Acute and Chronic Inflammation

Banun Kusumawardani Dept. Biomedic-Faculty of Dentistry Univ. Jember

Assigned Reading

Chapter 2, Acute and Chronic Inflammation in Robbins and Cotran Pathologic Basis of Disease, 7th Edition, p 47-86.

Introduction

Injurious stimuli cause a protective vascular connective tissue reaction called inflammation

Dilute Destroy Isolate Initiate repair

Acute and chronic forms

Acute inflammation

Immediate and early response to tissue injury (physical, chemical, microbiologic, etc.)

Vasodilation Vascular leakage and edema Leukocyte emigration (mostly PMNs)

The component of acute and chronic inflammatory responses: circulating cells and proteins, cells of blood vessels, and cells and proteins of extrcellular matrix
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Vasodilation

Brief arteriolar vasoconstriction followed by vasodilation

Accounts for warmth and redness Opens microvascular beds Increased intravascular pressure causes an early transudate (protein-poor filtrate of plasma) into interstitium (vascular permeability still not increased yet)
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(1) Vascular dilatation and increased blood flow causing erythema and warmth, (2) extravasation and deposition of plasma fluid and proteins (edema), and (3) leukocyte 7 emigration and accumulation in the site of injury

Vascular leakage

Vascular permeability (leakiness) commences

Transudate gives way to exudate (proteinrich) Increases interstitial osmotic pressure contributing to edema (water and ions)

Vascular leakage (contd)

Five mechanisms known to cause vascular leakiness

Histamines, bradykinins, leukotrienes cause an early, brief (15 30 min.) immediate transient response in the form of endothelial cell contraction that widens intercellular gaps of venules (not arterioles, capillaries)
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Vascular leakage (contd)

Cytokine mediators (TNF, IL-1) induce endothelial cell junction retraction through cytoskeleton reorganization (4 6 hrs post injury, lasting 24 hrs or more) Severe injuries may cause immediate direct endothelial cell damage (necrosis, detachment) making them leaky until they are repaired (immediate sustained response), or may cause delayed damage as in thermal or UV injury, or some bacterial toxins (delayed prolonged leakage)
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Vascular leakage (contd)

Marginating and endothelial cell-adherent leukocytes may pile-up and damage the endothelium through activation and release of toxic oxygen radicals and proteolytic enzymes (leukocyte-dependent endothelial cell injury) making the vessel leaky

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Vascular leakage (contd)

Certain mediators (VEGF) may cause increased transcytosis via intracellular vesicles which travel from the luminal to basement membrane surface of the endothelial cell

All or any combination of these events may occur in response to a given stimulus
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Leukocyte cellular events

Leukocytes leave the vasculature routinely through the following sequence of events:

Margination and rolling Adhesion and transmigration Chemotaxis and activation Phagocytosis and degranulation Leukocyte-induced tissue injury

They are then free to participate in:

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The leukocyte first roll, than become actived and adhere to endothelium, then transmigrate a cross the endothelium, pierce the basement membrane, and migrate toward chemoattractants emanating from the source of injury. Different molecules play predominant roles in different steps of this process: selectins in rolling; chemokines in activating the neutrophils to increase avidity of integrins; integrins in firm adhesion; and CD31 (PECAM-1) in transmigration 14

Margination and Rolling

With increased vascular permeability, fluid leaves the vessel causing leukocytes to settleout of the central flow column and marginate along the endothelial surface Endothelial cells and leukocytes have complementary surface adhesion molecules which briefly stick and release causing the leukocyte to roll along the endothelium like a tumbleweed until it eventually comes to a stop as mutual adhesion reaches a peak
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Margination and Rolling (contd)

Early rolling adhesion mediated by selectin family:

E-selectin (endothelium), P-selectin (platelets, endothelium), L-selectin (leukocytes) bind other surface molecules (i.e.,CD34, Sialyl-Lewis X-modified GP) that are upregulated on endothelium by cytokines (TNF, IL-1) at injury sites
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Adhesion

Rolling comes to a stop and adhesion results Other sets of adhesion molecules participate:
Endothelial: ICAM-1, VCAM-1 Leukocyte: LFA-1, Mac-1, VLA-4 (ICAM-1 binds LFA-1/Mac-1, VCAM-1 binds VLA-4)

Ordinarily down-regulated or in an inactive conformation, but inflammation alters this

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Transmigration (diapedesis)

Occurs after firm adhesion within the systemic venules and pulmonary capillaries via PECAM 1 (CD31) Must then cross basement membrane

Collagenases Integrins

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Transmigration (diapedesis) (contd)

Early in inflammatory response mostly PMNs, but as cytokine and chemotactic signals change with progression of inflammatory response, alteration of endothelial cell adhesion molecule expression activates other populations of leukocytes to adhere (monocytes, lymphocytes, etc)
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Chemotaxis

Leukocytes follow chemical gradient to site of injury (chemotaxis)

Soluble bacterial products Complement components (C5a) Cytokines (chemokine family e.g., IL-8) LTB4 (AA metabolite)

Chemotactic agents bind surface receptors inducing calcium mobilization and assembly of cytoskeletal contractile elements
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Chemotaxis and Activation

Leukocytes:

extend pseudopods with overlying surface adhesion molecules (integrins) that bind ECM during chemotaxis undergo activation:

Prepare AA metabolites from phospholipids Prepare for degranulation and release of lysosomal enzymes (oxidative burst) Regulate leukocyte adhesion molecule affinity as needed
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Phagocytosis and Degranulation

Once at site of injury, leukocytes:

Recognize and attach Engulf (form phagocytic vacuole) Kill (degrade)

