following effects:  Reaction of H2O2 with Fe or
2+
o ↓ Activity of the Na-K-ATPase 1+
Cu (Fenton Reaction)
+ +
 This causes Na to accumulate inside the cell and K  Conversion of O2 with H2O2 (Haber
to diffuse out. This is accompanied by isosmotic Weiss Reacton)
water gain, which causes cell swelling and ER  Mechanisms of damage to
dilation. macromolecules:
o Alteration of cellular energy metabolism
 Anaerobic glycolysis results to accumulation of lactic a. Lipid peroxidation
acid and Pi . This leads to a reduction in intracellular  (OH )
.
removes H
+
from
pH which may decrease the activity of some unsaturated fatty acids in
enzymes. membrane phospholipids 

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 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

Free Lipid radical  reacts with

O2 to form lipid peroxide radical
 reactsby removing another
+
H ,from a different unsaturated
fatty acid, initiating a chain
reaction
→ Loss of membrane integrity due to
destruction of fatty acids
b. Protein Interactions
→ Fragmentation, cross-linking, aggregation,
and eventual degradation of proteins due
.
to attack of (OH ) to sulfur-containg and
nitrogen-containing AAs (Cys Met, Arg,
His, Pro)
c. Sugars
.
→ Attack of (OH ) to sugars generate reactive
intermediates which modify proteins, Fig.19.Diagram of the Production and Effects of ROS to the mitochondria
forming advanced glycation end-products 2+ 2+
III. INFLUX OF Ca AND LOSS OF Ca HOMEOSTASIS
(AGE) 2+
d. DNA damage - Cytosolic Ca is maintained at low concentrations (-0.1umol) and
→ Causes structural DNA alteriations is mostly sequestered in the mitochondria and ER.
including strand-breaks, modified bases - Ischemia and certain toxins can cause Ca2+ influx across the
and strand cross-linking plasma membrane and release of Ca2+ from the mitochondria
 Nitric Oxide (NO) Peroxynitrite ion (ONOO )
- and ER.
2+
 NO and O2 interactions produce other free radicals - This increase in cytosolic Ca activates the following enzymes:
which may nitrosate amines or modify other o Phospholipases that degrade membrane phospholipids;
available groups o Proteases that break down membrane and cytoskeletal
 NO may react with superoxide radical to form proteins;
peroxynitrite ion o ATPases that hasten ATP depletion;
 Peroxynitrite may attack lipids, proteins, and DNA o Endonucleases that cause chromatin fragmentation

GENERATION OF FREE RADICALS

1. Normal metabolic processes such as the reduction of O2 to H2O
during respiration
2. Absorption of radiant energy (UV, x-rays) hydrolyze H2O into OH∙
and H∙ free radicals
3. Production by leukocytes during inflammation to sterilize infection
sites
4. Enzymatic metabolism of exogenous chemicals or drugs
5. Catalysis by transition metals like Fe and Cu
6. Conversion of NO to highly reactive forms or NO as a free radical
itself

REMOVAL OF FREE RADICALS

- Fortunately, free radicals are inherently unstable and generally
decay spontaneously.
- There are also several systems which contribute to free radical
inactivation which include:
o Antioxidants that block the initiation of free radical
formation or scavenge free radicals
 E.g. Vitamins E, A (retinoids), C, NO, and
glutathione
o Levels of transition metals that can participate in free
radical formation (Fe and Cu) are minimized by binding to
storage and transport proteins
 E.g. transferrin, ferritin, lactoferrin, ceruloplasmin
o Enzyme systems that scavenge free radicals
 E.g catalase (peroxisomes) and glutathione
peroxidase (cytosol and mitochondria)
catabolize H2O2; superoxide dismutase
catabolizes the superoxide anion
ROLE OF p53
o helps prevent and repair DNA damage, rescuing cells from
endogenous and exogenous causes of injury
o If DNA damage is irrepairable, it activates cel death
programs
o Under normal conditions and low oxidative stress, it
maintains expression of many antioxidant genes for cell
survival
o During severe oxidant stress, it activates different target
genes that impair oxidant defenses, allow cellular damage to
accumulate, and eventually cell death
It also directs metabolic pathways that reinforce its transcriptional
activity
Fig.20. Schematic Diagram that shows the deleterious effects of Inc
Extracellular Ca
IV. DEFECTS IN MEMBRANE PERMEABILITY
MECHANISMS OF MEMBRANE DAMAGE
- Membranes can be damaged by:
o ROS via lipid peroxidation
o Decreased phospholipid synthesis which decrease ATP
production and thus affect energy-dependent enzymatic
activities
o Increased phospholipid breakdown as a result of
2+
↑cytosolic [Ca ]
o Cytoskeletal abnormalities due to protease activation by
2+
↑cytosolic [Ca ] (proteases may damage cytoskeletal
elements, making it susceptible to stretching and rupture)
2+
o Or indirectly by ROS or Ca activation of enzymes
previously mentioned
- Increased plasma membrane permeability affects intracellular
osmolarity and enzyme activity
- Increased mitochondrial membrane permeability reduces ATP
synthesis and can drive apoptosis
- Altered lysosomal integrity unleashes extremely potent acid
hydrolases that can digest proteins, nucleic acids, lipids and
glycogen.

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 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

Fig.21. Mechanism ROS, Dec O2 and Inc Calcium that will lead to
Membrane Damage

CONSEQUENCES OF MEMBRANE DAMAGE

- MITOCHONDRIAL MEMBRANE DAMAGE
o Damage opens the mitochondrial permeability transition
pore which leads to decreased ATP and protein release
that triggers apoptotic death
- PLASMA MEMBRANE DAMAGE
o Results to osmotic imbalance and influx of fluids and
Fig.22. A diagram showing the deleterious effects of Inc Calcium in the
ions, as well as loss of cellular contents mitochondria
o Metabolites vital for ATP reconstitution may also leak out,
VI. DAMAGE TO DNA AND PROTEINS
further depleting energy stores
- LYSOSOMAL MEMBRANE DAMAGE - DNA damage exceeding normal repair capacity leads to
o Results to enzyme leakage into cytoplasm and activation activation of apoptosis
of acid hydrolases in an acidic intracellular pH of the - Accumulation of misfolded proteins lead to a stress response that
injured cell also triggers apoptotic pathways
o Lysosomal enzymes—RNAses, DNAses, proteases,
phosphatases, glucosidases and cathepsins—when SUBCELLULAR RESPONSES TO ADVERSE STIMULI
activated lead to enzymatic digestion of peoteins, RNA, 1. Lysosomal catabolism (heterophagy, autophagy)
DNA and glycogen—which ultimately leads to cell 2. SER induction (detoxification)
necrosis. 3. Mitochondrial changes
4. Cytoskeletal abnormalities
V. MITOCHONDRIAL DAMAGE
MORPHOLOGICAL ALTERATIONS IN CELL INJURY
- Mitochondria can be damaged by: - All stresses and noxious influences exert their effects first at the
o Increases in cytosolic [Ca2+] molecular or biochemical level
o ROS - A time lag between the stress and the morphologic changes of
o O2 deprivation cell injury and death exists and the duration of the delay may vary
with the sensitivity of the methods used to detect these changes
TWO MAJOR CONSEQUENCES OF MITOCHONDRIAL DAMAGE
- Morphological changes may be seen minutes to hours after injury
1. Often results in the formation of a high-conductance channel in when using histochemical or ultrastructural techniques but may
the membrane—the mitochondrial permeability transition pore. take hours to days before these changes can be seen by light
Opening of mitochondrial permeability transition pore microscopy or gross examination.
↓
Loss of mitochondrial membrane potential
↓
Failure of oxidative phosphorylation and progressive ATP depletion
↓
Cell necrosis

2. The mitochondria sequester several proteins that are capable of

activating apoptotic pathways between the inner and outer
membranes which include cytochrome c and caspases.
o Increased permeability of the outer mitochondrial
membrane may result to leakage of these proteins into
the cytosol and death by apoptosis.

