Inflammation III

-Morphologic patterns

Kusum Kapila
September 2006
 CLASSIFICATION OF
INFLAMMATION
Extent Exudate
Mild Suppurative
Moderate Fibrinous
Severe Serofibrinous
Duration Fibrino-purulent
Peracute Necrotizing
Acute Granulomatous,
Subacute Anatomic Modifiers
Chronic Interstitial
Chronic-active Broncho-interstital
Distribution Glomerulonephritis
Focal Submandibular
Multifocal Organ
Coalescent Nephritis
Locally Extensive Hepatitis
Diffuse Enteritis
Etc
 FOCAL

Definition: Single
abnormality or
inflamed area within
a tissue
Size: Varies from 1
mm to several
centimetres in
diameter
 MULTIFOCAL

Definition: Arising from

or pertaining to many
foci
(several foci separated
from one another)
Size: Variable.
Note: Each focus of
inflammation is
separated from other
inflamed foci by an
intervening zone of
relatively normal tissue.
 LOCALLY EXTENSIVE
Definition:
Involvement of
considerable area
within an organ.
Possible origin:
1. Severe local
reactions that
spread into adjacent
tissue
2. Coalescence of
foci in a multifocal
reaction
 DIFFUSE
Involves all the tissue
or organ in which the
inflammation is present
- Variations in severity
may exist eg: Interstitial
pneumonia.
Diffuse lesions are
often viral or toxic in
etiology.
Organ involved -
IMPORTANT
Morphologic Patterns in Acute and Chronic Inflammation

1- Serous Inflammation
Marked by a thin fluid that derived from blood serum or
mesothelial cells
2- Fibrinous Inflammation
A fibrinous exudate develops with large vascular leak
Characteristic of inflammation in body cavities
(pericardium and pleura)
3- Suppurative or Purulent Inflammation
Characterized by large amounts of purulent exudate (pus)
Pus consists of neutrophils, necrotic cells, and edema
4- Ulcers
A local defect or excavation of the surface of epithelial
covering
Sites: Skin, gastro-intestinal tract, urinary bladder, etc.
 Morphologic Patterns – Serous
Inflammation
Definition: Inflammatory
process characterized by
accumulation of fluid
relatively rich in protein on
body surfaces with little
cellular infiltrate.
Time: Usually acute
Causes: May be a dominant
pattern of exudation for a
wide variety of mild injuries.
Example: Traumatic blisters,
sunburn, within body cavities.
Gross : Yellow, straw-like
colour fluid, commonly seen
in very early stages of many
kinds of inflam responses.
 Morphologic Patterns –
fibrinous Inflammation
2-Fibrinous Inflam
A fibrinous exudate
develops with large
vascular leak
Characteristic of
inflammation in body
cavities
Sites:
a- pericardium
b- pleura
Example: Fibrinous
pericarditis secondary
to rheumatic fever
(rheumatic pericarditis)
EXUDATE: The inflammatory process can be
classified according to the predominant type of
inflammatory cells, plasma protein content, and
amount of fluid present.
A transudate has a specific gravity of less
than 1.012, a low protein content, and few if
any cells.
An exudate has a specific gravity of greater
than 1.020, a high protein content, and
usually contains leukocytes.
 Morphologic Patterns –
suppurative Inflammation
3- Suppurative or Purulent
Inflammation
Characterized by formation
of a large amounts of
purulent exudate (pus)
Usually caused by pyogenic
bacteria (pus-forming)
PUS consists of: PMNLs,
Necrotic cells, and Edema
fluid
-Appearance: yellow-white to
gray-white and varies from
watery to viscous
 Suppuration - Abscess
formation

Abscess:
A localized area of
tissue loss leading to
formation of a cavity
filled with pus /
purulent exudate
Morphologic Patterns in Acute
and Chronic Inflammation
Suppurative
inflammation could take
the form of:
2- Empyema:
Suppurative exudate
within a natural anatomic
cavity
e.g. Pleural/pericardial
empyema of gallbladder
etc
Spectrum of Inflammatory Responses
to Infection

Suppurative ( Polymorphonuclear )
Inflammation - aetiology
1. Pneumococci Acute lobar pneumonia
2. Staphylococci Abscess formation
3. Klebsiella Pneumonia

Name a pyogenic bacteria that causes Meningitis?

