1.

01 06/13/15
Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

Grig Misiona, MD

 Necrosis – type of cell death that occurs after

INTRODUCTION TO PATHOLOGY such abnormal stresses as ischemia and
PATHOLOGY chemical injury; always pathologic 

- The study (logos) of diseases (disease)
- The study of the structural, biochemical, and functional changes  Apoptosis – occurs due to activation of an
in cells, tissues, and organs that underlie the disease internally controlled suicide program;
- Foundation of medical science and practice physiologic and pathologic
- Scientific study of disease
- The study of structural and functional abnormalities that manifest I. CELLULAR ADAPTATION
th
as diseases of organs and organ systems (Rubin’s 7 ed.) - Occurs when excessive physiologic or pathologic stresses result
- The study of injury to cells and organs and of their capacity to in a new but altered steady state
th
adapt to such injury (Rubin’s 7 ed.)
DIVISIONS OF PATHOLOGY
1. General Pathology
o Concerned with the reactions of cells and tissues to
abnormal stimuli and to inherited defects, which are the
main causes of disease
2. Systemic Pathology
o Examines the alterations in specialized organs and
tissues that are responsible for disorders that involve
these organs

FOUR ASPECTS OF A DISEASE PROCESS THAT FORM THE

CORE OF PATHOLOGY
1. Etiology
o The cause of the disease
o 3 types: Fig.1. Schematic Diagram of the Overview of Cellular Response to
 Genetic Injury and Adaptation
 Acquired TYPES OF ADAPTATION
 Combined/Multifactorial 1. Physiologic
2. Pathogenesis o Response of cell to hormones or endogenous influence
o Refers to the sequence of events in the response of o e.g. runners, mountain climbers
cells or tissues to the etiologic agents, from the initial 2. Pathologic
stimulus to the ultimate expression of the disease o Response to injurious stimuli
o Answers the question, “How does the disease o e.g. prolonged hypertension
progress?”
3. Morphologic Changes ADAPTATIONS OF CELLULAR GROWTH AND
o Refer to the structural alterations in cells or tissues that DIFFERENTIATION
are either characteristic of a disease or diagnostic of an 1. HYPERPLASIA
th
etiologic process Rubin’s 7 ed:
o Can be gross or microscopic  An increase in cell number in an organ or tissue usually with
o There are diseases, which do not have pathognomonic increased mass as well
lesions like autoimmune diseases. This is where  May occur in response to an altered endocrine milieu, increased
immunology or molecular pathology comes in. functional demand, or chronic injury
4. Clinical Significance/Manifestation  May occur simultaneously with hypertrophy and are triggered by the
o Functional consequence of the alteration same external stimulus
o The end results of genetic, biochemical, and structural  Takes place if cell is capable of dividing
changes in cells and tissues are functional abnormalities
o What is the impact/effect on the patient?

CELLULAR RESPONSES TO STRESS AND NOXIOUS STIMULI

STAGES OR CELLULAR RESPONSE TO STRESS AND
INJURIOUS STIMULI
a. Cellular Adaptation
o Reversible functional and structural responses to more
severe physiologic stresses and some pathologic
stimuli, during which new but altered steady state are
achieved, allowing to cell to survive
b. Cell Injury Fig.2. Comparison of a Normal Bone Marrow(Left) with a
o Results when cells are stressed so severely they are no hyperplastic Bone Marrow (Right)
longer able to adapt th
o Or when cells are exposed to inherently damaging TYPES OF HYPERPLASIA (Robbins, 9 ed.)
agents or suffer from intrinsic abnormalities a. Physiologic
o When environmental changes exceed the cell’s capacity o Hormonal
th
to maintain normal homeostasis (Rubin’s 7 ed.)  increases the functional capacity of a tissue when
o Reversible Cell Injury needed
 When the stimulus is removed, the changes may  e.g. proliferation of the glandular epithelium of the
revert back to normal female breast at puberty and during pregnancy;
 For mild types of injury hyperplasia of endometrial glands
o Irreversible Cell Injury o Compensatory
 Permanent changes  Increases tissue mass after damage or partial
 Will eventually cause cell death with certainty resection
 There is failure of adaptive mechanism  e.g. liver cells after hepatectomy
th
c. Cell Death o Increased Functional Demand (Rubin’s 7 ed.)
o The end result of progressive cell injury  Increased physiological requirements may result to
o One of the most crucial events in the evolution of hyperplasia
disease in any tissue or organ  E.g. high altitudes, low oxygen tension causes
o A normal and essential process in embryogenesis, the hyperplasia of erythroid precurors in the bone
development of organs, and the maintenance of marrow and increased blood erythrocytes
homeostasis
Page 1 of 19
TRANSCRIBERS: Espinosa, Elvambuena, Manching, Miniano
 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

b. Pathologic MECHANISM OF HYPERTROPHY

o Caused by excesses of hormones or growth factors acting 1. The result of increased production of cellular proteins
on target cells (e.g. endometrial and prostatic hyperplasia) 2. Two main biochemical pathways involved in muscle hypertrophy:
o Also a characteristic response to certain viral infections a. Phosphoinositide 3-kinase/Akt pathway
(e.g. papillomaviruses) b. Signaling downsteam of G protein-coupled receptors
o May give rise to neoplasms 3. Hypertrophy may also b associated with a switch of contractile
o e.g. endometrial hyperplasia - balance between estrogen proteins from adult to fetal or neonatal forms
and progesterone is disturbed → results in increase amount 4. Some genes expressed only during early development are re-
of estrogen → hyperplasia of endometrial glands → causes expressed during hypertrophy and the products of these genes
abnormal menstrual bleeding; benign prostatic hyperplasia participate in the cellular response to stress
th
o Chronic Injury(Rubin’s 7 ed.) 5. In the heart, there at least two groups of signals to trigger gene
 Persistent injury may result to hyperplasia expression:
 Long standing inflammation of physical or chemical  Mechanical triggers – stretch
injury is often accompanied by a hyperplastic  Trophic triggers – polypeptide growth factors (IGF-1) and
response vasoactive agents (angiotensin II, α-adrenergic agonists)
 E.g. pressure from ill-fitting shoes causes
hyperplasia of the skin of the foot, so-called corns th
Rubin’s 7 ed.:
and calluses o Growth Factor Stimulation: some growth factors are key
initiators of hypertrophy (e.g. IGF-1)
o Neuroendocrine Stimulation: in some tissues, adrenergic
signaling may be important in initiating or facilitating
hypertrophy
o Ion Channels: ion fluxes may activate adaptation to
increased demand
o Other Chemical Mediators: NO, angiotensin II, and
bradykinin
o Oxygen Supply: ↑ functional demand requires ↑ energy
supply. Angiogenesis with oxygen delivery is stimulated if
tissue oxygen deficit is sensed, a key component in adaptive
Fig.3. Comparison of (Left) Normal Epidermis and hypertrophy
(Right) Thickened Epidermis due to Increased number of o Hypertrophy Antagonists: ANF and ↑ concentration of NO
th
squamous cells (Rubin’s 7 ed.) brake or prevent adaptation by hypertrophy

MECHANISMS OF HYPERPLASIA MYOCARDIAL HYPERTROPHY

1. Result of growth factor-driven proliferation of mature cells - Associated with reinduction of ANF gene expression
2. By increased output of new cells from tissue stem cells - Mechanical sensors appear to be the major triggers for
↑ local production of growth factors (GF) physiologic hypertrophy
↓ - Agonists and growth factors may be more important in pathologic
↑ GF receptors on responding cells states (e.g. ANF, IGF-1)
↓
Activation of particular intracellular signaling pathway
↓
↑ Activation of transcription factors
↓
Turn on many cellular genes (including genes encoding growth
factors, receptors for growth factors and cell cycle regulators)
↓
CELLULAR PROLIFERATION

2. HYPERTROPHY
- Increase in the size of cells due to the synthesis of more
structural components
- Leads to an increase in size of the organ
- Occurs in non-dividing cells (e.g. muscle cells)
- ***muscle cells may have a potential to divide in certain situations

TWO TYPES OF HYPERTROPHY

1. Physiologic Hypertrophy Fig.4. Diagrammatic representation of the general mechanism for
o Caused by increased functional demand myocardial hypertrophy
 e.g. endurance athletes, basketball players
SELECTIVE HYPERTROPHY
o Caused by specific hormonal stimulation (Inc Trophic - Hypertrophy prefers to increase size of cells and tissues but
Signals) Sometimes, a subcellular organelle may undergo selective
 Hypertrophy of breast in response to estrogen hypertrophy
and progestins - e.g. barbiturates cause hypertrophy of the sER in hepatocytes
 Uterine hypertrophy during pregnancy
th
o Puberty EFFECTOR PATWAYS OF HYPERTROPHY (Rubin’s, 7 ed.)
 Just as aging is associated with atrophy, the o Increase Protein Degradation: ubiquitin-proteasome system,
onset of puberty especially in males leads to activation of intracellular proteases and autophagy
greater muscle mass o Increased Protein Translation: increased translational efficiency
without changes in RNA levels
2. Pathologic Hypertrophy o Increased Gene Expression: concentration of key proteins are also
o Hypertrophy in hypertension (barado yung ugat/volume elevated by upreglation of their genes; increased gene transcription
overload -> excessive pumping of the heart -> increase in of growth-promoting factors (Fos and Myc)
muscle fibers/myosin to compensate) o Survival: Stimulation of specific receptors activates several
o Heart may lose capacity to adapt -> heart failure enzymes that promote cell survival, inhibiting cell death
o Remodelling Extracellular Matrix
o Recruitement of Satellite Cells

TRANSCRIBERS: Espinosa, Elvambuena, Manching, Miniano Page 2 of 19

 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

3. ATROPHY
- Shrinkage or reduction in the size of the cell due to decrease in 4. INADEQUATE NUTRITION
cell size and number - E.g. marasmus –assoc. w/ use of skeletal muscle as energy
source when adipose stores have been depleted) -> muscle
TYPES OF ATROPHY wasting
I. Physiologic Atrophy - Cachexia
- Common during normal development
- E.g. embryonic structures undergo atrophy during fetal 5. LOSS OF ENDOCRINE STIMULATION
development and uterus decreases in size shortly after parturition - Hormone-responsive tissues are dependent on endocrine
stimulation
II. Pathologic Atrophy - E.g. loss of estrogen stimulation after menopause -> physiologic
- Depends on underlying cause atrophy of endometrium, vaginal epithelium, breast
- Can be local or generalized
6. AGING
- Diminished body movement

7. PRESSURE
- Tissue compression for any length of time -> atrophy
- E.g. enlarging benign tumor -> atrophy of surrounding tissues
(ischemic changes caused by compromise of the blood supply
by the pressure exerted by the expanding mass)

Table 1.