Fig.23. Graphical Representation of the Morphological Alterations in Cell Injury

REVERSIBLE CELL INJURY

- Within limits, cell is capable of repairing derangements
- If the injurious stimulus subsides, cell will return to normalcy

FEATURES UNDER LIGHT MICROSCOPY

1. Cellular Swelling
o Appears whenever cells are incapable of maintaining
ionic and fluid homeostasis
o It is the result of failure of energy-dependent ion pumps in
plasma membrane

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 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

o Swelling results to the following:

 Pallor 3. Endoplasmic Reticulum
 Increased turgor o Disaggregation and Detachment of polysomes from the
 Increase in weight of organ surface of Rough ER
 Eosinophilic staining o Dilated cisternae due to fluid accumulation
 Vacuolar degeneration or hydropic change o Intracytoplasmic myelin figures
 HYDROPHIC SWELLING 4. Nucleus
o A reversible increase in cell volume o Segregation of granular and fibrillar components of the
o Characterized by a large pale, cytoplasm and nucleolus
normally located nucleus 5. Dilation of ER
o Unchanged number of organelles but dispersed o Detachment of polysomes
in a larger volume o Intracytoplasmic myelin figures
o Excess fluid preferentially accumulates in the 6. Nuclear alterations with disaggregation of granular and fibrillar
cisterna of the endoplasmic reticulum (ER), which elements
is dilated due to ionic shifts in this compartment 7. Lysosomal autophagy
8. Decreased ATP degeneration
9. Defects in protein synthesis

IRREVERSIBLE CELL INJURY

- Persistent or excessive injury causes cells to pass the point of no
return into irreversible injury or cell death
- May induce death via NECROSIS and APOPTOSIS

ULTRASTRUCTURAL FINDINGS
Fragmentation of cell membrane
1. Severe vacuolization of mitochondria
2. Rupture of lysosomes and leakage of lysosomal enzymes
(autolysis)

Fig. 24.

2. Fatty Change
o Occurs in hypoxic injury and various forms of toxic or
metabolic injury
o Manifestations:
 Lipid vacuoles in cytoplasm
o Usually in cells involved in fat metabolism such as
hepatocytes and myocardial cells.
Fig. 26. Graphical representation of the difference between Necrosis and
o Fat accumulation within the cell Apoptosis
o Grossly enlarged and yellowish
III. NECROSIS
ULTRASTRUCTURAL CHANGES - Gross and histologic correlate of cell death following irreversible
1. Plasma membrane alterations exogenous injury
o Formation of blebs that may detach withouth loss of cell - Cells are unable to maintain membrane integrity so contents
viability often leak out eliciting inflammation in surrounding tissue
o Blunting - Morpholic appearance is the result of:
o Loss of microvilli o Denaturation of intracellular proteins
2. Mitochondrial changes o Enzymatic digestion of the cells
o Swelling due to dissipation of mitochondrial energy  Enzymes are derived from lysosomes (autolysis)
gradient of from lysosomes of immigrant leukocytes
o Appearance of small amorphous densities
MORPHOLOGICAL CHANGES IN NECROSIS
- Increased cytoplasmic eosinophilia in H&E stains
o Due to loss of cytoplasmic RNA and binding of eosin to
denatured intracytoplasmic proteins
- More glassy homogenous appearance
o Due to loss of glycogen particles
- Cytoplasm becomes vacuolated and appears moth-eaten
o Due to digestion of cytoplasmic organelles
- Calcification of cells
o Due to calcified fatty acid residues and degraded
phospholipid precipitates
- Nuclear changes (due to nonspecific breakdown of DNA)
o Pyknosis
 Nuclear shrinkage and increased basophilia
 Chromatin condenses into a solid, shrunken
basophilic mass
Fig.25.  Also seen in apoptotic cell death
th
 From Rubin’s 7 ed:
 The nucleus becomes smaller and stains deeply

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 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

basophilic as chromatin clumping continues architecture is completely obliterated

o Karyorrhexis o Caseous – derived from cheesy white gross appearance of
 Pyknotic nucleus undergoes fragmentation the area of necrosis
th
 From Rubin’s 7 ed: o On microscopic exam, appears as amorphous granular
 The pyknotic nucleus breaks up into smaller debris enclosed within an inflammatory border
fragments scattered around the cytoplasm(Rubin’s (granulomatous reaction)
th
7 ed) o Ex. Tuberculous and fungal infections
th
o Karyolysis Rubin’s 7 ed:
 Fading of basophilia of the chromatin due to loss o Is characteristic of tuberculosis
of DNA because of enzymatic degradation by o The lesions of TB are granulomas or tubercles
endonucleases o In the center of such granulomas, the accumulated
 The pyknotic nucleus may be extruded from the mononuclear cells that mediate a chronic inflammatory
cell or it may progressively lose chromatin staining reaction to the offending mycobacteria are killed  lose
th
(Rubin’s 7 ed) their cellular outlines but do not disappear in lysis 
persist indefinitely as an amorphous, coarsely granular,
TYPES OF NECROSIS eosinophilic debris (which is grossly grayish white, soft and
1. COAGULATIVE NECROSIS friable, resembling a clumpy cheese, hence caseous)
o When denaturation is the primary pattern o Generally attributed to the toxic effects of mycobacterial
o Denaturation of both structural proteins and enzymes → cell walls, which contain complex waxes
no proteolysis → Preservation of the basic outline of the (peptidoglycolipids) that exert potent biological effects
coagulated cell (ghost cell) o Survival of mycobacteria is also linked to granuloma
o Characteristic of hypoxic death of cells in all tissues formation
except the brain
o Ex: myocardial infarct
th
Rubin’s 7 ed:
o Called coagulative necrosis because it resembles the
coagulation of proteins that occur upon heating (useful
morphologic descriptor)
o Refers to specific light microscopic appearances od dead
or dying cells
o Maintained cell outline, shortly after death
o Dead cells stain more deeply eosinophilic than usual
o Nuclear chromatin is initially clumped and then
redistributes along the nuclear membrane
o Nucleus manifests pyknosis, karyorrhexis and karyolysis ,
as described on the previous page
o Moreover, the following are also features of the dead cell:
dilated endoplasmic reticulum, disaggregated
ribosomes, swollen and calcified mitochondria, Fig.28.Caseous necrosis in a tuberculous lymph node. Hilar
aggregated cytoskeletal elements and plasma lymph node from a patient with active tuberculosis. Irregular pink
membrane blebs areas of caseous necrosis (arrow) are evident against a
o Overtime, the lytic activity of intracellular and extracellular background of lymphocytes.
enzymes causes the cell to disintegrate leading to
ACUTE INFLAMMATORY RESPONSE 3. LIQUEFACTIVE NECROSIS
o Dominant enzyme digestion
o Seen in focal bacterial or fungal infections (microbes →
accumulation of inflammatory cells)
o Occurs in hypoxic death of cells in the CNS
o Often in tissue with high fluid content
o End result: transformation of tissue into a liquid viscous
mass
 Pus – frequently creamy yellow bec of presence of
dead white cells; from acute inflammation
o Ex. Brain infarct, lung and liver abscesses
th
Rubin’s 7 ed:
o Appears when the rate at which necrotic cells dissolve
greatly exceeds the rate of repair
o Produced by rapid cell death and tissue dissolution caused
by hydrolases in polymorphonuclear cells (PMNs,
neutrophils) which localized as an acute inflammatory
response
o The result is often an abscess  a cavity formed by
liquefactive necrosis in a solid tissue  in time, will be
walled off by a fibrous capsule that contains its contents

