PRESENTOR:DR.T.NEELIMA 1st year postgraduate in the department of PATHOLOGY.

INTRODUCTION: Within the spectrum of systemic reaction to inflammation 2 physiological responses in particular are regarded as being associated with acute inflammation.
y The first involves the alteration of the temperature setpoint in the hypothalamus and the generation of the febrile response. y The second involves alterations in metabolism and gene regulation in the liver.

y Three cytokines that are released from the site of

tissue injury -- IL-1, TNF- and IL-6 are considered to regulate the febrile response, possibly as a protective mechanism. These cytokines mediate fever through the induction of PGE. y At the same time, IL-1 and IL-6 can act on the adrenal pituitary axis to generate adrenocorticotropic hormone (ACTH) and, subsequently, induce the production of cortisol. This provides a negative feedback loop, since corticosteroids inhibit cytokine gene-expression.

ACUTE PHASE REACTANTS

y Definition:

Proteins whose concentration either increase or decrease by atleast 25% following an infection or tissue trauma leading to a characteristic change in the levels and composition of plasma proteins

VARIOUS ACUTE PHASE REACTANTS 1. Alpha-1 antitrypsin. 2. Alpha-1 acid glycoprotein. 3.Cysteine protease inhibitor. 4.Haptoglobin. 5.Fibrinogen. 6.C-Reactive protein. 7.Complement factor 3. 8.Mannose binding protein.

VARIOUS ACUTE PHASE REACTANTS contd .. 9.LPS binding protein. 10.Ceruloplasmin. 11.Hemopexin. 12.Serum amyloid A. 13.Serum amyloid P.

y Although most APRs are synthesized by hepatocytes,

some are produced by other cell types, including monocytes, endothelial cells, fibroblasts and adipocytes. y There are 2 types of APRs- POSITIVE and NEGATIVE. y Positive APRs increase in plasma concentration during acute phase response.
y Negative APRs are decreased in plasma concentration

during the acute phase response to allow an increase in the capacity of the liver to synthesize the induced APRs

ACUTE PHASE RESPONSE

The varied concentrations of the acute phase proteins combined with fever and leucocytosis is called the acute phase response. Liver synthesizes acute phase proteins in response to circulatory cytokines produced during inflammation.(IL-6 and some extent IL-1)

FUNCTIONS OF ACUTE PHASE REACTANTS

 APRs have a wide range of activities that contribute

to host defense.They can directly neutralize inflammatory agents, help to minimize the extent of local tissue damage, as well as participate in tissue repair and regeneration.  There is a rapid increase in the plasma concentration of many complement cascade components ,the activation of which ultimately results in the local accumulation of neutrophils, macrophages and plasma proteins.

y . These participate in the killing of infectious agents,

the clearance of foreign and host cellular debris, and the repair of damaged tissue. y Coagulation components, such as fibrinogen, play an essential role in promoting wound healing.

ALPHA-1 ANTITRYPSIN
y Major component of

globulins which has the capacity to combine with and inactivate trypsin. y It is able to neutralise the activity of proteases and hence is an intrinsic factor in the homeostatic mechanism modulating endogenous proteolysis within body preventing inappropriately severe biochemical response to inflammation.

APPLIED PATHOLOGY
y 1.Alpha-1 antitrypsin defiency leads to-

a.EMPHYSEMA b.CIRRHOSIS. 2.Cigarette smoking is the major source of irritant that triggers leucocytes in lung to release proteases and AT acts an antiproteinase inhibiting damage to the lung.

ALPHA-1 ACID GLYCOPROTEIN(OROSOMUCOID)

y It is a binder of progesterone and hence helps in its

transport and metabolism. y It binds to certain drugs and keeps them in inactivated state. APPLIED PATHOLOGY: Measurement of this protein have clinical utility in interpreting levels of drugs (like LIDOCAINE)that may achieve high concentration without expected therapeutic effect owing to be complexed in inactive forms .

CYSTEINE PROTEASE INHIBITOR

y It is also an antiproteinase capable of inhibiting

complement components ,coagulation and fibrinolytic factors. APPLIED PATHOLOGY: Depressed levels are associated with1. SEVERE LIVER DISEASE 2. PROTEIN LOSING DISORDERS 3. DIC

HAPTOGLOBIN
y It combines with Hb released by lysis of RBC inorder

to preserve body iron and protein stores. APPLIED PATHOLOGY: Increased levels of haptoglobin seen inSTRESS INFECTION ACUTE INFLAMMATION TISSUE NECROSIS LIVER DISEASE

APPLIED PATHOLOGY contd

y Decreased levels of haptoglobin are seen iny

1.HEMOLYSIS and also in cases of slow and steady breakdown of RBC as in MECHANICAL HEART VALVES,HEMOGLOBINOPATHIES,EXERCISE ASSOCIATED TRAUMA. 2.THERMAL BURNS 3.AUTOIMMUNE HEMOLYTIC ANAEMIA. 4.LIVER DISEASE.