Fig.5. Normal uterus of a reproductive age woman revelas thick endometrium

composed of proliferative glands in abundant stroma

Fig. 6.The endometrium of a 75yr old woman is thin and contains only a few
atrophic and cystic glands

COMMON CAUSES OF ATROPHY

- The fundamental cellular changes in atrophy are the same:
Initial response (decrease in cell size and organelles)
↓
Reduced metabolic needs of the cell
↓
Cell function will be diminished but not dead, however gradual
reduction of blood supply
↓
Irreversible injury MECHANISM OF ATROPHY
↓
1. ↓Protein synthesis
Death (often by apoptosis) 2. ↑Protein degradation thru the ubiquitin proteosome pathway
Ubiquitin- Proteosome Pathway:
1. DECREASED WORKLOAD (ATROPHY OF DISUSE)
- Reversible once activity is resumed but prolonged disuse ->
apoptosis -> bone resorption -> osteoporosis of disuse
- E.g. Muscle atrophy due to immobilized fractured bone in a
plaster cast or bedrest

2. LOSS OF INNERVATION (DENERVATION ATROPHY)

- Nerve damage -> atrophy of muscles supplied by these nerves
- Normal metabolism and function is compromised
3. ↑Autophagy
3. DIMINISHED BLOOD SUPPLY (ISCHEMIA) - Number of Autophagic vacuoles and lysosomes
- Result of slowly developing arterial occlusive disease -> atrophy - Residual bodies – cell debris within the autophagic vacuoles that
of ischemic tissue resist digestion
- Senile atrophy – reduced blood supply of brain as a result of .4. ↓ Energy Utilization
atherosclerosis -> progressive atrophy of the brain among adults - A selective decrease in the use of free fatty acids as an energy
and also affects the heart source for muscle in response to unloading

BROWN ATROPHY
- Atrophy is often accompanied by increased autophagy ->
increased number of autophagic vacuoles (causes accumulation
of sarcophagus like lipofuscin granules, sufficient amounts will
impart brown discoloration to tissue)

Fig.7. Comparison of a Normal Brain (A) and an Ischemic one (B)

TRANSCRIBERS: Espinosa, Elvambuena, Manching, Miniano Page 3 of 19

 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

Fig.11.

-
-

MECHANISM OF METAPLASIA
- Result of a reprogramming of stem cells that are known to exist
in normal tissues or of undifferentiated mesenchymal cells
present in connective tissue
- Signals generated by cytokines, growth factors, ECM
components -> differentiation of stem cells to a particular
lineage
- Vitamin A (rRtionoic acid)
Fig. 9.
o Directly regulates gene transcription through nuclear
retinoid receptors; so deficiency or excess of which can
influence the differentiation of progenitors derived from
tissue stem cells
- Other external stimulus – exact mechanism is unknown but may
also alterFig.12.
the activity of transcription factors that regulate
differentiation
4. METAPLASIA 5. DYSPLASIA
- Reversible change in which one differentiated cell type
(epithelial or mesenchymal) is replaced by another cell type
- E.g. ni Doc: parang mga homosexuals 
- May represent an adaptive substitution of cells that are sensitive
to stress by cell types better able to withstand the adverse
environment
- Most common: columnar to squamous (in the respiratory tract
due to chronic irritation)

Fig.13.Nondysplastic Cervical Epithelium. No mitotic activity above

most basal layer cells but rather shows epithelial maturation with
flattening of cells and progressive dimunition of nuclei
Fig.10. Histologic specimen that shows the columnar to squamous hyperplasia

- E.g. secretory columnar epithelium in excretory ducts of the

salivary glands, pancreas, or bile ducts is replaced by stratified
squamous epithelium because of stones present in them
- E.g. respiratory epithelium becomes squamous due to vitamin A
(retinoic acid) deficiency
o In the case of respiratory epithelium, the mucus
secretion and ciliary action is lost and renders the body
more susceptible to infections
- Persistent predisposition to metaplasia may initiate malignant
transformation
- Another example: squamous to columnar (in Barrett’s
esophagus, due to refluxed gastric acid, glandular
(adeno)carcinoma may arise)

Fig.14. Dysplastic Epithelium of uterine cervix lacks normal polarity,

and individual cells show hyperchromatic nuclei and a greater than
normal nucleus-to-cytoplasm ratio

- Disoredered cellular growth and maturation

TRANSCRIBERS: Espinosa, Elvambuena, Manching, Miniano Page 4 of 19

 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

- Patterns that are exhibited in normal cells are disturbed by (1) - Recreational drugs (alcohol)
variations in cell size and shape, (2) nuclear enlargement, - Therapeutic drugs
irregularity, and hyperchromatism, (3) disorderly arrangement of
cells in epithelium 4. INFECTIOUS AGENTS
- Occurs most often in hyperplastic squamous epithelium, and in - Rickettsiae, Bacteria, Fungi, Higher forms of parasites
areas of squamous metaplasia
- Considered as a preneoplastic lesion and that it is a necessary 5. IMMUNOOGIC REACTIONS
stage in the multistep cellular evolution to cancer - Autoimmune diseases: d/t injurious reactions to endogenous
It is the morphologic exression of a disturbance in growth regulation, self-antigens
however, unlike cancer cells, dysplastic cells are not autonomous and - Immune reactions to external agents (microbes and
with intervention, the tissue may still revert to normal environmental substances)
II. CELL INJURY
TIMING AND CHANGES IN CELL INJURY 6. GENETIC DERANGEMENTS
CELL INJURY OCCURS WHEN CELLS:
- Genetic defects may cause cellular injury d/t deficiency of
- Are stressed so severely that they are unable to adapt
functional proteins (enzyme defects in inborn errors of
- Are exposed to inherently damaging agents metabolism)
- Suffer from intrinsic abnormalities - Accumulation of damaged DNA or misfolded proteins →
triggering of cell death of beyond repair
REVERSIBLE CELL INJURY - Variations in genetic makeup: can influence the susceptibility
- Functional and morphologic changes are reversible if the of cells to injury by chemicals and other environmental insults
damaging stimulus is removed (early stages, mild forms of
injury) 7. NUTRITIONAL IMBALANCES
- Hallmarks of reversible injury: - Major causes of cell injury
o ↓Oxidative phosphorylation → depletion of energy stores - Protein-calorie deficiencies, deficiencies of specific vitamins
(ATP) - Anorexia nervosa: self-induced starvation
o Cellular swelling due to changes in ion concentrations and - ↑↑cholesterol →↑predisposition to atherosclerosis
water influx - Obesity → diabetes and cancer
o Alterations in organelles (mitochondria and cytoskeleton)
MECHANISMS OF CELL INJURY
CELL DEATH PRINCIPLES RELEVANT TO CELL INJURY
- Point of irreversibility: beyond which the cell cannot recover and 1. Factors that influence the RESPONSE of a cell to injurious stimuli
dies o NATURE, DURATION AND SEVERITY of the injury
- TWO PRINCIPAL TYPES:  Small doses of a toxin or brief periods of ischemia 
1. NECROSIS reversible injury
o severe damage to membranes  Large doses of the same toxin or prolonged ischemia
o Lysosomal enzymes enter the cytoplasm and digest the  instantaneous cell death or slow, irreversible
cell injury (which also leads to death eventually)
o Cellular contents leak out
o Always a pathologic process 2. Factors that influence the CONSEQUENCES of cell injury
o TYPE, STATE AND ADAPTABILITY of the injured cell
2. APOPTOSIS  The nutritional and hormonal status and the
o Cell’s DNA or proteins are damaged beyond repair metabolic needs of the cell are important in its
o Nuclear dissolution, fragmentation of the cell without response to injury.
complete loss of membrane integrity and rapid removal of  Striated leg muscles, when deprived of blood supply
the cellular debris can be placed at rest and preserved but the striated
o Serves many normal functions cardiac muscles can not.
o Not necessarily associated with cell injury  Susceptibility to hypoxia:
 Neurons – very sensitive (mins)
CAUSES OF CELL INJURY  Myocytes, hepatocytes – intermediate (mins
1. HYPOXIA (OXYGEN DEPRIVATION) to hrs)
- Deficiency of oxygen  Fibroblasts, epidermis, muscle – low (many
- Most common cause of cell injury and death hours)
- Hypoxia = ↓aerobic oxidative respiration → cell injury  Two individuals who are exposed to identical toxin
- CAUSES OF HYPOXIA concentrations may produce no effect in one and cell
o Ischemia (↓blood flow) death in the other
o Inadequate oxygenation of the blood due to  May be due to genetic variations that affect
cardiorespiratory failure hepatic enzyme activity
o ↓oxygen-carrying capacity of the blood (anemia, CO
poisoning) 3. Cell injury results from different biochemical mechanisms acting
on several essential cellular components
- Cells have varying responses to the severity of the hypoxia: 4. Any injurious stimulus may simultaneous trigger multiple
o Narrowed artery →atrophy of the tissue supplied by the interconnected mechanisms that damage cells.
blood vessel
o More severe or sudden hypoxia  injury and cell death

2. PHYSICAL AGENTS
- Mechanical trauma
- Extremes of temperature (burns and deep cold)
- Sudden changes in atmospheric pressure
- Radiation
- Electric shock

3. CHEMICAL AGENTS AND DRUGS Fig.15. 1 Mechanism that can lead to apoptosis
- Glucose or salt in ↑ concentrations
- O2 at ↑ concentrations
- Trace amounts of arsenic, cyanide or mercuric salts
- Environmental and air pollutants
- Insecticides and herbicides
- Industrial and occupational hazards (CO, asbestos)

TRANSCRIBERS: Espinosa, Elvambuena, Manching, Miniano Page 5 of 19

 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

↓ O2 supply (i.e. ischemia)

↓
↓ Oxidative phosphorylation
↓
↓Cellular ATP, ↑ AMP
↓
Stimulation of PFK and phosphorylase activity
↓
↑ Anaerobic glycolysis
2+
6. Fig.16.The mechanisms of increased Calcium and o Failure of Ca pump which leads to its influx and may
th ROS that can lead to cell lysis damage the mitochondria (explained later).
o Disruption of the protein synthesis apparatus which
manifests as ribosome detachment from the rER and
polysome dissociation = ↓protein synthesis
o Depletion of O2 and glucose may result to protein
misfolding which may trigger an unfolded protein response
(may cause injury or death).
o Irreversible damage to mitochondrial and lysosomal
membranes, leading to cell necrosis.

