Inflammation and Repair

Luis P. Cruz, MD, FPSP, FPSO Asst.Prof VI

INFLAMMATION AND REPAIR

2nd Century AD: cardinal signs Aulus Celsus 18th century: John Hunter, vascular basis Rudolf Virchow, prior injury Julius Cohnheim, pmn emigration 19th century : Eli Metchnikoff, phagocytosis 1927 : Thomas Lewis, vascular permeability and migration of pmns

INFLAMMATION AND REPAIR

DEFINITION: 1. Reaction of vascularized tissues to local injury 2. Series of changes which take place in living tissue ff. injury 3. Local reaction of the body to injury 4. Reaction of irritated and damaged tissues which still retain viability

Reaction of a tissue and its microcirculation to a pathogenic insult, characterized by generation of inflammatory mediators and movement of fluid and leukocytes from the blood vessel into the extravascular tissues

INFLAMMATION AND REPAIR

Inflammation
Protective response intended to eliminate the initial cause of cell injury and the necrotic cells and tissues arising from the injury

Inflammation is intimately associated with the repair process which includes parenchymal cell regeneration and scarring

INFLAMMATION AND REPAIR

MAJOR COMPONENTS OF ACUTE INFLAMMATORY RESPONSE 1. Alterations in vascular caliber 2. Structural changes in microvasculature 3. Emigration of leucocytes/ Accumulation in focus of injury Sequence of Events : INITIATION : recognition that injury has occurred AMPLIFICATION: activation of soluble mediators and cellular systems TERMINATION : Inhibition of the mediators

INFLAMMATION AND REPAIR

CAUSES OF INFLAMMATION 1. Physical Agents: Heat, Trauma, irradiation 2. Chemical Agents: Organic and Inorganic 3. Microbial Infections: most important 4. Hypersensitivity Reactions 5. Necrosis of Tissues

Mycobacterium tuberculosis

INFLAMMATION AND REPAIR

CHANGES IN VASCULAR FLOW & CALIBER
1.

2.

3.

Transient vasoconstriction and vasodilatation occurs Slowing of the circulation secondary to increased permeability of the microvasculature (STASIS) Leucoytic margination

CELLULAR AND VASCULAR CHANGES

ADHESION AND TRANSMIGRATION

binding of complementary adhesion molecules on the leucocyte and endothelial surfaces

redistribution of adhesion molecules to surface induction of adhesion molecules on endothelium chemotaxis : locomotion oriented along a chemical gradient

INCREASED VASCULAR PERMEABILITY

MECHANISMS endothelial cell contraction, leading to formation of widened intercellular junctions and gaps cytoskeletal and junctional reorganization direct endothelial injury, resulting in endothelial cell necrosis and detachment

leukocyte-mediated injury leakage from regenerating capillaries

CELLULAR EVENTS
LEUCOCYTE EXTRAVASATION AND PHAGOCYTOSIS 1. Margination, rolling and adhesion 2. Transmigration across the endothelium (diapedesis) 3. Migration in interstitial tissues toward a chemotactic stimulus

ADHESION AND TRANSMIGRATION

BINDING OF COMPLEMENTARY ADHESION MOLECULES ON THE LEUKOCYTE AND ENDOTHELIAL SURFACES redistribution of adhesion molecules to surface induction of adhesion molecules on endothelium CHEMOTAXIS

locomotion oriented along a chemical gradient

exogenous : bacterial products endogenous : complement system (C5a) cytokines lipo-oxygenase pathway

Selectins bind selected sugars Selected + Lectins (sugars) = Selectins Some selectins are present on endothelial cells (E-Selectin) Some selectins are present on leukocytes (L-Selectin) Some selectins are present on platelets (P-Selectin)

Weak & transient binding Results in rolling

Rolling Selectins transiently bind to receptors PMNs bounce or roll along Rolling

Adhesion Mediated by integrins ICAM-1 and VCAM-1

Transmigration Mediated/assisted by PECAM-1 & ICAM-1 (Integrins) Diapedesis (cells crawling) Primary in venules Collagenases degrade BM Permeability

LEUKOCYTE ACTIVATION
production

of arachidonic acid metabolites degranulation and secretion of lysozyme modulation of leukocyte activation molecules PRIMING: increased rate and extent of leukocyte activation by exposure to a mediator

