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BY
DR. IKRAM UL HAQUE
ASSOCIAT PROFESSOR
AND CONSULTANT
HISTOPATHOLOGY
A N M C, LAHORE
EDUCATION IS
HANGING
AROUND
UNTIL YOU’VE
CAUGHT ON
Charles Darwin
INFLAMMATION
Reaction of a tissue and its microcirculation
to a pathogenic insult or it is a reaction
which is characterized by the generation of
inflammatory mediators and amount of
fluid and leucocytes from the blood into
extra vascular tissue
FOUR CARDINAL SIGNS OF
INFLAMMATION
• Rubor (redness)
• Color (heat)
• Tumor (swelling)
• Dolar (pain)
Aulus Celsus
Roman Encyclopedist
Rubor
Calor
Tumor
Dolor
5th (functio laesa)
HISTORICAL
HIGHLIGHTS
(Egypt, 3000 BC)
ACUTE
INFLAMMATIONNeutrophil
Polymorphonuclear
Leukocyte, PMN, PML
“Leukocyte”
Granulocyte, Neutrophilic
granulocyte
“Poly-”
Polymorph
ACUTE INFLAMMATION
•“PROTECTIVE”
(RESPONSE)
•NON-specific
STIMULI
for acute inflammation
•INFECTIOUS
•PHYSICAL
•CHEMICAL
• Tissue Necrosis
• Foreign Bodies (FBs)
• Immune “responses”, or “complexes”
ACUTE INFLAMMATION
•VASCULAR EVENTS
•CELLULAR EVENTS
(PolyMorphonuclear Neutrophil,
Leukocyte?, “POLY”, Neutrophil,
Granulocyte, Neutrophilic
Granulocyte
•“MEDIATORS”
Vascular Changes
• Changes in Vascular Flow
and Caliber
• Increased Vascular
Permeability
INCREASED PERMEABILITY
•DILATATION
•Endothelial “gaps”
•Direct Injury
•Leukocyte Injury
•Transocytosis (endo/exo)
•New Vessels
LEAKAGE OF
PROTEINACEOUS FLUID
(EXUDATE,
NOT TRANSUDATE)
EXTRAVASATION of
PMNs
• MARGINATION
(PMN’s go toward
wall)
• ROLLING (tumbling
and HEAPING)
• ADHESION
• TRANSMIGRATION
(DIAPEDESIS)
ADHESION MOLECULES
(glycoproteins) affecting
ADHESION and TRANSMIGRATION
• SECRETINS (from
endothelial cells)
• INTEGRINS (from many
cells)
CHEMOTAXIS
PMNs going to the site of “injury”
AFTER transmigration
LEUKOCYTE
“ACTIVATION”
• “triggered” by the offending stimuli for PMNs to:
–1) Produce eicosanoids (arachidonic acid
derivatives)
• Prostaglandin (and thromboxanes)
• Leukotrienes
• Lipoxins
–2) Undergo DEGRANULATION
–3) Secrete CYTOKINES
PHAGOCYTOSIS
• RECOGNITION
• ENGULFMENT
• KILLING
(DEGRADATION/
DIGESTION)
CHEMICAL MEDIATORS
• From plasma or cells
• Have “triggering” stimuli
• Usually have specific
targets
• Can cause a “cascade”
• Are short lived
CLASSIC MEDIATORS
• HISTAMINE
• SEROTONIN
• COMPLEMENT
• KININS
• CLOTTING
FACTORS
• EICOSANOIDS
• NITRIC OXIDE
• PAF
• CYTOKINES
• /CHEMOKINES
• LYSOSOME
CONSTITUENTS
• FREE RADICALS
• NEUROPEPTIDES
HISTAMINE
• Mast Cells,
basophils
• POWERFUL
Vasodilator
• Vasoactive
“amine”
• IgE on mast
cell
SEROTONIN
• (5HT, 5-Hydroxy-
Tryptamine)
• Platelets and
EnteroChromaffin Cells
• Also vasodilatation, but
more indirect
• Evokes N.O. synthetase
(a ligase)
COMPLEMENT SYSTEM
• >20
components,
in circulating
plasma
• Multiple sites
of action, but
LYSIS is the
underlying
theme
KININ SYSTEM
• BRADYKININ is KEY component, 9 aa’s
• ALSO from circulating plasma
• ACTIONS
– Increased permeability
– Smooth muscle contraction, NON vascular
–PAIN
CLOTTING
FACTORS
• Also from circulating plasma
• Coagulation, i.e., production of
fibrin
• Fibrinolysis
EICOSANOIDS
(ARACHIDONIC ACID DERIVATIVES)
•Part of cell membranes
•1) Prostaglandins (incl.