Fig.27. A. Normal heart. All myocytes are nucleated, and striations are clear B.
Myocardial infarction. The heart from a patient following acute MI. The necrotic
cells are deeply eosinophilic and most have lost their nuclei (Rubin’s 7th ed)

2. CASEOUS NECROSIS
o Distinctive form of coagulative necrosis but tissue
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 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death
Fig. 29.
4. GANGRENOUS NECROSIS
o Usually applied to a limb (lower leg) that has lost its blood
supply and has undergone coagulation necrosis
o 2 types:
 Dry Gangrene – bacterial infection superimposed on
coagulative necrosis (eg diabetic foot)
 Wet Gangrene – bacteria linfection superimposed on
liquefactive necrosis (eg acute gangrenous
appendicitis)
5. FAT NECROSIS
o Focal areas of fat destruction occurring as a result of
release of pancreatic lipases
 Pancreatic enzymes escape acinar cells → enzymes
liquefy fat cell membranes and split TG esters in fat
cells → FA combine with calcium → grossly visible
chalky white areas (fat saponification)
o Histologic: shadowy outlines of necrotic fat cells, with
basophilic calcium deposits, surrounded by an
inflammatory reactions
o Ex. Acute pancreatitis
th
Rubin’s 7 ed:
o Specifically affects adipose tissue and most commonly
results from pancreatitis or trauma
o The presence of triglycerides in adipose tissue determines
this type of necrosis
o Grossly, appears as an irregular, chalky white area
embedded in otherwise normal adipose tissue
o In traumatic fat necrosis, triglycerides and lipases are
released from the injured adipocytes
o In the breast, fat necrosis may mimic tumor
o Involves the following steps:
i. Phospholipases and proteases attack plasma
membranes of adipocytes, releasing their
stored triglycerides
ii. Pancreatic lipase hydrolyzes the triglycerides,
which produces free fatty acids
2+
iii. Free fatty acids bind Ca and precipitate as
soaps. These appear as amorphous, basophilic
deposits at the edges of irregular islands of
necrotic adipocytes.
TRANSCRIBERS: Espinosa, Elvambuena, Manching, Miniano
Fig.30.
6. FIBRINOID NECROSIS
o Seen in immune reactions involving blood vessels
o Occurs when there is deposition of Ag-Ab complexes in
the walls of arteries
o “immune complexes” + fibrin = “fibrinoid”
o Ex. Vasculitis
th
Rubin’s 7 ed:
o Is an alteration of injured blood vessels, in which
insudation and accumulation of plasma proteins cause the
wall to stain intensely with eosin
o The term fibrinoid necrosis is a misnomer, in a sense that
the eosinophilia of the accumulated plasma proteins
obscures the underlying alterations in the blood vessel,
making it difficult, if not impossible, to determine whether
there truly is necrosis in the vascular wall
Fig.31.
th
IV. PROGRAMMED CELL DEATH (PCD) Rubin’s 7 ed
- refers to processes that are lethal to individual cells and are
regulated by pre-existing signaling pathways
- part of balance between life and death of cells and determines
that a cell dies when it is no longer useful or when its survival
may be harmful to the larger organism
th
- Classification of PCD (Rubin’s 7 ed):
o Apoptosis
o Autophagy-associated cell death
o Necroptosis
o Pyroptosis
o Anoikis
o NETosis
o Pyrosis
o Entosis
APOPTOSIS
- Programmed cell death
- Pathway of cell death that is induced by tightly regulated suicide
program that activates enzymes that degrades the DNA, nuclear
and cytoplasmic proteins of a cell destined to die
- Plasma membrane remains intact, dead cell is rapidly cleared →
does not elicit an inflammatory reaction
- Ex. Epidermis, endometrial shredding during menses,
Page 11 of 19
 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

embryogenesis
th
Rubin’s 7 ed:
CAUSES OF APOPTOSIS  Apoptotic cells are recognized by nuclear fragmentation
In PHYSIOLOGIC SITUATIONS: and pyknosis, generally against a background of viable
- During embryogenesis, including implantation, organogenesis, cells.
developmental involution and metamorphosis.  Moreover, apoptosis occurs in single cells or small groups of
o Some aortic arches do not persist cells, whereas necrosis characteristically involves larger
o Pronephros and mesonephros regress in favor of the geographic areas of cell death
metanephros  Ultrastructural features of an apoptotic cell:
o Structures required only by one sex disappear on the other o Nuclear condensation and fragmentation
sex o Segregation of cytoplasmic organelles into distinct
o Disappearance of interdigital tissues to yield discrete fingers regions
and toes o Blebs of the plasma membrane
o Conversion of solid primordial into hollow tubes o Membrane-bound cellular fragments, which often
o Production of the four-chambered heart lack nuclei
o Removal of lymphocyte clones
- Hormone-dependent involution in the adult
o Endometrial cell during menstrual cycle
o Ovarian follicular atresia in menopause
o Regression of the lactating breast after weaning
o Prostatic atrophy after castration
- Cell deletion in proliferating cell populations to maintain constant
number of cell
o Intestinal crypt epithelia Fig.32.
o Red blood cells
o In chronic myeloid leukemia, the mutation inhibits
apoptosis and so polymorphonuclear cells accumulate
- Elimination of self-reactive lymphocytes
th
- Gametogenesis (Rubin’s 7 ed) BIOCHEMICAL FEATURES OF APOPTOSIS
o Adult men produce about 1000 new spermatozoa per second, - Protein cleavage
of which most undergo apoptosis because of intrinsic o Involves activation of several members of a family of
defects or external damage cysteine proteases (caspases)
o 99% of neonatal ovarian oocytes are eventually deleted by  Induce apoptosis
apoptosis  Cleaves vital cellular protsins
- Death of cells that have served their useful purpose  Activate DNAses
o Neutrophils after acute inflammatory response - DNA breakdown
o By Ca2+ and Mg2+ dependent endonucleases
In PATHOLOGIC CONDITIONS: - Phagocytic recognition
- Cell death produced by a variety of injurious stimuli o Expression of phosphatidylserine in the outer layer of
o Radiation and cytotoxic anticancer drugs damage DNA the plasma membranes of apoptotic cells
o Accumulation of unfolded proteins leading to endoplasmic o Expression of thrombospondin on the surface of
reticulum stress apoptotic bodies
- Cell death in certain infections, particularly viral diseases (viral
hepatitis) MECHANISM OF APOPTOSIS
- Pathologic atrophy in parenchymal organs after duct obstruction - May be divided into two phases:
(pancreas, parotid gland, kidney) 1. Initiation phase
o Caspases become catalytically active
MORPHOLOGICAL CHANGES IN APOPTOSIS o Occurs by signals from two distinct but convergent
- Cell shrinkage pathways
o dense cytoplasm  Extrinsic or receptor-initiated pathway
o normal but tightly packed organelles  Intrinsic or mitochondrial pathway
- Chromatin condensation
o most characteristic feature 2. Execution phase
o peripheral aggregation of chromatin o Phase wherein enzymes act to cause cell death.
o fragmentation of nucleus
th
- Formation of cytoplasmic blebs and apoptotic bodies From Rubin’s 7 ed:
- Phagocytosis of apoptotic cells, usually by macrophages - Apoptosis comprises several signaling pathways. These
pathways are not rigid categories, but rather are paradigms of
TABLE 2.FEATURES OF NECROSIS AND APOPTOSIS varied signaling mechanisms that lead to apoptosis. The several
Feature Necrosis Apoptosis pathways include:
o Extrinsic apoptosis – certain plasma membrane receptors
Cell size Enlarged (swelling) Reduced (shrinkage) are activated by their ligand
Pyknosis → o Intrinsic pathway – is initiated by diverse intracellular
Fragmentation into nucleosome stresses and is characterized by a central role for
Nucleus karyorrhexis →
size fragments mitochondria
karyolysis
o Inflammatory or infectious processes – may lead to
Plasma Intact; altered structure, apoptosis. Intracellular and extracellular infectious agents
Disrupted
membrane especially orientation of lipids both elicit this type of apoptosis, by diverse routes
Enzymatic o Perforin/granzymes pathway – is triggered when cytotoxic
Cellular Intact; may be released in T cells attack their cellular targets, with transfer of
digestion; may leak
contents apoptotic bodies granzymes B from the killer cell to its intended victim
out of cell
o p53-activated apoptosis – occurs in response to cellular
Adjacent
Frequent No stress or DNA damage
inflammation o Endoplasmic reticulum – may elicit apoptosis in which
Invariably Often physiologic, means of calcium signaling plays a central role
pathologic eliminating unwanted cells; may
Physiologic or
(culmination of be pathologic after some forms EXTRINSIC (DEATH RECEPTOR-INITIATED) PATHWAY
pathologic role
irreversible cell of cell injury, especially DNA CELL SURFACE DEATH RECEPTORS
injury) damage o Initiates the extrinsic pathway
o Members of the tumor necrosis factor (TNF) family that

