INFLAMMATION 1

ALIYU SALIHU
DEPARTMENT OF MORBID ANATOMY AND FORENSIC MEDICINE
USMANU DANFODIO UNIVERSITY, SOKOTO
CONTENTS
• INTRODUCTION
• HISTORICAL HIGHLIGHTS
• DEFINITION
• CLASSIFICATION
• AETIOLOGY
• PATHOGENESIS
• CHEMICAL MEDIATORS
• OUTCOME OF ACUTE INFLAMMATION
• MORPHOLOGIC FEATURES
INTRODUCTION
• Inflammation is part of the complex biologic response of vascular tissue to
harmful stimuli, such as pathogens, irritants or damaged cells
• It is a stereotypic response that involves various cell types, vessels,
connective tissue matrix and many chemical mediators.

• Primarily a protective mechanism, it may ultimately result in elimination of

both the injurious agent and the consequences of injury.

• However, inflammation may be potentially harmful

HISTORICAL PERSPECTIVE
• About 5000 yrs ago, the clinical features of inflammation were
described in Egypt
• About 3000 years later, Celsus described the 4 cardinal signs:
• tumour, (swelling)
• rubor, (redness)
• calor, (heat)
• dolor, (pain)
HISTORICAL PERSPECTIVE
• Almost 2000yrs later in the 19th century,
• Loss of function (functio laesa): the fifth cardinal sign was added by Rudolf
Virchow;
• Vasomotor and locomotor (leucocyte emigration) effects were observed by
Julius Cohnheim
• Phagocytosis was observed by Ellie Metchnikoff
• Role of chemical substances in mediating inflammation recognized by Sir
Thomas Lewis
DEFINITION
Inflammation is the response of vascularized living tissue to injury
CLASSIFICATION
1-Acute and
2- chronic inflammation
1- Acute-
the immediate and early response to an injurious agent
It is achieved by increased movement of plasma and leucocytes
(especially granulocytes) from the blood into the injured tissue.
2-Chronic-
of prolonged duration
• active inflammation, tissue destruction and attempts at repair are going on
simultaneously.
• Usually follows acute inflammation,
• May start ab initio as an insidious, low-grade, smouldering reaction
AETIOLOGY
• Infectious agents-bacteria, viruses and their toxins, fungi,parasites
• Physical agents – surgical incisions, trauma, burns, frostbite, etc.
• Chemical agents & Drugs, organic and inorganic poisons.
• Tissue necrosis from any cause eg severe Hypoxia/Ischaemia
• Inert material-Foreign bodies
• Immunologic reactions-cell mediated and ag-ab reactions
Purpose
• Production of an exudate which
• dilutes toxins & transports inflammatory cells to the site of injury to eliminate
the offending agent.
• Walling off the injurious agent or slowing down spread of the insult.
• Clearing the tissue debris which sets the stage for repair
SITE
Vascularized connective tissue: vessels, connective tissue matrix
COMPONENTS
• Phagocytes & other cells- neutrophils, monocytes, eosinophils, lymphocytes, basophils &
platelets.

• Vessels- arterioles, capillaries, post capillary venules

• Connective Tissue:

• Cells - Mast cells, fibroblasts, resident macrophages & lymphocytes

• Matrix – structural fibrous proteins (collagen, elastin) & adhesive glycoproteins

(fibronectin, laminin, nonfibrillar collagen, tenascin etc).
Pathogenesis
1-Vascular Events
A-Changes in vascular flow & calibre
B-Increased vascular permeability with marked outflow of fluid into the
interstitium (Oedema)

2-Cellular Events
A-Emigration of cells into the interstitium towards chemotactic stimulus
B-Engulfment, killing & degradation
 A-Changes in vascular flow & calibre

Haemodynamic changes occurs early in inflammation. Occurs in stages

Stage 1
Transient vasoconstriction of arterioles
Vasodilatation: 1st arterioles, then opening of new capillary beds leading
to increased blood flow. This causes heat and redness. Induced by
mediators notably histamine and nitric oxide (NO)
Stage 2.
This is followed by increased permeability of the microvasculature with
outpouring of protein rich fluid into the extravascular tissue.
Changes in vascular flow & calibre
Stage 3
Concentration of rbc’s in small vessels and increased viscosity of blood
will lead to vascular congestion and slowing of circulation referred to as
Stasis
Accumulation of blood leucocytes along vascular endothelium.
Endothelial cells are activated by mediators produced at sites of infection
leading to increased expression of adhesion molecules, adherence of
leucocytes to the endothelium and migration into the interstitial tissue.

