Pathology of the cell

Stephen J. Hess DDS

Terminology
Cellular Pathology Histopathology (tissue) Organ (systemic) Pathology Molecular Pathology (in the future)

Structure and function of the human cell

Nucleus Cytoplasm Cell Membrane

Nucleus

Nuclear envelope

Nucleolus

Nuclear pore

Nucleus
Consists of nucleic acids and nuclear proteins All human cells except RBCs and platelets need a nucleus Nucleic acids arranged in aggregates called chromatin during resting states and into chromosomes during mitosis Nucleolusspecialized organelle composed primarily of RNA

Genetic material is identical for all cells of an individual; however, it is expressed differently in various tissues of the body:

Differentiated cells (perform specialized functions) Undifferentiated cells (embryonic stem cells)

Differences
Differentiated cells
Specialized Abundant cytoplasm Low N:C ratio Many organelles Examples: liver and kidney cells

Undifferentiated cells
Embryonic Scant cytoplasm High N:C ratio Few organelles Examples: Many tumor cells

Cytoplasmic structures

Cytoplasm
Consists of amorphous matrix called hyaloplasm and fibrillar meshwork (framework) called cytoskeleton. Organelles in the cytoplasm:
Mitochondria Ribosomes Endoplasmic reticulum Golgi bodies Lysosomes Specialized organelles

Cytoplasmic Organelles
Mitochondria
Generate energy---rich in oxidative enzymes More mitochondria in cells with complex functions

Ribosomes
Free---synthesize proteins and enzymes for use within the cell RER ribosomessynthesize products for export

Cytoplasmic Organelles
Endoplasmic reticulum
Rough (RER)protein synthesis for export Smooth (SER)complex functions--catabolism of drugs, hormones, nutrients; synthesis of steroid hormones. Most prominent in liver and gonadal cells

Golgi bodies
Process proteins into secretory granules or lysosomes

Cytoplasmic Organelles
Lysosomes
Rich in lytic enzymes such as acid hydrolases Primary lysosomes originate from Golgi bodiescan give rise to secondary lysosomes called autophagosomes and heterophagosomes when they fuse with cytoplasmic vesicles. Maximally active at low ph

Exocytosis
extrusion of undigested material (residual bodies) from the cell

Cytoskeleton in the Hyaloplasm (ground substance of the cytoplasm)

3 types of filaments:
Microfilaments (composed of actin and myosin) Microtubules (tubulin)defects in this can cause ciliary motility problems Intermediate filaments
Used in immunohistochemistry to aid in tumor identification---5 classes:
Epithelial-keratins Mesenchymal-vimentin Muscle-desmin GlialGFAP (Glial fibrillary acid protein in astrocytes) Nerve-neurofilaments

Plasma membrane
Internal surface in continuity with endoplasmic reticulum External surface: Site of interaction with environment: serves as receptor, adhesion molecules, transducers of signals Requires energy expenditure; rupture or major damage to the membrane results in cell death

Cellular integration at single cell level and beyond

Autocrine stimulation: secretions from cell attach to cell membrane surface receptors and provide stimulation (self-stimulation) Paracrine stimulation: adjacent cells act on each other Endocrine stimulation: hormones transported by vascular system act on distant cells See figure 1.5 in text

Homeostasis= maintaining steady state with environment

Essential minerals= sodium, chloride, potassium, calcium, & iron

Cellular injury
Reversible Irreversible

Cellular Changes to injury

Acute injury typically involves changes in cell shape (cellular swelling or so-called hydropic swelling--influx of NA+ and water) Chronic injury causes adaptation in the cell--the most important are: atrophy hypertrophy hyperplasia dysplasia All these changes are potentially reversible on elimination of the cause---if not the cell may be permanently changed or transform into a neoplastic cell

Reversible cell injury

Typically a mild or brief injury First sign is usually cellular swelling (hydropic change or degeneration)---influx of Na+, Ca2, and water into cell due to altered permeability of cell membrane
Blebs form at the cells surface Loss of microvilli in endoplasmic reticulum Chromatin clumping