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 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

contain a cytoplasmic domain involved in protein-protein permeability transition pore), which is closed under normal
interactions (death domain) circumstances
o Best known: type 1TNF receptor (TNFR1) and Fas (CD95) - Attached to the inner membrane are several molecules that play
key roles as the apoptotic drama unfolds
- These molecules include Cyt c (a member of the electron
transport chain), Smac/Diablo (second mitochondria-derived
activator of caspases, which promotes caspase activation),
apoptosis-inducing factor (AIF) and others
- There is an electrochemical potential (Δψm) across the inner
membrane, with the interior of the mitochondrion charged
negatively and the exterior positively, thus:
2+
o If mitochondria accumulate Ca or generate excessive
ROS or if the Δψm or mitochondrial pH decrease, the
MPTP opens
+
o MPTP opening lets water, protons (H ) and salts into the
mitochondrial matrix
o The influx of H+, water and other solutes collapses Δψm
and the loss of membrane potential impairs mitochondrial
ATP production
o In parallel, the entry of large amounts of water causes
mitochondria to swell
o The outer mitochondrial membrane then becomes more
permeable, either due to its rupture or to the opening of
outer membrane pores
Fig.33. Graphical representation of the Extrinsic Pathway
o Consequent release of inner membrane constituents 9AIF,
Pathway:
Smac/Diablo, Cyt c, etc) into the cytosol has two important
FAS is cross-linked by its ligand
effects. First, there are metabolic consequences relating to
(membrane-bound Fas ligand or FasL)
these proteins exiting the mitochondria. Second, released
↓ mitochondrial constituents activate the next phase of
3 or more molecules of Fas join
apoptotic signaling.
↓
- The outer membrane components include both proapoptotic and
Cytoplasmic death domains form a binding site for an adapter protein
antiapoptotic proteins of the Bcl-2 family
that contains a death domain
- The members of the Bcl-2 family can be viewed as belonging to
(Fas-associated death domain or FADD)
one of three subfamilies, depending on the number of Bcl-2
↓
homology (BH) domains:
FADD attached todeath receptors
o The antiapoptotic (prosurvival) members have four BH
bind inactive caspase 8 and -10
domains (labeled BH1, BH2, etc) and are often referred to
↓
as multi-BH domain proteins. These include Bcl-2, Bcl-xL,
Multiple pro-caspase-8 molecules are brought into proximity and
Mcl-1 and others
cleaves one another
o Proapoptotic (antisurvival) members are divided into two
↓
groups:
Generation of active caspase 8
 One group contains three BH domains. The key
↓
members of this group are Bak and Bax. A third
Triggers a cascade of caspase activation (caspase-3, -6, and
member, Bok, Is less well understood. Bak is
-7); caspase-3 is the most commonly activated effector caspase. It
mainly a mitochondrial protein, while Bax is largely
stimulates enzymes that cause nuclear fragmentation (e.g. caspase-
cytoplasmic.
activated DNase (CAD), which degrades chromosomal DNA); it also
 A larger group of proapoptotic proteins, BH3-only
destabilizes the cytoskeleton as the cell begins to fragment into
th proteins, carry a single BH3 domain. These
apoptotic bodies (Rubin’s 7 ed)
th include Bim, Bid, Bik, Bad and others. Different
Rubin’s 7 ed:
BH3-only proteins can elicit apoptosis by
- TNFR activation by TNF-alpha may also stimulate the
inactivating prosurvival functions of Bcl-2 family
antiapoptotic protein NFkB, a transcription factor that directs
members or by directly stimulating death-inducing
production of proteins that inhibit apoptosis
properties of Bax and Bak.
- The extrinsic patway intersects the intrinsic (mitochondrial)
pathway via caspase-8, which cleaves a cytoplasmic protein,
Mechanisms that control the intrinsic pathway:
Bid. Truncated Bid (tBid) translocates to mitochondria, where it
o In a normal mitochondrion: Among other proteins, Cyt c and
can activate apoptosis through a separate signaling mechanism. Smac/Diablo are attached to the inner mitochondrial
membrane, facing the intermembranous space. Opposite
FLIP
these, and attached to the outer membrane, are complexes
- Protein that can inhibit the extrinsic pathway by binding pro- of Bax and/or Bak bound to antiapoptotic Bcl-2 family
caspase 8 without activation members. In this peaceful equilibrium, Bcl-2 inhibits
- Produced by some viruses and normal cells for protection from proapoptotic functions of Bax/Bak, and the mitochondrial
Fas-mediated apoptosis default setting is prosurvival.
o When the intrinsic pathway is triggered: many intracellular
INTRINSIC (MITOCHONDRIAL) PATHWAY agent provocateurs, often involving stress or injury, act via
- Result of increased mitochondrial permeability and release of BH3-only family members  increase in concentrations of
pro-apoptotic molecules into the cytoplasm, WITHOUT the role of some BH3-only proteins (e.g. by activating transcription) 
death receptors conformation from quiescent to active, modifying enzymes
- Anti-apoptotic proteins and so forth  now active BH3-only molecules may
o Bcl-2, Bcl-x interpose themselves into Bcl-2 complexes with Bak and Bax
o Normally reside in mitochondrial membranes and  cause these complexes to dissociate  liberation of Bax
cytoplasm and Bak  formation of channels in the outer membrane
- Pro-apoptotic proteins (MACs [mitochondrial apoptosis-induced channels]) 
o Bak, Bax, Bim release of toxic mitochondrial proteins into cytosol
th
Rubin’s 7 ed: EXECUTION PHASE OF APOPTOSIS
- the components of mitochondrial matrix, which is the interior of
these organelles, are constrained by the impermeability of the
inner mitochondrial membrane. - FINAL PHASE OF APOPTOSIS
- This barrier is traversed by the MPTP (mitochondrial