II. ACCUMULATION OF O2-DERIVED FREE RADICALS

(OXIDATIVE STRESS)
Fig.17.Mechanisms of membrane damage and
CHON misfolding which leads to cell lysis - Important in pathologic conditions such as:
o Chemical and radiation injury
I. ATP DEPLETION o Ischemia-reperfusion injury
- Frequently associated with hypoxic and chemical (toxic) injury o Cellular aging
- ATP is produced in two ways: o Microbial killing by phagocytes
o Oxidative phosphorylation of ADP (aerobic; efficient; major - FREE RADICALS
pathway) o Unstable, partially reduced molecules with unpaired
o Glycolytic pathway (anaerobic; inefficient) electrons in outer orbitals that make them particularly
- The MAJOR causes of ATP depletion are: reactive with other molecules
o ↓ O2 and nutrient supply o These free radicals damage:
o Mitochondrial damage  Lipids by peroxidizing double bonds—causing
o Toxins (e.g. cyanide) chain breakage
- Tissues with ↑glycolytic capacity are able to survive loss of  Proteins by oxidizing and fragmenting peptide
oxygen and decreased oxidative phosphorylation better than bonds
tissues with limited glycolytic capacity (e.g. liver vs. brain)  Nucleic acids by causing single strand breaks
- OXYGEN-DERIVED FREE RADICALS (ROS)
o Are the most common form of free radivals in biological
systems
o Major forms include:
-
 Superoxide anion (O2 )
o Produced mainly by leaks in
mitochondrial electron transport or as
part of inflammatory processes
 Hydrogen peroxide (H2O2)
-
o Formed from the conversion of (O2 )
by superoxide dismutase (SOD)
o Normally not injurious and can be
metabolized to HxO by catalase
o When produced in excess, it is
converted to highly reactive Hydroxyl
radical
o In neutrophils, it is converted by
myeloperoxidase to hypochlorite
which can kill cells if released
extracelllularly
o Reduced to HxO by (1) catalase and
Fig. 18. Mechanism of Ischemia which leads (2) Glutathione Peroxidase which
to cell lysis uses reduced glutathione (GSH) as a
- ATP is necessary for the following: cofactor, yielding oxidized
o Membrane transport glutathione (GSSG)
o Protein synthesis  Hydroxyl ions (OH)
o Lipogenesis o Most reactive ROS
o Deacylation-reacylation reactions for phospholipid turnover o Formed by:
- ATP depletion of 5% to 10% the normal levels have the  Radiolysis of water
following effects:  Reaction of H2O2 with Fe or
2+
o ↓ Activity of the Na-K-ATPase 1+
Cu (Fenton Reaction)
+ +
 This causes Na to accumulate inside the cell and K  Conversion of O2 with H2O2 (Haber
to diffuse out. This is accompanied by isosmotic Weiss Reacton)
water gain, which causes cell swelling and ER  Mechanisms of damage to
dilation. macromolecules:
o Alteration of cellular energy metabolism
 Anaerobic glycolysis results to accumulation of lactic a. Lipid peroxidation
acid and Pi . This leads to a reduction in intracellular  (OH )
.
removes H
+
from
pH which may decrease the activity of some unsaturated fatty acids in
enzymes. membrane phospholipids 

TRANSCRIBERS: Espinosa, Elvambuena, Manching, Miniano Page 6 of 19

 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

Free Lipid radical  reacts with

O2 to form lipid peroxide radical
 reactsby removing another
+
H ,from a different unsaturated
fatty acid, initiating a chain
reaction
→ Loss of membrane integrity due to
destruction of fatty acids
b. Protein Interactions
→ Fragmentation, cross-linking, aggregation,
and eventual degradation of proteins due
.
to attack of (OH ) to sulfur-containg and
nitrogen-containing AAs (Cys Met, Arg,
His, Pro)
c. Sugars
.
→ Attack of (OH ) to sugars generate reactive
intermediates which modify proteins, Fig.19.Diagram of the Production and Effects of ROS to the mitochondria
forming advanced glycation end-products 2+ 2+
III. INFLUX OF Ca AND LOSS OF Ca HOMEOSTASIS
(AGE) 2+
d. DNA damage - Cytosolic Ca is maintained at low concentrations (-0.1umol) and
→ Causes structural DNA alteriations is mostly sequestered in the mitochondria and ER.
including strand-breaks, modified bases - Ischemia and certain toxins can cause Ca2+ influx across the
and strand cross-linking plasma membrane and release of Ca2+ from the mitochondria
 Nitric Oxide (NO) Peroxynitrite ion (ONOO )
- and ER.
2+
 NO and O2 interactions produce other free radicals - This increase in cytosolic Ca activates the following enzymes:
which may nitrosate amines or modify other o Phospholipases that degrade membrane phospholipids;
available groups o Proteases that break down membrane and cytoskeletal
 NO may react with superoxide radical to form proteins;
peroxynitrite ion o ATPases that hasten ATP depletion;
 Peroxynitrite may attack lipids, proteins, and DNA o Endonucleases that cause chromatin fragmentation

GENERATION OF FREE RADICALS

1. Normal metabolic processes such as the reduction of O2 to H2O
during respiration
2. Absorption of radiant energy (UV, x-rays) hydrolyze H2O into OH∙
and H∙ free radicals
3. Production by leukocytes during inflammation to sterilize infection
sites
4. Enzymatic metabolism of exogenous chemicals or drugs
5. Catalysis by transition metals like Fe and Cu
6. Conversion of NO to highly reactive forms or NO as a free radical
itself

REMOVAL OF FREE RADICALS

- Fortunately, free radicals are inherently unstable and generally
decay spontaneously.
- There are also several systems which contribute to free radical
inactivation which include:
o Antioxidants that block the initiation of free radical
formation or scavenge free radicals
 E.g. Vitamins E, A (retinoids), C, NO, and Fig.20. Schematic Diagram that shows the deleterious effects of Inc
glutathione Extracellular Ca
o Levels of transition metals that can participate in free
radical formation (Fe and Cu) are minimized by binding to IV. DEFECTS IN MEMBRANE PERMEABILITY
storage and transport proteins MECHANISMS OF MEMBRANE DAMAGE
 E.g. transferrin, ferritin, lactoferrin, ceruloplasmin - Membranes can be damaged by:
o Enzyme systems that scavenge free radicals o ROS via lipid peroxidation
 E.g catalase (peroxisomes) and glutathione o Decreased phospholipid synthesis which decrease ATP
peroxidase (cytosol and mitochondria) production and thus affect energy-dependent enzymatic
catabolize H2O2; superoxide dismutase activities
catabolizes the superoxide anion o Increased phospholipid breakdown as a result of
2+
↑cytosolic [Ca ]
ROLE OF p53 o Cytoskeletal abnormalities due to protease activation by
2+
o helps prevent and repair DNA damage, rescuing cells from ↑cytosolic [Ca ] (proteases may damage cytoskeletal
endogenous and exogenous causes of injury elements, making it susceptible to stretching and rupture)
2+
o If DNA damage is irrepairable, it activates cel death o Or indirectly by ROS or Ca activation of enzymes
programs previously mentioned
o Under normal conditions and low oxidative stress, it - Increased plasma membrane permeability affects intracellular
maintains expression of many antioxidant genes for cell osmolarity and enzyme activity
survival - Increased mitochondrial membrane permeability reduces ATP
o During severe oxidant stress, it activates different target synthesis and can drive apoptosis
genes that impair oxidant defenses, allow cellular damage to - Altered lysosomal integrity unleashes extremely potent acid
accumulate, and eventually cell death hydrolases that can digest proteins, nucleic acids, lipids and
It also directs metabolic pathways that reinforce its transcriptional glycogen.
activity

TRANSCRIBERS: Espinosa, Elvambuena, Manching, Miniano Page 7 of 19

 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

Fig.21. Mechanism ROS, Dec O2 and Inc Calcium that will lead to
Membrane Damage

CONSEQUENCES OF MEMBRANE DAMAGE

- MITOCHONDRIAL MEMBRANE DAMAGE
o Damage opens the mitochondrial permeability transition
pore which leads to decreased ATP and protein release
that triggers apoptotic death
- PLASMA MEMBRANE DAMAGE
o Results to osmotic imbalance and influx of fluids and
Fig.22. A diagram showing the deleterious effects of Inc Calcium in the
ions, as well as loss of cellular contents mitochondria
o Metabolites vital for ATP reconstitution may also leak out,
VI. DAMAGE TO DNA AND PROTEINS
further depleting energy stores
- LYSOSOMAL MEMBRANE DAMAGE - DNA damage exceeding normal repair capacity leads to
o Results to enzyme leakage into cytoplasm and activation activation of apoptosis
of acid hydrolases in an acidic intracellular pH of the - Accumulation of misfolded proteins lead to a stress response that
injured cell also triggers apoptotic pathways
o Lysosomal enzymes—RNAses, DNAses, proteases,
phosphatases, glucosidases and cathepsins—when SUBCELLULAR RESPONSES TO ADVERSE STIMULI
activated lead to enzymatic digestion of peoteins, RNA, 1. Lysosomal catabolism (heterophagy, autophagy)
DNA and glycogen—which ultimately leads to cell 2. SER induction (detoxification)
necrosis. 3. Mitochondrial changes
4. Cytoskeletal abnormalities
V. MITOCHONDRIAL DAMAGE
MORPHOLOGICAL ALTERATIONS IN CELL INJURY
- Mitochondria can be damaged by: - All stresses and noxious influences exert their effects first at the
o Increases in cytosolic [Ca2+] molecular or biochemical level
o ROS - A time lag between the stress and the morphologic changes of
o O2 deprivation cell injury and death exists and the duration of the delay may vary
with the sensitivity of the methods used to detect these changes
TWO MAJOR CONSEQUENCES OF MITOCHONDRIAL DAMAGE
- Morphological changes may be seen minutes to hours after injury
1. Often results in the formation of a high-conductance channel in when using histochemical or ultrastructural techniques but may
the membrane—the mitochondrial permeability transition pore. take hours to days before these changes can be seen by light
Opening of mitochondrial permeability transition pore microscopy or gross examination.
↓
Loss of mitochondrial membrane potential
↓
Failure of oxidative phosphorylation and progressive ATP depletion
↓
Cell necrosis

2. The mitochondria sequester several proteins that are capable of

activating apoptotic pathways between the inner and outer
membranes which include cytochrome c and caspases.
o Increased permeability of the outer mitochondrial
membrane may result to leakage of these proteins into
the cytosol and death by apoptosis.