Arachidonic acid metabolites

Metabolites of AA - short-range hormones AA metabolites act locally at site of generation Rapidly decay or are destroyed

Arachidonic Acid

AA is released from the cell membrane by phospholipases which have themselves been activated by various stimuli and/or inflammatory mediators AA metabolism occurs via two major pathways named for the enzymes that initiate the reactions; lipoxygenase and cyclooxygenase

PGG2

PGH2

PGI2 TXA2

PGI2 PGD2 ; PGE2 Prostacyclin PGF2

Vasodilatation Inhibits Platelet Aggregation

TXA2 Thromboxane
Vasoconstriction Promotes Platelet Aggregation

Vasodilatation Edema

Arachidonic Acid Pathways

Lipoxygenase

Cyclooxygenase

5-HETE

Prostaglandins

Chemotaxis

5-HPETE

Vasodilatation Increased vascular permeability Vasodilatation Inhibits platlelet aggregation

Leukotriene generation
Vasoconstriciton Bronchospasm Increased vascular permeability

Prostacyclin

Leukotrienes

Thromboxane A2

Vasoconstriction Promotes platlelet aggregation

Inflammation and Repair

Luis P. Cruz, MD, FPSP, FPSO Asst.Prof VI

INFLAMMATION AND REPAIR

2nd Century AD: cardinal signs Aulus Celsus 18th century: John Hunter, vascular basis Rudolf Virchow, prior injury Julius Cohnheim, pmn emigration 19th century : Eli Metchnikoff, phagocytosis 1927 : Thomas Lewis, vascular permeability and migration of pmns

INFLAMMATION AND REPAIR

DEFINITION: 1. Reaction of vascularized tissues to local injury 2. Series of changes which take place in living tissue ff. injury 3. Local reaction of the body to injury 4. Reaction of irritated and damaged tissues which still retain viability

Reaction of a tissue and its microcirculation to a pathogenic insult, characterized by generation of inflammatory mediators and movement of fluid and leukocytes from the blood vessel into the extravascular tissues

INFLAMMATION AND REPAIR

Inflammation
Protective response intended to eliminate the initial cause of cell injury and the necrotic cells and tissues arising from the injury

Inflammation is intimately associated with the repair process which includes parenchymal cell regeneration and scarring

INFLAMMATION AND REPAIR

MAJOR COMPONENTS OF ACUTE INFLAMMATORY RESPONSE 1. Alterations in vascular caliber 2. Structural changes in microvasculature 3. Emigration of leucocytes/ Accumulation in focus of injury Sequence of Events : INITIATION : recognition that injury has occurred AMPLIFICATION: activation of soluble mediators and cellular systems TERMINATION : Inhibition of the mediators

INFLAMMATION AND REPAIR

CAUSES OF INFLAMMATION 1. Physical Agents: Heat, Trauma, irradiation 2. Chemical Agents: Organic and Inorganic 3. Microbial Infections: most important 4. Hypersensitivity Reactions 5. Necrosis of Tissues

Mycobacterium tuberculosis

INFLAMMATION AND REPAIR

CHANGES IN VASCULAR FLOW & CALIBER
1.

2.

3.

Transient vasoconstriction and vasodilatation occurs Slowing of the circulation secondary to increased permeability of the microvasculature (STASIS) Leucoytic margination

CELLULAR AND VASCULAR CHANGES

ADHESION AND TRANSMIGRATION

binding of complementary adhesion molecules on the leucocyte and endothelial surfaces

redistribution of adhesion molecules to surface induction of adhesion molecules on endothelium chemotaxis : locomotion oriented along a chemical gradient

INCREASED VASCULAR PERMEABILITY

MECHANISMS endothelial cell contraction, leading to formation of widened intercellular junctions and gaps cytoskeletal and junctional reorganization direct endothelial injury, resulting in endothelial cell necrosis and detachment

leukocyte-mediated injury leakage from regenerating capillaries

CELLULAR EVENTS
LEUCOCYTE EXTRAVASATION AND PHAGOCYTOSIS 1. Margination, rolling and adhesion 2. Transmigration across the endothelium (diapedesis) 3. Migration in interstitial tissues toward a chemotactic stimulus

