Inflammation Outcomes:

Healing, Sepsis

Summary of acute inflammation

Stimulated by physical injury, infection, foreign body

Resident macrophages and/or damaged endothelium, mast cells
IL-1, TNF, endothelin, histamine
Vascular response: vasodilation, endothelial contraction,
exudation of plasma
Neutrophils: marginate (selectin-glycoprotein), adhere (integrinCAM), extravasate (CD31), migrate (IL-8, chemotactic stimuli)
Phagocytosis: recognition, engulfment, killing
Phagocytosis receptors bind mannose, oxidized lipids,
lipopolysaccharides, lipoteichoic acids, opsonins
Killing is O2-dependent (respiratory burst, NADPH oxidase generated
H2O2; myeloperoxidase generated HOCl; iNOS generated NO) or
independent (lysozyme, lactoferrin, defensins)

Responding leukocytes cause pain and loss-of-function via

prostaglandins, enzymes
Complete resolution; fibrosis, organization or scarring; abcess
formation; progression to chronic inflammation

Outcomes of Acute Inflammation

Resolution of tissue structure and function with elimination of

stimulus
Tissue destruction and persistent inflammation
Abscess
pus-filled cavity (neutrophils, monocytes and liquefied cellular debris)
walled off by fibrous tissue and inaccessible to circulation
tissue destruction caused by lysosomal and other degradative enzymes

Ulcer
loss of epithelial surface
acute inflammation in epithelial surfaces

Fistula
abnormal communication between organs or an organ and a surface

Scar
Causes distortion of structure and sometimes altered function

Chronic inflammation
Marked by replacement of neutrophils and monocytes with lymphocytes,
plasma cells and macrophages
Accompanied by proliferation of fibroblasts and new vessels with
scarring

Causes of chronic inflammation

Persistent infections
Organisms usually of low toxicity that invoke delayed
hypersensitivity reaction
M. tuberculosis and T. pallidum causes granulomatous reaction

Prolonged exposure to potentially toxic agents

Exogenous agents include silica which causes silicosis
Endogenous causes include atherosclerosis caused by toxic
plasma lipid components

Autoimmunity
Auto-antigens provoke self-perpetuating immune responses that
cause chronic inflammatory diseases like RA, MS
Responses against common environmental substances cause
chronic allergic diseases, such as bronchial asthma

Granulomatous inflammation
Focus of chronic inflammation encountered in a limited
number of conditions
Cellular attempt to contain a foreign body or an offending
agent that is difficult to eradicate (i.e. Tb)
Microscopic aggregation of macrophages that are
transformed into epithelioid cells, surrounded by a collar
of lymphocytes and occasionally plasma cells
Epithelioid cells have a pale pink granular cytoplasm with
indistinct cell boundaries, often merging as giant cells
Foreign body epitheloids have dispersed nuclei
Infectious body epitheloids have marginal or horse-shoe nuclei

Enlarged granuloma with central necrosis is an abcess

Enlarged granuloma on a surface is an ulcer

Patterns of Inflammation

Serous Inflammation
Marked by outpouring of thin fluid
From blood serum, e.g. burn blisters
Effusion from mesothelial cells lining the pleural, peritoneal and pericardial cavity

Fibrinous Inflammation
A feature of pericardial and peritoneal inflammation
Vascular permeability allows larger molecules like fibrin to pass or procoagulant
stimulus exists in the interstitium (e.g. cancer cells)

Suppurative Inflammation
Characterized by production of large amount of pus composed of neutrophils,
necrotic cells and edema fluid
Involves pyogenic bacteria e.g. Streptococci and Staphylococcus aureus
Abscesses are focal localized collections of purulent inflammatory tissue caused
by suppuration.

Ulcers
Local defect or excavation of the surface of an organ or tissue by sloughing of
inflammatory necrotic tissue
Acute stage - intense polymorphonuclear infiltration and vascular dilation in
margin
Chronic stage - margin and base develop fibroblastic proliferation, scarring and
accumulation of lymphocytes, plasma cells and macrophages

Systemic inflammatory response

Acute Phase Response

Fever
Acute-phase protein secretion from liver
Leukocytosis
Tachycardia, increased blood pressure
Shivering, chills
Anorexia, somnolence, malaise

Septic shock

Acute Phase Proteins

Secretion of Acute Phase proteins by the liver

C-reactive Protein (CRP)

Serum Amyloid A (SAA)
Serum Amyloid P (SAP)
Complement
Fibrinogen
Prothrombin
Ferritin
Ceruloplasmin
1-antitrypsin
2-macroglobulin

Acute phase proteins bind:

Microbial constituents, acting as opsonins to fix
complement
Chromatin, aiding early clearing of necrotic cells

Autonomic and Behavioral Responses

Autonomic
redirection of blood flow from cutaneous to
vascular bed
increased pulse and blood pressure
decreased sweating