Fig.23. Graphical Representation of the Morphological Alterations in Cell Injury

REVERSIBLE CELL INJURY

- Within limits, cell is capable of repairing derangements
- If the injurious stimulus subsides, cell will return to normalcy

FEATURES UNDER LIGHT MICROSCOPY

1. Cellular Swelling
o Appears whenever cells are incapable of maintaining
ionic and fluid homeostasis
o It is the result of failure of energy-dependent ion pumps in
plasma membrane

TRANSCRIBERS: Espinosa, Elvambuena, Manching, Miniano Page 8 of 19

 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

o Swelling results to the following:

 Pallor 3. Endoplasmic Reticulum
 Increased turgor o Disaggregation and Detachment of polysomes from the
 Increase in weight of organ surface of Rough ER
 Eosinophilic staining o Dilated cisternae due to fluid accumulation
 Vacuolar degeneration or hydropic change o Intracytoplasmic myelin figures
 HYDROPHIC SWELLING 4. Nucleus
o A reversible increase in cell volume o Segregation of granular and fibrillar components of the
o Characterized by a large pale, cytoplasm and nucleolus
normally located nucleus 5. Dilation of ER
o Unchanged number of organelles but dispersed o Detachment of polysomes
in a larger volume o Intracytoplasmic myelin figures
o Excess fluid preferentially accumulates in the 6. Nuclear alterations with disaggregation of granular and fibrillar
cisterna of the endoplasmic reticulum (ER), which elements
is dilated due to ionic shifts in this compartment 7. Lysosomal autophagy
8. Decreased ATP degeneration
9. Defects in protein synthesis

IRREVERSIBLE CELL INJURY

- Persistent or excessive injury causes cells to pass the point of no
return into irreversible injury or cell death
- May induce death via NECROSIS and APOPTOSIS

ULTRASTRUCTURAL FINDINGS
Fragmentation of cell membrane
1. Severe vacuolization of mitochondria
2. Rupture of lysosomes and leakage of lysosomal enzymes
(autolysis)

Fig. 24.

2. Fatty Change
o Occurs in hypoxic injury and various forms of toxic or
metabolic injury
o Manifestations:
 Lipid vacuoles in cytoplasm
o Usually in cells involved in fat metabolism such as
hepatocytes and myocardial cells.
Fig. 26. Graphical representation of the difference between Necrosis and
o Fat accumulation within the cell Apoptosis
o Grossly enlarged and yellowish
III. NECROSIS
ULTRASTRUCTURAL CHANGES - Gross and histologic correlate of cell death following irreversible
1. Plasma membrane alterations exogenous injury
o Formation of blebs that may detach withouth loss of cell - Cells are unable to maintain membrane integrity so contents
viability often leak out eliciting inflammation in surrounding tissue
o Blunting - Morpholic appearance is the result of:
o Loss of microvilli o Denaturation of intracellular proteins
2. Mitochondrial changes o Enzymatic digestion of the cells
o Swelling due to dissipation of mitochondrial energy  Enzymes are derived from lysosomes (autolysis)
gradient of from lysosomes of immigrant leukocytes
o Appearance of small amorphous densities
MORPHOLOGICAL CHANGES IN NECROSIS
- Increased cytoplasmic eosinophilia in H&E stains
o Due to loss of cytoplasmic RNA and binding of eosin to
denatured intracytoplasmic proteins
- More glassy homogenous appearance
o Due to loss of glycogen particles
- Cytoplasm becomes vacuolated and appears moth-eaten
o Due to digestion of cytoplasmic organelles
- Calcification of cells
o Due to calcified fatty acid residues and degraded
phospholipid precipitates
- Nuclear changes (due to nonspecific breakdown of DNA)
o Pyknosis
 Nuclear shrinkage and increased basophilia
 Chromatin condenses into a solid, shrunken
basophilic mass
Fig.25.  Also seen in apoptotic cell death
th
 From Rubin’s 7 ed:
 The nucleus becomes smaller and stains deeply

TRANSCRIBERS: Espinosa, Elvambuena, Manching, Miniano Page 9 of 19

 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

basophilic as chromatin clumping continues architecture is completely obliterated

o Karyorrhexis o Caseous – derived from cheesy white gross appearance of
 Pyknotic nucleus undergoes fragmentation the area of necrosis
th
 From Rubin’s 7 ed: o On microscopic exam, appears as amorphous granular
 The pyknotic nucleus breaks up into smaller debris enclosed within an inflammatory border
fragments scattered around the cytoplasm(Rubin’s (granulomatous reaction)
th
7 ed) o Ex. Tuberculous and fungal infections
th
o Karyolysis Rubin’s 7 ed:
 Fading of basophilia of the chromatin due to loss o Is characteristic of tuberculosis
of DNA because of enzymatic degradation by o The lesions of TB are granulomas or tubercles
endonucleases o In the center of such granulomas, the accumulated
 The pyknotic nucleus may be extruded from the mononuclear cells that mediate a chronic inflammatory
cell or it may progressively lose chromatin staining reaction to the offending mycobacteria are killed  lose
th
(Rubin’s 7 ed) their cellular outlines but do not disappear in lysis 
persist indefinitely as an amorphous, coarsely granular,
TYPES OF NECROSIS eosinophilic debris (which is grossly grayish white, soft and
1. COAGULATIVE NECROSIS friable, resembling a clumpy cheese, hence caseous)
o When denaturation is the primary pattern o Generally attributed to the toxic effects of mycobacterial
o Denaturation of both structural proteins and enzymes → cell walls, which contain complex waxes
no proteolysis → Preservation of the basic outline of the (peptidoglycolipids) that exert potent biological effects
coagulated cell (ghost cell) o Survival of mycobacteria is also linked to granuloma
o Characteristic of hypoxic death of cells in all tissues formation
except the brain
o Ex: myocardial infarct
th
Rubin’s 7 ed:
o Called coagulative necrosis because it resembles the
coagulation of proteins that occur upon heating (useful
morphologic descriptor)
o Refers to specific light microscopic appearances od dead
or dying cells
o Maintained cell outline, shortly after death
o Dead cells stain more deeply eosinophilic than usual
o Nuclear chromatin is initially clumped and then
redistributes along the nuclear membrane
o Nucleus manifests pyknosis, karyorrhexis and karyolysis ,
as described on the previous page
o Moreover, the following are also features of the dead cell:
dilated endoplasmic reticulum, disaggregated
ribosomes, swollen and calcified mitochondria, Fig.28.Caseous necrosis in a tuberculous lymph node. Hilar
aggregated cytoskeletal elements and plasma lymph node from a patient with active tuberculosis. Irregular pink
membrane blebs areas of caseous necrosis (arrow) are evident against a
o Overtime, the lytic activity of intracellular and extracellular background of lymphocytes.
enzymes causes the cell to disintegrate leading to
ACUTE INFLAMMATORY RESPONSE 3. LIQUEFACTIVE NECROSIS
o Dominant enzyme digestion
o Seen in focal bacterial or fungal infections (microbes →
accumulation of inflammatory cells)
o Occurs in hypoxic death of cells in the CNS
o Often in tissue with high fluid content
o End result: transformation of tissue into a liquid viscous
mass
 Pus – frequently creamy yellow bec of presence of
dead white cells; from acute inflammation
o Ex. Brain infarct, lung and liver abscesses
th
Rubin’s 7 ed:
o Appears when the rate at which necrotic cells dissolve
greatly exceeds the rate of repair
o Produced by rapid cell death and tissue dissolution caused
by hydrolases in polymorphonuclear cells (PMNs,
neutrophils) which localized as an acute inflammatory
response
o The result is often an abscess  a cavity formed by
liquefactive necrosis in a solid tissue  in time, will be
walled off by a fibrous capsule that contains its contents

Fig.27. A. Normal heart. All myocytes are nucleated, and striations are clear B.
Myocardial infarction. The heart from a patient following acute MI. The necrotic
cells are deeply eosinophilic and most have lost their nuclei (Rubin’s 7th ed)

2. CASEOUS NECROSIS
o Distinctive form of coagulative necrosis but tissue
TRANSCRIBERS: Espinosa, Elvambuena, Manching, Miniano Page 10 of 19
 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

Fig. 29.
Fig.30.