Morphologic Patterns in Acute
and Chronic Inflammation
4- Ulcers
A local defect or
excavation of the
surface of epithelial
covering
Sites:
Skin
Gastro-intestinal tract
Urinary bladder
Female genital tract
Complications of ulcers
include :
Bleeding
Perforation
Fibrous scarring
 Spectrum of Inflammatory
Responses to Infection

Fibrinonecrotic Inflammation: Inflammation on

a well-vascularized epithelial surface (eg:
trachea, intestine, nasal passages),
characterized by necrosis of the surface
epithelium and presence of fibrin forming
Pseudomembranes/ Diphtheritic Membranes.
FIBRINOPURULENT EXUDATE: Term used to
classify an inflammatory process in which
neutrophils and fibrin are abundant.
Spectrum of Inflammatory Responses
to Infection
Haemorrhagic Inflammation: Haemorrhage
predominates, occurs due to severe injury to blood
vessel (acute pancreatitis) or depletion of coagulation
factors (meningococcal septicaemia – DIC)
Mucoid Exudate: Consists of mucus and pus (large
numbers of neutrophils and neutrophil debris).
Catarrhal inflammation - Synonym for mucopurulent
inflammation eg. Common cold.
Eosinophilic Inflammation: Eosinophils are the primary
inflammatory cell type present
Nonsuppurative Inflammation: This a microscopic
diagnosis as mononuclear cells (lymphocytes and
plasma cells) are present.
Lymphocytic Inflammation: Lymphocytes are the
predominant inflammatory cell type.
 Spectrum of Inflammatory Responses
to Infection
I- Acute Suppurative inflammation
II- Mononuclear and
Granulomatous
Inflammation :
Occur in response to:
viruses
intracellular
bacteria
spirochetes
intracellular
parasites
helminthes
 Granulomatous Inflammation

Definition:
Granulomatous
response characterized
by the presence of
lymphocytes,macropha
ges, and plasma cells
.Macrophages can be
clustered around the
foreign matter and be
as "epithelioid,"
or"multinucleated "
 Spectrum of Inflammatory Responses
to Infection

III a. Cytopathic-
Inflammation :
Viral-mediated damage
to host cells in the
absence of host
inflammatory response
Formation of viral
inclusions within cells
Examples
Cytomegalovirus CMV
Herpes Simplex
 Spectrum of
Inflammatory
Responses to
Infection
III b. Cytoproliferative Inflammation
Human Papilloma Virus HPV
Over 60 distinct types
produces proliferative
lesions of squamous
epithelium
condyloma
accuminatum
(6,10,11)
common warts
(1,2,4)
flat warts
Condyloma acuminatum-HPV 6,10,11
 Viral Inclusions

Molluscum contagiosum CMV

Rabies – negri bodies

Herpes simplex virus
 Spectrum of Inflammatory Responses
to Infection
IV NECROTIZING INFLAMMATION:
Definition: Inflammation characterized primarily by
necrosis variable amount of haemmorrhage, edema
and inflammatory cells
-Necrotizing inflammation is often associated with -

interruption of blood flow, such as in mycotic

diseases of the gastrointestinal tract that result in
arterial thrombosis – vascular obstruction.
-It is also seen in association with toxin-producing
bacteria
- gangrenous infections.
Histologically, there is only scant evidence of vascular
or leucocytic contributions.
 Spectrum of Inflammatory Responses
to Infection
IV. Necrotizing Inflammation :
Clostridium perfringens
Organisms secrete toxins causing
rapid severe tissue damage and cell death.
Few inflammatory cells are involved
Lesions resemble ischemic necrosis
Entamoeba histolytica
Colonic ulcers and liver abscesses
Extensive liquefactive necrosis
Absence of a prominent inflammatory infiltrate
viruses
total destruction of temporal lobes of the brain by
herpes virus
the liver by HBV
Spectrum of Inflammatory Responses
to Infection

V. Chronic Inflammation and

Scarring :

Chronic inflammation may lead to

extensive scarring eg.
“Pipe-stem” fibrosis of the liver
caused by schistosoma eggs
(Bilharzial liver disease)
Constrictive (fibrous) pericarditis
secondary to tuberculous
pericarditis
Resolution Outcome of Acute Inflammation
Suppuration-
Abscess
formation
Organisation-
scar formation
regeneration
Persistent
inflammation
Resolution
(chronic
inflammation)
Mediators
INJURY Acute inflammation Abscess formation

