-by Dr Shruthi B S

References REFERENCES
1. Robbins & Cotron Pathological basis of diseases -7th edn. 2. Walter, Hamilton & Israels Principles of pathology for dental students 5th edn 3. Boyd text book of pathology 9th edn. 4. Text book of Pathology Rubin, John L.Farber 2nd edn. 5. Text book of oral pathology Shafer 4th edn. 6. Contemporary oral & maxillofacial surgery Peterson. 7. Textbook of medical pharmacology - tripathi 8. Google search

Introduction
Inflammation L.inflammatio; inflammare = to set on fire

Inflammation is a protective response intended to eliminate the initial cause of cell injury as well as the necrotic cells and tissues resulting from the original insult.

Definition
Acc to Robins Inflammation is a complex reaction to injurious agents such as microbes & damaged, usually necrotic, cells that consists of vascular responses, migration & activation of leukocytes, & systemic reactions.

 Acc to J. B. Walter & M. S. Israel Inflammation is the reaction of the vascular and supporting elements of the tissue to injury and results in the formation of a protein rich exudates, provided the injury has not been so severe as to destroy the area.

Cardinal signs

Historical highlights
Celsus (3000 BC) Roman writer listed 4 cardinal signs

Virchow 5th clinical sign, loss of function ( functiolaesa )

Historical highlights
John Hunter(1793) Salutary effect

Julius Cohnheim (18391884) -observed inflamed blood vessels under microscope

Historical highlights
Elie Metchnikoff (1880) Phagocytosis

Sir Thomas Lewis Chemical mediators

Inflammatory cells

Acute inflammation
Acute inflammation is a rapid response to an injurious agent that serves to deliver mediators of host defense leukocytes and plasma proteins to the site of injury.

 Acute inflammation has three major components: (1) alterations in vascular caliber that lead to an increase in blood flow (2) structural changes in the microvasculature that permit plasma proteins and leukocytes to leave the circulation (3) emigration of the leukocytes from the microcirculation, their accumulation in the focus of injury, and their activation to eliminate the offending agent

Stimuli for acute inflammation

Infections (bacterial, viral, parasitic) and microbial toxins Trauma (blunt and penetrating) Physical and chemical agents (thermal injury, e.g., burns or frostbite; irradiation; some environmental chemicals) Tissue necrosis (from any cause) Foreign bodies (splinters, dirt, sutures) Immune reactions (also called hypersensitivity reactions)

Stimuli for acute inflammation

Infection (bacterial, viral, parasitic) Trauma

Physical injury

Foreign bodies (splinters, dirt, sutures)

Immune reactions

Tissue Necrosis

ACUTE INFLAMMATION

VASCULAR CHANGES CELLULAR CHANGES

Vasoconstriction * Vasodilatation * Permeability * Stasis * Transmigration
*

Exudation of leukocytes * Phagocytosis

*

Vascular changes
Alteration in the microvasculature is the earliest response to tissue injury Two changes are 1. Changes in Vascular Flow and Caliber 2. Increased Vascular Permeability (Vascular Leakage)

Increased viscosity & stasis of blood

Changes in the vascular flow

Transient vasoconstriction vasodilation

Normal axial blood flow

Permeability of vasculature

viscosity Stasis of blood

Vascular leakage
Hallmark of acute inflammation

Loss of plasma protein IOP & HP Outflow of fluid

Edema
Starlings Hypothesis

Vascular leakage

Cellular changes
A critical function of inflammation is to deliver leukocytes to the site of injury and to activate the leukocytes to perform their normal functions in host defense. Two processes

Extravasation
The sequence of events in the journey of leukocytes from the vessel lumen to the interstitial tissue, called extravasation. Events are 1. Margination, rolling, and adhesion to Endothelium 2. Transmigration across the endothelium (diapedesis) 3. Migration in interstitial tissues toward a chemotactic stimulus

Margination, rolling, and adhesion

Blood flow slows Rows of early leukocytes in inflammation tumble slowly (stasis), along the hemodynamic endothelium and conditions change adhere (wall shear stress transiently (a decreases), and process called more white cells rolling), finally assume a coming to rest at The endothelium can be virtually lined peripheral some point where by white cells, an appearance calledposition along the they adhere pavementing. endothelial firmly surface. This (resembling