4. GANGRENOUS NECROSIS
o Usually applied to a limb (lower leg) that has lost its blood 6. FIBRINOID NECROSIS
supply and has undergone coagulation necrosis o Seen in immune reactions involving blood vessels
o 2 types: o Occurs when there is deposition of Ag-Ab complexes in
 Dry Gangrene – bacterial infection superimposed on the walls of arteries
coagulative necrosis (eg diabetic foot) o “immune complexes” + fibrin = “fibrinoid”
 Wet Gangrene – bacteria linfection superimposed on o Ex. Vasculitis
th
liquefactive necrosis (eg acute gangrenous Rubin’s 7 ed:
appendicitis) o Is an alteration of injured blood vessels, in which
insudation and accumulation of plasma proteins cause the
5. FAT NECROSIS wall to stain intensely with eosin
o Focal areas of fat destruction occurring as a result of o The term fibrinoid necrosis is a misnomer, in a sense that
release of pancreatic lipases the eosinophilia of the accumulated plasma proteins
 Pancreatic enzymes escape acinar cells → enzymes obscures the underlying alterations in the blood vessel,
liquefy fat cell membranes and split TG esters in fat making it difficult, if not impossible, to determine whether
cells → FA combine with calcium → grossly visible there truly is necrosis in the vascular wall
chalky white areas (fat saponification)
o Histologic: shadowy outlines of necrotic fat cells, with
basophilic calcium deposits, surrounded by an
inflammatory reactions
o Ex. Acute pancreatitis
th
Rubin’s 7 ed:
o Specifically affects adipose tissue and most commonly
results from pancreatitis or trauma
o The presence of triglycerides in adipose tissue determines
this type of necrosis
o Grossly, appears as an irregular, chalky white area
embedded in otherwise normal adipose tissue
o In traumatic fat necrosis, triglycerides and lipases are
released from the injured adipocytes
o In the breast, fat necrosis may mimic tumor
o Involves the following steps:
i. Phospholipases and proteases attack plasma
membranes of adipocytes, releasing their Fig.31.
stored triglycerides
ii. Pancreatic lipase hydrolyzes the triglycerides,
which produces free fatty acids th
2+ IV. PROGRAMMED CELL DEATH (PCD) Rubin’s 7 ed
iii. Free fatty acids bind Ca and precipitate as
soaps. These appear as amorphous, basophilic - refers to processes that are lethal to individual cells and are
deposits at the edges of irregular islands of regulated by pre-existing signaling pathways
necrotic adipocytes. - part of balance between life and death of cells and determines
that a cell dies when it is no longer useful or when its survival
may be harmful to the larger organism
th
- Classification of PCD (Rubin’s 7 ed):
o Apoptosis
o Autophagy-associated cell death
o Necroptosis
o Pyroptosis
o Anoikis
o NETosis
o Pyrosis
o Entosis
APOPTOSIS
- Programmed cell death
- Pathway of cell death that is induced by tightly regulated suicide
program that activates enzymes that degrades the DNA, nuclear
and cytoplasmic proteins of a cell destined to die
- Plasma membrane remains intact, dead cell is rapidly cleared →
does not elicit an inflammatory reaction
- Ex. Epidermis, endometrial shredding during menses,

TRANSCRIBERS: Espinosa, Elvambuena, Manching, Miniano Page 11 of 19

 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

embryogenesis
th
Rubin’s 7 ed:
CAUSES OF APOPTOSIS  Apoptotic cells are recognized by nuclear fragmentation
In PHYSIOLOGIC SITUATIONS: and pyknosis, generally against a background of viable
- During embryogenesis, including implantation, organogenesis, cells.
developmental involution and metamorphosis.  Moreover, apoptosis occurs in single cells or small groups of
o Some aortic arches do not persist cells, whereas necrosis characteristically involves larger
o Pronephros and mesonephros regress in favor of the geographic areas of cell death
metanephros  Ultrastructural features of an apoptotic cell:
o Structures required only by one sex disappear on the other o Nuclear condensation and fragmentation
sex o Segregation of cytoplasmic organelles into distinct
o Disappearance of interdigital tissues to yield discrete fingers regions
and toes o Blebs of the plasma membrane
o Conversion of solid primordial into hollow tubes o Membrane-bound cellular fragments, which often
o Production of the four-chambered heart lack nuclei
o Removal of lymphocyte clones
- Hormone-dependent involution in the adult
o Endometrial cell during menstrual cycle
o Ovarian follicular atresia in menopause
o Regression of the lactating breast after weaning
o Prostatic atrophy after castration
- Cell deletion in proliferating cell populations to maintain constant
number of cell
o Intestinal crypt epithelia Fig.32.
o Red blood cells
o In chronic myeloid leukemia, the mutation inhibits
apoptosis and so polymorphonuclear cells accumulate
- Elimination of self-reactive lymphocytes
th
- Gametogenesis (Rubin’s 7 ed) BIOCHEMICAL FEATURES OF APOPTOSIS
o Adult men produce about 1000 new spermatozoa per second, - Protein cleavage
of which most undergo apoptosis because of intrinsic o Involves activation of several members of a family of
defects or external damage cysteine proteases (caspases)
o 99% of neonatal ovarian oocytes are eventually deleted by  Induce apoptosis
apoptosis  Cleaves vital cellular protsins
- Death of cells that have served their useful purpose  Activate DNAses
o Neutrophils after acute inflammatory response - DNA breakdown
o By Ca2+ and Mg2+ dependent endonucleases
In PATHOLOGIC CONDITIONS: - Phagocytic recognition
- Cell death produced by a variety of injurious stimuli o Expression of phosphatidylserine in the outer layer of
o Radiation and cytotoxic anticancer drugs damage DNA the plasma membranes of apoptotic cells
o Accumulation of unfolded proteins leading to endoplasmic o Expression of thrombospondin on the surface of
reticulum stress apoptotic bodies
- Cell death in certain infections, particularly viral diseases (viral
hepatitis) MECHANISM OF APOPTOSIS
- Pathologic atrophy in parenchymal organs after duct obstruction - May be divided into two phases:
(pancreas, parotid gland, kidney) 1. Initiation phase
o Caspases become catalytically active
MORPHOLOGICAL CHANGES IN APOPTOSIS o Occurs by signals from two distinct but convergent
- Cell shrinkage pathways
o dense cytoplasm  Extrinsic or receptor-initiated pathway
o normal but tightly packed organelles  Intrinsic or mitochondrial pathway
- Chromatin condensation
o most characteristic feature 2. Execution phase
o peripheral aggregation of chromatin o Phase wherein enzymes act to cause cell death.
o fragmentation of nucleus
th
- Formation of cytoplasmic blebs and apoptotic bodies From Rubin’s 7 ed:
- Phagocytosis of apoptotic cells, usually by macrophages - Apoptosis comprises several signaling pathways. These
pathways are not rigid categories, but rather are paradigms of
TABLE 2.FEATURES OF NECROSIS AND APOPTOSIS varied signaling mechanisms that lead to apoptosis. The several
Feature Necrosis Apoptosis pathways include:
o Extrinsic apoptosis – certain plasma membrane receptors
Cell size Enlarged (swelling) Reduced (shrinkage) are activated by their ligand
Pyknosis → o Intrinsic pathway – is initiated by diverse intracellular
Fragmentation into nucleosome stresses and is characterized by a central role for
Nucleus karyorrhexis →
size fragments mitochondria
karyolysis
o Inflammatory or infectious processes – may lead to
Plasma Intact; altered structure, apoptosis. Intracellular and extracellular infectious agents
Disrupted
membrane especially orientation of lipids both elicit this type of apoptosis, by diverse routes
Enzymatic o Perforin/granzymes pathway – is triggered when cytotoxic
Cellular Intact; may be released in T cells attack their cellular targets, with transfer of
digestion; may leak
contents apoptotic bodies granzymes B from the killer cell to its intended victim
out of cell
o p53-activated apoptosis – occurs in response to cellular
Adjacent
Frequent No stress or DNA damage
inflammation o Endoplasmic reticulum – may elicit apoptosis in which
Invariably Often physiologic, means of calcium signaling plays a central role
pathologic eliminating unwanted cells; may
Physiologic or
(culmination of be pathologic after some forms EXTRINSIC (DEATH RECEPTOR-INITIATED) PATHWAY
pathologic role
irreversible cell of cell injury, especially DNA CELL SURFACE DEATH RECEPTORS
injury) damage o Initiates the extrinsic pathway
o Members of the tumor necrosis factor (TNF) family that

TRANSCRIBERS: Espinosa, Elvambuena, Manching, Miniano Page 12 of 19

 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

contain a cytoplasmic domain involved in protein-protein permeability transition pore), which is closed under normal
interactions (death domain) circumstances
o Best known: type 1TNF receptor (TNFR1) and Fas (CD95) - Attached to the inner membrane are several molecules that play
key roles as the apoptotic drama unfolds
- These molecules include Cyt c (a member of the electron
transport chain), Smac/Diablo (second mitochondria-derived
activator of caspases, which promotes caspase activation),
apoptosis-inducing factor (AIF) and others
- There is an electrochemical potential (Δψm) across the inner
membrane, with the interior of the mitochondrion charged
negatively and the exterior positively, thus:
2+
o If mitochondria accumulate Ca or generate excessive
ROS or if the Δψm or mitochondrial pH decrease, the
MPTP opens
+
o MPTP opening lets water, protons (H ) and salts into the
mitochondrial matrix
o The influx of H+, water and other solutes collapses Δψm
and the loss of membrane potential impairs mitochondrial
ATP production
o In parallel, the entry of large amounts of water causes
mitochondria to swell
o The outer mitochondrial membrane then becomes more
permeable, either due to its rupture or to the opening of
outer membrane pores
Fig.33. Graphical representation of the Extrinsic Pathway
o Consequent release of inner membrane constituents 9AIF,
Pathway:
Smac/Diablo, Cyt c, etc) into the cytosol has two important
FAS is cross-linked by its ligand
effects. First, there are metabolic consequences relating to
(membrane-bound Fas ligand or FasL)
these proteins exiting the mitochondria. Second, released
↓ mitochondrial constituents activate the next phase of
3 or more molecules of Fas join
apoptotic signaling.
↓
- The outer membrane components include both proapoptotic and
Cytoplasmic death domains form a binding site for an adapter protein
antiapoptotic proteins of the Bcl-2 family
that contains a death domain
- The members of the Bcl-2 family can be viewed as belonging to
(Fas-associated death domain or FADD)
one of three subfamilies, depending on the number of Bcl-2
↓
homology (BH) domains:
FADD attached todeath receptors
o The antiapoptotic (prosurvival) members have four BH
bind inactive caspase 8 and -10
domains (labeled BH1, BH2, etc) and are often referred to
↓
as multi-BH domain proteins. These include Bcl-2, Bcl-xL,
Multiple pro-caspase-8 molecules are brought into proximity and
Mcl-1 and others
cleaves one another
o Proapoptotic (antisurvival) members are divided into two
↓
groups:
Generation of active caspase 8
 One group contains three BH domains. The key
↓
members of this group are Bak and Bax. A third
Triggers a cascade of caspase activation (caspase-3, -6, and
member, Bok, Is less well understood. Bak is
-7); caspase-3 is the most commonly activated effector caspase. It
mainly a mitochondrial protein, while Bax is largely
stimulates enzymes that cause nuclear fragmentation (e.g. caspase-
cytoplasmic.
activated DNase (CAD), which degrades chromosomal DNA); it also
 A larger group of proapoptotic proteins, BH3-only
destabilizes the cytoskeleton as the cell begins to fragment into
th proteins, carry a single BH3 domain. These
apoptotic bodies (Rubin’s 7 ed)
th include Bim, Bid, Bik, Bad and others. Different
Rubin’s 7 ed:
BH3-only proteins can elicit apoptosis by
- TNFR activation by TNF-alpha may also stimulate the
inactivating prosurvival functions of Bcl-2 family
antiapoptotic protein NFkB, a transcription factor that directs
members or by directly stimulating death-inducing
production of proteins that inhibit apoptosis
properties of Bax and Bak.
- The extrinsic patway intersects the intrinsic (mitochondrial)
pathway via caspase-8, which cleaves a cytoplasmic protein,
Mechanisms that control the intrinsic pathway:
Bid. Truncated Bid (tBid) translocates to mitochondria, where it
o In a normal mitochondrion: Among other proteins, Cyt c and
can activate apoptosis through a separate signaling mechanism. Smac/Diablo are attached to the inner mitochondrial
membrane, facing the intermembranous space. Opposite
FLIP
these, and attached to the outer membrane, are complexes
- Protein that can inhibit the extrinsic pathway by binding pro- of Bax and/or Bak bound to antiapoptotic Bcl-2 family
caspase 8 without activation members. In this peaceful equilibrium, Bcl-2 inhibits
- Produced by some viruses and normal cells for protection from proapoptotic functions of Bax/Bak, and the mitochondrial
Fas-mediated apoptosis default setting is prosurvival.
o When the intrinsic pathway is triggered: many intracellular
INTRINSIC (MITOCHONDRIAL) PATHWAY agent provocateurs, often involving stress or injury, act via
- Result of increased mitochondrial permeability and release of BH3-only family members  increase in concentrations of
pro-apoptotic molecules into the cytoplasm, WITHOUT the role of some BH3-only proteins (e.g. by activating transcription) 
death receptors conformation from quiescent to active, modifying enzymes
- Anti-apoptotic proteins and so forth  now active BH3-only molecules may
o Bcl-2, Bcl-x interpose themselves into Bcl-2 complexes with Bak and Bax
o Normally reside in mitochondrial membranes and  cause these complexes to dissociate  liberation of Bax
cytoplasm and Bak  formation of channels in the outer membrane
- Pro-apoptotic proteins (MACs [mitochondrial apoptosis-induced channels]) 
o Bak, Bax, Bim release of toxic mitochondrial proteins into cytosol
th
Rubin’s 7 ed: EXECUTION PHASE OF APOPTOSIS
- the components of mitochondrial matrix, which is the interior of
these organelles, are constrained by the impermeability of the
inner mitochondrial membrane. - FINAL PHASE OF APOPTOSIS
- This barrier is traversed by the MPTP (mitochondrial

