34 rane as well as may interact with DNA of the target cell.

In
proliferating cells, there is inhibition of DNA replication and
eventual cell death by apoptosis (e.g. epithelial cells). In non-
proliferating cells there is no effect of inhibition of DNA
SECTION I

synthesis and in these cells there is cell membrane damage

followed by cell death by necrosis (e.g. neurons).

MORPHOLOGY OF CELL INJURY

After having discussed the molecular and biochemical
mechanisms of various forms of cell injury, we now turn to
light microscopic morphologic changes of reversible and
General Pathology and Basic Techniques

irreversible cell injury.

Depending upon the severity of cell injury, degree of
damage and residual effects on cells and tissues are variable.
In general, morphologic changes in various forms of cell
injury can be classified as shown in Table 3.2 and are
discussed below.

MORPHOLOGY OF REVERSIBLE CELL INJURY

In conventional description of morphologic changes, the term
Figure 3.10 Mechanisms of cell injury by ionising radiation.
degeneration has been used to denote morphology of
reversible cell injury. However, now it is realised that this
poisoning, the greatest damage occurs to cells of the alimen- term does not provide any information on the nature of
tary tract where it is absorbed and kidney where it is excreted. underlying changes and thus currently more acceptable
Cyanide kills the cell by poisoning mitochondrial cyto- terms of retrogressive changes or simply reversible cell injury
chrome oxidase thus blocking oxidative phosphorylation. are applied to non-lethal cell injury.
Other examples of directly cytotoxic chemicals include Following morphologic forms of reversible cell injury are
chemotherapeutic agents used in treatment of cancer, toxic included under this heading:
heavy metals such as mercury, lead and iron. 1. Hydropic change (cloudy swelling, or vacuolar
degeneration)
CONVERSION TO REACTIVE TOXIC METABOLITES. 2. Fatty change
This mechanism involves metabolic activation to yield 3. Hyaline change
ultimate toxin that interacts with the target cells. The target 4. Mucoid change
cells in this group of chemicals may not be the same cell that
metabolised the toxin. Example of cell injury by conversion Hydropic Change
of reactive metabolites is toxic liver necrosis caused by carbon Hydropic change means accumulation of water within the
tetrachloride (CCl4), acetaminophen (commonly used anal- cytoplasm of the cell. Other synonyms used are cloudy
gesic and antipyretic) and bromobenzene. Cell injury by CCl4 swelling (for gross appearance of the affected organ) and
is classic example of an industrial toxin (earlier used in dry- vacuolar degeneration (due to cytoplasmic vacuolation).
cleaning industry) that produces cell injury by conversion
to a highly toxic free radical, CCl3, in the body’s drug-meta- ETIOLOGY. This is the commonest and earliest form of cell
bolising P450 enzyme system in the liver cells. Thus, it injury from almost all causes. The common causes include
produces profound liver cell injury by free radical generation.
Other mechanism of cell injury includes direct toxic effect 
 TABLE 3.2: Classification of Morphologic Forms of
Cell Injury.
on cell membrane and nucleus.
Mechanism of Nomenclature
Cell Injury
Pathogenesis of Physical Injury
1. Reversible cell injury Retrogressive changes
Injuries caused by mechanical force are of medicolegal (older term: degenerations)
significance. But they may lead to a state of shock. Injuries
2. Irreversible cell injury Cell death—necrosis
by changes in atmospheric pressure (e.g. decompression
sickness) are detailed in Chapter 5. Radiation injury to human 3. Programmed cell death Apoptosis
by accidental or therapeutic exposure is of importance in 4. Residual effects of Subcellular alterations
treatment of persons with malignant tumours as well as may cell injury
have carcinogenic influences (Chapter 8). 5. Deranged cell metabolism Intracellular accumulation
Killing of cells by ionising radiation is the result of direct of lipid, protein, carbohydrate
formation of hydroxyl radicals from radiolysis of water
6. After-effects of necrosis Gangrene, pathologic calcification
(Fig. 3.10). These hydroxyl radicals damage the cell memb-
acute and subacute cell injury from various etiologic agents INTRACELLULAR HYALINE. Intracellular hyaline is 35
such as bacterial toxins, chemicals, poisons, burns, high fever, mainly seen in epithelial cells. A few examples are as follows:
intravenous administration of hypertonic glucose or saline 1. Hyaline droplets in the proximal tubular epithelial cells in

CHAPTER 3
etc. cases of excessive reabsorption of plasma proteins.
PATHOGENESIS. Cloudy swelling results from impaired 2. Hyaline degeneration of rectus abdominalis muscle called
regulation of sodium and potassium at the level of cell Zenker’s degeneration, occurring in typhoid fever. The
membrane. This results in intracellular accumulation of muscle loses its fibrillar staining and becomes glassy and
sodium and escape of potassium. This, in turn, leads to rapid hyaline.
flow of water into the cell to maintain iso-osmotic conditions 3. Mallory’s hyaline represents aggregates of intermediate
and hence cellular swelling occurs. In addition, influx of filaments in the hepatocytes in alcoholic liver cell injury.
calcium too occurs. Hydropic swelling is an entirely 4. Nuclear or cytoplasmic hyaline inclusions seen in some