Adhesio n molecul es

Adhesion molecules

Selectins
The selectins are a family of three closely related proteins that differ in their cellular distribution Selectins bind, through their lectin domain, to sialylated forms of oligosaccharides (e.g., sialylated Lewis X), which E-selectin- bound to various themselves are covalentlyendothelium mucin like glycoproteins P-selectin- endothelium various mucin-like glycoproteinsbinding of selectins to their & fast on rate ligands has a platelets but also has a fast off rate and is of low affinity; this property allows selectins to mediate L-selectin- leukocyte initial attachment and subsequent rolling of leukocytes on endothelium in the face of flowing blood

Integrins
Integrins are transmembrane heterodimeric glycoproteins, made up of and chains, that are expressed on many cell types and bind to ligands on endothelial cells, other leukocytes, and the extracellular matrix . The integrins LFA-1 and Mac-1 (CD11a/CD18 and CD11b/CD18) bind to ICAM-1, and the integrins (such as VLA-4) bind VCAM-1.

Ig family molecules
The immunoglobulin family molecules include two endothelial adhesion molecules: ICAM-1 (intercellular adhesion molecule 1) VCAM-1 (vascular cell adhesion molecule 1) Both these molecules serve as ligands for integrins found on leukocytes

Mucin like glycoproteins

Mucin-like glycoproteins, such as heparan sulfate, serve as ligands for the leukocyte adhesion molecule called CD44. These glycoproteins are found in the extracellular matrix and on cell

Process of migration of the leukocytes through the endothelium, called transmigration or diapedesis. Chemokines stimulate the cells to migrate through interendothelial spaces toward the chemical concentration gradient, i.e, towards the site of injury or infection.

 The type of emigrating leukocyte varies with the age of the inflammatory response and with the type of stimulus. In most forms of acute inflammation, neutrophils predominate in the inflammatory infiltrate during the first 6 to 24 hours, then are replaced by monocytes in 24 to 48 hours.

Why neutrophils?
Neutrophils are more numerous in the blood They respond more rapidly to chemokines They may attach more firmly to the adhesion molecules that are rapidly induced on endothelial cells, such as P- and Eselectins In addition, after entering tissues, neutrophils are short-lived; they undergo apoptosis and disappear after 24 to 48 hours, whereas monocytes survive longer

Schematic & histologic sequence of events following acute injury

Early (neutrophilic) Infiltration

Later (mononuclear) cellular Infiltrates

Chemotaxis
It is the locomotion of leukocytes oriented along a chemical gradient towards the site of injury All granulocytes, monocytes and, to a lesser extent, lymphocytes respond to chemotactic stimuli with varying rates of speed. 1. Exogenous- bacterial products 2. Endogenous

Endogenous substances
(1)Components of the complement system, particularly C5a; (2)Products of the lipoxygenase pathway, mainly leukotriene B4 (LTB4); and (3)Cytokines, particularly those of the chemokine family (e.g., IL-8).

Mechanism

Chemotactic agents Leukocyte receptors Increase in cytosolic Ca Polymerization & reorganization of actin

Linear assembly of actin polymers along filopod Leukocyte moves by pulling back of the

The functional responses that are induced on leukocyte activation include the following:
Production of arachidonic acid metabolites Degranulation and secretion of lysosomal enzymes Secretion of cytokines Modulation of leukocyte adhesion molecules

Phagocytosis
It is defined as the process of engulfment of solid particulate material by the cells( cell eating) Phagocytosis and the release of enzymes by neutrophils and macrophages are responsible for eliminating the injurious agents

Phagocytes

Neutrophil

Monocyte

Macrophage

3 steps

Extensions of the 1.RECOGNITION AND ATTACHMENT cytoplasm (pseudopods) flow around the particle Elimination Mannose receptors to be engulfed,of infectious agents and necrotic and cells is their killing and degradation within forms phagosome. scavenger receptors are two neutrophils and macrophages The limiting important receptors membrane of this phagocytic vacuole microbes are opsonized by then fuses with the specific proteins (opsonins) limiting membrane of a lysosomal major opsonins are IgG granule, resulting in antibodies, the C3b discharge of the granule's contents breakdown product of into the complement, and certain phagolysosome Phagocytosis is plasma lectins

 Phagocytosis stimulates:
A burst in oxygen consumption, Glycogenolysis, Increased glucose oxidation via the hexosemonophosphate shunt, and Production of reactive oxygen intermediates (ROIs, also called reactive oxygen species).