TRANSCRIBERS: Espinosa, Elvambuena, Manching, Miniano Page 13 of 19

 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

Mitochondrial Pathway Death Receptor Pathway repair.

o If damage is too great to be repaired p53 triggers
  apoptosis
o When p53 is mutated or absent (certain
Activation of Initiator Activation of Initiator cancers)incapable of inducing apoptosis cells with
damaged DNA survivesneoplasms
o p53 stimulates transcription of pro-apoptotic proteins (Bcl
caspase-9 caspase-8 and 10
Family: Bax, Bak, and BH3-onl proteins)

C. Protein Misfolding
o Chaperones in ER are responsible for proper folding of
proteins
o misfolded proteins are ubiquinated targeted by
Cleavage of initiator into active form proteasomes
o accumulation of misfolded proteins triggers Unfolded
 Protein Response
o UPR: (1) increases production of chaperones, (2)
Activation of executioner caspases (Caspase-3 and 6) enhances proteosomal degradation, (3) slow protein
transcription
 o Failure to copeactivation of caspases apoptosis (ER
stress)
Cleaves inhibitor of cytoplasmic DNAse(it becomes
D. Apoptosis Induced by TNF Receptor Family
activated na) o TNF: does not kill the tumor directly induces
thrombosis of tumor blood vessels ischemic death of
 tumor
o while TNF induces apoptosis, it also promote cell
DNAse cleaves DNA into nucleosome-sized pieces. survival: activation of transcription factor NF-kB
Caspases also degrades structural component of nuclear o NF-kB (1) stimulates anti-apoptotic members of Bcl-2
matrix family, (2) activates a number of inflammatory responses

 E. Cytotoxic T Lymphocyte-Mediated Apoptosis

o CTL recognize foreign antigens presented on surface of
infected host cellactivation of CTLs secretion of
Fragmentation of Nuclei
perforinentry of CTL granule serine protease
granzymescleaves proteins at aspartate residues
activates caspases
REMOVAL OF DEAD CELLS o CTL also express FasL on surfaceand may kill target
cells by ligation of Fas receptors
- Apoptotic cells and their fragments undergo changes in
th
membranes that actively promote phagocytosis so it is cleared Rubin’s 7 ed:
before they undergo secondary necrosis and release their cellular Other pathways of programmed cell death (PCD):
contents. (can result in injurious inflammation). A. Apoptosis activated by p53
- Translocation of phosphatidylserine to outer membrane leaflet - normally, p53 is present in very small amounts, mostly in the
allowing for recognition and recruitment of phagocytes cytosol, where it is bound mainly to Mdm2, an E3 Ub ligase
- Also expresses soluble factors like thrombospondinadhesive - when a cell is injured, p53 undergoes diverse moleculae
glycoproptein recognized by phagocytes modifications including: phosphorylation, monoubiquitination
- Can become coated with natural antibodies and proteins of at multiple sites and others, which relax p53 binding by
complement system (c1q), recognized by phagocytes Mdm2, which both allows p53 to accumulate and targets it to
- Process of phagocytosis of apoptotic cells is so efficient, dead the mitochondria or nucleus, depending on the specific
cells disappear within minutes. molecular modification
- within the nucleus, p53 then activated transcription of many
th
Rubin’s 7 ed: proapoptotic proteins, such as Bad, Bax, NOXA and PUMA
- Once apoptosis has propelled a cell to DNA fragmentation and  repression of prosurvival proteins
cytoskeletal dissolution  apoptotic body remains  - protein-protein interactions between p53 and Bcl-2 family
phagocytosed by tissue macrophages members also enhance induction of apoptosis
- Phosphatidylserine, which translocated from inside of the cell - cytosolic p53 directly activates Bax  Bax relocates to
membrane to the outside, is recognized by macrophages and mitochondria  apoptosis
activates ingestion of an apoptotic cell’s mortal remains without - mitochondrial-targeted p53 acts as a functional BH3-only
release of intracellular constituents, avoiding an inflammatory protein  disrupts complex between Bax and its inhibitor 
reaction apoptosis
- Mononuclear phagocytes ingest the debris from apoptotic cells, - p53 also regulates cell cycle, metabolism and other cell
but recruitment of neutrophils or lymphocytes is rare functions.

CLINICO-PATHOLOGIC CORRELATIONS B. Calcium release by ER elicits apoptosis

- prolonged release of calcium from the ER, due to cell stress,
A. Growth Factor Deprivation  mitochondrial p. is also a key to apoptosis
o Hormone-sensitive cells deprived of the relevant hormone - the proximity of the ER to the mitochondria is key to this
o Lymphocytes not stimulated by antigens and cytokines, process: calcium released by the ER may be taken up by
2+
and neurons deprived of nerve growth factor die by mitochondria  increase in mitochondrial Ca  opening of
apoptosis MPTP  release of Cyt c  apoptosis
2+
o Is attributable to decreased synthesis of Bcl-2 and Bcl-x - sustained release of Ca from ER  release of caspase-12
and activation of Bim and other pro-apoptotic members of (normally bound to ER membrane) activation of caspase-
the Bcl family. 12  activation of caspase-9  triggers executioner
caspase-3
B. DNA Damage
o Exposure of cells to radiation or chemotherapeutic agents C. Autophagy in PCD
induces apoptosis (genotoxic stress) - may promote excessive removal of cell organelles, and so
o Involves tumor-suppressor gene p53accumulates and irrevocably interfere with vital cellular functons
arrests cell cycle (at the G1 phase) to allow time for - it may also destroy proteins that sustain cell survival