Cell Injury and Cellular Adaptations

reversible change upon removal of the injurious agent. viral infections.
5. Russell’s bodies representing excessive immunoglobulins
MORPHOLOGIC FEATURES. Grossly, the affected in the rough endoplasmic reticulum of the plasma cells
organ such as kidney, liver, pancreas, or heart muscle is (Fig. 3.12).
enlarged due to swelling. The cut surface bulges outwards
and is slightly opaque. EXTRACELLULAR HYALINE. Extracellular hyaline is seen
Microscopically, it is characterised by the following in connective tissues. A few examples of extracellular hyaline
features (Fig. 3.11): change are as under:
i) The cells are swollen and the microvasculature 1. Hyaline degeneration in leiomyomas of the uterus
compressed. (Fig. 3.13).
ii) Small clear vacuoles are seen in the cells and hence 2. Hyalinised old scar of fibrocollagenous tissues.
the term vacuolar degeneration. These vacuoles represent 3. Hyaline arteriolosclerosis in renal vessels in hypertension
distended cisternae of the endoplasmic reticulum. and diabetes mellitus.
iii) Small cytoplasmic blebs may be seen. 4. Hyalinised glomeruli in chronic glomerulonephritis.
iv) The nucleus may appear pale. 5. Corpora amylacea are rounded masses of concentric hya-
line laminae seen in the prostate in the elderly, in the brain
Hyaline Change and in the spinal cord in old age, and in old infarcts of the
lung.
The word ‘hyaline’ means glassy (hyalos = glass). Hyaline is
a descriptive histologic term for glassy, homogeneous, Mucoid Change
eosinophilic appearance of material in haematoxylin and Mucus secreted by mucous glands is a combination of
eosin-stained sections and does not refer to any specific proteins complexed with mucopolysaccharides. Mucin, a
substance. Though fibrin and amyloid have hyaline appear- glycoprotein, is its chief constituent. Mucin is normally
ance, they have distinctive features and staining reactions produced by epithelial cells of mucous membranes and
and can be distinguished from non-specific hyaline material. mucous glands, as well as by some connective tissues like
Hyaline change is associated with heterogeneous pathologic in the umbilical cord. By convention, connective tissue
conditions. It may be intracellular or extracellular. mucin is termed myxoid (mucus like). Both types of mucin

Figure 3.11 Hydropic change kidney. The tubular epithelial cells are distended with cytoplasmic vacuoles while the interstitial vasculature is
compressed. The nuclei of affected tubules are pale.
 36
SECTION I
General Pathology and Basic Techniques

Figure 3.12 Intracellular hyaline as Russell’s bodies in the plasma

cells. The cytoplasm shows pink homogeneous globular material due to
accumulated immunoglobulins. Figure 3.13 Extracellular hyaline deposit in leiomyoma uterus. The
centres of whorls of smooth muscle and connective tissue show pink
homogeneous hyaline material (connective tissue hyaline).
are stained by alcian blue. However, epithelial mucin stains
positively with periodic acid-Schiff (PAS), while connective CONNECTIVE TISSUE MUCIN. A few examples of
tissue mucin is PAS negative but is stained positively with disturbances of connective tissue mucin are as under:
colloidal iron. 1. Mucoid or myxoid degeneration in some tumours e.g.
myxomas, neurofibromas, fibroadenoma, soft tissue
EPITHELIAL MUCIN. Following are some examples of sarcomas etc(Fig. 3.15) .
functional excess of epithelial mucin: 2. Dissecting aneurysm of the aorta due to Erdheim’s medial
1. Catarrhal inflammation of mucous membrane (e.g. of degeneration and Marfan’s syndrome.
respiratory tract, alimentary tract, uterus). 3. Myxomatous change in the dermis in myxoedema.
2. Obstruction of duct leading to mucocele in the oral cavity 4. Myxoid change in the synovium in ganglion on the wrist.
and gallbladder.
3. Cystic fibrosis of the pancreas. SUBCELLULAR ALTERATIONS IN CELL INJURY
4. Mucin-secreting tumours (e.g. of ovary, stomach, large Certain morphologically distinct alterations at subcellular
bowel etc) (Fig. 3.14) . level are noticeable in both acute and chronic forms of cell

Figure 3.14 Epithelial mucin. Mucinous cystadenoma of the ovary Figure 3.15 Connective tissue mucin (myxoid change) in
showing intracytoplasmic mucinous material in the epithelial cells lining neurofibroma.
the cyst.
injury. These occur at the level of cytoskeleton, lysosomes, of cell injury in mitochondria may be seen in the following 37
endoplasmic reticulum and mitochondria: conditions:

1. CYTOSKELETAL CHANGES. Components of cyto- i) Megamitochondria. Megamitochondria consisting of

CHAPTER 3
skeleton may show the following morphologic abnormalities: unusually big mitochondria are seen in alcoholic liver disease
and nutritional deficiency conditions.
i) Defective microtubules:
ii) Alterations in the number of mitochondria may occur. Their
In Chédiak-Higashi syndrome characterised by poor
phagocytic activity of neutrophils. number increases in hypertrophy and decreases in atrophy.
Poor sperm motility causing sterility. iii) Oncocytoma in the salivary glands, thyroid and kidneys
Immotile cilia syndrome (Kartagener’s syndrome) consists of tumour cells having very large mitochondria.
characterised by immotile cilia of respiratory tract and iv) Myopathies having defect in mitochondria have abnormal