Reversible cell injury

Less energy is generated due to switch to anaerobic glycolysis; ph becomes more acidic due to lactic acid buildup; organelles tend to disintegrate and curl up forming myelin figures If oxygen is restored and nucleus is undamaged and source of injury removed, the cell will revert to its normal state

Reversible cell injury

Functional changes associated with reversible cell injury:
Reduced energy production Decreased protein synthesis Increased autophagy (sequestering of damaged proteins and potentially toxic products formed during cell injury)

Slide 1.6

Irreversible cell injury

1. Nuclear changes due to damage: Pyknosis (condensation of chromatin or shrinkage of nucleus) Karyorrhexis (fragmentation of nucleus into nuclear dust) Karyolysis (dissolution and lysis of chromatin and nuclear structure)
2. Loss of cell integrity 3. Rupture of cell membrane central factor

in pathogenesis of irreversible cell injury

Slide 1.7

Cytoplasmic enzymes released from dying/dead cells:

AST (aspartate aminotransferase) ALT (alanine aminotransferase) LDH (lactic dehydrogenase) CK (creatine kinase)

Causes of cellular injury (see table 1-2)

Hypoxia / anoxia Toxins
Direct toxicity (mercury, heavy metals) Indirect toxicity (carbon tetrachloride)

Microbes Inflammation and immune reactions Genetic and metabolic disorders Physical

Hypoxia / anoxia

CAUSES:
1. 2. 3. 4. O2 supply interrupted (suffocation) Inadequate pulmonary transfer of O2 (pneumonias) Inadequate transport of O2 in blood (anemia) Inability of cell to use O2 (cyanide poisoning)

Some cells can survive hypoxia much longer than others

Brain-minutes; heart 1-2 hours; kidney-several hours; fibroblasts-24 hours (connective tissue cells are the most resistant to anoxia)

Re-oxygenation
Can completely repair a short-lived reversible cell injury Oversupply of O2 can lead to the formation of free oxygen radicals (hydrogen peroxide H2O2, hydroxyl radical OH, and superoxide O2-which cause additional tissue damage which is termed reperfusion injury

Free radicals
Unstable, highly reactive atoms or molecules with an unpaired electron in their outer orbit Highly reactive, tend to self propagate Can cause cell damage by lipid peroxidation (affects cell membrane); inactivation of enzymes, and by causing mutations through blocking of DNA transcription Normally these are formed in small quantities and neutralized by anti-oxidants such as catalase (scavenger enzyme)

Free radicals may be initiated in cells by:

Absorption of radiant energy (UV, radiation) Enzymatic metabolism of exogenous chemical or drugs Small amounts of toxic intermediates such as superoxide generated during normal metabolic processes Transition metals (copper, iron) to donate or accept free electrons Nitric oxide (which can act as a free radical; also acts as a chemical mediator

From: Essentials of Rubins Pathology; E. Rubin

Toxic injury
Directly toxic to cell:
Heavy metals such as mercury that inactivate cellular enzymes

Indirectly toxic:
carbon tetrachlorideupon ingestion it is changed to CCl3 which acts as a free radical and damages cell membranes

Other causes of cell injury

Microbial
Bacterialtoxins Viral---kill from within cell or induce immune response

Mediators of inflammation/ immune reactions---see chapters 2 and 3 Genetic/ metabolic disturbances Physicaltemperature; radiation

Cellular adaptations to injury

Cellular adaptations to injury

Atrophy Hypertrophy and hyperplasia Metaplasia/dysplasia Intracellular accumulations Aging

Atrophy
Decrease in size of a cell, tissue, organ, or entire body and reduced metabolism Atrophic cells contain a brown pigment, lipofuschin (called the wear and tear pigment), which imparts a brown color to an organ Physiologic atrophy -occurs with age and essentially involves the entire body Pathologic atrophy due to inadequate nutrients and stimulation
Vascular insufficiency Muscle-wasting Spinal cord injury

Atrophy

Dr. Hess-age 24

Dr. Hess-age 63

Hypertrophy
Increase in the size of tissues or organs due to an enlargement of individuals cells
bodybuilding