Behavioral

Rigors (Shivering)
Chills
Anorexia
Somnolence
Malaise

Sepsis
Systemic Inflammatory Response Syndrome involves
two or more of the following
temperature >38.3C or <36C
heart rate >90 beats/min; <32 mm Hg
respiratory rate >20 breaths/min, PaCO2 or need for mechanical
ventilation
WBC count >12,000/uL or <4,000/uL or >10% immature forms
(bands)

Sepsis is defined as SIRS associated with suspected or

confirmed infection--positive blood cultures are not
necessary
Severe sepsis is sepsis complicated by a predefined
organ dysfunction
Septic shock is cardiovascular collapse (hypotension)
related to severe sepsis despite adequate fluid
resuscitation

Septic stimuli
Gram-negative bacteria

LPS, endotoxin
Binds to LPS binding protein (LBP)
Binds to CD14 opsonin receptor
TLR-4 binds LPS and LPS-LBP
Stimulates release of TNF, IL-1, IL-6

Gram-positive bacteria

Exotoxins, superantigens
Bind Vb regions of TCRs and/or to MHC-II
TLR-2 binds cell wall components
Stimulates release of IFN-g, TNF, IL-1, IL-6

Progression of sepsis
Cytokine release and amplification
Vasular response and neutrophil migration

Coagulation cascade
Short arm, extrinsic pathway, activated by expression of Tissue
Factor VIIa Xa thrombin fibrin
high plasma levels of plasminogen-activator inhibitor type-1
(PAI-1) suppress plasmin and fibrinolysis
disseminated intravascular coagulation in 30-50% cases

Counter-inflammatory response
Apoptosis of Th and B-cells

Systemic acute phase response

increased cortisol production and release of catecholamines
upregulation of adhesion molecules
release of prostanoids and platelet-activating factor (PAF)

Organ failure

Multiple organ failure

Neutrophils damage tissue directly by
releasing lysosomal enzymes and
superoxide-derived free radicals
TNF- induces nitric oxide synthase
nitric oxide causes further vascular instability
contributes to direct myocardial depression

Widespread vasodilation
Decreased production of vasopressin
(ADH) and glucocorticoids
Circulatory collapse and tissue hypoxia

Findings of shock at autopsy

Congestion of lung
may also have fibrinous casts lining alveolar
spaces

Petechial or ecchymotic hemorrhages on

serosal and endothelial surfaces
Necrosis
proximal tubular epithelium in kidneys
entrilobular hepatocytes

Restoration of Structure and Function

Occurs if connective tissue structure relatively intact
Surviving parenchymal cells must have the capacity to
regenerate
Labile Cells
Actively divide throughout life
cells of the epidermis and gastrointestinal mucosa
cells lining surface of the genitourinary tract
hematopoietic cells of the bone marrow

Stable Cells
Undergo few divisions normally, but can be activated from G0
cells when needed

hepatocytes
renal tubular cells
parenchymal cells of glands
mesenchymal cells (smooth muscle, cartilage, connective tissue,
endothelium, osteoblasts)

Regeneration
Proliferation of cells and tissues to replace
lost structures
Whole organs and complex tissues rarely
regenerate after injury
Compensatory growth rather than true
regeneration
Liver hypoplasia and kidney hypertrophy

Continuously renewing tissues regenerate

after injury if tissue stem cells are not
destroyed

Stem Cells
Characterized by self-renewal properties and
capacity to generate differentiated cell lineages
obligatory asymmetric replication
one daughter cell retains its self-renewing capacity
the other enters a differentiation pathway

stochastic differentiation
stem cell divisions generate either two self-renewing stem cells
or two cells that differentiate
Stimulation for either outcome is conjectureseemingly random

embryonic stem cells (ES cells) are pluripotent

adult (somatic) stem cells are restricted by niche
skin, gut lining, cornea, hematopoietic tissue

ES cells and KO/transgenic mice

KO mice have specific gene deletion or
inactivation

Transform cultured ES cells

Transformants injected into blastocysts
Blastocyst transplanted to surrogate dam
Mouse develops in utero

Transgenic mice have specific human

gene insertion or replacement
Transformed ES cells injected into blastocysts
Continued development in surrogate dam

Somatic cell cloning

Reproductive
Transfer of adult nucleus into enucleated
oocyte restores pluripotency
Transfer of resulting embryo to surrogate dam
Production of cloned individual

Therapeutic
Transfer of adult nucleus into enucleated
oocyte restores pluripotency
Induced to differentiate into various cell types
in vitro
Injected into damaged organ

Induced Pluripotent Stem Cells

Mouse ES cell pluripotency depends on
the expression of Oct3/4, Sox2, c-myc,
Klf4, Nanog
Human fibroblasts from adults and
newborns have been reprogrammed
Oct3/4, Sox2, c-myc and Kfl4
Oct3/4, Sox2, Nanog, and Lin28