Cell Injury and Cellular Adaptations

consequent chronic infection due to defective clearance of cristae.
inhaled bacteria.
Defects in leucocyte function of phagocytes such as
migration and chemotaxis. INTRACELLULAR ACCUMULATIONS
ii) Defective microfilaments: Intracellular accumulation of substances in abnormal amounts
In myopathies can occur within the cytoplasm (especially lysosomes) or
Muscular dystrophies nucleus of the cell. This phenomenon was previously referred
to as infiltration, implying thereby that something unusual
iii) Accumulation of intermediate filaments: Various classes has infiltrated the cell from outside which is not always the
of intermediate filaments (cytokeratin, desmin, vimentin, case. Intracellular accumulation of the substance in mild
glial fibrillary acidic protein, and neurofilament) may degree causes reversible cell injury while more severe damage
accumulate in the cytosol. For example: results in irreversible cell injury.
Mallory’s body or alcoholic hyaline as intracytoplasmic Such abnormal intracellular accumulations can be divided
eosinophilic inclusion seen in alcoholic liver disease which into 3 groups:
is collection of cytokeratin intermediate filaments. i) Accumulation of constituents of normal cell metabolism
Neurofibrillary tangles, neurities and senile plaques in produced in excess e.g. accumulations of lipids (fatty change,
Alzheimer’s disease are composed of neurofilaments and cholesterol deposits), proteins and carbohydrates. In
paired helical filaments. addition, deposits of amyloid and urate are discussed
separately later.
2.L YSOSOMAL CHANGES. Lysosomes contain powerful
ii) Accumulation of abnormal substances produced as a result
hydrolytic enzymes. Heterophagy and autophagy are the two
of abnormal metabolism due to lack of some enzymes e.g.
ways by which lysosomes show morphologic changes of
storage diseases or inborn errors of metabolism. These are
phagocytic function.
discussed in Chapter 10.
i) Heterophagy. Phagocytosis (cell eating) and pinocytosis iii) Accumulation of pigments e.g. endogenous pigments under
(cell drinking) are the two forms by which material from special circumstances, and exogenous pigments due to lack
outside is taken up by the lysosomes of cells such as of enzymatic mechanisms to degrade the substances or
polymorphs and macrophages to form phagolysosomes. This transport them to other sites.
is termed heterophagy. Microbial agents and foreign These pathologic states are discussed below.
particulate material are eliminated by this mechanism.
ii) Autophagy. This is the process by which worn out FATTY CHANGE (STEATOSIS)
intracellular organelles and other cytoplasmic material form
Fatty change, steatosis or fatty metamorphosis is the
autophagic vacuole that fuses with lysosome to form
intracellular accumulation of neutral fat within parenchymal
autophagolysosome. cells. It includes the older, now abandoned, terms of fatty
iii) Indigestible material. Some indigestible exogenous degeneration and fatty infiltration because fatty change neither
particles such as carbon or endogenous substances such as necessarily involves degeneration nor infiltration. The
lipofuscin may persist in the lysosomes of the cells for a long deposit is in the cytosol and represents an absolute increase
time as residual bodies. in the intracellular lipids. It is especially common in the liver
iv) Storage diseases. As discussed in Chapter 10, a group of but may occur in other non-fatty tissues like the heart, skeletal
lysosomal storage diseases due to hereditary deficiency of muscle, kidneys (lipoid nephrosis or minimum change
enzymes may result in abnormal collection of metabolites in disease) and other organs.
the lysosomes of cells.
Fatty Liver
3. SER CHANGES. Hypertrophy of smooth endoplasmic
reticulum of liver cells as an adaptive change may occur in Liver is the commonest site for accumulation of fat because
response to prolonged use of barbiturates. it plays central role in fat metabolism. Depending upon the
cause and amount of accumulation, fatty change may be mild
4. MITOCHONDRIAL CHANGES. Mitochondrial injury and reversible, or severe producing irreversible cell injury
plays an important role in cell injury. Morphologic changes and cell death.
 38 ETIOLOGY. Fatty change in the liver may result from one From diet as chylomicrons (containing triglycerides and
of the two types of causes: phospholipids) and as free fatty acids; and
1. Conditions with excess fat (hyperlipidameia), exceeding the From adipose tissue as free fatty acids.
Normally, besides above two sources, a small part of
SECTION I

capacity of the liver to metabolise it.

2. Liver cell damage, when fat cannot be metabolised in it. fatty acids is also synthesised from acetate in the liver cells.
Most of free fatty acid is esterified to triglycerides by the
These causes are listed below:
action of α-glycerophosphate and only a small part is
1. Conditions with excess fat: changed into cholesterol, phospholipids and ketone bodies.
i) Obesity While cholesterol, phospholipids and ketones are used in the
ii) Diabetes mellitus body, intracellular triglycerides are converted into
iii) Congenital hyperlipidaemia lipoproteins, which requires ‘lipid acceptor protein’.
General Pathology and Basic Techniques

2. Liver cell damage: Lipoproteins are released from the liver cells into circulation
i) Alcoholic liver disease (most common) as plasma lipoproteins (LDL, VLDL).
ii) Starvation In fatty liver, intracellular accumulation of triglycerides
iii) Protein calorie malnutrition can occur due to defect at one or more of the following 6
iv) Chronic illnesses (e.g. tuberculosis) steps in the normal fat metabolism shown in Fig. 3.16:
v) Acute fatty liver in late pregnancy 1. Increased entry of free fatty acids into the liver.
vi) Hypoxia (e.g. anaemia, cardiac failure) 2. Increased synthesis of fatty acids by the liver.
vii) Hepatotoxins (e.g. carbon tetrachloride, chloroform,
3. Decreased conversion of fatty acids into ketone bodies
ether, aflatoxins and other poisons)
resulting in increased esterification of fatty acids to
viii) Drug-induced liver cell injury (e.g. administration of
triglycerides.
methotrexate, steroids, CCl 4 , halothane anaesthetic,
4. Increased α-glycerophosphate causing increased
tetracycline etc)
esterification of fatty acids to triglycerides.
ix) Reye’s syndrome
5. Decreased synthesis of ‘lipid acceptor protein’ resulting
PATHOGENESIS. Mechanism of fatty liver depends upon in decreased formation of lipoprotein from triglycerides.
the stage at which the etiologic agent acts in the normal fat 6. Block in the excretion of lipoprotein from the liver into
transport and metabolism. Hence, pathogenesis of fatty liver plasma.
is best understood in the light of normal fat metabolism in In most cases of fatty liver, one of the above mechanisms
the liver (Fig. 3.16). is operating. But in the case of liver cell injury by chronic
Lipids as free acids enter the liver cell from either of the alcoholism, many factors are implicated which includes:
following 2 sources: increased lipolysis;
increased free fatty acid synthesis;
decreased triglyceride utilisation;
decreased fatty acid oxidation to ketone bodies; and
block in lipoprotein excretion.
Even a severe form of liver cell dysfunction may be
reversible; e.g. an alcoholic who has not developed
progressive fibrosis in the form of cirrhosis, the enlarged fatty
liver may return to normal if the person becomes teetotaller.