ADHESION AND TRANSMIGRATION

BINDING OF COMPLEMENTARY ADHESION MOLECULES ON THE LEUKOCYTE AND ENDOTHELIAL SURFACES redistribution of adhesion molecules to surface induction of adhesion molecules on endothelium CHEMOTAXIS

locomotion oriented along a chemical gradient

exogenous : bacterial products endogenous : complement system (C5a) cytokines lipo-oxygenase pathway

Selectins bind selected sugars Selected + Lectins (sugars) = Selectins Some selectins are present on endothelial cells (E-Selectin) Some selectins are present on leukocytes (L-Selectin) Some selectins are present on platelets (P-Selectin)

Weak & transient binding Results in rolling

Rolling Selectins transiently bind to receptors PMNs bounce or roll along Rolling

Adhesion Mediated by integrins ICAM-1 and VCAM-1

Transmigration Mediated/assisted by PECAM-1 & ICAM-1 (Integrins) Diapedesis (cells crawling) Primary in venules Collagenases degrade BM Permeability

LEUKOCYTE ACTIVATION
production

of arachidonic acid metabolites degranulation and secretion of lysozyme modulation of leukocyte activation molecules PRIMING: increased rate and extent of leukocyte activation by exposure to a mediator

Arachidonic acid metabolites

Metabolites of AA - short-range hormones AA metabolites act locally at site of generation Rapidly decay or are destroyed

Arachidonic Acid

AA is released from the cell membrane by phospholipases which have themselves been activated by various stimuli and/or inflammatory mediators AA metabolism occurs via two major pathways named for the enzymes that initiate the reactions; lipoxygenase and cyclooxygenase

PGG2

PGH2

PGI2 TXA2

PGI2 PGD2 ; PGE2 Prostacyclin PGF2

Vasodilatation Inhibits Platelet Aggregation

TXA2 Thromboxane
Vasoconstriction Promotes Platelet Aggregation

Vasodilatation Edema

Arachidonic Acid Pathway

Lipoxygenase

5-HETE, 5-HPETE, Leukotrienes

Cyclooxygenase

Spasm (Vaso, Broncho)

Prostaglandins - EDEMA Prostacyclin vs TXA2

Vasodilatation vs. Vasoconstriction Platelet aggregation Inhibits vs. promotes

Arachidonic Acid Metabolites

Participate in every aspect of acute inflammation Effective Anti-inflammatory agents act on AA pathways
Aspirin and Non-Steroidal Anti-inflammatory Drugs (NSAIDs) - Cyclooxygenase path Steroids act, in part, by inhibiting Phospholipase A2

AA metabolites (eicosanoids)
Cyclooxygenases synthesize Prostaglandins Thromboxanes Lipoxygenases synthesize Leukotrienes Lipoxins

Platelet-Activating Factor (PAF)

Another phospholipid-derived mediator released by phospholipases Induces aggregation of platelets Causes vasoconstriction and bronchoconstriction 100 to 1,000 times more potent than histamine in inducing vasodilation and vascular permeability Enhances leukocyte adhesion, chemotaxis, degranulation and the oxidative burst It does everything!

Cytokines

Polypeptides that are secreted by cells Act to regulate cell behaviors Autocrine, paracrine or endocrine effects These biological response modifiers are being actively investigated for therapeutic use in controlling the inflammatory response.

Lymphocyte function
1. Macrophages make IL-1 & TNF-
2. T-cells make TNF- (lymphotoxin) 3. Can be autocrine, paracrine, endocrine 4. IL-1, TNF, IL-6 acute phase responses, fever, (appetite, slow wave sleep, circ. pmn, ACTH, corticosteroids)

5. TNF notable for role in septic shock and maintenance of body mass (cachexia in cancer from TNF- )

MEDIATORS IN INFLAMMATION

VASODILATION - prostaglandins VASCULAR PERMEABILITY vasoactive amines; PAF; C3a; C5a; bradykinin; leukotriene CHEMOTAXIS: C5a; leukotrieneB4; bacterial products FEVER : interleukin 1; TNF; prostaglandins PAIN: prostaglandins TISSUE DAMAGE: neutrophil/macrophage lysozymes; oxygen metabolites

MEDIATORS IN INFLAMMATION

Plasma-derived

Circulating precursors Have to be activated Sequestered intracellular Synthesized de novo

Cell-derived

Most mediators bind to receptors on cell surface but some have direct enzymatic or toxic activity Mediators are tightly regulated