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 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death
Mitochondrial Pathway Death Receptor Pathway
 
Activation of Initiator Activation of Initiator
caspase-9 caspase-8 and 10
Cleavage of initiator into active form
 Protein Response
Activation of executioner caspases (Caspase-3 and 6)
 o
Cleaves inhibitor of cytoplasmic DNAse(it becomes
activated na)
 tumor
DNAse cleaves DNA into nucleosome-sized pieces.
Caspases also degrades structural component of nuclear
matrix
 E. Cytotoxic T Lymphocyte-Mediated Apoptosis
Fragmentation of Nuclei
REMOVAL OF DEAD CELLS
- Apoptotic cells and their fragments undergo changes in
membranes that actively promote phagocytosis so it is cleared
before they undergo secondary necrosis and release their cellular
contents. (can result in injurious inflammation).
- Translocation of phosphatidylserine to outer membrane leaflet
allowing for recognition and recruitment of phagocytes
- Also expresses soluble factors like thrombospondinadhesive
glycoproptein recognized by phagocytes
- Can become coated with natural antibodies and proteins of
complement system (c1q), recognized by phagocytes
- Process of phagocytosis of apoptotic cells is so efficient, dead
cells disappear within minutes.
th
Rubin’s 7 ed:
- Once apoptosis has propelled a cell to DNA fragmentation and
cytoskeletal dissolution  apoptotic body remains 
phagocytosed by tissue macrophages
- Phosphatidylserine, which translocated from inside of the cell
membrane to the outside, is recognized by macrophages and
activates ingestion of an apoptotic cell’s mortal remains without
release of intracellular constituents, avoiding an inflammatory
reaction
- Mononuclear phagocytes ingest the debris from apoptotic cells,
but recruitment of neutrophils or lymphocytes is rare
CLINICO-PATHOLOGIC CORRELATIONS
A. Growth Factor Deprivation  mitochondrial p.
o Hormone-sensitive cells deprived of the relevant hormone
o Lymphocytes not stimulated by antigens and cytokines,
and neurons deprived of nerve growth factor die by
apoptosis
o Is attributable to decreased synthesis of Bcl-2 and Bcl-x
and activation of Bim and other pro-apoptotic members of
the Bcl family.
B. DNA Damage
o Exposure of cells to radiation or chemotherapeutic agents
induces apoptosis (genotoxic stress)
o Involves tumor-suppressor gene p53accumulates and
arrests cell cycle (at the G1 phase) to allow time for
TRANSCRIBERS: Espinosa, Elvambuena, Manching, Miniano
repair.
o If damage is too great to be repaired p53 triggers
apoptosis
o When p53 is mutated or absent (certain
cancers)incapable of inducing apoptosis cells with
damaged DNA survivesneoplasms
o p53 stimulates transcription of pro-apoptotic proteins (Bcl
Family: Bax, Bak, and BH3-onl proteins)
C. Protein Misfolding
o Chaperones in ER are responsible for proper folding of
proteins
o misfolded proteins are ubiquinated targeted by
proteasomes
o accumulation of misfolded proteins triggers Unfolded
o UPR: (1) increases production of chaperones, (2)
enhances proteosomal degradation, (3) slow protein
transcription
Failure to copeactivation of caspases apoptosis (ER
stress)
D. Apoptosis Induced by TNF Receptor Family
o TNF: does not kill the tumor directly induces
thrombosis of tumor blood vessels ischemic death of
o while TNF induces apoptosis, it also promote cell
survival: activation of transcription factor NF-kB
o NF-kB (1) stimulates anti-apoptotic members of Bcl-2
family, (2) activates a number of inflammatory responses
o CTL recognize foreign antigens presented on surface of
infected host cellactivation of CTLs secretion of
perforinentry of CTL granule serine protease
granzymescleaves proteins at aspartate residues
activates caspases
o CTL also express FasL on surfaceand may kill target
cells by ligation of Fas receptors
th
Rubin’s 7 ed:
Other pathways of programmed cell death (PCD):
A. Apoptosis activated by p53
- normally, p53 is present in very small amounts, mostly in the
cytosol, where it is bound mainly to Mdm2, an E3 Ub ligase
- when a cell is injured, p53 undergoes diverse moleculae
modifications including: phosphorylation, monoubiquitination
at multiple sites and others, which relax p53 binding by
Mdm2, which both allows p53 to accumulate and targets it to
the mitochondria or nucleus, depending on the specific
molecular modification
- within the nucleus, p53 then activated transcription of many
proapoptotic proteins, such as Bad, Bax, NOXA and PUMA
 repression of prosurvival proteins
- protein-protein interactions between p53 and Bcl-2 family
members also enhance induction of apoptosis
- cytosolic p53 directly activates Bax  Bax relocates to
mitochondria  apoptosis
- mitochondrial-targeted p53 acts as a functional BH3-only
protein  disrupts complex between Bax and its inhibitor 
apoptosis
- p53 also regulates cell cycle, metabolism and other cell
functions.
B. Calcium release by ER elicits apoptosis
- prolonged release of calcium from the ER, due to cell stress,
is also a key to apoptosis
- the proximity of the ER to the mitochondria is key to this
process: calcium released by the ER may be taken up by
2+
mitochondria  increase in mitochondrial Ca  opening of
MPTP  release of Cyt c  apoptosis
2+
- sustained release of Ca from ER  release of caspase-12
(normally bound to ER membrane) activation of caspase-
12  activation of caspase-9  triggers executioner
caspase-3
C. Autophagy in PCD
- may promote excessive removal of cell organelles, and so
irrevocably interfere with vital cellular functons
- it may also destroy proteins that sustain cell survival
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 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death
D. Necroptosis
- PCD independent of caspases
- Commonly initiated by Fas ligand (FasL) or TNF-
alphabinding to its respective receptors  receptor-bound
complexes incorporating caspase-8, two IAP proteins (E3 Ub
ligases), along with several other proteins, and the receptor
activating proteins (RIP1, RIP3)
- This complex sits on the knife edge of several alternative
fates, but activation of RIP1 and RIP3 leads to cell death by
necroptosis
- RIP3 is the epeicenter of this process  increased cytosolic
2+
Ca  activation of calpain and other degradative enzymes
 attacks lysosome membranes  release of lysosomal
hydrolases into the cytosol
- Calpain also damages mitochondria, precipitating metabolic
dysfunction with impaired ATP generation and iron release,
with consequent increases in ROS and damage to proteins,
lipids and DNA
- AIF is also released by the mitochondria, which enters the
nucleus and activates DNA degradation
- A bioenergetic crisis with the morphological features of
necrosis ensues
- Cells then release molecules called damage-associated
molecular patterns (DAMPs) that provoke inflammation
- Physiologically, necroptosis participates in development,
particularly at bone growth plate, lower portion of the
intestinal crypts
- may be important in cancer cells, since apoptosis is blocked
in the latter
- it is a double-edged sword and may participate in pathologic
processes such as neurodegenerative diseases and
ischemia/reperfusion injury
E. Anoikis
- activated by loss of cell attachments
- means “homelessness” in greek
- a variety of apoptosis that occurs in epithelial cells and is
caused by loss of cell adhesion or inappropriate cell
adhesion
- correct binding of a cell to ECM helps to determine whether
that cell is in its appointed location
- efficiently deletes cells that have been displaced from their
proper residence
- prevents wandering cells or cell clusters from developing
colonies at distant or improper ECM sites, and so helps
protect against the developing metastases
- operates via intrinsic or extrinsic classical apoptotic
pathways, both of which are upregulated when a cell
becomes detached
- a cell that loses contact with its normal ECM, like one that is
pushed off the tip of an intestinal villus by proliferating cells
deeper in the crypts, is stimulated to undergo anoikis by loss
of integrin-mediated survival signalling
- if a detached cancer cell makes contact with inappropriate
ECM components, anoikis may be activated
F. Granzymes
- released by lymphocytes and kill cells via apoptosis
- NK cells and cytotoxic T cells release two major molecular
species: perforin and granzymes
- Perforin punches a hole in the plasma membrane of a target
cell, through which proteins from the lymphocyte enter
- Granzymes are a family of multifunctional serine proteases,
among which the best understood is granzyme B
- Activates cytosolic Bid, a BH3-only protein, by cleaving it to
tBid  tBid increases mitochondrial release of Cyt c and
other cell death effector proteins
- also converst several procaspases notably caspase-3) to
active caspases
- Granzyme A is also released by the two cells mentioned
- Both A and B activate DNA nicking enzyme, CAD (caspase-
activated Dnase), which degrades genomic DNA
G. Pyroptosis
- is a cell death program that relies on caspase-1 (IL-1beta
converting enzyme)
- infectious agents, particularly viruses, stimulate inflammatory
reactions by interacting with members of a group of cell
membrane receptors called pattern recognition receptors
- although caspase-1 is a cysteine protease involved in PCD,
TRANSCRIBERS: Espinosa, Elvambuena, Manching, Miniano
it is independent of apoptotic signaling, and its activation
does not bring about apoptosis
- instead, caspase -1 is a proinflammatory protease that is
produced by a structure called an inflammasome 
activation of caspase-1  cleaves select cellular molecules,
including enzymes that are important fro glycolysis, thereby
depleting cellular energy
- also produces ion-permeable plasma pores  influx of water
and solutes to provoke cell swelling and then death
- elicits inflammation, by activating proinflammatory cytokines
- implicated in the pathogenesis of metabolic syndrome and
the etiology of type 2 diabetes mellitus
H. NETosis
- Neutrophil extracellular traps (NETs) are structures produced
by polymorphonuclear granulocytes
- NETs function as chromatin traps for bacteria and other
pathogens and contain antimicrobial cell products
- Can kill bacterial, fungal and protozoal pathogens
- Result from activation of a cell death program, mainly in
neutrophils, but also including eosinophils and mast cells
(NETosis)
- May be composed of either nuclear or mitochondrial
chromatin and do not necessarily need self-sacrifice of the
neutrophil that contributes the chromatin
- NETosis requires both autophagy and nicotinamide adenine
dinucleotide phosphate (NADPH) oxidase activity and is
characterized by destruction of the cell’s nuclear envelope
and the membranes of most cytoplasmic granules
- Chromatin aggregation results, and the cell extrudes a NET
containing both chromatin and strongly microbicidal histones
and hidtone cleavage products
- Cells with NETosis do not present “eat me” signals (cell
membrane phosphatidylserine) that are characteristic of
apoptosis
- Lacking these signals, NETotic cells are not preemptively
removed by macrophages and are able to stimulate
inflammatory responses
I. Entosis
- is a type of cellular cannibalism in which cells that are not
professional phagocytes engulf nearby living cells
- aggressor cells may engulf cells of either the same or other
lineages
- e.g. hepatocytes may ingest and destroy autoreactive T
lymphocytes  inhibits experimental autoimmune liver
disease
- often seen in tumors
- vacuoles containing cells undergoing entosis may fuse with
lysosomes in which case target cells usually die, although
death is not an inevitable outcome
- the cannibalized cell, or parts thereof, may survive the
process
- its nuclear material may become part of the aggessor cell,
leading to multinucleate cells, polyploidy or aneuploidy
- some engulfed cells actually escape their captors and re-
emerge unscathed
INTRACELLULAR ACCUMULATIONS
- One of the manifestations of metabolic derangements
- May accumulate transiently or permanently
- May be harmless to the cells, but on occasion they are severely
toxic
- May be located in either the cytoplasm (frequently within
phagolysosomes) or the nucleus
- In inherited storage diseases accumulation is progressive, and
the overload may cause cellular injury
- Three categories:
o Normal cellular constituent (EXCESS water, lipids,
proteins, and carbohydrates)
o Abnormal substance, either exogenous (mineral or
products of infectious agents) or endogenous (product
of abnormal synthesis or metabolism)
o Pigments
TYPES OF ABNORMALITIES THAT RESULT TO
INTRACELLULAR ACCUMULATIONS
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 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