MORPHOLOGIC FEATURES. Grossly, the liver in fatty

change is enlarged with a tense, glistening capsule and
rounded margins. The cut surface bulges slightly and is
pale-yellow to yellow and is greasy to touch (Fig. 3.17).
Microscopically, characteristic feature is the presence of
numerous lipid vacuoles in the cytoplasm of hepatocytes.
Fat in H & E stained section prepared by paraffin-
embedding technique appear non-staining vauloes
because it is dissolved in alcohol (Fig. 3.18):
i) The vacuoles are initially small and are present around
the nucleus (microvesicular).
ii) But with progression of the process, the vacuoles
become larger pushing the nucleus to the periphery of
the cells (macrovesicular).
iii) At times, the hepatocytes laden with large lipid
Figure 3.16 Lipid metabolism in the pathogenesis of fatty liver. vacuoles may rupture and lipid vacuoles coalesce to form
Defects in any of the six numbered steps (corresponding to the description fatty cysts.
in the text) can produce fatty liver by different etiologic agents.
 turns macrophages into foam cells. The examples are as 39
follows:
1. Fibrofatty plaques of atherosclerosis (Chapter 15).

CHAPTER 3
2. Clusters of foam cells in tumour-like masses called
xanthomas and xanthelasma.

Stromal Fatty Infiltration

This form of lipid accumulation is quite different from fatty
change just described. Stromal fatty infiltration is the
deposition of mature adipose cells in the stromal connective
tissue in contrast to intracellular deposition of fat in the

Cell Injury and Cellular Adaptations

parenchymal cells in fatty change. The condition occurs most
often in patients with obesity. The two commonly affected
organs are the heart and the pancreas. Thus, heart can be the
site for intramyocardial fatty change as well as epicardial
(stromal) fatty infiltration. The presence of mature adipose
cells in the stroma generally does not produce any
dysfunction. In the case of heart, stromal fatty infiltration is
associated with increased adipose tissue in the epicardium.

INTRACELLULAR ACCUMULATION OF PROTEINS

Figure 3.17 Fatty liver. Sectioned slice of the liver shows pale yellow Pathologic accumulation of proteins in the cytoplasm of cells
parenchyma with rounded borders. may occur in the following conditions:
1. In proteinuria, there is excessive renal tubular reabsorp-
iv) Infrequently, lipogranulomas may appear consisting of tion of proteins by the proximal tubular epithelial cells which
collections of lymphocytes, macrophages, and some multi- show pink hyaline droplets in their cytoplasm. The change
nucleated giant cells. is reversible so that with control of proteinuria the protein
v) Fat can be demonstrated in fresh unfixed tissue by droplets disappear.
frozen section followed by fat stains such as Sudan dyes 2. The cytoplasm of actively functioning plasma cells shows
(Sudan III, IV, Sudan black) and oil red O. Alternatively, pink hyaline inclusions called Russell’s bodies representing
osmic acid which is a fixative as well as a stain can be synthesised immunoglobulins.
used to demonstrate fat in the tissue. 3. In α1-antitrypsin deficiency, the cytoplasm of hepatocytes
shows eosinophilic globular deposits of a mutant protein.
Cholesterol Deposits
4. Mallory’s body or alcoholic hyalin in the hepatocytes is
Intracellular deposits of cholesterol and its esters in macro- intracellular accumulation of intermediate filaments of
phages may occur when there is hypercholesterolaemia. This cytokeratin and appear as amorphous pink masses.

Figure 3.18 Fatty liver. Many of the hepatocytes are distended with large fat vacuoles pushing the nuclei to the periphery (macrovesicles),
while others show multiple small vacuoles in the cytoplasm (microvesicles).
 40 INTRACELLULAR ACCUMULATION OF GLYCOGEN detected by incubation of tissue section in the solution of
dihydroxy phenyl alanine (DOPA). If the enzyme is present,
Conditions associated with excessive accumulation of
dark pigment is identified in pigment cells. This test is called
intracellular glycogen are as under:
as DOPA reaction and is particularly useful in differentiating
SECTION I

1. In diabetes mellitus, there is intracellular accumulation of

amelanotic melanoma from other anaplastic tumours.
glycogen in different tissues because normal cellular uptake
Various disorders of melanin pigmentation cause
of glucose is impaired. Glycogen deposits in diabetes mellitus
generalised and localised hyperpigmentation and
are seen in epithelium of distal portion of proximal convolu-
hypopigmentation:
ted tubule and descending loop of Henle, in the hepatocytes,
in beta cells of pancreatic islets, and in cardiac muscle cells. i) Generalised hyperpigmentation:
Deposits of glycogen produce clear vacuoles in the cytoplasm a) In Addison’s disease, there is generalised hyper-
of the affected cells. Best’s carmine and periodic acid-Schiff pigmentation of the skin, especially in areas exposed to light,
General Pathology and Basic Techniques