Oxygen-Dependent Antimicrobial Activity

Oxygen-Independent Antimicrobial Activity

Increased production of lactate & action of carbonic anhydrase Lactoferrin Lysozyme Phagocytin, defensins, Major basic protein, Bactericidal permeability increasing protein

Nitric oxide mechanism

NO is released from endothelial cells & macrophages Fungicidal & antiparasitic action

Why is the host cell not affected by the ROI?

Defects in leukocyte function

Disease Genetic Leukocyte adhesion deficiency 1 Leukocyte adhesion deficiency 2

Defect chain of CD11/CD18 integrins Fucosyl transferase required for synthesis of sialylated oligosaccharide (receptor for selectin) Decreased oxidative burst NADPH oxidase (membrane component) NADPH oxidase (cytoplasmic components)

Chronic granulomatous disease X-linked Autosomal recessive

Myeloperoxidase deficiency Chdiak-Higashi syndrome

Absent MPO-H2O2 system Protein involved in organelle membrane docking and fusion Acquired

Termination
mediators of inflammation have short half-lives a variety of stop signals that serve to actively terminate the reaction These active mechanisms include A switch in the production of pro-inflammatory leukotrienes to anti-inflammatory lipoxins from arachidonic acid The liberation of an anti-inflammatory cytokine, transforming growth factor- (TGF-), from macrophages and other cells Neural impulses (cholinergic discharge) that inhibit the production of TNF in macrophages

Chemical mediators of inflammation

General principles
Mediators originate either from plasma or from cells production of active mediators is triggered by microbial products or by host proteins perform their biologic activity by initially binding to specific receptors on target cells One mediator can stimulate the release of other mediators by target cells themselves

 Mediators can act on one or few target cell types Once activated and released from the cell, most of these mediators are short-lived Most mediators have the potential to cause harmful effects.

Vasoactive Amines
1. Histamine Released from mast cells , basophils and platelets Stimuli (1)Physical injury such as trauma, cold, or heat; (2)Immune reactions involving binding of antibodies to mast cells; (3)Fragments of complement called anaphylatoxins (C3a and C5a); (4)Histamine-releasing proteins derived from leukocytes, and (5)Neuropeptides (e.g., substance P); and (6) cytokines (IL-1, IL-8).

Actions
In humans, histamine causes dilation of the arterioles and increases the permeability of venules. It is considered to be the principal mediator of the immediate transient phase of increased vascular permeability, causing venular gaps. Itching & pain mediator

Serotonin
Released by platelets and enterochromaffin cells Released when platelets aggregate after contact with collagen, thrombin, adenosine diphosphate (ADP), and antigen-antibody complexes Increases the vascular permeability

Plasma Proteases
Plasma proteins that belong to three interrelated systems: The complement, Kinin, and Clotting systems

Complement system
20 component proteins (and their cleavage products) found in greatest concentration in plasma This system functions in both innate and adaptive immunity for defense against microbial agents. C3 and C5 are the most important inflammatory mediators.