Dr Anunobi
Vascular events
B-Increased vascular permeability
• Loss of protein from plasma
• Decreased intravascular OP & Increased interstitial OP
• Marked outflow of fluid into the interstitium (Oedema)
• Production of this protein-rich fluid – exudate – is the
hallmark of acute inflammation
Proposed mechanisms of Vascular Leakage
1. Contraction of endothelial cells
2. Direct Endothelial Injury
3. Leukocyte-mediated Endothelial Injury
4. Increased Transcytosis
5. Neovascularisation
Contraction of endothelial cells (type 1)

• Is the most common mechanism of vascular leakage

• Immediate Transient Response
• Phosphorylation of contractile and cytoskeletal proteins

• Of rapid onset, reversible & short lived (15 to 30mins)

• Mediated by histamine, bradykinin, leukotrienes, substance P etc
Eg mild thermal injury
Endothelial cell contraction (type 2)

• Delayed prolonged response (4-6hrs), long-lived (>24hrs)

• Mediated by cytokines (IL1, TNF, IFNγ), hypoxia, sublethal injury (x-

irradiation, ultraviolet radiation, etc)

• Structural reorganization of endothelial cytoskeleton resulting in

endothelial retraction and formation of gaps
• Eg sun burns from UV radiation
Endothelial Injury
• Direct Endothelial Injury due to
• Necrotizing injuries e.g. severe burns, lytic bacterial
injuries
• Immediate sustained reaction
• Affects all levels of the microvasculature
• Often complicated by thrombosis
Leukocyte-mediated Endothelial Injury via
• oxygen derived free radicals
• proteolytic enzymes released by activated leukocytes
Increased Transcytosis
• Increased transport of fluids and proteins
• Occurs across channels made up of clusters of vesicles & vacuoles
(vesiculovacuolar organelle) located close to intercellular junctions
• Mediated by Vascular Endothelial Growth Factor (VEGF) & other
mediators e.g. histamine.
2-Cellular Events
• Aim is to deliver leucocytes to site of injury (Extravasation)
• Activate leucocytes which
• Kill microbes
• Clear necrotic debris & foreign bodies
• Cause tissue damage
Cellular events
• The histologic feature of inflammation is the infiltration of leucocytes.
• The sequence of events of leucocyte extravation is as follows:
 Cellular Events
Emigration
• Margination, Rolling, Adhesion
• Transmigration (Diapedesis)
• Migration in interstitium towards chemotactic stimulus
• All these processes are mediated by adhesion molecules
• The products of inflammation, such as histamine,
promote the immediate expression of P-selectin on
endothelial cell surfaces. This receptor binds weakly
to carbohydrate ligands on leukocyte surfaces and
causes them to “roll” along the endothelial surface as
bonds are made and broken.
• Cytokines from injured cells induce the expression of
E-selectin on endothelial cells, which functions
similarly to P-selectin.
• Cytokines also induce the expression of
immunoglobulin ligands such as ICAM-1 and VCAM-1
on endothelial cells, which further slow leukocytes
down.
• ICAM-1 and VCAM-1 bind to leucocyte integrin
receptor molecules LFA-1 and VLA-4 respectively
effecting adhesion and transmigration.
• CD31 (PECAM-1) in transmigration
Chemotaxis
• Locomotion along a chemical gradient
• Mediated by Chemoattractants which may be endogenous or exogenous
• Endogenous Chemoattractants
• Products of the Complement System (C5a)
• Products of the Lipoxygenase pathway (LTB4)
• Cytokines (IL-8)
• Exogenous: bacterial products such as-
• Peptide products
• Lipid products
Phagocytosis
• process of engulfment of solid particulate material by phagocytes;
polymorphonuclear Neutrophils ( Microphages)
Circulating Monocytes and Tissue macrophages
• Phagocytosis of the microbe by polymorphs and macrophages involves 3 steps;
• Recognition & attachment
Leucocytes express several receptors eg Toll-like receptors,G protein receptors for microbial
products. Receptors for opsonins.
• Engulfment
Dependent on cytoskeletal proteins e.g. actin
• Killing & Degradation
accomplished largely by reactive oxygen species (ROS) and reactive nitrogen species following
respiratory burst
Recognition and Attachement
• Initiated by expression of cell surface receptors on phagocytes
Mannose receptors and scavenger receptor
• Further enhanced by coating of microbes with specific protein called
Opsonin
• Opsonised microbes creates bond between the bacteria and cell
membrane of phagocytic cells
• Example of opsonins includes;
fc fragment of IgG
C3b
Lectin
Engulfment
• Opsonised microbes are engulfed by phagocytes for subsequent
killing and degredation.
• The processes includes;
extension of cytoplasmic pseudopod around the particle to form
phagocytic vacuole
the plasma membrane enclosing the particle detached to become
free Phagosome within the cell.
eventually the phagosome fused with the lysosome of the
phagocyte to form phagolysosome
Killing and Degredation
• Final phase in microbial killing and disposal
• Achieved via;
Intracellular or extracellular mechanism.
Intracellular Mechanism:
this is achieved via oxygen dependent and oxygen independent
pathway
Oxygen Dependent(Oxidative) Pathway
• Most efficient mechanism of microbial killing by elaboration of
reactive oxygen species
• Activated phagocytes stimulates a respiratory burst leading to high
oxygen consumption and production of reactive oxygen metabolites.
• This required NADPH Oxidase which is present in the cell membrane
of phagosome, reducing oxygen to superion(O’ )
2

