Subject: Pathology Topic: Cell Injury and Death I Lecturer: Dr.

Luis Cruz Date of Lecture: 06/09/2011 Transcriptionist: Desiree Timtiman Pages: 12

PATHOLOGY y study of suffering or study of disease y study of the structural, biochemical, and functional consequences of injurious stimuli on cells, tissues, and organs y structural changes: cell tissue organ and systems y Serve as bridge between basic sciences and clinical medicine, and is the scientific foundation for all of medicine. y MAJOR DIVISIONS: o Anatomic  General y Acc to Doc, memorize understand the 1st seven chapters of robbins! y Concerned with the reactions of cells and tissues to abnormal stimuli and to inherited defects  Systemic y Examines the alterations in specialized organs and tissues that are responsible for disorders that involved these organs o Clinical  Deals with laboratory side of pathology (hematology, microbiology, etc)  Also used in correlation of anatomic changes with physiologic changes in the cells ASPECTS OF DISEASE PROCESSES What is the cause? how it happened what are affected as seen in the cells or tissues examined correlate with the individual s sign and symptoms 1. Etiology or cause y Major classes: o Genetic  Born with it (ex. Cleft palate, polydactyly, etc)  Inherited mutations  Disease-associated gene variants  polymorphism o Acquired  Primarily environmental  Infectious (microbiologic or biologic)  Nutritional  Chemical  Physical

2. Pathogenesis y sequence of events in the response of cells or tissues to the cause 3. Morphologic Changes y structural alterations 4. Functional Derangement y functional alterations y its clinical significance ex. etiology: infection pathogenesis: injury due to mosquito bite disruption of skin scratching the area with dirty nails infection Abscess functional derangement of limb due to abscess morphologic changes: abscess functional derangement: functionally deranged limb INTRACELLULAR SYSTEM VULNERABLE INJURY(Target of Injurious Stimuli) 1. Integrity of cell membrane 2. Aerobic Respiration 3. Synthesis of protein and enzyme 4. Cytoskeletal system 5. Intact genetic apparatus TO

PRINCIPLES AND CONCEPTS Homeostasis y Present state of cell without any injurious stimuli y equilibrium y steady state Adaptation y Introduce stimulus(injurious or noninjurious cell reacts depending on the lethality of the stimulus(lethal or sublethal) adaptive state or higher level of equilibrium y new but altered steady state achieved to preserve cell viability y ultimate goal of adaptation: viability y reversible functional and structural responses to more severe physiologic stresses and some pathologic stimuli y Types of adaptation: o Atrophy  decrease in cell size o Hypertrophy  increase in cell size entails an increase in building blocks(protein synthesis)

SY 2011-2012

Hyperplasia  increase in the number of cells as a result of cell division also entails an increase in protein synthesis Metaplasia  replace adult cell by another type  ex. Secretory columnar epithelium injurious stimuli protective stratified squamous epithelium

REACTIONS OF CELLS TO STIMULI y cells can adapt to environment by hypofunctioning or hyperfunctioning y a persistent sublethat injury can lead to hyperplasia and hypertrophy y Hypofunctioning o If it s not functioning it becomes small o Related to atrophy y Hyperfunctioning o Components are added for it to hyperfunction o Related to hyperplasia and hypertrophy y Vulnerable systems are related to adaptability MECHANISMS OF CELL INJURY y The cellular response to injurious stimuli depends on the type of injury, its duration and its severity y The consequences of cell injury depend on the type, state and adaptability of the cell y Cell injury results from functional and biochemical abnormalities of several essential cellular components HYPERTROPHY y Result of increased of production of cellular proteins y Increase in size of an organ or tissue due to increase in size of the cells y CAUSES: 1. Physiologic a. Hormonal  estrogen stimulation of uterus in pregnancy  average female has a uterus as big as her clenched fist and an average Filipino newborn baby is 3 kilos, hence there is a need for both hypertrophy and hyperplasia to accommodate the fetus b. Compensatory 2. Pathologic  Ex. Heart in CHF a. Excessive Hormonal stimulation b. Viral-induced

increase in size of an organ due to increase in number of cells CAUSES : 1. Physiologic a. Hormonal y estrogen stimulation of uterus; occurs with hypertrophy y glandural proliferation of breast during pregnancy b. Compensatory 2. Pathologic a. Excessive Hormonal stimulation y ex. Endometrial hyperplasia b. Viral induced y growth factors produced by virus y

Normal cell in homeostasis has to adapt because of increase demand or stresses. If it does not adapt due to some injurious stimulus, it will result into cell injury. Cell injury can lead to subcellular alterations which can t be seen under the light microscope or reversible cell injury called light microscopic pattern of injury that is observable under the light microscope. If cell is unable to adapt due to severe, progressive and irreversible injury the cell may die or undergo apoptosis (programmed cell death) or necrosis.