FIBRINOGEN
y It is a coagulant factor. y Its levels are elevated in pregnacy and oral

contraceptive use. APPLIED PATHOLOGY:  Fibrinogen, plays an essential role in promoting wound healing.

y COMPLEMENT FACTOR 3:

It acts as an opsonin and aids in microbial resistance. APPLIED PATHOLOGY: Depression of C occurs in AI disorders where complement system is activated and C becomes bound to immune complexes deposited in tissues thereby removing them from plasma.

Hence C is a convenient marker for rheumatic disorders like-LUPUS ERYTHEMATOSIS RHEUMATOID ARTHRITIS and also inRECURRENT PYOGENIC INFECTIONS GLOMERULONEPHRITIS.

y CERULOPLASMIN:

It inactivates reactive oxygen metabolites. It increases in pregnancy and OC pill use. APPLIED PATHOLOGY: WILSON S DISEASE:It results from disordered copper metabolism due to ceruloplasmin deficiency leading to toxic deposition of copper in tissues.

HEMOPEXIN
y Hemopexin binds with heme released by degradation

of hemoglobin. APPLIED PATHOLOGY: Decreased levels of hemopexin are seen in LIVER FAILURE INTRAVASCULAR HEMOLYSIS.

C-REACTIVE PROTEIN
It reduces the ability of neutrophils to attach to vascular endothelium , favouring their demargination and thus contributing to leucocytosis , while preventing neutrophilendothelial adhesion in uninflammed organs.

Raised levels of C-reactive protein activates complement and also macrophages to release more cytokines.

APPLIED PATHOLOGY
 CRP has significant proinflammatory effects in

endothelial cells including high levels of expression of intercellular and vascular cell adhesion molecules and increases binding of LDL resulting in foam cell formation leading to ATHEROSCLEROSIS.

CRP levels are also elevated in y UNSTABLE ANGINA y POST MENOPAUSAL HORMONE THERAPY y RHEUMATOID ARTHRITIS y ALLERGIC RHINITIS y ASTHMA

MANNOSE BINDING PROTEIN

Mannose binding protein is synthesized through mannose binding lectin pathway.This pathway is triggered when lectin binds mannose groups in bacteria leading to the synthesis of mannose binding proteins. These proteins have 3 functions. 1.Opsonisation. 2.Chemotaxis. 3.Lysis of the cell.

SERUM AMYLOID A
It is synthesized in the liver . The levels of serum amyloid A increase in chronic inflammatory and traumatic conditions . It is found in SECONDARY AMYLOIDOSIS. ( largest group of diseases associated with amyloidosis )

APPLIED PATHOLOGY:  SAA may remodel HDL3 and act as a signal to redirect it from hepatocytes to macrophages, which can then engulf cholesterol and lipid debris at sites of necrosis. Excess cholesterol could thus be redistributed for use in tissue repair or excreted.
 Other putative protective roles for SAA are the

inhibition of thrombin-induced platelet activation, as well as inhibition of the oxidative burst in neutrophils, which would help prevent oxidative tissue destruction

SERUM AMYLOID P SAP is the circulating form of amyloid P component, which is a constituent of all types of amyloid deposits. APPLIED PATHOLOGY:  . Amyloid P component (AP), derived from SAP, is associated with secondary amyloid plaques and all other forms of amyloid deposits, including those present in Alzheimer's disease.  AP has also been shown to act as an elastase inhibitor, which suggest a role for SAP on amyloid deposit in protecting the fibrils from degradation by proteolytic enzymes.

FUNCTIONS OF ACUTE PHASE REACTANTS

PROTEIN
1.Alpha-1 antitrypsin 2.Alpha-1 acid glycoprotein 3.Cysteine protease inhibitor 4.Haptoglobin. 5.Fibrinogen. 6.C-Reactive protein and complement factor 3.

FUNCTION
1.Inactivates proteases. 2.Transports progesterone. 3.Antiproteinase. 4.Binds hemoglobin. 5.Coagulation factor. 6.Opsonic activity and directly participates in microbial resistance.

FUNCTIONS OF ACUTE PHASE REACTANTS

PROTEIN
7. Mannose binding protein. 8.LPS binding protein. 9.Ceruloplasmin. 10.Hemopexin. 11.Serum amyloid protein A 12.Serum amyloid protein P

FUNCTION
7.Opsonin. 8.Opsonin. 9.Inactivates reactive oxygen metabolites. 10.Heme binding protein. 11.Apolipoprotein. 12.Elastase inhibitor.

