Cell Injury & Adaptation

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 Outlines
• Introduction
• Adaptations of Cellular Growth and
Differentiation
• Causes of Cell Injury
• Morphologic Alterations in Cell Injury
• Mechanisms of Cell Injury
• Necrosis
• Apoptosis
• Intracellular Accumulations
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Introduction

• Cells intracellular milieu is normally tightly regulated

such that it remains fairly constant, a state referred
to as homeostasis.
• Adaptations are reversible morphological and
structural changes to changes in physiology and
some pathologic stimuli
• These mechanism during which new but altered
steady states are achieved allows cells to survive
and continue to function.

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 Cont’d…
• Cell injury is a sequence of event that follows if the
limits of adaptive responses are exceeded or if cells
are exposed to injurious stress

• Cell injury is reversible up to a certain point, but if

the stimulus persists or is severe enough from
the beginning, the cell suffers irreversible injury
and ultimately undergoes cell death.

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 Cont’d…
• Cell death, the end result of progressive cell injury, is
one of the most crucial events in the evolution of
disease in any tissue or organ.
• Necrosis and apoptosis are the two principal
mechanisms of cell death.
• Nutrient deprivation triggers an adaptive cellular
response called autophagy that may also culminate
in cell death.

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 Cont’d…
• Metabolic derangements in cells may be
associated with intracellular accumulations of a
number of substances
• Calcium is often deposited at sites of cell death,
resulting in pathologic calcification.
• The normal process of aging is accompanied by
characteristic morphologic and functional changes
in cells.

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Adaptations of Cellular Growth
and Differentiation
• Adaptations are reversible changes in the size,
number , phenotype , metabolic activity or
functions of cells in response to changes in their
environment.
• Includes;
• Hypertrophy
• Hyperplasia
• Atrophy
• Metaplasia

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 Cont’d…
❑Hypertrophy –refers to increase in cell size
• Usually due to increased work load , hormone and
growth factor stimulation. for instance, Skeletal muscle
and cardiac muscle
mechanism:
• Hypertrophy occurs due to increased protein
production as stimulation of mechanical sensors
,growth factors and vasoactive agents
• Hypertrophy can be physiologic or pathologic.

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Biochemical mechanisms of myocardial hypertrophy 11
Photomicrograph of myometrium before and during pregnancy 12
 Cont’d…
❑Hyperplasia –refers to increase in cell number .
➢Physiologic-through hormone stimulation when
needed and compensatory after tissue resection or
damage. For instance ,breast enlargement during
puberty
➢Pathologic –usually due to excess hormone. E.g:
Endometrial hyperplasia, BPH
• Cells in hyperplasia ,due to lack of genetic mutations
in their cells their growth is regulated one.
• But can provide fertile soil for malignancy

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 Cont’d…
• Mechanism: hyperplasia occurrence is growth factor driven
proliferation of mature cells and increased output of new
cells from tissue stem cells.
❑Atrophy –refers to reduced cell size and number
➢Physiologic- common during normal development eg
Embryonic structures like thyroglossal duct
➢Pathologic –several causes, include decreased work load
,blood supply, innervation ,nutrition and endocrine
stimulation and pressure over surrounding tissue by tumors.

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Brain atrophy 15
 Cont’d…
❑Metaplasia –refers to re differentiation of one cell
type to another .
• Occurs due to reprograming of stem cells from normal
tissues and activity that alter transcription factor that
regulate differentiation.
• The differentiation of stem cells to a particular lineage
is brought about by signals generated by cytokines,
growth factors, and extracellular matrix components
in the cells’ environment.

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• These external stimuli promote the expression of
genes that drive cells toward a specific
differentiation pathway.
• direct link between transcription factor
dysregulation and metaplasia is seen with
vitamin A (retinoic acid) deficiency or excess, both
of which may cause metaplasia.
• Retinoic acid regulates gene transcription directly
through nuclear retinoid receptors which can
influence the differentiation of progenitors derived
from tissue stem cells

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Metaplasia of columnar to squamous epithelium 18
Causes of cell injury
• Cell injury results when cells are stressed so
severely that they are no longer able to adapt.
• Causes of cell injury include ;
1. hypoxia – decreased blood supply , CRF ,anemia
,CO poisoning .
2.physical –trauma , burn , atmospheric pressure
change
3.chemical agents and drugs –alcohol ,poisons…
4.infectious –viruses ,bacteria …