Hypertrophied heart (lt), normal heart (middle), heart with cell injury (upper rt), heart with necrosis (lower rt) Morphologic change: hypertrophied heart Functional derangement: decreased in blood volume ejected by the heart and as a physiologic response leads to HPN

HYPERPLASIA

Signals that result into cardiac hypertrophy:

mechanical triggers (stretch)  best explained by Starling s law y stretching the muscle has a corresponding amount of contraction y overstretching can cause dilation o trophic triggers (activation of a-adrenergic receptors)  hormonal  growth factors Signal transduction pathways can be turned on by the stimuli and lead to: o induction of genes that stimulate protein synthesis such as growth factors and structural proteins o

Synthesis of more proteins and myofilaments per cell which achieves improved performance and thus, a balance between demand and the cell functional capacity since its a reversible adaptive mechanism, removing the stresses will cause the heart to revert back to its normal functioning cell In summary, stable tissue abnormal stimulus(inc in functional[work]/metabolic demand, inc endocrine stimulus or persistent tissue injury adaptive response(hypertrophy or hyperplasia or both) stable tissue return back to normal cell or persistent altered state At a certain point, however, the adaptive response can bring about a dysfunctional state in the condition

End result of Hyperplasia and Hypertrophy:

This is a schematic diagram of hypertrophy and hyperplasia.

AGENESIS y failure of formation of embryonic cell mass APLASIA y failure of differentiation to organ specific tissue (ex. Kidney) y Failure of cell production y Fetal life o results in agenesis y later life o cause of permanent loss of precursor cells in proliferative tissue such as bone marrow y Aplastic Anemia o aplasia in the bone marrow o Remember that BM contains the precursor cells for RBC, WBC, and platelets DYSGENESIS y failure to undergo structural organization of tissues into organs HYPOPLASIA y decrease in cell production that is less extreme than that found in aplasia; failure to grow to full size; y ex. Klinefelter and Turner Syndrome o dysgonadal syndrome o partial lack of growth and maturation of gonadal structures

He didn t go into so much details in this diagram but its self explanatory. I ll let your brains figure it out! Haha!

ATROPHY y Decrease in the size of an organ or tissue resulting from decrease in the mass of preexisting cells y Decrease in the mass of cell is the result of decrease in organelles; unnecessary organelles can be loss for it to be viable y Results from decreased protein synthesis and increased protein degradation because of reduced metabolic activity y Ubiquitin-proteasome pathway o main pathway in the degradation of proteins o disuse and nutrient deficiency activates ubiquitin ligases o Ubiquitin ligases  Attaches ubiquitin to cellular proteins and target these proteins for degradation in proteasomes o responsible for accelerated proteolysis y Accompanied by increased AUTOPHAGY and HETEROPHAGY o Autophagy- eating up your cells o Heterophagy- eaten up by another cell y Marked by presence of AUTOPHAGIC GRANULES y Autophagic granules o Intracytoplasmic vacuoles containing debris from degraded organelles y Cancer cachexia is an example of atrophy y CAUSES : Physiologic: o Tissues/ structures present in embryo or in childhood(e.g. thymus) may undergo

atrophy as growth and development progress o Thymus disappears by the age of 2 y/o. Pathologic: 1. Decreased workload or disused o Immobilized fractured bone in cast arm results in disused of muscles within the cast which leads to atrophy 2. Loss of innervations/ dennervation atrophy o Damage to the nerves leads to atrophy of the muscle fibers supplied by those nerves o Due transaction of nerve or infection like polio 3. Ischemia o Diminished blood supply or oxygen deprivation 4. Inadequate nutrition (ex. Marasmus) 5. Loss of endocrine stimulation o Deprivation of hormonal stimulation o Ex. Loss of estrogen stimulation after menopause results in physiologic atrophy of the endometrium, vagina epi and breast 6. Senile atrophy o Aging o Decrease bld supply due to atherosclerosis o Reduced activity leads to reduction in size of the skeletal muscle 7. Pressure or Physical stress o tissue compression for any length of time can cause atrophy o ex. Benign tumor can cause atrophy in the surrounding uninvolved tissues o ex. bed ulcers Kinds of atrophy: o General Atrophy  Starvation atrophy  Senile atrophy o Local Atrophy  Disuse Atrophy  Pressure Atrophy  Endocrine Atrophy  Denervation Atrophy

Patient with cancer cachexia

The figure above shows both atrophy and hypertrophy of sk. Muscle. Note the distinctive features of sk. Muscle: eccentrically multinucleated cell. The hypertrophied muscle is possibly compensating for the atrophied muscle.