• Superoxide is subsequently converted into H2O2 which has

bactericidal properties:
2O’2 + 2H+ H2O2
• Most efficient bactericidal pathway is achieved via
A- MPO dependent pathway by neutrophils in the presence of halides
to produce hypohalous acid
B- MPO independent pathway by monocytes via Haber-Weiss reaction
using O’ or Fenton reactions using Fe++ to produce hydroxyl radical
2
H2O2-MPO-halide System
• NADPH-------NADP => Oxygen to superoxide
• NADPH Oxidase

• Superoxide………>Hydrogen peroxide
• spontaneous dismutation

• Hydrogen Peroxide + Halide (Cl-) > Hypochlorite

• MPO (myeloperoxidase)
• H2O2- MPO- Halide system is the most efficient bactericidal system of
neutrophils.

Dr Anunobi
Oxygen-independent
Lysozyme
• Lactoferrin
• Major Basic Protein
• Defensins
• Elastase
Chemical mediators

• Any chemical messenger that acts on blood vessels, inflammatory

cells, or other cells to contribute to an inflammatory response
• The morphologic alterations associated in the vascular and cellular
events of inflammation are initiated and maintained by chemical
substances (chemical mediators).
• Mediators may be produced locally by cells (cell derived) at the site
of inflammation or may be derived from circulating inactive
precursors (plasma protein derived) (typically synthesized by the
liver); that are activated at the site of inflammation
Groups of Mediators:
A. Exogenous
• Endotoxins
B. Endogenous
– Plasma
– Leukocytes
– Endothelial cells
– Fibroblasts
CHEMICAL MEDIATORS
• Their principal actions are either in the form of:
1. Vasodilation
2. Increased Vascular Permeability
3. Chemotaxic Leukocyte Activation
CHEMICAL MEDIATORS
• Vasodilation
• Prostaglandins, Nitric Oxide
• Increased Vascular Permeability
• Vasoactive amines (histamine, serotonin), C3a and C5a,
Bradykinin, Leukotrienes, PAF,
• Chemotaxic Leukocyte Activation
• C5a, LTB4, Chemokines
Properties
• The actions of most mediators are tightly regulated and short lived.
• Once activated and released from the cells, mediators;
a) quickly decay (e.g). Arachidonic acid metabolites) or
b) are inactivated by enzymes (e.g., Kininase inactivates bradykinin) or
c) are eliminated (e.g. anti-oxidants scavenge toxic 02 metabolites) or
d) are inhibited (e.g. complement regulatory proteins block complement activities).
Classification
1-Cell derived mediators
Preformed Mediators in secretory granules:
• Histamine and
• Serotonin.
Newly synthesized
• Prostaglandins
• Leucotrienes
• Platelet activating factor (PAF)
• Reactive oxygen species (ROS)
• Cytokines
• Nitric Oxide
• Neuropeptides
Vasoactive amines
• Histamine is found in secretory granules of mast cells that are
normally adjacent to blood vessels. Others cells include basophils and
platelets
• Released by mast cell degranulation in response to physical injury,
immune reactions, anaphylatoxins (C3a, C5a), etc
• Histamine acts on the vasculature by binding to specific H1 receptors
in the vascular to induce endothelial cell contraction and gap
formation
• Actions : dilation of the arterioles, increases vascular permeability of
venules.
serotonin
• Serotonin is a preformed vasoactive mediator present in platelets
• Release is stimulated by platelet aggregation after contact with
collagen, Ag-Ab complex, PAF
• Actions are similar to those of histamine
Arachidonic acid metabolites
• AA (a fatty acid) has two main sources
• derived from diet and
• conversion of essential fatty acid, linoleic present in the body as a
component of cell membrane phospholipids
Arachidonic acid metabolites
• Leucocytes, mast cells, endothelial cells and platelets are the major
sources of AA
• It is released through the activation of cellular phospholipases (eg
phospholipase A2) by mechanical, chemical, physical, other mediators
eg C5a
• Act locally at the site of generation and decay spontaneously
• AA metabolites are synthesised by two major classes of enzymes
• Cyclo-oxygenases (prostaglandins, thromboxane A2, prostacyclin)