(PAS) staining may be employed to confirm the presence of and of buccal mucosa.
glycogen in the cells. b) Chloasma observed during pregnancy is the hyper-
2. In glycogen storage diseases or glycogenosis, there is defec- pigmentation on the skin of face, nipples, and genitalia and
tive metabolism of glycogen due to genetic disorders. These occurs under the influence of oestrogen. A similar appear-
conditions along with other similar genetic disorders are ance may be observed in women taking oral contraceptives.
discussed in Chapter 10. c) In chronic arsenical poisoning, there is characteristic rain-
drop pigmentation of the skin.
PIGMENTS ii) Focal hyperpigmentation:
a) Cäfe-au-lait spots are pigmented patches seen in
Pigments are coloured substances present in most living
neurofibromatosis and Albright’s syndrome.
beings including humans. There are 2 broad categories of
b) Peutz-Jeghers syndrome is characterised by focal peri-oral
pigments: endogenous and exogenous (Table 3.3) .
pigmentation.
c) Melanosis coli is pigmentation of the mucosa of the colon.
A. ENDOGENOUS PIGMENTS
d) Melanotic tumours, both benign such as pigmented naevi
Endogenous pigments are either normal constituents of cells (Fig. 3.19 ), and malignant such as melanoma, are associated
or accumulate under special circumstances e.g. melanin, with increased melanogenesis.
ochronosis, haemoprotein-derived pigments, and lipofuscin. e) Lentigo is a pre-malignant condition in which there is focal
hyperpigmentation on the skin of hands, face, neck, and arms.
Melanin f) Dermatopathic lymphadenitis is an example of deposition
of melanin pigment in macrophages of the lymph nodes
Melanin is the brown-black, non-haemoglobin-derived
draining skin lesions.
pigment normally present in the hair, skin, choroid of the
eye, meninges and adrenal medulla. It is synthesised in the iii) Generalised hypopigmentation:Albinism is an extreme
melanocytes and dendritic cells, both of which are present degree of generalised hypopigmentation in which tyrosinase
in the basal cells of the epidermis and is stored in the form of activity of the melanocytes is genetically defective and no
cytoplasmic granules in the phagocytic cells called the melanin is formed. Albinos have blond hair, poor vision and
melanophores, present in the underlying dermis. Melano- severe photophobia. They are highly sensitive to sunlight.
cytes possess the enzyme tyrosinase necessary for synthesis Chronic sun exposure may lead to precancerous lesions and
of melanin from tyrosine. However, sometimes tyrosinase is squamous and basal cell cancers of the skin in such
present but is not active and hence no melanin pigment is individuals.
visible. In such cases, the presence of tyrosinase can be iv) Localised hypopigmentation:
a) Leucoderma is a form of partial albinism and is an inherited
disorder.

 TABLE 3.3: Pigments of the Body. b) Vitiligo is local hypopigmentation of the skin and is more
A. ENDOGENOUS PIGMENTS common. It may have familial tendency.
1. Melanin c) Acquired focal hypopigmentation can result from various
2. Melanin-like pigment
causes such as leprosy, healing of wounds, DLE, radiation
a. Alkaptonuria
b. Dubin-Johnson syndrome dermatitis etc.
3. Haemoprotein-derived pigments
i) Haemosiderin Melanin-like Pigments
ii) Acid haematin (Haemozoin)
c. Bilirubin ALKAPTONURIA. This is a rare autosomal recessive
d. Porphyrins disorder in which there is deficiency of an oxidase enzyme
4. Lipofuscin (Wear and tear pigment)
required for break-down of homogentisic acid which then
B. EXOGENOUS PIGMENTS accumulates in the tissues and is excreted in the urine
1. Inhaled pigments
(homogentisic aciduria). The urine of patients of
2. Ingested pigments
3. Injected pigments (Tattooing) alkaptonuria, if allowed to stand for some hours in air, turns
black due to oxidation of homogentisic acid. The pigment is
 41

CHAPTER 3
Cell Injury and Cellular Adaptations
Figure 3.19 Compound naevus showing clusters of benign naevus cells in the dermis as well as in lower epidermis. These cells contain
coarse, granular, brown-black melanin pigment.

melanin-like and is deposited both intracellularly and Accordingly, the effects of haemosiderin excess are as
intercellularly and is termed ochronosis, first described by under (Fig. 3.21 ):
Virchow. Most commonly affected tissues are the cartilages, a) Localised haemosiderosis. This develops whenever there
capsules of joints, ligaments and tendons. is haemorrhage into the tissues. With lysis of red cells,
DUBIN-JOHNSON SYNDROME. Hepatocytes in patients haemoglobin is liberated which is taken up by macrophages
of Dubin-Johnson syndrome, an autosomal recessive form where it is degraded and stored as haemosiderin. A few
of hereditary conjugated hyperbilirubinaemia, contain examples are as under :
melain-like pigment in the cytoplasm (Chapter 21). The changing colours of a bruise or a black eye are caused
by the pigments like biliverdin and bilirubin which are
Haemoprotein-derived Pigments formed during transformation of haemoglobin into
haemosiderin.
Haemoproteins are the most important endogenous
Brown induration in the lungs as a result of small haemor-
pigments derived from haemoglobin, cytochromes and their
rhages as occur in mitral stenosis and left ventricular failure.
break-down products. For an understanding of disorders of
Microscopy reveals the presence of ‘heart failure cells’ which
haemoproteins, it is essential to have knowledge of normal
are haemosiderin-laden alveolar macrophages.
iron metabolism and its transport which is described in
b) Generalised (Systemic or Diffuse) haemosiderosis.
Chapter 12. In disordered iron metabolism and transport,
Systemic overload with iron may result in generalised
haemoprotein-derived pigments accumulate in the body.
haemosiderosis. There can be two types of patterns:
These pigments are haemosiderin, acid haematin
(haemozoin), bilirubin, and porphyrins.

