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Chronic Inflammation


 When a damaging stimulus persists,

complete healing cannot occur, and
chronic inflammation results

 In chronic inflammation the tissue damage

continues along with attempts to repair

 Chronic inflammation often ocurs without

a preceding acute inflammatory reactions.
 Causes of chronic inflammation

1. Persistence of infections by

 Cause an delayed type of immune reaction

 Results in a granulomatous inflammation

 Bacteria like M. tuberculosis, T. pallidum;

viruses; fungi; parasites etc
 Prolonged exposure to potentially toxic
 Exogenous- silica particles – silicosis
 Endogenous- toxic plasma lipid components-

 Reaction against the body’s own tissues
 Results in chronic tissue damage and inflammation
 Rheumatoid arthritis.
Types of Chronic Inflammation:

There are 2 types of Chronic inflammation

1) Chronic non specific inflammation

2) Chronic granulomatous inflammation

Features of Non-specific chronic

It is characterized by

 Cellular reaction of mononuclear cells

(lymphocytes, plasma cells and macrophages)

 Tissue destruction- seen as areas of necrosis in the

affected tissues- caused by the persisting
microorganisms and the inflammatory cells

 Often involves Scarring.

It is mediated by the interaction of monocytes-
macrophages with lymphocytes.

 Monocytes are recruited from the circulation

by various chemo tactic factors.

 Cytokines derived from monocytes-

macrophage s activate lymphocytes. The
activated T- lymphocytes, in turn are the
source of additional cytokines that activate

 B-lymphocytes activation by macrophage-

presented antigen results in the formation of
antibody-producing plasma cells.
Example of Chronic Inflammation

Chronic peptic ulcer is an example of

chronic inflammation where tissue
damage due to acid-peptic digestion
and tissue repair are going on at the
same time.
Peptic ulcer
Cells involved in chronic
The cellular component of chronic
inflammatory responses recruited from
circulation are :

 Macrophages
 Lymphocytes
 Plasma cells
 Dendritic cells
 Eosinophils
Those recruited from affected tissues are:

 Fibroblasts

 Vascular endothelial cells.

Granulomatous inflammation:
 It is a distinct type of chronic inflammation.
 There is a focal collection of activated
macrophages called epithelioid cells.
 Granuloma: it is the focus of chronic
inflammation consisting of
 Epithelioid cells
 Lymphocytes
 Plasma cells and
 Giant Cells.
Types of granulomas
 Based on mechanism:
 Immune granuloma - there is a cell mediated immune
response against an insoluble particle like microbes
 Eg: tuberculosis, Sarcoidosis, Fungal infections
 Foreign body granuloma- they result form a relatively
inert substances- the foreign body may be seen in the
center of the granuloma
 Eg: talc, sutures
 Based on morphology:
 Caseating granulomas: there are areas of caseous
necrosis (seen as cheesy white areas) in the affected
tissues. Seen in cases of tuberculosis.
 Noncaseating granulomas- there is no central caseation.
It is seen in sarcoidosis, fungal infection.
 Granuloma formation is seen in
some chronic diseases

 In chronic inflammations
macrophages form groups called

 Granulomatous inflammation is
 when an organism is of low

pathogenicity but excites an

immune response e.g.

Mycobacterium tuberculosis

Mycobacterium leprae



 It involves activation of macrophages by
interactions with T lymphocytes. Poorly
digestible antigen is presented by macrophages
to CD4+ lymphocytes. Interaction with the
antigen-specific T cells receptor of these cells
triggers the release of cytokines(especially
interferon gamma) which mediate the
transformation of monocytes and macrophages
to epithelioid cells and giant cells.
Langhans Giant Cell

Lymphocytic Rim
e c rosis
se ous N

Epithelioid Macrophage
Granulomatous inflammation


Granuloma made up of macrophages

Tuberculosis is an example of
granulomatous inflammation

 A granuloma in TB is called a

 A tubercle is composed of
activated macrophages with
surrounding lymphocytes
and fibroblasts

 In TB the granulomas
undergo caseation necrosis
and heal by fibrosis when the
immunity is good
Caseating granulomas are seen commonly in TB

epithelioid cells lymphocyte

giant cells

Area of caseation
Granulomatous inflammation can be a tissue
response to some foreign materials

 Granulomas form when a non-living material is

deposited in the tissue and cannot be degraded
easily e.g. urate crystals in gout, inhaled organic
 Foreign body giant cells are formed by the
fusion of macrophages around the material
 Sarcoidosis is a granulomatous disease of
unknown cause in which the granulomas do not
show caseation and heal by fibrosis
Giant cells form by fusion of macrophages

Langhan giant cell Foreign body giant cell

Non caseating granulomas

Noncaseating granuloma in
Granuloma healing by fibrosis Sarcoidosis
Miliary TB

Pulmonary dissemination
Miliary tuberculosis, Spleen
Secondary tuberculosis

 In secondary TB initial tuberculous infection is at the

apex of the upper lobe of a lung with little lymph node
Spinal TB - Potts Disease
Thanks for your precious time.

Allah Hafiz