GROWTH FACTORS
Competent factors which render cells in G or G phase of the cell cycle competent to respond Eg: Epidermal growth factor. Platelet derived growth factor. Fibroblast growth factors. Transforming growth factors(TGF- and TGF- ) Nerve growth factor. Insulin-like growth factors(IGF-1 and IGF-2) etc.

MECHANISM OF ACTION OF GROWTH FACTORS

y Growth factors act by two mechanisms. They are:

1.Over production by cell into surroundings. 2.Interactions of GFs with high affinity receptors.

DIFFERENCE BETWEEN COMPETENCE FACTOR AND PROGRESSIVE FACTORS

Competent factors render the cell competent to respond while the progressive factors , stimulate DNA synthesis in cells already competent to respond

y Growth factors play a role in inducing normal cells to

produce an integrin.This receptor anchors the cell to collagen via fibronectin in the extracellular matrix. y Continued exposure to growth factors of normal epithelial cells in culture anchored to collagen gel induces DNA synthesis and triggers the commencement of the mitotic cycle.(G to S phase)

APPLIED PATHOLOGY: Cancer cells differ fundamentally from normal cells when exposed to growth factors in passing straight into mitotic division without an initial phase of co-ordinated integrin mediated attachment to the matrix.

EPIDERMAL GROWTH FACTOR

HISTORY: It was first extracted from submaxillary gland and human urine and was noted to have the ability to cause separation of eyelids of newborn mouse.  It is a progressive factor acts on a variety of epithelial tissues and fibroblasts leading to increased DNA synthesis in these cells

APPLIED PATHOLOGY
y EGF levels are elevated in serum of patients associated

with1.GASTRIC CARCINOMA. 2.CARCINOMA OF TONGUE. y EGF levels are also elevated in KELOID formations.

PLATELET DERIVED GROWTH FACTOR

 It is stored in -granules of platelets and released

when activated.  It is also produced by activated macrophages and other cells.  It acts as a competence factor hence an additional action of a progression factor such as EGF or IGF is needed for cell division.  It acts on fibroblasts ,smooth muscle cells and monocytes.  It also has a chemotactic activity.

APPLIED PATHOLOGY
y PDGF levels are elevated in CARCINOMAS

SARCOMAS LYMPHOMAS (but never in the normal individuals) y Eg : In patients with BREAST CARCINOMA, there is an excellent correlation between stage of the cancer and serum level of the growth factor.

FIBROBLAST GROWTH FACTOR

 It consists of two groups-basic FGF (b FGF)

acidic FGF(a FGF)  Basic FGF is formed in many tissues while acidic FGF is restricted to brain and neural tissue.  They bind to heparin and particularly heparan sulphate.

 They are not present in body fluids and their action is

local , being restricted to immediate area of secreting cell.

 It stimulates the formation of mesoderm from

ectoderm,an effect inhibited by heparin.

 In response to injury their important action is

stimulation of growth of fibroblasts and endothelial cells(angiogenesis)

APPLIED PATHOLOGY
y Elevated levels of FGF is seen in EPITHELIAL CELL

TUMORS.Among them it is more prominent in RENAL CELL CARCINOMA. y It is also elevated in CNS TUMORS and LYMPHOMAS. y Elevated FGF is a good prognostic indicator in patients with NON SMALL CELL CARCINOMA OF LUNG.

TRANSFORMING GROWTH FACTORS(TGF and TGF )

 TGF- was first identified as a secretion of virally

transformed fibroblasts that can make other fibroblasts exhibit transformation.(such as ability to grow in soft agar)  It closely resembles EGF and binds to EGF receptors.

TGF It is a family of proteins involving promotion or

inhibition of cell growth.  The main action is to inhibit the cell growth. eg:It has been implicated in the cessation of mitotic activity of liver cells following the regenaration caused by hepatectomy.

TGF- contd .
 It is chemotactic to fibroblasts and stimulates the

production of connective tissue matrix proteins such as collagen and fibronectins.  It has mesoderm inducing properties during embryogenesis. Both TGF s act synergistically with FGF and magnify its effects.

APPLIED PATHOLOGY
y TGF- is an excellent marker for presence of

malignancy.Hence it is useful in screening. y TGF- is not that tumour specific.It shows some specificity for BREAST CARCINOMA. y TGF- is an effective predictor of diagnosis of malignancy at an early stage.It also aids in the prognosis of HEPATOCELLULAR CARCINOMA.