TRANSCRIBERS: Espinosa, Elvambuena, Manching, Miniano Page 14 of 19

 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

D. Necroptosis it is independent of apoptotic signaling, and its activation

- PCD independent of caspases does not bring about apoptosis
- Commonly initiated by Fas ligand (FasL) or TNF- - instead, caspase -1 is a proinflammatory protease that is
alphabinding to its respective receptors  receptor-bound produced by a structure called an inflammasome 
complexes incorporating caspase-8, two IAP proteins (E3 Ub activation of caspase-1  cleaves select cellular molecules,
ligases), along with several other proteins, and the receptor including enzymes that are important fro glycolysis, thereby
activating proteins (RIP1, RIP3) depleting cellular energy
- This complex sits on the knife edge of several alternative - also produces ion-permeable plasma pores  influx of water
fates, but activation of RIP1 and RIP3 leads to cell death by and solutes to provoke cell swelling and then death
necroptosis - elicits inflammation, by activating proinflammatory cytokines
- RIP3 is the epeicenter of this process  increased cytosolic - implicated in the pathogenesis of metabolic syndrome and
2+
Ca  activation of calpain and other degradative enzymes the etiology of type 2 diabetes mellitus
 attacks lysosome membranes  release of lysosomal
hydrolases into the cytosol H. NETosis
- Calpain also damages mitochondria, precipitating metabolic - Neutrophil extracellular traps (NETs) are structures produced
dysfunction with impaired ATP generation and iron release, by polymorphonuclear granulocytes
with consequent increases in ROS and damage to proteins, - NETs function as chromatin traps for bacteria and other
lipids and DNA pathogens and contain antimicrobial cell products
- AIF is also released by the mitochondria, which enters the - Can kill bacterial, fungal and protozoal pathogens
nucleus and activates DNA degradation - Result from activation of a cell death program, mainly in
- A bioenergetic crisis with the morphological features of neutrophils, but also including eosinophils and mast cells
necrosis ensues (NETosis)
- Cells then release molecules called damage-associated - May be composed of either nuclear or mitochondrial
molecular patterns (DAMPs) that provoke inflammation chromatin and do not necessarily need self-sacrifice of the
- Physiologically, necroptosis participates in development, neutrophil that contributes the chromatin
particularly at bone growth plate, lower portion of the - NETosis requires both autophagy and nicotinamide adenine
intestinal crypts dinucleotide phosphate (NADPH) oxidase activity and is
- may be important in cancer cells, since apoptosis is blocked characterized by destruction of the cell’s nuclear envelope
in the latter and the membranes of most cytoplasmic granules
- it is a double-edged sword and may participate in pathologic - Chromatin aggregation results, and the cell extrudes a NET
processes such as neurodegenerative diseases and containing both chromatin and strongly microbicidal histones
ischemia/reperfusion injury and hidtone cleavage products
- Cells with NETosis do not present “eat me” signals (cell
E. Anoikis membrane phosphatidylserine) that are characteristic of
- activated by loss of cell attachments apoptosis
- means “homelessness” in greek - Lacking these signals, NETotic cells are not preemptively
- a variety of apoptosis that occurs in epithelial cells and is removed by macrophages and are able to stimulate
caused by loss of cell adhesion or inappropriate cell inflammatory responses
adhesion
- correct binding of a cell to ECM helps to determine whether I. Entosis
that cell is in its appointed location - is a type of cellular cannibalism in which cells that are not
- efficiently deletes cells that have been displaced from their professional phagocytes engulf nearby living cells
proper residence - aggressor cells may engulf cells of either the same or other
- prevents wandering cells or cell clusters from developing lineages
colonies at distant or improper ECM sites, and so helps - e.g. hepatocytes may ingest and destroy autoreactive T
protect against the developing metastases lymphocytes  inhibits experimental autoimmune liver
- operates via intrinsic or extrinsic classical apoptotic disease
pathways, both of which are upregulated when a cell - often seen in tumors
becomes detached - vacuoles containing cells undergoing entosis may fuse with
- a cell that loses contact with its normal ECM, like one that is lysosomes in which case target cells usually die, although
pushed off the tip of an intestinal villus by proliferating cells death is not an inevitable outcome
deeper in the crypts, is stimulated to undergo anoikis by loss - the cannibalized cell, or parts thereof, may survive the
of integrin-mediated survival signalling process
- if a detached cancer cell makes contact with inappropriate - its nuclear material may become part of the aggessor cell,
ECM components, anoikis may be activated leading to multinucleate cells, polyploidy or aneuploidy
- some engulfed cells actually escape their captors and re-
F. Granzymes emerge unscathed
- released by lymphocytes and kill cells via apoptosis
- NK cells and cytotoxic T cells release two major molecular
species: perforin and granzymes INTRACELLULAR ACCUMULATIONS
- Perforin punches a hole in the plasma membrane of a target
cell, through which proteins from the lymphocyte enter - One of the manifestations of metabolic derangements
- Granzymes are a family of multifunctional serine proteases, - May accumulate transiently or permanently
among which the best understood is granzyme B - May be harmless to the cells, but on occasion they are severely
- Activates cytosolic Bid, a BH3-only protein, by cleaving it to toxic
tBid  tBid increases mitochondrial release of Cyt c and - May be located in either the cytoplasm (frequently within
other cell death effector proteins phagolysosomes) or the nucleus
- also converst several procaspases notably caspase-3) to - In inherited storage diseases accumulation is progressive, and
active caspases the overload may cause cellular injury
- Granzyme A is also released by the two cells mentioned - Three categories:
- Both A and B activate DNA nicking enzyme, CAD (caspase- o Normal cellular constituent (EXCESS water, lipids,
activated Dnase), which degrades genomic DNA proteins, and carbohydrates)
o Abnormal substance, either exogenous (mineral or
G. Pyroptosis products of infectious agents) or endogenous (product
- is a cell death program that relies on caspase-1 (IL-1beta of abnormal synthesis or metabolism)
converting enzyme) o Pigments
- infectious agents, particularly viruses, stimulate inflammatory
reactions by interacting with members of a group of cell TYPES OF ABNORMALITIES THAT RESULT TO
membrane receptors called pattern recognition receptors INTRACELLULAR ACCUMULATIONS
- although caspase-1 is a cysteine protease involved in PCD,

TRANSCRIBERS: Espinosa, Elvambuena, Manching, Miniano Page 15 of 19

 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

A. Normal or increased production of normal endogenous substance - Causes:

+ inadequate rate of metabolism  normal endogenous o Toxins, protein malnutrition, diabetes mellitus, obesity,
substance accumulation anoxia, alcohol abuse
o Fatty change in the liver - Mechanisms:
o Reabsorption protein droplets in the tubules of the kidneys o Excessive entry or defective metabolism and export of lipid
o Alcohol alters mitochondrial and microsomal
B. Defects in protein folding and transport because of a mutated functionsincreased synthesis and reduced breakdown of
gene + inability to degrade the abnormal protein efficiently  lipids
abnormal endogenous substance accumulation o CCl4 and protein malnutrition reduced synthesis of
o Accumulation of mutated α1-antitrypsin in liver cells apoproteins
o Various mutated proteins in degenerative disorders of the o Hypoxia inhibits fatty acid oxidation
central nervous system o Starvationincreases fatty acid mobilization from
peripheral stores
C. Defects, usually inherited, in enzymes that are required for the
metabolism of the substance normal endogenous substance
accumulation
o Diseases caused by genetic defects in enzymes involved
in the metabolism of lipid and carbohydrates
o Abnormal exogenous substance is deposited and
accumulates

D. Absence of the enzymatic machinery to degrade the substance

and the ability to transport it to other sites  abnormal
exogenous substance accumulation
o Accumulations of carbon particles and nonmetabolizable
chemicals such as silica

Fig.35. Mechanism of steatosis in the liver

- Morphology
o Change appears as clear vacuoles within parenchymal
cells
o Identification requires the avoidance of fat solvents
o To identify the fat, it is necessary to prepare frozen tissue
sections of either fresh or aqueous formalin fixed
tissues
o May then be stained with Sudan IV or Oil Red-O, both of
which impart an orange-red color to the contained lipids
o The periodic acid-Schiff (PAS) reaction, coupled with
digestion by the enzyme diastase, is used to identify
glycogen, although it is not specific

LIVER
- Organ enlarges and becomes increasingly yellow until it begins
with the development of minute, membrane-bound inclusions
(liposomes) closely applied to the ER

HEART
- Prolonged moderate hypoxia intracellular deposits of fat, which
create grossly apparent bands of yellowed myocardium
alternating with bands of darker, red-brown, uninvolved
myocardium (tigered effect)
- More profound hypoxia or by some forms of myocarditis (e.g.,
diphtheria infection)  shows more uniformly affected myocytes.

CHOLESTEROL AND CHOLESTEROL ESTERS

- Manifested histologically by intracellular vacuoles in several

pathologic processes:

I. Atherosclerosis
o Foam cells - smooth muscle cells and macrophages
Fig.34. Effects of different compounds at high concentrations in the cell
within the intimal layer of the aorta and large arteries which
are filled with lipid vacuoles
o Aggregates of foam cells in the intima produce the yellow
TYPES OF INTRACELLULAR ACCUMULATIONS
cholesterol-laden atheromas which may rupture
1. LIPIDS
o Extracellular cholesterol esters may crystallize in the
- May be triglycerides, cholesterol/cholesterol esters, and
shape of long needles, producing distinctive clefts in tissue
phospholipids (components of the myelin figures found in necrotic
sections.
cells)
II. Xanthomas
- Abnormal complexes of lipids and carbohydrates accumulate in
the lysosomal storage diseases o Intracellular accumulation of cholesterol within
macrophages is also characteristic of acquired and
hereditary hyperlipidemic states
STEATOSIS (FATTY CHANGE)
o Clusters of foamy cells are found in the subepithelial
connective tissue of the skin and in tendons, producing
- Abnormal accumulations of triglycerides within parenchymal cells tumorous masses
- Often seen in the liver because it is the major organ involved in III. Cholesterolosis
fat metabolism o Focal accumulations of cholesterol-laden macrophages in
- Also occurs in heart, muscle, and kidneys the lamina propria of the gallbladder

TRANSCRIBERS: Espinosa, Elvambuena, Manching, Miniano Page 16 of 19

 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

IV. Niemann-Pick disease, type C heart muscle cells

o lysosomal storage disease - Glycogen storage diseases, or glycogenoses: enzymatic
o Caused by mutations affecting an enzyme involved in defects in the synthesis or breakdown of glycogen
cholesterol trafficking, resulting in cholesterol accumulation
4. PIGMENTS
2. PROTEINS - Colored substances which can either be a normal constituent of
- Appear as rounded, eosinophilic droplets, vacuoles, or cells or abnormal that accumulate in cells only under special
aggregates in the cytoplasm circumstances
- In amyloidosis, abnormal proteins deposit primarily in - Can be exogenous or endogenous
extracellular spaces