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 Cont’d…
5.immunologic –autoimmunity , immune reactions
6.genetic derangement – down syndrome ,sickle cell
anemia
7.nutritional status -malnutrition

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Morphologic alterations in cell injury

• There is a time lag between the stress and the

morphologic changes of cell injury or death
• All stresses and noxious influences exert their
effects first at the molecular or biochemical level.
• With histochemical or ultra structural techniques,
changes may be seen in minutes to hours after
injury
• However, it may take considerably longer (hours
to days) before changes can be seen by light
microscopy or on gross examination.
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 Cont’d…
❑Reversible injury – Characterized by cellular swelling
and fatty change.
• Generalized cellular swelling is first appearance of
almost all cell injury, may appear as small clear
vacuoles
• Blebbing of cell membrane (blunting , bulging , loss of
microvillus)
• Mitochondria swelling ( small amorphous densities)

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 Cont’d…
• Detachment of ribosomes from ER , ER dilation ,
myelin figures
• Nuclear alteration like disaggregation of granular
and fibrillar components.
• If injury abates these morphological changes can
return to normalcy otherwise irreversible cell injury
occurs ending up in cell death.
• Cell death –the two principal mechanisms are
necrosis and apoptosis

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Necrosis

• The morphologic appearance of necrosis as well

as necroptosis is the result of degeneration of
intracellular proteins and enzymatic digestion of
the lethally injured cell.
• Enzymes that digest the cells are derived from
themselves and leucocyte lysosomes

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 Cont’d…
• Characteristics of necrosis;
• Increased eosinophilia – due to loss of
cytoplasmic RNA and denatured cytoplasmic
proteins
• Glassy homogenous appearance –due to
glycogen loss
• Myelin figures –phospholipid precipitates
appear as large whorled masses

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Photomicrograph showing Morphologic changes in
reversible cell injury and necrosis 29
 Cont’d…
• EM - calcification ,dilated mitochondria ,
intracytoplasmic myelin figures , amorphous debris
,fluffy material .
• Nuclear changes
• Pyknosis – solid ,shrunken basophilic mass
• Karyolysis –faded basophilia of chromatin due
to loss of DNA by endonucleases
• Karyorrhexis –fragmentation of pyknotic
nucleus
• Total loss of nucleus after a day or two.

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 Patterns of tissue necrosis
• When large number of cells die tissue is called
necrotic.
❑Coagulative necrosis –
• When blood supply is obstructed to organs infarct
occurs
• infarct is localized area of coagulative necrosis.
• Cells architecture is preserved for some days or
weeks until phagocytosis.

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Photomicrograph of edge of infarct in kidney 32
❑Liquefactive necrosis –
due to digestion of dead
cells, formation of liquid
viscous mass
• For unknown reasons,
hypoxic death of cells
within the central
nervous system often
manifests as liquefactive
necrosis.

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 Cont’d…
❑Gangrenous necrosis –
not specific type but its
given to coagulative
necrosis of limb
• when bacteria is
superimposed its called
wet gangrene

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❑Caseous necrosis –
cheese like due to
friable white
appearance
• Microscopically
appearance is a
collection of
fragmented or lysed
cells and amorphous
granular debris
enclosed within a
distinctive
inflammatory border 35
Photomicrograph showing caseous necrosis 36
❑Fat necrosis –fat
destruction , foci of
shadowy outline of
necrotic fat cells ,
basophilic , calcium
deposit surrounded by
inflammatory reaction
• The fatty acids, so
derived, combine with
calcium to produce
grossly visible chalky-
white areas (fat
saponification) 37
Photomicrograph showing fat necrosis 38
 Cont’d…
❑Fibrinous necrosis –
occurs due to immune
reaction in blood vessel,
immune complex
deposition results in
bright pink and
amorphous appearance

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 Apoptosis
• Is programmed cell death
• Physiologic –during embryogenesis and development
• Hormone dependent tissues
• Removal of immature lymphocytes in proliferating cell
population
• Removal of harmful self reacting lymphocytes
• Cells that performed their function like lymphocytes
after inflammation

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 Cont’d…
• Pathologic causes :
• DNA damage
• Accumulation of misfolded proteins
• Cell death in certain inflammation
• Pathological atrophy after duct obstruction

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 Cont’d…
• Morphologic changes –
• cell shrinkage
• Chromatin condensation
• Formation of cytoplasmic blebs and apoptotic
bodies
• Phagocytosis of apoptotic cells or cell bodies