APPLIED PATHOLOGY contd

y One third of the patients who developed

carcinoma(ADENO/SQUAMOUS CELL CARCINOMA) of LUNG were seropositive for TGF- . y TGF has high sensitivity and high specificity. y TGF- is elevated in1.HEPATOCELLULAR CARCINOMA 2.BLADDER CARCINOMA. y TGF- has a role in bone resorption and also in scerotic metastasis.

NERVE GROWTH FACTOR

 It is involved in the development and maintenance of

the sympathetic nervous system and neural crest derived neurons.  It is not involved in nerve cell division but involves branching and organisation of nerve cell dendritic processes both in CNS and PNS.  They have a neurotropic effect and selectively prevent cell death.

APPLIED PATHOLOGY:  It has been suggested that lack of NGF is responsible for the neuron loss that characterises some degenerative diseases. Eg : Alzheimer s disease. Amyotropic lateral sclerosis. Parkinsons disease.  NGF plays a role in the inflammation caused by RSV infection.

INSULIN LIKE GROWTH FACTORS

 They resemble proinsulin and circulate in blood

bound to protein .They are also called somatomedins.  They have limited mitogenic activity but appear necessary for cell survival.  They have their own specific receptors but there is some cross reactivity with insulin receptors.

APPLIED PATHOLOGY:  In adults ,the IGF-1 blood level is regulated by growth hormone and is hence high in ACROMEGALY.  RELAXIN , secreted by ovary ,is related to IGF family and is involved in the maturation of the female genital tract during pregnancy.  IGF-1 along with EGF and FGF cause NODULAR HYPERPLASIA OF THYROID.

VASCULAR ENDOTHELIAL GROWTH FACTOR

y It promotes blood vessel formation.

APPLIED PATHOLOGY: y VEGF promotes angiogenesis in CANCER,CHRONIC INFLAMMATORY STATES and WOUND HEALING. y It plays a role in RETINOPATHY OF PREMATURITY by promoting angiogenesis through the internal limiting membrane of retina into vitreous.(lack of O exposure)

VON HIPPEL LINDAU DISEASE

y VHL gene mutation leads to elevated levels of

VEGF,PDGF AND TGF .They inturn lead toANGIOGENESIS ENDOTHELIAL STABILIZATION AUTOCRINE GROWTH STIMULATION

ROLE OF VEGF,PDGF AND TGF IN VON HIPPEL LINDAU DISEASE

GM-CSF
y It stimulates the proliferation and differentiation of

progenitor cells. y It is a central regulator of innate immunity. APPLIED PATHOLOGY: GM-CSF deficiency leads to decreased degradation of surfactant due to dysfunctional alveolar macrophages leading to PULMONARY ALVEOLAR PROTEINOSIS.

GROWTH FACTOR RECEPTOR DEFECTS

y There are 3 known pathologic mechanisms that can

result in causing abnormally prolonged receptor dimerization that results in continuous mitogenic signalling. 1.Loss of extracellular binding domain leading to permanent dimerisation of GF receptor 2.Mutations in transmembrane domain that promote dimerization. 3.Over expression of receptor leading to increased concentration of dimers.

EPIDERMAL GROWTH FACTOR RECEPTOR

y Increase in the expression of this growth factor

receptor is seen in ASBESTOS ASSOCIATED MALIGNANCIES ( CARCINOMA OF LUNG /MESOTHELIOMA) The primary effect of asbestos as a carcinogen is to cause mutations in the EGFr gene. y Increased levels of EGFr is also useful in early tumour detection.It is highly sensitive marker for lung carcinomas.

Neu/HER-2 RECEPTOR
y The level of expression of this receptor in BREAST

CARCINOMA correlates with the extent of the tumour . y It is the best prognostic indicator of survival rates exceeding the extent of lymphnode involvement as a prognostic indicator. y It is also an excellent indicator in recurrent disease.

Erb-2 receptor
y Elevated levels of erb-2 receptor expression is seen in-

1.COLORECTAL CARCINOMA. 2.PANCREATIC CARCINOMA. 3.PROSTATIC CARCINOMA. 4.HEPATIC CARCINOMA. 5.OVARIAN CARCINOMA.

PLATELET DERIVED GROWTH FACTOR RECEPTOR

y Over expression of PDGFr along with EGFr is noted

in CNS neoplasms likeASTROCYTOMA. GLIOBLASTOMA.

Thus growth factors and their receptors have a wide spectrum in the pathogenesis of various disorders in the human body.

BOOKS OF REFERENCE
y WALTER AND ISRAEL-GENERAL PATHOLOGY. y JOHN BERNARD HENRY-CLINICAL DIAGNOSIS

AND MANAGEMENT. y ROBBINS PATHOLOGIC BASIS OF DISEASE. y GANONG S TEXTBOOK OF PHYSIOLOGY. y WEB PAGES OF INTERNET.

THANK YOU.