• Lipoxygenases (leukotrienes, lipoxins)
• Steroids inhibit phospholipases while aspirin ibuprofen and
indomethacin (NSAIDS) inhibit cyclo-oxygenases
Prostaglandins
• Prostaglandins (PGD2, PGE2, PGF2-alpha). PGD2 and PGE2 act on blood
vessels to cause increased
• venular permeability, vasodilation and bronchodilation.
• The prostaglandins contribute to
• pain and fever that accompany inflammation
• Thromboxane A2 (TXA2)
• causes vasoconstriction, bronchoconstriction and platelet aggregation.
• Platelets contain the enzyme thromboxane synthase and hence TXA2 is the
major Pg produced in platelets.
• Endothelial cells lack thromboxane synthase but contain prostacycline
synthase.
• Prostacycline (PGI2)
• induces vasodilatation, bronchodilatation, anti-aggregation agent for
platelets
Lipo-oxygenase pathway
• The lipoxygenase enzymes are responsible for production of
leucotrienes secreted mainly by leucocytes.
• 5-HETE : potent chemotactic agent for neutrophils
• LTB4 : chemotactic agent, neutrophil activation, aggregation and adhesion of
cells to venular endothelium
• LTC4, LTD4, LTE4 : smooth muscle contraction (vasoconstriction,
bronchoconstriction, ) and increased vascular permeability
PAF(Platelet Activating Factor)
• It is generated by the stimulation of virtually all inflammatory cells and
injured tissue cells by the action of phospholipase A2 on the membrane
phospholipid of the cells.
• It is a mediator with broad spectrum of inflammatory effects originally
named for its ability to aggregate platelets.
• Actions
• Platelet aggregation and release
• Increased vascular permeability and vasodilation in low concentration(100 to 1000
times more potent than histamine)
• Brochoconstriction
• Adhesion of leucocytes to endothelium(enhances leucocyte intergrin binding)
• Chemotaxis, degranulation and oxidative burst
Reactive oxygen species and NO
• Oxygen derived free radicals are synthesised via NADPH oxidase
pathway and are released from activated neutrophils and
macrophages.
• They include superoxide anion(O2), Hydrogen peroxide (H2O2),
hydroxyl radicals OH
• Within lysososomes they function to destroy phagocytosed microbes
and necrotic cells.
Reactive oxygen species and NO
• When secreted at higher levels the oxygen free radicals are
responsible for
• Endothelial cell damage leading to increased vascular permeability
• Activation of protease and inactivation of antiprotease (alpha 1 antitrypsin)
causing tissue matrix damage
• Damage to other cells, rbcs etc
• Actions of free radicals are countered by antioxidants
Nitric oxide (NO)
• NO is a short lived soluble free radical gas synthesized by many cell
types
• When produced by endothelial cells
• Vasodilation
• Antagonises platelet activation
• Reduction of leucocyte recruitment
• Activated macrophages use it as cytotoxic agents for killing of
microbes.
Cytokines and chemokines
• They are produced by many cell types mainly by activated
lymphocytes and macrophages.
• They modulate the function of other cell types
• Eg TNF, IL-1, IL-6, chemokines( acute inflammation), IL-12, IF gamma,
IL-17( chronic inflammation)
• IL-1, TNF (alpha and beta):produced mainly by activated macrophages
• stimulate the expression of endothelial adhesion molecules
• elaboration of other cytokines, chemokines, growth factors
• increases the surface thrombogenicity of endothelium, fibroblastic
proliferation and acute phase reactions (fever, loss of appetite, production of
slow wave sleep)
• IF-gamma causes activation of macrophages and neutrophils
and it is associated with synthesis of nitric acid synthetase .
chemokines
• Are family of small proteins that act as chemoattractants for specific
types of leucocytes. They stimulate leucocyte recruitment and control
of cell migration through tissues
• Four majour groups
• C-X-C chemokines. IL-8 causes activation and chemotaxis of neutrophils
• C-C chemokines
• C chemokines
• CX3C chemokines
Plasma proteases