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morphologic appearance of apoptosis 43
 Cont’d…
❑Biochemical features of apoptosis:
• Apoptosis results from activation of caspases
• The activation of caspases depends on a finely tuned
balance between production of pro-apoptotic and
anti-apoptotic proteins
• two types of caspases, initiator caspases ( cas 8,9,10)
and executioner caspases ( cas 3 and 6)
• they are proenzymes they have to be cleaved to be
activated

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 Cont’d…

• Two mechanisms of apoptosis ,both lead to

executioner caspases:
• Intrinsic (Mitochondrial) pathway
• Extrinsic (Death receptor) pathway

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 Cont’d…
1.Intrinsic (mitochondrial)pathway
• Major mechanism
• Mediated by bcl2 family
• Lack of growth factor and other surviving signals
produce activation of sensors Bim,Bid,Bad,puma,
noxa (BH3 only proteins) leading to Bax and Bak
activation on the mitochondria and increase
mitochondrial permeability which causes the intra
mitochondrial cyt-c to be released to the cytosol

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 Cont’d…
• Leakage of cytc is followed by binding to Apaf -1
and this complex binds to caspase 9
• Normal growth factor and other surviving signals
produce antiapoptotic proteins Bcl2 ,Bcl xl and Mcl
-1 they control mitochondrial permeability
• These proteins are antagonized by BH3 only
proteins which leads to increased mitochondrial
permeability.

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 Cont’d…
2. Extrinsic (death receptor) pathway
• Member of TNF family TNF R 1 and Fas (CD 95)
have cytoplasmic death domain
• Ligand of Fas(Fas ligand) is expressed in T cells and
some cytotoxic T lymphocytes
• Engagement of their protein on plasma membrane
cause death domain to bind to FADD which
activates cytoplasmic caspase 8 or 10 and after
cleaving becomes active and enter executioner
phase
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 Cont’d…

• Clearance of apoptotic cells –apoptotic cells

produce a number of “eat-me” signals
• Efflux of phosphatidilserine to outer membrane
attracts phagocytosing receptors

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Mechanism of cell injury
• Cell injury results from different biochemical
mechanisms acting on several essential cellular
components
• It is a complex process that depends on nature of
injury ,duration ,severity and adaptability status of
the cell

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 Cont’d…
❑Depletion of ATP –ATP is used for virtually all
synthetic and degradative processes of cell.
• Produced by two mechanisms:
1. oxidative phosphorylation of ADP using oxygen
and
2.glycolytic pathway –using glycolysis in the
absence of oxygen

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 Cont’d…
❑Depletion of ATP can be due to ischemia ,toxin
mitochondrial damage resulting in;
1.Na+,K+,ATPase on plasma membrane reduction
resulting in influx of Na+ and cellular swelling
,dilation of ER
2.anerobic metabolism –lactic acid accumulation
and inorganic phosphate and decrease in cellular PH
and decrease in activity of some cellular enzymes

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 Cont’d…
3.Failure of Ca2+ pump leading to influx of Ca2+
4.structural disruption of protein synthetic apparatus
detachment of ribosomes from RER leading to
decreased protein synthesis
5. decreased oxygen and glucose leads to misfolded
protein response that culminate in cell death
6.damage to mitochondria and lysosomes

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 Cont’d…
❑Mitochondrial damage –site of ATP production
• Increased cytosolic Ca2+ , oxygen deprivation and
toxins can damage mitochondria and leads to three
major consequences,
1.Formation of high conductance channels in their
membrane(MPTP) giving rise to loss of potential
resulting in oxygen phosphorylation failure and
progress to depletion of ATP .

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 Cont’d…
2.Abnormal oxidative phosphorylation also leads
to the formation of reactive oxygen species

3.Mitochondria is capable of apoptosis activation by

releasing cytc and caspases in the cytosol

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❑Influx of Ca2+ and loss of calcium homeostasis -
• Release of Ca2+ from cell store and influx from
extracellular matrix cause cell injury
• 1.activation of MPTP in mitochondria
• 2.induction of apoptosis by activating caspases and
increase mitochondrial permeability

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 Cont’d…
❑Accumulation of oxygen derived free radicals
(oxidative stress) -
• Free radicals are chemical species that have a single
unpaired electron in an outer orbit
• Energy created by this configuration is released
through reactions with adjacent molecules such as
inorganic and organic chemicals

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 Cont’d…
• Free radicals initiate autocatalytic reactions and
propagate chain of damage (lipid peroxidation
,protein oxidation and DNA damage)

• Oxidative stress occurs when ROS are produced in

excess or removal is slow.