The Early Steps

The alternative pathway can be triggered by microbial surface molecules (e.g., endotoxin, or LPS), complex polysaccharides, and cobra venom. It involves a distinct set of plasma components (properdin, and factorsis triggered by fixation of The classical pathway B and D). In this pathway, theto antibody (IgM or IgG) of C3has combined Cl spontaneous cleavage that that occurs normally is enhanced and stabilizedanda complex with antigen, and proteolysis of C2 by C4, and of C3b and aformation of product of Factor B subsequent breakdown a C4b2b complex that called Bb; as aC3bBb complex is a C3 convertase functions the C3 convertase. In the lectin pathway, mannose-binding lectin, a plasma collectin, binds to carbohydratecontaining proteins on bacteria and viruses and directly activates Cl

The Early Steps of Complement Activation

the classical pathway, which is triggered by fixation of Cl to antibody (IgM or IgG) combined with antigen The classical pathway is triggered by fixation of Cl to antibody (IgM or IgG) that has combined with antigen, and proteolysis of C2 and C4, and subsequent formation of a C4b2b complex that functions as a C3 convertase. The alternative pathway can be triggered by microbial surface molecules (e.g., endotoxin, or LPS), complex polysaccharides, and cobra venom. It involves a distinct set of plasma components (properdin, and factors B and D). In this pathway, the spontaneous cleavage of C3 that occurs normally is enhanced and stabilized by a complex of C3b and a breakdown product of Factor B called Bb; the C3bBb complex is a C3 convertase The lectin pathway, in which plasma mannose-binding lectin binds to carbohydrates on microbes and directly activates Cl.In the lectin pathway, mannose-binding lectin, a plasma collectin, binds to carbohydrate-containing proteins on bacteria and viruses and directly activates Cl

The Late Steps of Complement Activation

The C3b that is generated by any of the pathways binds to the C3 convertase and produces a C5 convertase, which cleaves C5. C5b remains attached to the complex and forms a substrate for the subsequent binding of the C6C9 components. Polymerized C9 forms a channel in lipid membranes, called the membrane attack complex, which allows fluid and ions to enter and causes cell lysis.

The Late Steps

Polymerized C9 forms a channel in lipid membranes, called the membrane attack complex, which allows fluid and ions to enter and causes cell

C3b binds to the C3 convertase and produces a C5 convertase, which cleaves . C5b forms a substrate for the subsequent binding of the C6C9

Actions
Vascular phenomena Aphylatoxins (C3a, C5a)- increase vascular permeability & vasodilation C5a also activates the lipoxygenase pathway of arachidonic acid (AA) metabolism Leukocyte adhesion, chemotaxis, and activation C5a is a powerful chemotactic agent for neutrophils, monocytes, eosinophils, and basophils Phagocytosis. C3b-opsonin

Kinin system
The kinin system generates vasoactive peptides from plasma proteins, called kininogens, by the action of specific proteases called kallikreins Activation of the kinin system results in the release of the vasoactive nonapeptide bradykinin.

Plasma prekallikrein XIIa Factor Kallikrei n High-molecular-weight Bradykinin kininogen

Actions
Bradykinin increases vascular permeability causes contraction of smooth muscle, pain when injected into the skin dilation of blood vessels

Clotting system
The clotting system and inflammation are intimately connected processes. Factor XII initiates clotting cascade as it encounters collagen or basement membrane or activated platelets The protease thrombin formed from its precurses prothrombin provides the main link between the coagulation system and inflammation

 Thrombin binds to receptors that are called protease-activated receptors (PARs) It causes 1.mobilization of P-selectin 2.production of chemokines 3.expression of endothelial adhesion molecules for leukocyte integrins 4.induction of cyclooxygenase-2 5. production of Prostaglandins 6. production of PAF and nitric oxide 7.changes in endothelial shape

Fibrinolytic system
Plasminogen activator Plasminog en C3 C3a

Plasmin

Fibrin split products

Actions: 1.Stimulates the kinin system to generate bradykinin. 2.Splits off complement C3 to form C3a . 3.Fibrin products : Increases vascular permeability

Arachidonic Acid Metabolites

Arachidonic acid (AA) is derived from dietary sources or by conversion from the essential fatty acid linoleic acid It does not occur free in the cell but is normally esterified in membrane phospholipids It is released from membrane phospholipids through the action of cellular phospholipases

mechanical, chemical, and physical stimuli or by other mediators (e.g., C5a)

increase in cytoplasmic Ca2+ and activation of various kinases activation of phospholipase A2