A. Normal or increased production of normal endogenous substance - Causes:

+ inadequate rate of metabolism  normal endogenous o Toxins, protein malnutrition, diabetes mellitus, obesity,
substance accumulation anoxia, alcohol abuse
o Fatty change in the liver - Mechanisms:
o Reabsorption protein droplets in the tubules of the kidneys o Excessive entry or defective metabolism and export of lipid
o Alcohol alters mitochondrial and microsomal
B. Defects in protein folding and transport because of a mutated functionsincreased synthesis and reduced breakdown of
gene + inability to degrade the abnormal protein efficiently  lipids
abnormal endogenous substance accumulation o CCl4 and protein malnutrition reduced synthesis of
o Accumulation of mutated α1-antitrypsin in liver cells apoproteins
o Various mutated proteins in degenerative disorders of the o Hypoxia inhibits fatty acid oxidation
central nervous system o Starvationincreases fatty acid mobilization from
peripheral stores
C. Defects, usually inherited, in enzymes that are required for the
metabolism of the substance normal endogenous substance
accumulation
o Diseases caused by genetic defects in enzymes involved
in the metabolism of lipid and carbohydrates
o Abnormal exogenous substance is deposited and
accumulates

D. Absence of the enzymatic machinery to degrade the substance

and the ability to transport it to other sites  abnormal
exogenous substance accumulation
o Accumulations of carbon particles and nonmetabolizable
chemicals such as silica

Fig.35. Mechanism of steatosis in the liver

- Morphology
o Change appears as clear vacuoles within parenchymal
cells
o Identification requires the avoidance of fat solvents
o To identify the fat, it is necessary to prepare frozen tissue
sections of either fresh or aqueous formalin fixed
tissues
o May then be stained with Sudan IV or Oil Red-O, both of
which impart an orange-red color to the contained lipids
o The periodic acid-Schiff (PAS) reaction, coupled with
digestion by the enzyme diastase, is used to identify
glycogen, although it is not specific

LIVER
- Organ enlarges and becomes increasingly yellow until it begins
with the development of minute, membrane-bound inclusions
(liposomes) closely applied to the ER

HEART
- Prolonged moderate hypoxia intracellular deposits of fat, which
create grossly apparent bands of yellowed myocardium
alternating with bands of darker, red-brown, uninvolved
myocardium (tigered effect)
- More profound hypoxia or by some forms of myocarditis (e.g.,
diphtheria infection)  shows more uniformly affected myocytes.