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❑Generation of free radicals -
• Reduction- oxidation reactions that occur during
normal metabolic processes
• Absorption of UV light , ionizing radiation can
hydrolyze water into ˙OH and hydrogen free
radicals
• O2_• production from activated leucocytes

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 Cont’d…

• Enzymatic metabolism of drugs

• Fe and Cu catalyze free radical formation by fenton
reaction

• NO can be converted to ONOO-,NO2 ,NO3-

• Reperfusion of ischemic tissues

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 Cont’d…
• Removal of free radicals -
• SOD (Super oxide dismutase) converts superoxide to
hydrogen peroxide
• Storage of Fe and Cu in form of ferritin and
ceruloplasmin
• Catalase(peroxisomes) catalyses H2O2 to O2 and H2O
• glutathione peroxidase (GSH) catalyses free radical
breakdown

• Endogenous or exogenous antioxidants eg. Vitamins E, A, C and

β-carotene are also important in removal of free radicals
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 Cont’d…
❑Defects in membrane permeability-
• ROS by lipid peroxidation
• Decreased phospholipid synthesis due to defective
mitochondrial synthesis
• Increased phospholipid break down
• Cytoskeletal abnormality

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 Cont’d…
• The most important sites of membrane damage
during cell injury are the mitochondrial membrane,
the plasma membrane, and membranes of
lysosomes

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❑Damage to DNA and proteins –
• Cells have mechanisms that repair damage to DNA
• Accumulation of damaged DNA and misfolded
proteins triggers apoptosis

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Intracellular accumulations
• Abnormal accumulation of substances
• Can be excess accumulation of normal cellular
constituents or abnormal accumulation which can
either be exogenous or endogenous
• Lipids –triglycerides ,cholesterol and phospholipid
• Phospholipids are components of myelin figures

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 Cont’d…
Steatosis-(fatty change)
abnormal accumulation of
TGA in cells
• Excess accumulation
within liver from
excessive entry or
defective metabolism
and export
Morphology –is clear
vacuole

Fatty liver 75
 Cont’d…
• Proteins –round eosinophilic vacuole in cytoplasm
• EM- amorphous , fibrillar structures
• Defective intracellular transport
• Accumulation of cytoskeletal protein
• Aggregation of abnormal proteins as in amyloidosis
• Redistribution droplets in PCT (renal) associated
with proteinuria

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Protein reabsorption droplets in the renal
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tubular epithelium
 Cont’d…
• Hyaline change –homogenous glassy pink
appearance
• This morphologic change is produced by a
variety of alterations and does not represent a
specific pattern of accumulation. For instance,
Intracellular accumulations of protein
• Glycogen –Excessive intracellular deposits of
glycogen are seen in patients with an abnormality
in either glucose or glycogen metabolism
• Appear as clear vacuoles in the cytoplasm
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 Cont’d…
• Pigments –exogenous –carbon causing coal
workers pneumoconiosis
• Endogenous –
• lipofuscin –formed by lipid peroxidation ,not
injurious but is a telltale sign of previous injury
• Melanin –non hemoglobin derived brown black
pigment normally found in skin

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Photomicrograph showing Lipofuscin granules in a cardiac
myocyte 80
• Hemosiderin – hemoglobin derived golden brown
fine granular pigment
• When there is a local or systemic excess of iron,
ferritin forms hemosiderin granules, which are
easily seen with the light microscope

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Pathologic calcification

❑Dystrophic calcification –occurs when calcification

occur in necrotic tissue despite normal serum calcium
level
• Appear as basophilic amorphous granular and
sometimes clumped appearance
• can be intracellular, extracellular, or in both locations.
• It is a telltale sign of previous injury
• The progressive acquisition of outer layers may create
lamellated configurations, called psammoma bodies

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Dystrophic calcification of the aortic valve. 83
 Cont’d…
• Metastatic calcification –due to hypercalcemia
affects gastric mucosa ,kidney, lung ,systemic
arteries and pulmonary veins
• Usually the mineral salts cause no clinical
dysfunction
• on occasion massive involvement of the lungs
produces remarkable x-ray images and respiratory
compromise. Massive deposits in the kidney
(nephrocalcinosis) may in time cause renal damage

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