Inflammatory actions of eicosanoids

Action Vasoconstriction Vasodilation Increased vascular permeability Chemotaxis, leukocyte adhesion Metabolite Thromboxane A2, leukotrienes C4, D4, E4 PGI2, PGE1, PGE2, PGD2 Leukotrienes C4, D4, E4 Leukotriene B4, HETE, lipoxins

Platelet activating factor

PAF is another bioactive phospholipid-derived mediator. A variety of cell types, including platelets, basophils (and mast cells), neutrophils, monocytes/macrophages, and endothelial cells, can elaborate PAF. PAF mediates its effects via a single G-proteincoupled receptor, and its effects are regulated by a family of inactivating PAF acetylhydrolases

 In addition to platelet stimulation, PAF causes Vasoconstriction and bronchoconstriction, and induces vasodilation and increased venular permeability at extremely low concentrations increased leukocyte adhesion to endothelium (by enhancing integrin-mediated leukocyte binding), chemotaxis, degranulation, and the oxidative burst

- boosts the synthesis of other mediators, particularly eicosanoids, by leukocytes and other cells.

Cytokines
Cytokines are proteins produced by many cell types (principally activated lymphocytes and macrophages, but also endothelium, epithelium, and connective tissue cells) that modulate the functions of other cell types TNF and IL-I are two of the major cytokines that mediate inflammation. They are produced mainly by activated macrophages

CHEMOKINES
Chemokines are a family of small (8 to 10 kD) proteins that act primarily as chemoattractants for specific types of leukocytes. About 40 different chemokines and 20 different receptors for chemokines have been identified. Chemokines stimulate leukocyte recruitment in inflammation and control the normal migration of cells through various tissues.

four major groups

 Some chemokines are produced transiently in response to inflammatory stimuli and promote the recruitment of leukocytes to the sites of inflammation.

Other chemokines are produced constitutively in tissues and function in organogenesis to organize different cell types in different anatomic regions of the tissues.

Nitric Oxide
NO, a pleiotropic mediator of inflammation, was discovered as a factor released from endothelial cells that caused vasodilation by relaxing vascular smooth muscle and was therefore called endothelium-derived relaxing factor. NO is a soluble gas that is produced not only by endothelial cells, but also by macrophages and some neurons in the brain. NO acts in a paracrine manner on target cells through induction of cyclic guanosine monophosphate (GMP), which, in turn, initiates a series of intracellular events leading to a response, such as the relaxation of vascular smooth muscle cells.

 Since the half-life of NO is only seconds, the gas acts only on cells in close proximity to where it is produced. In addition, NO reduces platelet aggregation and adhesion, inhibits several features of mast cell-induced inflammation, and serves as an endogenous regulator of leukocyte recruitment. Thus, production of NO is an endogenous compensatory mechanism that reduces inflammatory responses.

 NO and its derivatives are microbicidal, and thus NO is also a mediator of host defense against infection High levels of NO production by a variety of cells appear to limit the replication of bacteria, helminths, protozoa, and viruses (as well as tumor cells).

Oxygen-derived Free Radicals Oxygen-derived free radicals may be released extracellularly

from leukocytes after exposure to microbes, chemokines, and immune complexes, or following a phagocytic challenge. Superoxide anion, hydrogen peroxide (H2O2), and hydroxyl radical (OH) are the major species produced within the cell, and these metabolites can combine with NO to form other reactive nitrogen intermediates. Extracellular release of low levels of these potent mediators can increase the expression of chemokines (e.g., IL-8), cytokines, and endothelial leukocyte adhesion molecules, amplifying the cascade that elicits the inflammatory response.

 The physiologic function of these reactive oxygen intermediates is to destroy phagocytosed microbes. At higher levels, release of these potent mediators can be damaging to the host. Serum, tissue fluids, and host cells possess antioxidant mechanisms that protect against these potentially harmful oxygen-derived radicals. Thus, the influence of oxygen-derived free radicals in any given inflammatory reaction depends on the balance between the production and the inactivation of these metabolites by cells and tissues

Lysosomal Constituents

Neuropeptides

Morphologic forms

Outcome of acute inflammation

Resolution of acute inflammation