CHOLESTEROL AND CHOLESTEROL ESTERS

- Manifested histologically by intracellular vacuoles in several

pathologic processes:

I. Atherosclerosis
o Foam cells - smooth muscle cells and macrophages
Fig.34. Effects of different compounds at high concentrations in the cell
within the intimal layer of the aorta and large arteries which
are filled with lipid vacuoles
o Aggregates of foam cells in the intima produce the yellow
TYPES OF INTRACELLULAR ACCUMULATIONS
cholesterol-laden atheromas which may rupture
1. LIPIDS
o Extracellular cholesterol esters may crystallize in the
- May be triglycerides, cholesterol/cholesterol esters, and
shape of long needles, producing distinctive clefts in tissue
phospholipids (components of the myelin figures found in necrotic
sections.
cells)
II. Xanthomas
- Abnormal complexes of lipids and carbohydrates accumulate in
the lysosomal storage diseases o Intracellular accumulation of cholesterol within
macrophages is also characteristic of acquired and
hereditary hyperlipidemic states
STEATOSIS (FATTY CHANGE)
o Clusters of foamy cells are found in the subepithelial
connective tissue of the skin and in tendons, producing
- Abnormal accumulations of triglycerides within parenchymal cells tumorous masses
- Often seen in the liver because it is the major organ involved in III. Cholesterolosis
fat metabolism o Focal accumulations of cholesterol-laden macrophages in
- Also occurs in heart, muscle, and kidneys the lamina propria of the gallbladder