Healing
Mediators Regeneration
Persistent infection
Chronic inflammation Scarring
Persistent toxins
Autoimmune diseases
 Resolution
Means complete restoration of the tissues to normal
Favouring factors
Minimal cell death and tissue damage
Occurrence in an organ or tissue which has
regenerative capacity (eg the liver) rather than in one
which cannot regenerate (eg. the central nervous
system)
Rapid destruction of the causal agent
(eg. phagocytosis of bacteria)
Rapid removal of fluid and debris by good local
vascular drainage
 Sequence of events leading to
resolution of pneumonia

Phagocytosis of bacteria
(eg pneumococci) by
neutrophils and
intracellular killing
Fibrinolysis
Phagocytosis of debris, by
macrophages and carriage
to lymphatics and lymph
nodes
Disappearance of vascular
dilatation
 Abscess Formation

1- Abscess:
A localized area of
tissue loss leading to
formation of a cavity
filled with pus /
purulent exudate
Organisation
cavity
Replacement by
granulation tissue
Increased fibrin
which cannot be
removed
 Organisation - organ
Substantial necrotic
tissue not easily
digested
Exudate and debris
cannot be removed
or discharged
 Outcome of Acute
Inflammation:
Fibrosis – Repair by
Connective Tissue
Replacement’
a. Substantial tissue
destruction
b. Occurs when
affected tissue can
not degenerate
c. Occurs when fibrin
exudation is abundant
as in effusions
following pneumonias
 Outcome of Acute
Inflammation:
Chronic
Inflammation
a. Persistent stimuli
progression of
inflammatory process
b. Primary purpose is
to contain and
remove pathologic
agents or processes.
ANATOMIC MODIFIERS:
Terms used to describe a specific area within an
organ that may be affected by inflammation or
degenerative conditions.
Example: Cardiac Inflammation
Endocardium - Endocarditis
valvular/mural
Myocardium - Cardiomyopathy/myocarditis
Pericardium - Pericardial effusion,
pericarditis
Pancarditis - Involves all layers
 Effects of acute
inflammation
Beneficial Harmful
Dilution of toxins Digestion of normal
Entry of antibodies tissue
Transport of drugs Swelling
Fibrin formation Raised Intracranial
Delivery of nutrients pressure
and oxygen acute epiglottitis
Stimulation of Allergic
immune response inflammatory
response
Local Clinical Effects of Acute And
Chronic Inflammation

Mainly related to:

1.Loss of organ secretory / metabolic
function function
e.g. hepatitis, thyroiditis, pancreatitis,
2. Damage and Loss of vital functioning
tissues causing organ failure
e.g. acute / chronic pneumonitis,
hepatitis,
glomerulonephritis
3. Compression of vital organs :
nerves, blood vessels, lymphatics
Local Clinical Effects of Acute And
Chronic Inflammation

4. Interferences with normal mechanical function:

a. post-burn scarring over joints
b. scarring of articular joints in rheumatoid
arthritis (RA)
c. adhesions over peritoneal surface (?) and
pericardial cavity
5.Hemorrhage:
Ulcer
Damaged blood vessels
6. Obstruction of vital organ passages:
a- inflammatory exudate
B- fibrous tissue formation (scarring) leading to
stricture formation
 Inflammation
Systemic Manifestations
Fever - clinical hallmark of inflammation - Endogenous
pyrogens: IL-2 ,TNF-α
Constitutional symptoms - malaise, anorexia,nausea
Weight loss - due to negative nitrogen balance
Hyperplasia of reticuloendothelial system-LN, spleen
Leukocytosis - may be neutrophils, eosinophils, or
lymphocytes
Anemia –blood loss,chronic due to toxic depression of bone
marrow
Acute Phase Reactants - non-specific elevation of many
serum proteins
ESR high-raised plasma proteins causing increased
rouleaux formation of RBC
Amyloidosis – longstanding chronic infection
 Inflammation
Systemic Manifestations
Leukocytosis: most bacterial infection
Lymphocytosis: Infectious mononucleosis,
mumps,
German measles
Eosinophilia: bronchial asthma,
hay fever,
parasitic infestations
Leukopenia: typhoid fever,
infection with
rickettsiae/protozoa