Plasma Mediator Systems - Interaction

1. Kinin 2. Clotting 3. Complement 4. Fibrinolytic

Kinin cascade

Leads to formation of bradykinin Bradykinin causes

Increased vascular permeability Arteriolar dilatation Smooth muscle contraction

Bradykinin is short lived (kininases) Vascular actions similar to histamine

Complement system

Role in immunity (C5-9 complex)

Membrane Attack Complex (MAC C5-9) Punches a hole in the membrane

Complement system

Role in inflammation (c3a and c5a)

Vascular effects
Increase vascular permeability and vasodilation Similar to histamine

Activates lipoxygenase pathway of arachidonic acid metabolism (c5a)

Complement system

Leukocyte activation, adhesion and chemotaxis (c5a) Phagocytosis c3b acts as opsonin and promotes phagocytosis by cells bearing receptors for c3b

Inflammatory Mediators from Complement

Phagocytosis: C3b and C3bi are opsonins Control:

Convertases are destabilized by "decay accelerating factor" (DAF)

Inability to express DAF causes paroxysmal nocturnal hemoglobinuria C1 inhibitor (C1INH) deficiency causes hereditary angioneurotic edema

Vasoactive amines

Histamine

Found in mast cells, basophils and platelets Released in response to stimuli Promotes arteriolar dilation and venular endothelial contraction

results in widening of interendothelial cell junctions with increased vascular permeability

Serotonin

Vasoactive effects similar to histamine Found in platelets Released when platelets aggregate

Bradykinin: Potent biomolecule 1. Vasodilatation 2. Increased vascular permeability 3. Contraction of smooth muscle 4. Pain on injection 5. Short life, kininase degrades Factor XII activated by: 1. Plasmin 2. Kallikrein 3. Collagen & basement membrane 4. Activated platelets 5. Co-factor = HMWK Vascular Permeability: - Bradykinin

- Fibrionopeptides
- Fibrin Split Prod. - Factor Xa - Leukotrienes

LIVER CIRRHOSIS

MACROPHAGE PRODUCTS FOR DESTRUCTION/ FIBROSIS A. Tissue Injury

toxic oxygen metabolites proteases neutrophil chemotactic factors amino acid metabolites nitric oxides growth factors (PDGF,FGF,TGFb) fibrogenic cytokines angiogenesis factor remodelling collagenases

COMPONENTS OF FIBROSIS
1. 2. 3. 4.

Formation of New blood Vessels Migration and Proliferation of Fibroblasts Deposition of Extracellular Matrix Maturation and Organization of Fibrous Tissue *GRANULATION TISSUE

MORPHOLOGIC PATTERNS IN ACUTE AND CHRONIC INFLAMMATION

BASIC PATTERNS OF INFLAMMATION 1. serous inflammation 2. fibrinous inflammation 3. suppurative or purulent inflammation 4. ulceration FACTORS THAT MODIFY THE INFLAMMATORY RESPONSE 1. nature and intensity of the injury 2. site and tissue affected 3. responsiveness of the host

GRANULOMATOUS INFLAMMATION
DEFINITION: Distinctive aggregation of chronic inflammatory reaction in which the predominant cell type is an activated macrophage (EPITHELOID CELL) GRANULOMA : Microscopic aggregation of macrophages transformed into EPITHELOID CELLS surrounded by a collar of mononuclear cells

GRANULOMA

GRANULOMATOUS INFLAMMATION
Types of Granuloma 1. Foreign body granuloma 2. Immune granuloma Histologic Features 1. epitheloid cell 2. giant cells (Langhans type) 3. inflammatory cells /fibroblasts 4. central caseation necrosis

EPITHELOID CELL

LANGHANS TYPE GIANT CELL

CLINICO-PATHOLOGIC DIFFERENCES BETWEEN ACUTE AND CHRONIC INFLAMMATION

ACUTE

CHRONIC

1. Pathologic Features A. Gross organ larger than normal ...smaller B . Histologiic exudative, polys proliferative, monos 2. Clinical Features A. Onset B. Duration rapid short insiduous long

SCHEMA OF INFLAMMATORY RESPONSE

INJURY VASCULAR RESPONSE INFLAMMATORY RESPONSE INVADERS PROMPTLY DESTROYED NO NECROSIS OF CELLS
EXUDATE RESOLVED
RESTITUTION OF NORMAL STRUCTURES

INVADERS NOT PROMPTLY DESTROYED NECROSIS OF CELLS

STABLE / LABILE
FRAMEWORK INTACT DESTROYED REGENERATION RESTITUTION

EXUDATES ORGANIZED
SCARRING

PERMANENT
SCARRING

Mild Heart Injury

Fibrinous Pericarditis

Lobar Pneumonia

Amebic Abscess

M . I.