1. HAEMOSIDERIN. Iron is stored in the tissues in 2 forms:

Ferritin, which is iron complexed to apoferritin and can
be identified by electron microscopy.
Haemosiderin, which is formed by aggregates of ferritin
and is identifiable by light microscopy as golden-yellow to
brown, granular pigment, especially within the mononuclear
phagocytes of the bone marrow, spleen and liver where
break-down of senescent red cells takes place. Haemosiderin
is ferric iron that can be demonstrated by Perl’s stain that
produces Prussian blue reaction. In this reaction, colourless
potassium ferrocyanide reacts with ferric ions of
haemosiderin to form deep blue ferric-ferrocyanide (Fig. 3.20).
Excessive storage of haemosiderin occurs in situations
when there is increased break-down of red cells, or systemic
overload of iron due to primary (idiopathic, hereditary)
haemochromatosis, and secondary (acquired) causes such as
in thalassaemia, sideroblastic anaemia, alcoholic cirrhosis, Figure 3.20 Haemosiderin pigment in the cytoplasm of hepatocytes
multiple blood transfusions etc. seen as Prussian blue granules.
 42 in the hepatocytes. Another variety of haematin pigment is
formalin pigment formed in blood-rich tissues which have been
preserved in acidic formalin solution.
SECTION I

3. BILIRUBIN. Bilirubin is the normal non-iron containing

pigment present in the bile. It is derived from porphyrin ring
of the haem moiety of haemoglobin. Normal level of bilirubin
in blood is less than 1 mg/dl. Excess of bilirubin or hyper-
bilirubinaemia causes an important clinical condition called
jaundice. Normal bilirubin metabolism and pathogenesis of
jaundice are described in Chapter 21. Hyperbilirubinaemia
may be unconjugated or conjugated, and jaundice may
General Pathology and Basic Techniques

appear in one of the following 3 ways:

a) Prehepatic or haemolytic, when there is excessive destruc-
tion of red cells.
b) Posthepatic or obstructive, which results from obstruction
to the outflow of conjugated bilirubin.
c) Hepatocellular that results from failure of hepatocytes to
Figure 3.21 Effects of haemosiderosis. conjugate bilirubin and inability of bilirubin to pass from
the liver to intestine.
Excessive accumulation of bilirubin pigment can be seen
Parenchymatous deposition of haemosiderin occurs in the
in different tissues and fluids of the body, especially in the
parenchymal cells of the liver, pancreas, kidney, and heart.
hepatocytes, Kupffer cells and bile sinusoids. Skin and sclerae
Reticuloendothelial deposition occurs in the liver, spleen,
become distinctly yellow. In infants, rise in unconjugated
and bone marrow.
bilirubin may produce toxic brain injury called kernicterus.
Generalised or systemic overload of iron may occur due
to following causes: 4.PORPHYRINS. Porphyrins are normal pigment present
i) Increased erythropoietic activity: In various forms of in haemoglobin, myoglobin and cytochrome. Porphyria
chronic haemolytic anaemia, there is excessive break-down refers to an uncommon disorder of inborn abnormality of
of haemoglobin and hence iron overload. The problem is porphyrin metabolism. It results from genetic deficiency of
further compounded by treating the condition with blood one of the enzymes required for the synthesis of haem,
transfusions (transfusional haemosiderosis) or by parenteral resulting in excessive production of porphyrins. Often, the
iron therapy. The deposits of iron in these cases, termed as genetic deficiency is precipitated by intake of some drugs.
acquired haemosiderosis, are initially in reticuloendothelial Porphyrias are associated with excretion of intermediate
tissues but may secondarily affect other organs. products in the urine—delta-aminolaevulinic acid, porpho-
ii) Excessive intestinal absorption of iron: A form of bilinogen, uroporphyrin, coproporphyrin, and protoporphy-
haemosiderosis in which there is excessive intestinal rin. Porphyrias are broadly of 2 types—erythropoietic and
absorption of iron even when the intake is normal, is known hepatic.
as idiopathic or hereditary haemochromatosis. It is an autosomal
dominant disease associated with much more deposits of iron (a) Erythropoietic porphyrias. These have defective
than cases of acquired haemosiderosis. It is characterised synthesis of haem in the red cell precursors in the bone
by triad of pigmentary liver cirrhosis, pancreatic damage marrow. These may be further of 2 subtypes:
resulting in diabetes mellitus, and skin pigmentation. On the Congenital erythropoietic porphyria, in which the urine is
basis of the last two features, the disease has come to be red due to the presence of uroporphyrin and coproporphyrin.
termed as bronze diabetes. The skin of these infants is highly photosensitive. Bones and
iii) Excessive dietary intake of iron: A common example of skin show red brown discolouration.
excessive intake of iron is Bantu’s disease in black tribals of Erythropoietic protoporphyria, in which there is excess of
South Africa who conventionally brew their alcohol in cast protoporphyrin but no excess of porphyrin in the urine.
iron pots that serves as a rich source of additional dietary (b) Hepatic porphyrias. These are more common and have
iron. The excess of iron gets deposited in various organs a normal erythroid precursors but have a defect in synthesis
including the liver causing pigment cirrhosis. of haem in the liver. Its further subtypes include the
2. ACID HAEMATIN (HAEMOZOIN). Acid haematin or following:
haemozoin is a haemoprotein-derived brown-black pigment Acute intermittent porphyria is characterised by acute
containing haem iron in ferric form in acidic medium. But it episodes of 3 patterns: abdominal, neurological, and psycho-
differs from haemosiderin because it cannot be stained by tic. These patients do not have photosensitivity. There is
Prussian blue (Perl’s) reaction, probably because of formation excessive delta aminolaevulinic acid and porphobilinogen
of complex with a protein so that it is unable to react in the in the urine.
stain. Haematin pigment is seen most commonly in chronic Porphyria cutanea tarda is the most common of all
malaria and in mismatched blood transfusions. Besides, the porphyrias. Porphyrins collect in the liver and small quantity
malarial pigment can also be deposited in macrophages and is excreted in the urine. Skin lesions are similar to those in
variegate porphyria. Most of the patients have associated Inhaled Pigments 43
haemosiderosis with cirrhosis which may eventually develop
The lungs of most individuals, especially of those living in
into hepatocellular carcinoma.
urban areas due to atmospheric pollutants and of smokers,

