Cell Injury

Dr. Srikumar

Cells are stressed so severely that they are no longer able to adapt Exposed to inherently damaging agents.

Causes
Hypoxia Physical agents Chemical agents and drugs Infectious agents Immunological reactions Genetic defects Nutritional imbalances

Hypoxia
Due to Ischaemia (loss of blood supply) Inadequate oxygenation of blood (cardio respiratory failure) Depletion of oxygen carrying capacity of blood (anaemia) Poisoning of oxidative enzymes (CO poisoning)

Physical agents
Trauma- abrasion, laceration, contusion, haemorrhage, fracture, crush injury Hyperthermia- heat stroke, heat cramps, heat exhaustion Hypothermia- generalized or localized Changes in atmospheric pressure- Caisson disease Electric shock- burns / ventricular arrhythmia Thermal injury- various degrees of burns

Chemical agents and drugs

Virtually any chemical agent can cause cell injury. Injury due to poisons (toxic substances-Ar, Cy, Hg). Air pollutants,insecticides,CO, asbestos, alcohol. Can cause:Metabolic effects, corrosive effects, mutagenic effects

One or two general mechanisms: 1. Some chemicals act directly by combining with a critical molecular component or cellular organelle. 2. Many other toxic chemicals are not intrinsically biologically active, must be first converted to reactive toxic metabolites, which then act on target cells.

Radiation injury
Electro magnetic waves ( X- rays and gamma rays) High- energy neutrons and charged particles ( alpha and beta particles and protons) Cause damage to DNA / cell membranes/ cytoplasmic alterations/ vascular damage. Target effect Indirect effect ( after a latent period )

Infectious agents
Bacteria, viruses, fungi, parasites, rickettsiae Insects, snakes, spiders, jelly fish etc., Injury is due toIntracellular multiplication Competition for essential nutrients Production of toxic substances Hypersensitivity reactions

Nutritional imbalances
Inadequate intake of food, anorexia Malabsorption Protein calorie malnutrition Excessive intake of lipids (dietary excess)

Other Causes
Genetic (Downs, Sickle cell), Immunologic (anaphylactic reaction to foreign protein).

Pathogenesis of cell injury

No common pathway. Important mechanisms involve: Hypoxia / ischaemia / metabolic / toxins / infective and target cell membranes / mitochondria / cytoskeleton / cellular DNA Can be sublethal or lethal. Sublethal- reversible Lethal- nonreversible. Cell death is primarily recognized by changes in the nucleus. **

Intracellular damage
Four intracellular systems are particularly vulnerable: 1. Maintenance of the integrity of cell membranes 2. Aerobic respiration 3. Protein synthesis 4. Preservation of the integrity of the genetic apparatus of the cell.

Common biochemical themes

Important in the mediation of cell injury: ATP depletion. Irreversible mitochondrial damage Intracellular calcium and loss of calcium homeostasis Defects in membrane permeability Oxygen and oxygen-derived free radicals

Forms and patterns of cell injury

Patterns of reversible acute cell injury Patterns of cell death after irreversible injury ( necrosis) Pattern of cell death by suicide called apoptosis

Reversible cell injury

2 patterns: cellular swelling and fatty change. Cellular swelling: also called hydropic change or vacuolar degeneration. Appears whenever cells are incapable of maintaining ionic and fluid homeostasis. First manifestation of almost all forms of cell injury. When all cells in an organ are affected, there is pallor, increased weight and increased turgor.

Morphology
Small clear vacuoles seen in the cytoplasm plasma membrane alterations: blebbing, blunting or distortion of microvilli: mitochondrial and endoplasmic reticulum dilation nuclear alterations.

Fatty change
Occurring in hypoxic injury and various forms of toxic or metabolic injury Lipid vacuoles in the cytoplasm. Principally seen in cells participating in fat metabolism ( hepatocytes and myocardial cells).

Fatty change

Irreversible cell injury

Accumulation of amorphous, calcium-rich densities in the mitochondrial matrix. Cell membrane damage is the central factor Progressive loss of membrane phospholipids, cytoskeletal abnormalities, toxic oxygen radicals, lipid breakdown products.

Dead cells
Cytoplasm: Increased eosinophilia Glassy homogenous appearance Nuclear changesKaryolysis Pyknosis Karyorrhexis

Progression of cell injury

Apoptosis
Means a falling away form Programmed cell death. Can be both physiological or pathological. Usually involves single cells or clusters of cells - appear as round or oval masses with intensely eosinophilic cytoplasm.

Apoptosis

Necrosis
Refers to a sequence of morphologic changes that follow cell death in living tissue. This occurs in the setting of irreversible exogenous injury. Types of necrosis are: Coagulative necrosis Liquefactive necrosis Caseous necrosis Fat necrosis Gangrene

Necrosis
Result of two concurrent processes: 1. Denaturation of proteins. 2. Enzymatic digestion of the cell (autolytic or heterolytic). Requires hours to develop. Classic histological picture not apparent until 4 to 12 hours after irreversible injury has occurred.

Coagulative necrosis
When denaturation of proteins is the primary factor Preservation of the basic structural outline of the coagulated cell or tissue for a span of few days Affected tissues exhibit a firm texture. Seen in hypoxic cell death in all tissues except brain Myocardial Infarction is a prime example: coagulated, anucleate cells may persist for weeks

Coagulative necrosis

Nuclear ghosts

Liquefactive necrosis
Characteristic of focal bacterial or occasionally fungal infections In brain hypoxic death cells invokes this type of necrosis Complete digestion of dead cells Transformation of tissue into a liquid viscous mass If initiated by acute inflammation,the material is frequently creamy yellow because of the presence of dead white cells and is called pus

Liquefactive necrosis

Liquefactive necrosis

Liquefactive necrosis

Caseous necrosis
Distinctive form of coagulative necrosis. Seen most often in tuberculous infection. Caseous- white and cheesy in the area of necrosis ( gross). Histology: necrotic focus appears as granular debris composed of fragmented, coagulated cells and enclosed within a distinctive inflammatory border. Tissue architecture is completely obliterated.

Caseous necrosis

Caseative necrosis

Other types of necrosis

Fat necrosis Descriptive of a focal area of fat destruction. Occurs in acute pancreatitis. Pancreatic enzymes escape form acinar cells and ducts and liquefy fat cell membranes. Chalky white areas.

Gangrenous necrosis Usually applied to a limb that has lost it blood supply and has undergone coagulative necrosis. There is superimposed bacterial infection and there is liquefactive action of the bacteria and leukocytes ( wet gangrene)

Gangrene

Necrosis vs Apoptosis
Pathologic (hypoxia, toxins). Consequence of irreversible cell injury. "cell homicide" Many cells affected - Cell swelling, Organelle disruption, Loss of membrane integrity. - Coagulation or liquefaction Physiologic, genetically regulated process. Occasionally pathologic. "cell suicide" Few cells affected. - Cell shrinkage, apoptotic bodies which are eaten by macrophages.

Karyorrhexis and karyolysis: Orderly nuclear random, diffuse fragmentation condensation and and dissolution of the nucleus. fragmentation. Inflammation with injury to surrounding normal tissues. No Inflammation or tissue injury.

Thank you
Pathologic Basis of disease Robbins & Cotran, 8th Ed General & systemic pathology Underwood, 2nd Ed Principles of Internal Medicine Harrisons, 15th Ed Textbook of Medical Physiology Guyton, 9th Ed Aids to Pathology Dixon/ Quirke, 4th Ed Surgical Pathology Ackerman, 9th Ed; Lecture notes on Pathology Cotton, 4th Ed; http://clinicalpathology.wordpress.com/