Generated cells from endodermal,

mesodermal, and ectodermal origin
c-myc and Kfl4 are oncogenes

Stem Cells in Homeostasis and Healing

Bone marrow
Hematopoietic Stem Cells generate all of the blood cell lineages
Marrow Stromal Cells generate precursors of tissue to which migrated

Liver
Oval cells are bipotential progenitors of hepatocytes and biliary cells

Brain
Neural precursor cells generate neurons, astrocytes, and
oligodendrocytes in the subventricular zone and the dentate gyrus of the
hippocampus

Skin
Hair follicle bulge, interfollicular areas of the surface epidermis, and
sebaceous glands

Intestinal epithelium
crypts are monoclonal structures derived from single stem cells
villus contains cells from multiple crypts

Skeletal and cardiac muscle

satellite cells beneath the myocyte basal lamina generate differentiated
myocytes after injury

Cornea
limbal stem cells maintain corneal transparency

Proliferative capacity of tissues

Labile tissues
Continuously dividing tissues containing stem
cells

Stable tissues
Parenchymal cells of solid organs in G0
Endothelial cells, fibroblasts, smooth muscle
Limited regeneration after wounding

Permanent tissues
Absolutely nonproliferative
Cardiac muscle, neurons

Growth factors
Polypeptides that promote survival and
proliferation by signal transduction
Increase in cell size
true growth factors

Increase in cell number

mitogens

Protection from apoptosis

survival factors

Signaling mechanisms
Receptors with intrinsic tyrosine kinase activity
Dimeric transmembrane molecules
Ligand binding induces stable dimerization and
phosphorylation

7tm GPCRs
Seven transmembrane proteins
Ligand binding induces association with GTP-binding
protein, which swaps GDP for GTP
Gi or Gs protein inactivates or stimulates another
effector
Gs activates membrane adenylyl cyclase; GTPGDP
cAMP activates PKA, etc.

Receptors without intrinsic enzymatic activity

Monomeric transmembrane molecules
Ligand binding stimulates interaction with JAKs

Growth Factor-mediated Proliferation

Platelet Derived Growth Factor (PDGF)
promotes the chemotactic migration of fibroblasts and smooth muscles
chemotactic for monocytes
competence factor that promotes the proliferative response of fibroblasts and
smooth muscles upon concurrent stimulation with progression factors

Epidermal Growth Factor (EGF)

promotes growth for fibroblasts, endothelial and epithelial cells
is a progession factor - promotes cell-cycle progression.

Fibroblast Growth Factor (FGF)

promote synthesis of fibronectin and other extracellular matrix proteins

chemotactic for fibroblast and endothelial cells
promotes angiogenesis
links extracellular matrix components (collagen, proteoglycans) and
macromulocules (fibrin, heparin) to cell-surface integrins.

Transforming Growth Factors (TGFs)

TGF- - similar to EGF
TGF- - mitosis inhibitor that aids in modulating the repair process. May be
responsible for hypertrophy by preventing cell division. Chemotactic for
macropahges and fibroblasts

Macrophage-derived cytokines (IL-1 and TNF)

promote proliferation of fibroblasts, smooth muscle and endothelial cells

Repair Process
Removal of Debris
begins early and initiated by liquefaction and
removal of dead cells and other debris

Formation of Granulation Tissues

connective tissue consisting of capillaries and
fibroblasts that fills the tissue defect created by
removal of debris

Scarring
fibroblasts produce collagen until granulation
tissue becomes less vascular and less cellular
progessive contraction of the wound occurs,
resulting in deformity of original structure

Factors that Impede Repair

Retention of debris or foreign body

Impaired circulation
Persistent infection
Metabolic disorders

diabetes

Dietary deficiency

ascorbic acid
protein

Healing and granulation

Fibroplasia is a response to
Damaged connective tissue
Parenchymal damage exceeds regenerative capacity

Hyperplasia of connective tissue

Neovascularization
Granulation
coordinated proliferation of fibroblasts with a rich bed
of capillaries
intensely hyperemic with a roughened or granular,
glistening surface
healthy granulation tissue resists secondary infections

Healing by First Intention

Clean, surgical incision or other clean narrow cut
Focal disruption of epithelial basement
membrane with little cell damage
Regeneration dominates fibrosis
Scabbing with fibrin-clotted blood
Neutrophils migrate to edges
Epidermis becomes mitotic and deposits ECM
Macrophages replace neutrophils
Vascularization and collagen deposition fills gap
Contraction of collagen minimizes epidermal
regeneration

Healing by Second Intention

Larger area of tissue injury such as abcess,
ulcer, infarction that destroys ECM
Large clot or scab with fibrin and fibronectin fills
gap
Larger volume of necrotic debris must be
removed by more neutrophils and macrophages
Opportunity for collateral damage by phagocytes

Scar tissue formed from vascular cells,

fibroblasts, and myofibroblasts
Contraction of myofibroblasts distorts tissue
More prone to infection

Keloidexcessive cutaneous fibrosis

Granulation at tracheotomy