TRANSCRIBERS: Espinosa, Elvambuena, Manching, Miniano Page 16 of 19

 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death
IV. Niemann-Pick disease, type C
o lysosomal storage disease
o Caused by mutations affecting an enzyme involved in
cholesterol trafficking, resulting in cholesterol accumulation
2. PROTEINS
- Appear as rounded, eosinophilic droplets, vacuoles, or
aggregates in the cytoplasm
- In amyloidosis, abnormal proteins deposit primarily in
extracellular spaces
CAUSES
a. In disorders with heavy protein leakage across the glomerular
filter there is increased reabsorption of the protein into
vesiclesprotein appears as pink hyaline droplets within the
cytoplasm of the tubular cell
b. Normal secreted proteins produced in excessive amounts (e.g.
plasma cells engaged in active synthesis of immunoglobulins)
c. ER becomes hugely distended, producing large, homogeneous
eosinophilic inclusions called Russell bodies.
d. Defective intracellular transport and secretion of critical proteins
o α1-antitrypsin deficiency
 Inheritable disorder in which mutations in the gene
coding for α1-antitrypsin yield an insoluble protein
that is not easily exported. It accumulates in liver
cells, thereby causing cell injury and eventually
th
cirrhosis (Rubins, 7 ed.)
e. Accumulation of cytoskeletal proteins
o Types of cytoskeletal proteins
҂ Microtubules (20Ŕ25 nm in diameter)
҂ Thin actin filaments (6Ŕ8 nm)
҂ Thick myosin filaments (15 nm)
҂ Intermediate filaments (10 nm)
o Provide a flexible intracellular scaffold that organizes the
cytoplasm and resists forces applied to the cells
o Five classes of intermediate filaments:
1. Keratin filaments (characteristic of epithelial cells)
2. Neurofilaments (neurons)
3. Desmin filaments (muscle cells)
4. Vimentin filaments (connective tissue cells)
5. Glial filaments (astrocytes)
o Accumulations of keratin filaments and neurofilaments
are associated with certain types of cell injury
o Alcoholic hyaline is an eosinophilic cytoplasmic inclusion
in liver cells that is characteristic of alcoholic liver
disease
o Neurofibrillary tangle found in the brain in Alzheimer
disease contains neurofilaments
f. Aggregation of abnormal proteins
o Can be intracellular, extracellular, or both, and the
aggregates may either directly or indirectly cause the
pathologic changes
o Amyloidosis
o Proteinopathies or protein-aggregation diseases.
HYALINE CHANGE
- An alteration within cells or in the extracellular space that gives a
homogeneous, glassy, pink appearance in sections stained with
hematoxylin and eosin
- E.g. Reabsorption droplets, Russel bodies, alcoholic hyaline
- In long-standing hypertension and diabetes mellitus, walls of
arterioles, especially in the kidney, become hyalinized, resulting
from extravasated plasma protein and deposition of basement
membrane material.
3. GLYCOGEN
- Readily available energy source stored in the cytoplasm of
healthy cells
- Abnormality in either glucose or glycogen metabolismexcessive
intracellular deposits of glycogen
- Glycogen masses appear as clear vacuoles within the cytoplasm
- Dissolves in aqueous fixatives
- For localization, tissues are best fixed in absolute alcohol
- Staining with Best carmine or the PAS reaction imparts a rose-
to-violet color to the glycogen
- Diastase digestion before staining serves as a further control by
hydrolyzing the glycogen
- Diabetes mellitus: glycogen is found in renal tubular epithelial
cells, within liver cells, β cells of the islets of Langerhans, and
TRANSCRIBERS: Espinosa, Elvambuena, Manching, Miniano
heart muscle cells
- Glycogen storage diseases, or glycogenoses: enzymatic
defects in the synthesis or breakdown of glycogen
4. PIGMENTS
- Colored substances which can either be a normal constituent of
cells or abnormal that accumulate in cells only under special
circumstances
- Can be exogenous or endogenous
EXOGENOUS PIGMENTS
- Most common is carbon (coal dust; a ubiquitous air pollutant of
urban life)inhaledpicked up by macrophages within the
alveolitransported through lymphatic channels to the regional
lymph nodes in the tracheobronchial regionanthracosis
(accumulations of this pigment blacken the tissues of the lungs
and lymph nodes)
- Coal worker's pneumoconiosis- aggregates of carbon dust
may induce a fibroblastic reaction or even emphysema in coal
miners
- Tattooing
o A form of localized, exogenous pigmentation of the skin
o Pigments inoculated are phagocytosed by dermal
macrophages where in which they reside for the remainder
of the life  the pigments do not usually evoke any
inflammatory response
ENDOGENOUS SUBSTANCE
I. Lipofuscin
o An insoluble pigment, also known as lipochrome or wear-
and-tear pigment
o Polymers of lipid and phospholipids in complex with
protein (derived through lipid peroxidation)
o Telltale sign of free radical injury
o Histology: yellow-brown, finely granular cytoplasmic, often
perinuclear pigment.
II. Melanin
o Endogenous, non-hemoglobin-derived, brown black
pigment
o Formed when the enzyme tyrosinase catalyzes the
oxidation of tyrosine to dihydroxyphenylalanine in
melanocytes
III. Homogentisic acid
o A black pigment that occurs in patients with alkaptonuria,
a rare metabolic disease
o Pigment is deposited in the skin, connective tissue, and
cartilage
o Pigmentation is known as ochronosis
IV. Hemosiderin
o hemoglobin-derived, golden yellow-to-brown, granular or
crystalline pigment
o one of the major storage forms of iron
o local or systemic excess of iron causes ferritin to form
hemosiderin granules
o Causes: increased absorption of dietary iron, hemolytic
anemias, repeated blood transfusions
o Hemochromatosis
 An inherited disease with extreme accumulation of
iron associated with liver, heart, and pancreatic
damage, resulting in liver fibrosis, heart failure, and
diabetes mellitus
V. Bilirubin
o Derived from hemoglobin, but contains no iron.
o Kernicterus
 A condition where unconjugated bilirubin is found in
the brain and may lead to death.
5. PATHOLOGIC CALCIFICATION
- Abnormal tissue deposition of calcium salts with smaller amounts
of iron, magnesium, and other mineral salts
DYSTROPHIC CALCIFICATION
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 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death
- Occurs despite normal serum levels of calcium and in the
absence of derangements in calcium metabolism
- Deposition occurs locally in dying tissues
- Encountered in areas of necrosis, whether they are of
coagulative, caseous, or liquefactive type, and in foci of
enzymatic necrosis of fat
- Present in the atheromas of advanced atherosclerosis
- Aging or damaged heart valves
- Morphology
o Basophilic, amorphous granular, sometimes clumped
appearance; fine, white granules or clumps, often felt as
gritty deposits
o Single necrotic cells may constitute seed crystals that
become encrusted by the mineral deposits
o Progressive acquisition of outer layers may create
lamellated configurations, called psammoma bodies
Some types of papillary cancers (e.g., thyroid) are apt
to develop psammoma bodies
o In asbestosis, calcium and iron salts gather about long
slender spicules of asbestos in the lung, creating exotic,
beaded dumbbell forms
- Pathogenesis:
o Calcium is concentrated in membrane-bound vesicles in
cells by a process that is initiated by membrane damage
and has several steps:
Calcium ion binds to the phospholipids present in the
vesicle membrane
 o By products of oxidative phosphorylation and have
Phosphatases associated with the membrane generate
phosphate groups, which bind to the calcium
 peroxidise, SOD, catalase
The cycle of calcium and phosphate binding is repeated,
raising the local concentrations and producing a deposit
near the membrane
 expression of genes
A structural change occurs in the arrangement of calcium
and phosphate groups, generating a microcrystal, which
can then propagate and lead to more calcium deposition
 and intracellular signaling pathways triggered by
Final common pathway is the formation of crystalline
calcium phosphate mineral in the form of an apatite
similar to the hydroxyapatite of bone
METASTATIC CALCIFICATION
- May occur in normal tissues and results from hypercalcemia
secondary to some disturbance in calcium metabolism.
- Causes of hypercalcemia
o Increased secretion of parathyroid hormone (PTH) with
subsequent bone resorption (hyperparathyroidism,
ectopic secretion of PTH-related protein by malignant
tumors)
o Destruction of bone tissue, secondary to primary tumors
of bone marrow or diffuse skeletal metastasis,
accelerated bone turnover or immobilization;
o Vitamin D–related disorders (vitamin D intoxication,
sarcoidosis (in which macrophages activate a vitamin D
precursor), and idiopathic hypercalcemia of infancy
(Williams syndrome)
o Renal failure, which causes retention of phosphate,
leading to secondary hyperparathyroidism
o Less common causes include aluminum
intoxicationoccurs in patients on chronic renal dialysis,
and milk-alkali syndromedue to excessive ingestion of
calcium and absorbable antacids such as milk or calcium
carbonate.
- Principally affects the interstitial tissues of the gastric mucosa,
kidneys, lungs, systemic arteries, and pulmonary veins
- All of these tissues excrete acid and therefore have an internal
alkaline compartment that predisposes them to metastatic
calcification.
- Massive involvement of the lungs produces remarkable x-ray
films and respiratory deficits.
- Massive deposits in the kidney (nephrocalcinosis) may in time
cause renal damage
- Morphology
o May occur as noncrystalline amorphous deposits or, at
other times, as hydroxyapatite crystals.
TRANSCRIBERS: Espinosa, Elvambuena, Manching, Miniano
CELLULAR AGING
- Is the result of a progressive decline in cellular function and
viability caused by genetic abnormalities and the accumulation of
cellular and molecular damage due to the effects of exposure to
exogenous influences
FACTORS
A. DECREASED CELLULAR REPLICATION
- Senescence
o Non dividing state after a fixed number of divisions
- Werner’s Syndrome
o Disease of premature aging; defective DNA; reduced
capacity to divide
- Telomeres
o When somatic cells replicate, a small section of the
telomere is not duplicated and telomeres become
progressively shortenedAs telomeres shorten the ends
of chromosomes cannot be protected and are seen as
broken DNA, which activates the DNA damage response
and signals cell cycle arrest
B. ACCUMULATION OF METABOLIC AND GENETIC DAMAGE
- Life span is determined by a balance between damage resulting
from metabolic events occurring within the cell and counteracting
molecular responses that can repair the damage
- Reactive oxygen species
deleterious effects on DNA and cellular membrane.
o Antioxidants to counteract ROS: Vit E, glutathione
- Calorie Restriction
o Effect mediated by a family of proteins called sirtuins:
 Has histone deacetylase activity which promotes
 It also increases insulin sensitivity and glucose
metabolism
 Growth factors, such as insulin-like growth factor,
these hormones also influence life span.
 Transcription factors activated by insulin receptor
signaling may induce genes that reduce
longevity, and insulin receptor mutations are
associated with increased life span.
Fig.36. Several factors and their mechanisms that effect to cellular ageing
END
Sample problems
1. A 52-year-old woman loses her right kidney following an automobile
accident. A CT scan of the abdomen 2 years later shows marked
enlargement of the left kidney. The renal enlargement is an example
of which of the following adaptations?
A. Atrophy
B. Dysplasia
C. Hyperplasia
D. Hypertrophy
E. Metaplasia
2. A 10-year-old girl presents with advanced features of progeria.
This child has inherited mutations in the gene that encodes which of
the following types of intracellular proteins?
A. Helicase
B. Lamin
C. Oxidase
D. Polymerase
E. Topoisomerase
3. A 47-year-old man with a history of heavy smoking complains of
Page 18 of 19
 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

chronic cough. A “coin lesion” is discovered in his right upper lobe atypia. Which of the following terms best describes this
on chest X-ray. Bronchoscopy and biopsy fail to identify a mass, morphologic response to persistent injury in the esophagus of this
but the bronchial mucosa displays squamous metaplasia. What is patient?
the most likely outcome of this morphologic adaptation if the
patient stops smoking? A. Atypical hyperplasia
A. Atrophy B. Complex hyperplasia
B. Malignant transformation C. Glandular metaplasia
C. Necrosis and scarring D. Simple hyperplasia
D. Persistence throughout life E. Squamous metaplasia
E. Reversion to normal

4. You are asked to present a grand rounds seminar on the role of

abnormal proteins in disease. In this connection, intracellular
accumulation of an abnormally folded protein plays a role in the
pathogenesis of which of the following diseases?
A. AA amyloidosis
B. AL amyloidosis
C. α1-antitrypsin deficiency
D. Gaucher disease
E. Tay-Sachs disease

5. A 68-year-old man with a history of gastroesophageal reflux

disease suffers a massive stroke and expires. The esophagus at
autopsy is shown in the image. Histologic examination of the
abnormal tissue shows intestine-like epithelium composed of
goblet cells and surface cells similar to those of incompletely
intestinalized gastric mucosa. There is no evidence of nuclear

TRANSCRIBERS: Espinosa, Elvambuena, Manching, Miniano Page 19 of 19