Thromboxanes)
•2) Leukotrienes
•3) Lipoxins (new)
MULTIPLE ACTIONS AT MANY LEVELS
Prostaglandins
(thromboxanes included)
•Pain
•Fever
•Clotting
Leukotrienes
•Chemotaxis
•Vasoconstriction
•Increased Permeability
Lipoxins
•INHIBIT chemotaxis
•Vasodilatation
•Counteract actions of
leukotrienes
Platelet-Activating Factor
(PAF)
• Phospholipid
• From MANY cells,
like eicosanoids
• ACTIVATE
PLATELETS,
powerfully
CYTOKINES/CHEMOKINES
• CYTOKINES are PROTEINS produced by
MANY cells, but usually LYMPHOCYTES
and MACROPHAGES, numerous roles in
acute and chronic inflammation
–TNFα, IL-1, by
macrophages
• CHEMOKINES are small proteins which are
attractants for PMNs (>40)
NITRIC OXIDE
• Potent vasodilator
• Produced from the action
of nitric oxide synthetase
from arginine
LYSOSOMAL CONSTITUENTS
• PRIMARY
• Also called
AZUROPHILIC, or
NON-specific
• Myeloperoxidase
• Lysozyme (Bact.)
• Acid Hydrolases
• SECONDARY
• Also called SPECIFIC
• Lactoferrin
• Lysozyme
• Alkaline Phosphatase
• Collagenase
FREE RADICALS
• O2– (SUPEROXIDE)
•H2O2 (PEROXIDE)
•OH- (HYDROXYL RADICAL)
•VERY VERY
DESTRUCTIVE
NEUROPEPTIDES
• Produced in CNS (neurons)
• SUBSTANCE P
• NEUROKININ A
OUTCOMES OF
ACUTE INFLAMMATION
• 1) 100% complete
RESOLUTION
• 2) SCAR
• 3)CHRONIC inflammation
Morphologic PATTERNS
of Acute INFLAMMATION
(EXUDATE)
•Serous (watery)
•Fibrinous (hemorrhagic,
rich in FIBRIN)
•Suppurative (PUS)
•Ulcerative
BLISTER, “Watery”, i.e., SEROUS
FIBRINOUS
PUS
=
PURULENT
ABSCESS
=
POCKET
OF
PUS
PURULENT, FIBRINOPURULENT
ULCERATIVE
SEQUENCE OF EVENTS
• NORMAL HISTOLOGY 
• VASODILATATION 
• INCREASED VASCULAR PERMEABILITY 
• LEAKAGE OF EXUDATE 
• MARGINATION, ROLLING, ADHESION 
• TRANSMIGRATION (DIAPEDESIS) 
• CHEMOTAXIS 
• PMN ACTIVATION 
• PHAGOCYTOSIS: Recognition, Attachment,
Engulfment, Killing (degradation or digestion) 
• TERMINATION 
• 100% RESOLUTION, SCAR, or CHRONIC
inflammation
CHRONIC INFLAMMATION
(MONOS)
LYMPHOCYTE
MONOCYTE
MACROPHAGE
HISTIOCYTE
CAUSES of
CHRONIC INFLAMMATION
•1) PERSISTENCE of
Infection
•2) PROLONGED
EXPOSURE to insult
•3) AUTO-IMMUNITY
Cellular Players
•LYMPHOCYTES
•MACROPHAGES
(aka, HISTIOCYTES)
• PLASMA CELLS
• EOSINOPHILS
• MAST CELLS
MORPHOLOGY
•INFILTRATION
•TISSUE DESTRUCTION
•HEALING
GRANULOMAS
GRANULOMATOUS INFLAMMATION
4 COMPONENTS
FIBROBLASTS
LYMPHS
HISTIOS
“GIANT” CELLS
GRANULOMAS
GRANULOMATOUS INFLAMMATION
CASEATING (TB)
NON-CASEATING
LYMPHATIC
DRAINAGE
• SITE REGIONAL LYMPH NODES
SYSTEMIC MANIFESTATIONS
(NON-SPECIFIC)
• FEVER, CHILLS
• C-Reactive Protein (CRP)
• “Acute Phase” Reactants
• Erythrocyte Sedimentation Rate
(ESR) increases
• Leukocytosis
• Pulse, Blood Pressure
• Cytokine Effects, e.g., TNF(α), IL-1
NORMAL SPE
Serum
Protein
Electrophoresis
In ACUTE
Inflammation
Alpha-1 & alpha-2
are increased,
i.e.,
“acute phase”
reactants.

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Acute and chronic inflammation