• Complement system: complement components, present in inactive
forms in plasma are numbered C1 to C9
• The functional roles of complement system
• source of vasoactive mediators, increasing vascular permeability,
anaphylatoxins
• Production of leucocytic chemoattractants
• Opsonisation and enhancement of leucocyte phagocytosis
• Cell lysis
Complement system
• Complements are activated through two pathways
• The classical pathway
• The alternative pathway
• Lectin pathway
• Classical pathway is activated by fixation of C1 to antigen-antibody
(IgG or IgM) complex, proteases
• The alternative pathway is activated by microbial surfaces,
polysaccharides, endotoxin, cobra venom factor, radiographic contrast
media. These act on C3
• Lectin pathway is activated by microbial CHO interacting with
mannose binding lectins
Complement system
• The three pathways lead to production of
• C3 convertase,(C4b2b, C3bBb)
• C5 convertase, (C4b2a3b, C3bBb3b),
• C3a, C3b, C5a, C5b,
• membrane attack complex(MAC) C5b-9 leading to cell injury
Biologic functions
• Three general categories
1-Cell lysis; C5b binds to late component C6-C9 forming MAC.
Punches holes in cell membrane
2-Inflammation; anaphylatoxins ( C3a and C5a) stimulate histamine release
from mast cell---increase vasodilatation
C5a activate AA metabolism
C5a is a powerful leukocyte chemoattractant
3-Opsonisation and Phagocytosis : C3b, is an opsonin, when fixed to the
bacterial cell wall enhances phagocytosis by neutrophils and macrophages
which bear cell surface receptors for C3b;
Coagulation and kinin systems
• Hageman factor (factor XII) is a protein synthesised by the liver that
circulates in an inactive form until it encounters collagen, basement
membrane, or activated platelets.
• Activated Hageman factor (factor XIIa) initiates four systems
• The kinin system
• The clotting system inducing the activation of thrombin, fibrinopeptides, and
factor X
• The fibrinolytic system
• The complement system
Kinin system
• This system on activation generates bradykinin.
• Kallikrein is formed from plasma prekallikrein by the action of
prekallikrein activator which is a fragment of factor XIIa (Hageman
factor).
• Kallikrein then acts on high molecular weight kininogen to form
bradykinin.
• Actions of bradykinin:
• Bronchial smooth muscle contraction, vasodilatation, increased vascular
permeability and pain when injected into the skin
• It is quickly inactivated by enzyme kininase
Clotting system
• Factor XIIa initiates clotting system cascade leading to formation of
thrombin from prothrombin.
• Thrombin acts on fibrinogen to produce fibrin and fibrinopeptides
• Actions
• Increased vascular permeability
• Chemotaxis for leucocytes
Figure 2-15 Interrelationships between the four plasma mediator systems triggered by activation of factor XII (Hageman factor).Note that thrombin induces inflammation
by binding to protease-activated receptors (principally PAR-1) on platelets, endothelium, smooth muscle cells, and other cells.

i
© 2005 Elsevier
Outcomes of Acute Inflammation
❑ Complete resolution
• is the usual outcome
• Is seen when:
a. the injury is limited
b. short-lived
c. there has been little tissue destruction
d. damaged parenchymal cells can regenerate (regeneration)
Outcomes of Acute Inflammation
❑ Healing by connective tissue replacement (fibrosis).
• This occurs after
a. substantial tissue destruction
b. injury involves tissues that are incapable of regeneration
c. when there is abundant fibrin exudation in tissue or serous cavities
❑ Progression to chronic inflammation
Morphologic patterns of Acute inflammation
• Serous inflammation marked by fluid that may be derived from
plasma or from secretions of mesothelial cells
• Fibrinous inflammation is associated with greater increase in vascular
permeability allowing large molecules such as fibrinogen to pass
through the vascular barrier and deposited in extracellular space
• Suppurative or purulent inflammation