CHAPTER 3
 Mixed (Variegate) porphyrias. It is rare and combines
show a large number of inhaled pigmented materials. The
skin photosensitivity with acute abdominal and neurological
most commonly inhaled substances are carbon or coal dust;
manifestations.
others are silica or stone dust, iron or iron oxide, asbestos
Lipofuscin (Wear and Tear Pigment) and various other organic substances. These substances may
produce occupational lung diseases called pneumoconiosis
Lipofuscin or lipochrome is yellowish-brown intracellular
(Chapter 17). The pigment particles after inhalation are taken
lipid pigment (lipo = fat, fuscus = brown). The pigment is
up by alveolar macrophages. Some of the pigment-laden
often found in atrophied cells of old age and hence the name
macrophages are coughed out via bronchi, while some settle

Cell Injury and Cellular Adaptations

‘wear and tear pigment’. It is seen in the myocardial fibres,
in the interstitial tissue of the lung and in the respiratory
hepatocytes, Leydig cells of the testes and in neurons in senile
bronchioles and pass into lymphatics to be deposited in the
dementia. However, the pigment may, at times, accumulate
hilar lymph nodes. Anthracosis (i.e. deposition of carbon
rapidly in different cells in wasting diseases unrelated to
particles) is seen in almost every adult lung and generally
aging.
provokes no reaction of tissue injury (Fig. 3.23). However,
By light microscopy, the pigment is coarse, golden-brown extensive deposition of particulate material over many years
granular and often accumulates in the central part of the in coal-miners’ pneumoconiosis, silicosis, asbestosis etc.
cells around the nuclei. In the heart muscle, the change is provoke low grade inflammation, fibrosis and impaired
associated with wasting of the muscle and is commonly respiratory function.
referred to as ‘brown atrophy’ (Fig. 3.22). The pigment
Ingested Pigments
can be stained by fat stains but differs from other lipids in
being fluorescent and having acid-fastness. Chronic ingestion of certain metals may produce
pigmentation. The examples are as under:
By electron microscopy, lipofuscin appears as intralysoso- i) Argyria is chronic ingestion of silver compounds and
mal electron-dense granules in perinuclear location. These results in brownish pigmentation in the skin, bowel, and
granules are composed of lipid-protein complexes. kidney.
Lipofuscin represents the collection of indigestible material ii) Chronic lead poisoning may produce the characteristic blue
in the lysosomes after intracellular lipid peroxidation and is lines on teeth at the gumline.
therefore an example of residual bodies. Unlike in normal iii) Melanosis coli results from prolonged ingestion of certain
cells, in aging or debilitating diseases the phospholipid end- cathartics.
products of membrane damage mediated by oxygen free iv) Carotenaemia is yellowish-red colouration of the skin
radicals fail to get eliminated and hence are deposited as caused by excessive ingestion of carrots which contain
lipofuscin pigment. carotene.

B. EXOGENOUS PIGMENTS Injected Pigments (Tattooing)

Exogenous pigments are the pigments introduced into the body Pigments like India ink, cinnabar and carbon are introduced
from outside such as by inhalation, ingestion or inoculation. into the dermis in the process of tattooing where the pigment

Figure 3.22 Brown atrophy of the heart. The lipofuscin pigment granules are seen in the cytoplasm of the myocardial fibres, especially around
the nuclei.
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SECTION I
General Pathology and Basic Techniques

Figure 3.23 Anthracosis lung. There is presence of abundant coarse black carbon pigment in the septal walls and around the bronchiole.

is taken up by macrophages and lies permanently in the

connective tissue. The examples of injected pigments are
prolonged use of ointments containing mercury, dirt left
accidentally in a wound, and tattooing by pricking the skin
with dyes.

MORPHOLOGY OF IRREVERSIBLE
CELL INJURY (CELL DEATH)
Cell death is a state of irreversible injury. It may occur in the
living body as a local or focal change (i.e. autolysis, necrosis
and apoptosis) and the changes that follow it (i.e. gangrene
and pathologic calcification), or result in end of the life
(somatic death). These pathologic processes involved in cell
death are described below.

AUTOLYSIS
Autolysis (i.e. self-digestion) is disintegration of the cell by its
own hydrolytic enzymes liberated from lysosomes. Autolysis
can occur in the living body when it is surrounded by
inflammatory reaction (vital reaction), but the term is generally
used for postmortem change in which there is complete
absence of surrounding inflammatory response. Autolysis
is rapid in some tissues rich in hydrolytic enzymes such as in
the pancreas, and gastric mucosa; intermediate in tissues like
the heart, liver and kidney; and slow in fibrous tissue.
Morphologically, autolysis is identified by homogeneous and
eosinophilic cytoplasm with loss of cellular details and
remains of cell as debris.