Schematic diagram of autophagy leading to atrophy

This is an example of an atrophied brain. Compare the sulci of the normal brain(lt) and atrophied brain (rt) The sulci is wider due to the thinned gyri of the atrophied brain.

METAPLASIA y A reversible change in which one mature/adult cell type (epithelial or mesenchymal) is replaced by another mature cell type y A protective mechanism rather than a premalignant change y According to older schools, dysplasia is a continuous spectrum of metaplasia y CAUSES : o Persistent Irritation o Infection o Malnutrition y Examples: o Bronchial (pseudostratified, ciliated columnar) to stratified squamous epithelium  E.g., respiratory tract of smokers  St. sq is more protective than columnar but this will cause to the loss of secretory function that traps foreign material leading to compensatory mechanism: coughing o Endocervical (columnar) to squamous epithelium  E.g., chronic cervicitis o Esophageal (squamous) to gastric or intestinal epithelium  E.g., Barrett esophagus  Mucous barrier is more protective than st. squamous ep.

atrophied testes(rt)due to loss of hormonal stimulation. (lack of use daw sabi ni fi! Lol!)

Arrow is pointing at the Squamous metaplasia Transition area in the cervix from endocervical epi to st. sq.

Transformation zone (OBGYN terminology)/ squamocolumnar zone/ squamocolumnar junction/ transition zone

*calculus- stone *chronic trauma leading to cartilage osseous due to calcification * vit a deficiency loss of translucency due to kerato-conjunctivitis or keratinization of cornea

Same as the principles mentioned above. If the cell is able to adapt it will survive and leads to adaptive changes: hypertrophy, hyperplasia, metaplasia and atrophy. And if the cell is unable to adapt it will not survive and lead to cell death

DYSPLASIA y Deranged development y Proliferation and atypical cytologic alterations y change in size, shape and organization NOT an adaptive mechanism but a change for the WORSE Cell Adaptation Key Facts: y Adaptable within physiological limits; beyond physiologic limits may cause cell death y Heat shock proteins can respond to injury by producing cell stress proteins, which protect from damage and help in recovery y Increased demands met by hypertrophy and hyperplasia y Reduced demand met by atrophy y Apoptosis- cell loss from tissues can be achieved by programmed cell death y Tissues can adapt to demand by a change in differentiation known as metaplasia

Reaction of cells to injury on a biochemical level y Functional (biochemical)changes occur before gross morphologic changes appear y Changes occur as follows: Ultrastructural light microscopic changes gross morphological change y Again, the light microscopic changes that can be appreciated are fatty change and cellular swelling Reactions of cell injury y Reversible injury(degeneration) o Cell functions impaired but cell can recover o Removing the stimuli will return the cell back to its original state y Irreversible injury o Cessation of all cell functions with cellular death o Apoptosis  Programmed cell death o Necrosis  Sum of degradative and inflammatory reactions occurring after tissue death

Note the influx of calcium, sodium and radicals that brings about cellular changes. This will be further discussed in the succeeding lectures.

REVERSIBLE INJURY : Morphologic changes y Light microscopic changes o Cell swelling (a/k/a hydropic change) o Fatty change  Cell is replaced by a blank space which is actually fat that was removed by the alcohol (this is during the process of tissue slide preparation) with the nucleus at the periphery y Ultrastructural changes o Cannot be seen but implied o Alterations of cell membrane o Swelling of and small amorphous deposits in mitochondria o Swelling of RER and detachment of ribosomes o Seen as cytoplasmic blebs IRREVERSIBLE INJURY: Morphologic changes y Light microscopic changes o Increased cytoplasmic eosinophilia (loss of RNA, which is more basophilic) o Cytoplasmic vacuolization o Nuclear chromatin clumping  Very hard to distinguished y Ultrastructural changes o Breaks in cellular and organellar membranes o Larger amorphous densities in mitochondria o Nuclear changes:  Pyknosis y Nuclear shrinkage and increased basophilia  Karyorrhexis

Fragmentation of the pyknotic nucleus Karyolysis y Fading of basophilia of chromatin y Dissolution y

Lung with pneumonia showing morphologic changes in the alveoli. Most cells in the picture are eosinophilic and lacking nucleus or having fragmented nucleus.