WOUND HEALING Induction of an acute inflammatory response Parenchymal cell regeneration Migration and proliferation of both parenchymal and connective tissue cells Synthesis of ECM Remodelling of parenchymal elements to restore tissue function Remodelling of connective tissue to achieve wound strength

Phases of Wound Healing

Inflammatory Phase Proliferative Phase Remodelling Phase

Phases of Wound Healing

Inflammatory Phase (Substrate, Lag, or Exudative) - 0 to 4 days Proliferative Phase (Collagen, Fibroplasia or Fibroblastic Stage) - 4 to 42 days Remodelling Phase (Maturation) - 3 to 6 weeks onwards

Events During Inflammatory Phase

Vasoconstriction Vasodilation Endothelial cell gap formation & increased permeability Clot formation Migration of inflammatory cells

Creation of Hemostasis
Clot formation
fibrin mesh aggregated platelets

Creation of Hemostasis
Fibrin = end product of coagulation cascade
Intrinsic pathway = factor XII activation Extrinsic pathway = factor VII activation

Fibrin = 1o component of provisional matrix

Inflammatory Phase
Migration of inflammatory cells initially PMNs (neutrophils) predominate gradually replaced by macrophages

Inflammatory Phase

Most important cell in wound healing Macrophage (monocyte)

Interleukin I (IL-1) Tumor necrosis factor (TNF-a)

Fibronectin

Produced by fibroblasts & epithelial cells Is a glycoprotein Facilitates attachment of migrating cells (PMNs, monoctyes, fibroblasts & endothelial cells) onto fibrin latticework Binds and acts as reservoir for various cytokines

Proliferative Phase

Migration of fibroblasts Production of glycosaminoglycans & collagen Wound tensile strength directly proportional to amount of collagen in the wound

Remodelling Phase

Accelerated collagen synthesis & degradation (but no net increase in collagen content) Collagen fibers become more organized Type III collagen is replaced by Type I collagen More stable crosslinks are formed

Wound Closure

Healing by first or primary intention Healing by secondary intention Healing by tertiary intention (delayed primary closure)

REPAIR
FACTORS INFLUENCING REPAIR GROWTH FACTORS CELL-CELL AND CELL-MATRIX INTERACTIONS EXTRACELLULAR MATRIX SYNTHESIS AND COLLAGENIZATION

REPAIR

FACTORS MODIFYING THE QUALITY OF THE INFLAMMATORY-REPARATIVE RESPONSE 1. ADEQUACY OF BLOOD SUPPLY 2. NUTRITION 3. PRESENCE OR ABSENCE OF INFECTION 4. HEALTH STATUS 5. INTAKE OF DRUGS , e.g., STEROIDS

Neutrophils noted at the incision margin Basal cells at the cut edge begin to exhibit increased mitotic activity Epithelial cell migration at the cut edge of the dermis, depositing basement membrane component

Replacement by macrophages with formation of granulation tissues

Collagen deposition

Continued epithelial cell proliferation

Neovascularization peaks at day 5

Continued collagen accumulation and fibroblast proliferation 2nd wk Diminished leukocyte infiltrates, edema and vascularity

By the end of the 1st month the scar comprises of connective tissues devoid of inflammatory cells

TERMINOLOGY
RESTITUTION : attainment of pre-existing tissue architecture after inflammation RESOLUTION : the inflammatory response has successfully dealt with the injury with little or no damage ORGANIZATION : inflammatory response causes excessive exudation or tissue death and when local conditions are unfavorable for removal of debris REGENERATION : replacement of dead cells by new cells of the same type

Hypertrophic Scars

Elevated but limited to boundaries of injury Occur at any age or site Regress or improve spontaneously Equal sex ratios Less familial or racial influence

Keloid

Extend beyond borders of original wound More frequent among blacks Significant familial predilection Most common at age 10 to 30 yrs Rarely subsides, difficult to treat