NECROSIS
Necrosis is defined as a localised area of death of tissue
followed by degradation of tissue by hydrolytic enzymes
liberated from dead cells; it is invariably accompanied by
inflammatory reaction.
Necrosis can be caused by various agents such as
hypoxia, chemical and physical agents, microbial agents,
immunological injury, etc. Two essential changes characterise Figure 3.24 Necrosis and apoptosis. A, Cell necrosis is identified
irreversible cell injury in necrosis of all types (Fig. 3.24,A): by homogeneous, eosinophilic cytoplasm and nuclear changes of
pyknosis, karyolysis, and karyorrhexis. B, Apoptosis consists of
i) Cell digestion by lytic enzymes. Morphologically this condensation of nuclear chromatin and fragmentation of the cell into
change is identified as homogeneous and intensely membrane-bound apoptotic bodies which are engulfed by macrophages.
eosinophilic cytoplasm. Occasionally, it may show hydrolytic enzymes. The common examples are infarct brain 45
cytoplasmic vacuolation or dystrophic calcification. and abscess cavity.
ii) Denaturation of proteins. This process is morphologically Grossly, the affected area is soft with liquefied centre

CHAPTER 3
seen as characteristic nuclear changes in necrotic cell. These containing necrotic debris. Later, a cyst wall is formed.
nuclear changes may include: condensation of nuclear
Microscopically, the cystic space contains necrotic cell
chromatin (pyknosis) which may either undergo dissolution
debris and macrophages filled with phagocytosed
(karyolysis) or fragmentation into many granular clumps
material. The cyst wall is formed by proliferating
(karyorrhexis) (see Fig. 3.7).
capillaries, inflammatory cells, and gliosis (proliferating
glial cells) in the case of brain and proliferating fibroblasts
Types of Necrosis
in the case of abscess cavity (Fig. 3.26).
Morphologically, there are five types of necrosis: coagulative,

Cell Injury and Cellular Adaptations

liquefaction (colliquative), caseous, fat, and fibrinoid necrosis. 3. CASEOUS NECROSIS. Caseous necrosis is found in the
centre of foci of tuberculous infections. It combines features
1. COAGULATIVE NECROSIS. This is the most common of both coagulative and liquefactive necrosis.
type of necrosis caused by irreversible focal injury, mostly
from sudden cessation of blood flow (ischaemia), and less Grossly, foci of caseous necrosis, as the name implies,
often from bacterial and chemical agents. The organs resemble dry cheese and are soft, granular and yellowish.
commonly affected are the heart, kidney, and spleen. This appearance is partly attributed to the histotoxic
effects of lipopolysaccharides present in the capsule of the
Grossly, foci of coagulative necrosis in the early stage are tubercle bacilli, Mycobacterium tuberculosis.
pale, firm, and slightly swollen. With progression, they
become more yellowish, softer, and shrunken. Microscopically, the necrosed foci are structureless,
Microscopically, the hallmark of coagulative necrosis is eosinophilic, and contain granular debris (Fig. 3.27). The
the conversion of normal cells into their ‘tombstones’ i.e. surrounding tissue shows characteristic granulomatous
outlines of the cells are retained so that the cell type can inflammatory reaction consisting of epithelioid cells with
still be recognised but their cytoplasmic and nuclear interspersed giant cells of Langhans’ or foreign body type
details are lost. The necrosed cells are swollen and appear and peripheral mantle of lymphocytes.
more eosinophilic than the normal, along with nuclear
changes described above. But cell digestion and lique- 4. FAT NECROSIS. Fat necrosis is a special form of cell death
occurring at two anatomically different locations but
faction fail to occur (c.f. liquefaction necrosis). Eventually,
the necrosed focus is infiltrated by inflammatory cells and morphologically similar lesions. These are: following acute
the dead cells are phagocytosed leaving granular debris pancreatic necrosis, and traumatic fat necrosis commonly in
and fragments of cells (Fig. 3.25). breasts.
In the case of pancreas, there is liberation of pancreatic
2. LIQUEFACTION (COLLIQUATIVE) NECROSIS. Lique- lipases from injured or inflamed tissue that results in necrosis
faction or colliquative necrosis occurs commonly due to of the pancreas as well as of the fat depots throughout the
ischaemic injury and bacterial or fungal infections. It occurs peritoneal cavity, and sometimes, even affecting the extra-
due to degradation of tissue by the action of powerful abdominal adipose tissue.

Figure 3.25 Coagulative necrosis in infarct kidney. The affected area on right shows cells with intensely eosinophilic cytoplasm of tubular cells
but the outlines of tubules are still maintained. The nuclei show granular debris. The interface between viable and non-viable area shows non-
specific chronic inflammation and proliferating vessels.
 46
SECTION I
General Pathology and Basic Techniques

Figure 3.26 Liquefactive necrosis brain. The necrosed area on right side of the field shows a cystic space containing cell debris, while the
surrounding zone shows granulation tissue and gliosis.

Fat necrosis hydrolyses neutral fat present in adipose cells has the staining properties of fibrin. It is encountered in
into glycerol and free fatty acids. The damaged adipose cells various examples of immunologic tissue injury (e.g. in
assume cloudy appearance. The leaked out free fatty acids immune complex vasculitis, autoimmune diseases,
complex with calcium to form calcium soaps (saponification) Arthus reaction etc), arterioles in hypertension, peptic
discussed later under dystrophic calcification. ulcer etc.

Grossly, fat necrosis appears as yellowish-white and firm Microscopically, fibrinoid necrosis is identified by
deposits. Formation of calcium soaps imparts the necrosed brightly eosinophilic, hyaline-like deposition in the vessel
foci firmer and chalky white appearance. wall. Necrotic focus is surrounded by nuclear debris of
Microscopically, the necrosed fat cells have cloudy neutrophils (leucocytoclasis) (Fig. 3.29). Local haemor-
appearance and are surrounded by an inflammatory rhage may occur due to rupture of the blood vessel.
reaction. Formation of calcium soaps is identified in the
tissue sections as amorphous, granular and basophilic APOPTOSIS
material (Fig. 3.28).
Apoptosis is a form of ‘coordinated and internally
5. FIBRINOID NECROSIS. Fibrinoid necrosis is programmed cell death’ having significance in a variety of
characterised by deposition of fibrin-like material which physiologic and pathologic conditions (apoptosis is a Greek

Figure 3.27 Caseous necrosis lymph node. There is eosinophilic, amorphous, granular material, while the periphery shows granulomatous
inflammation.