Pure hypertrophy occurs only in the heart and striated musclescells contain more myofilaments which allow them to contract more efficiently
Example: Heart under strain of hypertension increases in size because individual cardiac muscle cells increase in size (i.e.,: left ventricular hypertrophy with HBP)

**Often occurs in conjunction with hyperplasia**

Hypertrophy

Hypertrophy of the left ventricle due to hypertension

Hyperplasia
Increase in the size of organs or tissues due to increase in the numbers of cells Occurs in response to:
Hormonal stimulation (pregnancy)---more endometrial cells (endomertrial hyperplasia) Chronic injury (denture induced papillary hyperplasia) Idiopathic factors ( examplepolyps)

Hyperplasia

Metaplasia
Change of one mature cell type into another mature cell typeusually caused by irritation Example: Bronchioles change from columnar respiratory type epithelium to stratified squamous epithelium in response to smoke irritation

Dysplasia

Premalignant condition Characterized by disorderly arrangement of cells and nuclear atypia Can be reversible or progress to neoplasia

Intracellular accumulations
May result from an overload of metabolites or exogenous material, phagocytosis, or from blocked excretion of the material

Intracellular Accumulations
Examples:
Anthracosis (coal particles) Hemosiderosis (blood derived brown pigment) Lipid (fat) accumulation
Obesity Steatosis (fatty deposits) secondary to alcohol abuse or diabetes

Cholesterol (most damaging of intracellular category) Lipofuschin (mixture of lipids and proteins with golden brown pigment called ceroid; also called the wear and tear pigment---seen with organ atrophy) Glycogen

Anthracosis

Coal miners lungno increased risk for malignancy; there is an increased risk for fibrosis

Anthracosis

Hemosiderin
Golden yellow to brown hemoglobin-derived pigment which accumulates in tissues where there is a local or systemic excess of iron. Example: bruise Systemic overload is called hemosiderosis-- Iron overload due to blood breakdown; usually young patients May be due to frequent transfusions or due to intraalveolar bleeding in the lungs Hereditary Hemochromatosis Genetic defect in iron uptake regulation; extensive buildup of iron leading to joint pain, liver fibrosis, heart failure, pancreatic problems (can result in diabetes) Treatment: phlebotomy

Hemosiderin

Lipid accumulations
Fat is normally stored in the liver in the form of triglycerides. Fatty change (steatosis) can be found in livers of obese patients as well as in alcoholics (more common)

Lipofuschin
Brownish pigment; represents complexes of lipid and protein derived from free radicalcatalyzed peroxidation of polyunsaturated lipids of subcellular membranes Also called the aging pigment---function of age or atrophy (marker of past free radical injury) Found in the heart, brain, liver, and smooth muscle

Cellular Aging

Aging
In 1900, the average life expectancy was 47 years---has increased by 30 years from 1900 to 2000 In 1985 scientists discovered the enzyme telomerase which rebuilds teleomeres to their former length
Internal clock appears to be related to telomeres at the end of chromosomes; chromosomal ends shorten with each division; only about 50 divisions possible Cancer cells appear to resurrect telomerase and enable runaway cell division

Theories of Aging
Wear and tear hypothesis
Organs with cells that do not regenerate decline in functionbrain and heart Some cells in tissues are replaced by multipotential stem cells

Genetic hypothesis
Aging is predetermined process

Probably a blend of theories

Cellular aging
Results from:
Accumulating cellular damage by free radicals or defective DNA repair Reduced capacity to divide (replicative senescence)
Progressive shortening of chromosomal ends (teleomeres)

Reduced ability to repair damaged DNA Other factors

Accumulation of metabolic damage Possible role of growth factors that promote aging

Cellular Death
All humans cells have a finite life span Cellular death occurs in several different forms: Necrosis (from external source) Apoptosis (programmed cell death internal source--requires energy-involves gene activation and enzyme action) Autolysis (cessation of oxygenation and blood flow in a dead organism lead to dissolution of the cells and tissues)
Post-mortem process