CAUSES EXOGENOUS PIGMENTS

a. In disorders with heavy protein leakage across the glomerular
filter there is increased reabsorption of the protein into - Most common is carbon (coal dust; a ubiquitous air pollutant of
vesiclesprotein appears as pink hyaline droplets within the urban life)inhaledpicked up by macrophages within the
cytoplasm of the tubular cell alveolitransported through lymphatic channels to the regional
b. Normal secreted proteins produced in excessive amounts (e.g. lymph nodes in the tracheobronchial regionanthracosis
plasma cells engaged in active synthesis of immunoglobulins) (accumulations of this pigment blacken the tissues of the lungs
c. ER becomes hugely distended, producing large, homogeneous and lymph nodes)
eosinophilic inclusions called Russell bodies. - Coal worker's pneumoconiosis- aggregates of carbon dust
d. Defective intracellular transport and secretion of critical proteins may induce a fibroblastic reaction or even emphysema in coal
o α1-antitrypsin deficiency miners
 Inheritable disorder in which mutations in the gene - Tattooing
coding for α1-antitrypsin yield an insoluble protein o A form of localized, exogenous pigmentation of the skin
that is not easily exported. It accumulates in liver o Pigments inoculated are phagocytosed by dermal
cells, thereby causing cell injury and eventually macrophages where in which they reside for the remainder
th
cirrhosis (Rubins, 7 ed.) of the life  the pigments do not usually evoke any
e. Accumulation of cytoskeletal proteins inflammatory response
o Types of cytoskeletal proteins
҂ Microtubules (20Ŕ25 nm in diameter) ENDOGENOUS SUBSTANCE
҂ Thin actin filaments (6Ŕ8 nm)
҂ Thick myosin filaments (15 nm) I. Lipofuscin
҂ Intermediate filaments (10 nm) o An insoluble pigment, also known as lipochrome or wear-
o Provide a flexible intracellular scaffold that organizes the and-tear pigment
cytoplasm and resists forces applied to the cells o Polymers of lipid and phospholipids in complex with
o Five classes of intermediate filaments: protein (derived through lipid peroxidation)
1. Keratin filaments (characteristic of epithelial cells) o Telltale sign of free radical injury
2. Neurofilaments (neurons) o Histology: yellow-brown, finely granular cytoplasmic, often
3. Desmin filaments (muscle cells) perinuclear pigment.
4. Vimentin filaments (connective tissue cells)
5. Glial filaments (astrocytes) II. Melanin
o Accumulations of keratin filaments and neurofilaments o Endogenous, non-hemoglobin-derived, brown black
are associated with certain types of cell injury pigment
o Alcoholic hyaline is an eosinophilic cytoplasmic inclusion o Formed when the enzyme tyrosinase catalyzes the
in liver cells that is characteristic of alcoholic liver oxidation of tyrosine to dihydroxyphenylalanine in
disease melanocytes
o Neurofibrillary tangle found in the brain in Alzheimer
disease contains neurofilaments III. Homogentisic acid
f. Aggregation of abnormal proteins o A black pigment that occurs in patients with alkaptonuria,
o Can be intracellular, extracellular, or both, and the a rare metabolic disease
aggregates may either directly or indirectly cause the o Pigment is deposited in the skin, connective tissue, and
pathologic changes cartilage
o Amyloidosis o Pigmentation is known as ochronosis
o Proteinopathies or protein-aggregation diseases.
IV. Hemosiderin
HYALINE CHANGE o hemoglobin-derived, golden yellow-to-brown, granular or
- An alteration within cells or in the extracellular space that gives a crystalline pigment
homogeneous, glassy, pink appearance in sections stained with o one of the major storage forms of iron
hematoxylin and eosin o local or systemic excess of iron causes ferritin to form
- E.g. Reabsorption droplets, Russel bodies, alcoholic hyaline hemosiderin granules
- In long-standing hypertension and diabetes mellitus, walls of o Causes: increased absorption of dietary iron, hemolytic
arterioles, especially in the kidney, become hyalinized, resulting anemias, repeated blood transfusions
from extravasated plasma protein and deposition of basement o Hemochromatosis
membrane material.  An inherited disease with extreme accumulation of
iron associated with liver, heart, and pancreatic
3. GLYCOGEN damage, resulting in liver fibrosis, heart failure, and
- Readily available energy source stored in the cytoplasm of diabetes mellitus
healthy cells
- Abnormality in either glucose or glycogen metabolismexcessive V. Bilirubin
intracellular deposits of glycogen o Derived from hemoglobin, but contains no iron.
- Glycogen masses appear as clear vacuoles within the cytoplasm o Kernicterus
- Dissolves in aqueous fixatives  A condition where unconjugated bilirubin is found in
- For localization, tissues are best fixed in absolute alcohol the brain and may lead to death.
- Staining with Best carmine or the PAS reaction imparts a rose-
to-violet color to the glycogen 5. PATHOLOGIC CALCIFICATION
- Diastase digestion before staining serves as a further control by - Abnormal tissue deposition of calcium salts with smaller amounts
hydrolyzing the glycogen of iron, magnesium, and other mineral salts
- Diabetes mellitus: glycogen is found in renal tubular epithelial
cells, within liver cells, β cells of the islets of Langerhans, and DYSTROPHIC CALCIFICATION

TRANSCRIBERS: Espinosa, Elvambuena, Manching, Miniano Page 17 of 19

 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

- Occurs despite normal serum levels of calcium and in the CELLULAR AGING
absence of derangements in calcium metabolism
- Deposition occurs locally in dying tissues - Is the result of a progressive decline in cellular function and
- Encountered in areas of necrosis, whether they are of viability caused by genetic abnormalities and the accumulation of
coagulative, caseous, or liquefactive type, and in foci of cellular and molecular damage due to the effects of exposure to
enzymatic necrosis of fat exogenous influences
- Present in the atheromas of advanced atherosclerosis
- Aging or damaged heart valves FACTORS
- Morphology A. DECREASED CELLULAR REPLICATION
o Basophilic, amorphous granular, sometimes clumped - Senescence
appearance; fine, white granules or clumps, often felt as o Non dividing state after a fixed number of divisions
gritty deposits - Werner’s Syndrome
o Single necrotic cells may constitute seed crystals that o Disease of premature aging; defective DNA; reduced
become encrusted by the mineral deposits capacity to divide
o Progressive acquisition of outer layers may create - Telomeres
lamellated configurations, called psammoma bodies o When somatic cells replicate, a small section of the
Some types of papillary cancers (e.g., thyroid) are apt telomere is not duplicated and telomeres become
to develop psammoma bodies progressively shortenedAs telomeres shorten the ends
o In asbestosis, calcium and iron salts gather about long of chromosomes cannot be protected and are seen as
slender spicules of asbestos in the lung, creating exotic, broken DNA, which activates the DNA damage response
beaded dumbbell forms and signals cell cycle arrest
- Pathogenesis:
o Calcium is concentrated in membrane-bound vesicles in B. ACCUMULATION OF METABOLIC AND GENETIC DAMAGE
cells by a process that is initiated by membrane damage - Life span is determined by a balance between damage resulting
and has several steps: from metabolic events occurring within the cell and counteracting
Calcium ion binds to the phospholipids present in the molecular responses that can repair the damage
vesicle membrane - Reactive oxygen species
 o By products of oxidative phosphorylation and have
Phosphatases associated with the membrane generate deleterious effects on DNA and cellular membrane.
phosphate groups, which bind to the calcium o Antioxidants to counteract ROS: Vit E, glutathione
 peroxidise, SOD, catalase
The cycle of calcium and phosphate binding is repeated, - Calorie Restriction
raising the local concentrations and producing a deposit o Effect mediated by a family of proteins called sirtuins:
near the membrane  Has histone deacetylase activity which promotes
 expression of genes
A structural change occurs in the arrangement of calcium  It also increases insulin sensitivity and glucose
and phosphate groups, generating a microcrystal, which metabolism
can then propagate and lead to more calcium deposition  Growth factors, such as insulin-like growth factor,
 and intracellular signaling pathways triggered by
Final common pathway is the formation of crystalline these hormones also influence life span.
calcium phosphate mineral in the form of an apatite  Transcription factors activated by insulin receptor
similar to the hydroxyapatite of bone signaling may induce genes that reduce
longevity, and insulin receptor mutations are
METASTATIC CALCIFICATION associated with increased life span.
- May occur in normal tissues and results from hypercalcemia
secondary to some disturbance in calcium metabolism.
- Causes of hypercalcemia
o Increased secretion of parathyroid hormone (PTH) with
subsequent bone resorption (hyperparathyroidism,
ectopic secretion of PTH-related protein by malignant
tumors)
o Destruction of bone tissue, secondary to primary tumors
of bone marrow or diffuse skeletal metastasis,
accelerated bone turnover or immobilization;
o Vitamin D–related disorders (vitamin D intoxication,
Fig.36. Several factors and their mechanisms that effect to cellular ageing
sarcoidosis (in which macrophages activate a vitamin D
precursor), and idiopathic hypercalcemia of infancy END
(Williams syndrome) Sample problems
o Renal failure, which causes retention of phosphate,
leading to secondary hyperparathyroidism 1. A 52-year-old woman loses her right kidney following an automobile
o Less common causes include aluminum accident. A CT scan of the abdomen 2 years later shows marked
intoxicationoccurs in patients on chronic renal dialysis, enlargement of the left kidney. The renal enlargement is an example
and milk-alkali syndromedue to excessive ingestion of of which of the following adaptations?
calcium and absorbable antacids such as milk or calcium A. Atrophy
carbonate. B. Dysplasia
- Principally affects the interstitial tissues of the gastric mucosa, C. Hyperplasia
kidneys, lungs, systemic arteries, and pulmonary veins D. Hypertrophy
- All of these tissues excrete acid and therefore have an internal E. Metaplasia
alkaline compartment that predisposes them to metastatic
calcification. 2. A 10-year-old girl presents with advanced features of progeria.
- Massive involvement of the lungs produces remarkable x-ray This child has inherited mutations in the gene that encodes which of
films and respiratory deficits. the following types of intracellular proteins?
- Massive deposits in the kidney (nephrocalcinosis) may in time
cause renal damage A. Helicase
- Morphology B. Lamin
o May occur as noncrystalline amorphous deposits or, at C. Oxidase
other times, as hydroxyapatite crystals. D. Polymerase
E. Topoisomerase

3. A 47-year-old man with a history of heavy smoking complains of

TRANSCRIBERS: Espinosa, Elvambuena, Manching, Miniano Page 18 of 19

 Cellular Responses to Stress and Toxic Insults: Adaptation, Injury & Death

chronic cough. A “coin lesion” is discovered in his right upper lobe atypia. Which of the following terms best describes this
on chest X-ray. Bronchoscopy and biopsy fail to identify a mass, morphologic response to persistent injury in the esophagus of this
but the bronchial mucosa displays squamous metaplasia. What is patient?
the most likely outcome of this morphologic adaptation if the
patient stops smoking? A. Atypical hyperplasia
A. Atrophy B. Complex hyperplasia
B. Malignant transformation C. Glandular metaplasia
C. Necrosis and scarring D. Simple hyperplasia
D. Persistence throughout life E. Squamous metaplasia
E. Reversion to normal

4. You are asked to present a grand rounds seminar on the role of

abnormal proteins in disease. In this connection, intracellular
accumulation of an abnormally folded protein plays a role in the
pathogenesis of which of the following diseases?
A. AA amyloidosis
B. AL amyloidosis
C. α1-antitrypsin deficiency
D. Gaucher disease
E. Tay-Sachs disease

5. A 68-year-old man with a history of gastroesophageal reflux

disease suffers a massive stroke and expires. The esophagus at
autopsy is shown in the image. Histologic examination of the
abnormal tissue shows intestine-like epithelium composed of
goblet cells and surface cells similar to those of incompletely
intestinalized gastric mucosa. There is no evidence of nuclear

TRANSCRIBERS: Espinosa, Elvambuena, Manching, Miniano Page 19 of 19