CAUSES OF INJURY: y Hypoxia y Chemicals and drugs y Physical Agents y Microbiologic Agents y Immunologic reactions y Genetic Defects y Nutritional Imbalances y Aging

MECHANISMS OF CELL INJURY y Loss of calcium homeostasis o related to ATP depletion, because maintaining intracellular Calcium necessitates ATP y Defects in membrane permeability o Due to defective Na-K channel which is also ATP dependent o Sodium is retained inside the cell due to lack of Na-K ATPase pump. This will lead to swelling due to increase water content of the cell (water follows sodium). o Vulnerable in injurious stimuli y ATP depletion

y y

o Loss of aerobic respiration (TCA and ETC) Oxygen and oxygen-derived free radicals Membrane damage and loss of calcium homeostasis are most crucial

LOSS OF CALCIUM HOMEOSTASIS y Some models of cell death suggest that a massive influx of calcium causes cell death y Too much cytoplasmic calcium: o Denatures proteins o Poisons mitochondria (oxidative phosphorylation and aerobic respiration) o Inhibits cellular enzymes (protein synthesis)

Schematic diagram of mechanism of cell injury.

INTEGRITY OF CELL MEMBRANES y Injured membranes are leaky y Enzymes and other proteins that escape through the leaky membranes make their way to the bloodstream, where they can be measured in the serum Some enzymes that leak out are dangerous to the cell and cause lysis or metabolic derangement

increase cytosolic calcium can increase your ATPase, Phospholipase, Protease and endonuclease causing the decreased in ATP, decreased in phospholipids(component of cell membrane), disruptions of membrane and cytoskeletal proteins and damage the nuclear chromatin, respectively

HYPOXIC CELL INJURY y Hypoxia o any state of reduction of O2 supplied to cells and tissues and results in decreased ATP production. y Hypoxia can result from: o cardiorespiratory failure o loss of blood supply o reduced transport of O2 in blood (anemia or CO toxicosis)  anemia because of less O2 carrier  CO toxicosis: CO has a greater affinity to Hgb than Oxygen, replacing it and decreasing the oxygen tension leading to a decrease in release of oxygen in the tissue. o blockage of cell enzymes (e.g. cyanide)  affects the CYP450  blocks the last electron acceptor in ETC no ATP production o Ischemia is decreased blood supply or perfusion of tissues usually due to constriction or obstruction of blood vessels.  Spastic phenomenon y Vasospasm or vasoconstriction for a long time leads to hypoxic episodes, however, when bld vessels dilates, too much blood passes through leading to ischemia reperfussion injury (increase in bld supply hyperoxygenation inc free radicals)

y y

Ischemia tends to injure tissue faster because substrates for glycolysis are not delivered, anaerobic generation of ATP stops faster, glycolytic function is inhibited by metabolite accumulation.

Schematic diagram of hypoxia and its effects on the cellular components of the cell.

ISCHEMIA -- REPERFUSION INJURY Reoxygenation by increased generation of free radicals y Compromised cellular antioxidant defenses Promotion of the mitochondrial permeability transition precludes mitochondrial energization and ATP recovery y Inflammation resulting from cytokines and increased adhesion molecules from parenchymal and endothelial cells. Leukocyte influxes adds to damage. y Activation of complement pathway

Mitochondrial oxidative phosphorylation is disrupted first Decreased ATP o Decreased Na/K ATPase gain of intracellular Na cell swelling o Decreased ATP-dependent Ca pumps increased cytoplasmic Ca concentration o Altered metabolism depletion of glycogen o Lactic acid accumulation decreased pH o Detachment of ribosomes from RER decreased protein synthesis End result is cytoskeletal disruption with loss of microvilli, bleb formation, etc

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Oxygen and oxygen derived free radicals causing cell injury

y y y

Mitochondrial swelling with formation of large amorphous densities in matrix Lysosomal membrane damage leakage of proteolytic enzymes into cytoplasm Mechanisms include: o Irreversible mitochondrial dysfunction markedly decreased ATP o Severe impairment of cellular and organellar membranes

EXAMPLES OF FREE RADICALS y Chemical (e.g., CCl4, acetaminophen) y Inflammation / Microbial killing y Irradiation (e.g., UV rays skin cancer) y Oxygen (e.g., exposure to very high oxygen tension on ventilator) y Physiological age-related changes MECHANISMS OF FREE RADICAL INJURY y Lipid peroxidation damage to cellular and organellar membranes y Protein cross-linking and fragmentation due to oxidative modification of amino acids and proteins y DNA damage due to reactions of free radicals with thymine

FREE RADICAL y Free radicals have an unpaired electron in their outer orbit y Free radicals cause chain reactions y Generated by: o Absorption of radiant energy o Oxidation of endogenous constituents o Oxidation of exogenous compounds

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Free radicals and it s pathologic effects.

End of transcription Whew! I didn t thought I ll be making a twelvepaged tranx for an hour lecture!! Hahaha! Anyways, good luck and study hard batch 2014! Here s to a great year for all of us! In all these things we have complete victory through him who loved us. Romans 8:37-39

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