The histological signs of necrosis are the same as those of irreversible cell injury: cell membrane rupture and nuclear changes

Forms of necrosis
Coagulative Liquefactive Caseous Fat Fibrinoid

Necrosis
Coagulative Necrosis
Most common Tissue looks like solid mass of boiled meat Sudden cessation of cell function due to blockage/inactivation of most enzymes Outline and architecture of dead tissue is preserved (very little autolysis). city of the dead. Necrotic tissue appears paler than normal Examples: MI, infarcts of solid organs such as kidney

Coagulative necrosis

Coagulative necrosis

Loss of cross-striations and nuclei

Liquefactive necrosis
Characterized by the dissolution of tissues, transforming it into paste-like or watery debris Due to the action of hydrolytic enzymes released from dead cellsmost commonly in a brain infarct Can be due to lysosomal action from inflammatory cells such as seen in an abscess Examples: brain infarct, abscess, wet gangrene

Liquefactive necrosis

Liquefactive necrosis

Caseous necrosis
Soft, yellow-white, and cheesy Structure-less necrosis Typically seen with tuberculosis and deep fungal infections Granulomatous appearance with amorphous central section surrounded by epithelioid histiocytes, lymphocytes, and some giant cells.

Caseous necrosistuberculous lung

W.B. Saunders Company items and derived items Copyright (c) 1999 by W.B. Saunders Company Slide 1.17

Granuloma
Epithelioid macrophage T lymphocyte

Multinucleated giant cells form from coalescing macrophages

(Enzymatic) Fat necrosis

Form of liquefactive necrosis of fat tissue caused by lipolytic enzymes---involves fat around pancreas usually and develops in the course of acute pancreatitis. As triglycerides are digested, free fatty acids are released and precipitate as calcium salts Grossly fat tissue appears soft and gelatinous initially, but later has chalky gritty white patches composed of calcium soaps/salts ( a type of dystrophic calcification)---formation of these soaps is called saponification

Fibrinoid necrosis
Limited to small blood vessels, usually small arteries, arterioles, glomeruli affected by autoimmmune disease Walls of vessels and also kidney glomeruli are impregnated with fibrin and appear red microscopically

Fibrinoid necrosis

Fibrinoid necrosis

Outcomes of cellular necrosis

Repair by regeneration (liver/kidney) Repair by fibrous scarring (heart) Calcification (dystrophic) Resorption of necrotic tissue with formation of a pseudocyst (brain) Secondary complications
gangrene

Gangrene
Wet gangrene---superimposed bacterial infection of tissue which has undergone ischemic coagulative necrosis, leading to inflammation and secondary liquefaction necrosis Black, foul smelling, pus containing Dry gangrene---tissue dries out and becomes dark and mummified Gangrene can occur with diabetics typically when there is significant peripheral vascular disease usually on lower extremity or toes due to peripheral vascular disease Gas gangrene occurs with some Clostridium infections

Dry gangrene
Toe becomes mummified

Wet gangrene

Calcifications
Necrotic or inflamed tissue attracts calcium salt and frequently undergoes calcification Calcification of necrotic tissue is called dystrophic calcification (Note: this is in contrast to conditions of hypercalcemia (example: hyperparathyroidism) which gives rise to metastatic calcificationsdeposition of calcium in normal tissues)

APOPTOSIS
Active form of cell death-requires energy and requires activation of a certain set of genes (suicide genes) and enzymes Called programmed cell death Typically affects single cells Remnants of cell are taken up by macrophages or PMNs

Apoptosis Versus Necrosis

Apoptosis
Physiologic-single cell Cell shrinkage Intact organelles Requires energy-gene expression and protein synthesis Cell rounded up @fragmented Occurs in minutes NO inflammation Apoptotic bodies phagocytosed

Necrosis
Passivedoes not require energy or protein synthesis-exogenous injury Involves many contiguous cells Membrane ruptures Free radicals Cell swelling Membrane blebs Organelles breakdown Ghost cell residual Takes hours Intense inflammation

End of Chapter 1