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(A) Phagocytosis of a particles/bacterium involves attachment and binding of Fc and C3b to receptors on the leukocyte membrane, engulfment anf fusion of lysosomes with phagocytic vacuoles, followed by destruction of ingested particles within the phagolysosomes. During phagocytosis, granule contents may be released into extracellular tissues. (B) Production of 23 microbicidal reactive oxygen intermediates within phagocytic vesicles

Recognition and Binding

Opsonized by serum complement, immunoglobulin (C3b, Fc portion of IgG) Corresponding receptors on leukocytes (FcR, CR1, 2, 3) leads to binding

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Phagocytosis and Degranulation

Triggers an oxidative burst (next slide) engulfment and formation of vacuole which fuses with lysosomal granule membrane (phagolysosome) Granules discharge within phagolysosome and extracellularly (degranulation)
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Oxidative burst

Reactive oxygen species formed through oxidative burst that includes:

Increased oxygen consumption Glycogenolysis Increased glucose oxidation Formation of superoxide ion

2O2 + NADPH 2O2-rad + NADP+ + H+

O2 + 2H+ H2O2 (dismutase)

Reactive oxygen species

Hydrogen peroxide alone insufficient MPO (azurophilic granules) converts hydrogen peroxide to HOCl- (in presence of Cl- ), an oxidant/antimicrobial agent Therefore, PMNs can kill by halogenation, or lipid/protein peroxidation
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Degradation and Clean-up

Reactive end-products only active within phagolysosome Hydrogen peroxide broken down to water and oxygen by catalase Dead microorganisms degraded by lysosomal acid hydrolases

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Leukocyte granules

Other antimicrobials in leukocyte granules:

Bactericidal permeability increasing protein (BPI) Lysozyme Lactoferrin Defensins (punch holes in membranes)

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Leukocyte-induced tissue injury

Destructive enzymes may enter extracellular space in event of:

Premature degranulation Frustrated phagocytosis (large, flat) Membranolytic substances (urate crystals) Persistent leukocyte activation (RA, emphysema)

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Defects of leukocyte function

Defects of adhesion:

LFA-1 and Mac-1 subunit defects lead to impaired adhesion (LAD-1) Absence of sialyl-Lewis X, and defect in Eand P-selectin sugar epitopes (LAD-2) Microtubule assembly defect leads to impaired locomotion and lysosomal degranulation (Chediak-Higashi Syndrome)
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Defects of chemotaxis/phagocytosis:

Defects of leukocyte function

Defects of microbicidal activity:

Deficiency of NADPH oxidase that generates superoxide, therefore no oxygen-dependent killing mechanism (chronic granulomatous disease)

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Chemical mediators

Plasma-derived:

Complement, kinins, coagulation factors Many in pro-form requiring activation (enzymatic cleavage) Preformed, sequestered and released (mast cell histamine) Synthesized as needed (prostaglandin)
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Cell-derived:

Chemical mediators (contd)

May or may not utilize a specific cell surface receptor for activity May also signal target cells to release other effector molecules that either amplify or inhibit initial response (regulation) Are tightly regulated:

Quickly decay (AA metabolites), are inactivated enzymatically (kininase), or are scavenged (antioxidants)
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Chemical mediators of inflammation. EC: endothelial cells

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Specific mediators

Vasoactive amines

Histamine: vasodilation and venular endothelial cell contraction, junctional widening; released by mast cells, basophils, platelets in response to injury (trauma, heat), immune reactions (IgEmast cell FcR), anaphylatoxins (C3a, C5a fragments), cytokines (IL-1, IL-8), neuropeptides, leukocyte-derived histamine-releasing peptides
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Specific mediators (contd)

Serotonin: vasodilatory effects similar to those of histamine; platelet dense-body granules; release triggered by platelet aggregation Clotting system Complement Kinins
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Plasma proteases

Clotting cascade

Cascade of plasma proteases

Hageman factor (factor XII) Collagen, basement membrane, activated platelets converts XII to XIIa (active form) Ultimately converts soluble fibrinogen to insoluble fibrin clot Factor XIIa simultaneously activates the brakes through the fibrinolytic system to prevent continuous clot propagation
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Interrelationships between the four plasma mediators systems triggered by activation of factor XII (Hageman factor). Thrombin induces inflammation by binding to protease-activated receptors (PAR-1) on platelets, endothelium, smooth muscle cells and other cells
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Kinin system

Leads to formation of bradykinin from cleavage of precursor (HMWK)

Vascular permeability Arteriolar dilation Non-vascular smooth muscle contraction (e.g., bronchial smooth muscle) Causes pain Rapidly inactivated (kininases)
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Complement system

Components C1-C9 present in inactive form

Activated via classic (C1) or alternative (C3) pathways to generate MAC (C5 C9) that punch holes in microbe membranes In acute inflammation

Vasodilation, vascular permeability, mast cell degranulation (C3a, C5a) Leukocyte chemotaxin, increases integrin avidity (C5a) As an opsonin, increases phagocytosis (C3b, C3bi)

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The activation and function of the complement system. Activation of complement by different pathways leads to cleavage of C3. the functions of the complement system are mediated by breakdown products of C3 and other complement proteins, and by the membrane attack complex (MAC)
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Specific Mediators (contd)

Arachidonic acid metabolites (eicosanoids)

Prostaglandins and thromboxane: via cyclooxygenase pathway; cause vasodilation and prolong edema; but also protective (gastric mucosa); COX blocked by aspirin and NSAIDS

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Specific Mediators (contd)

Leukotrienes: via lipoxygenase pathway; are chemotaxins, vasoconstrictors, cause increased vascular permeability, and bronchospasm Derived also from cell membrane phospholipid, causes vasodilation, increased vascular permeability, increases leukocyte adhesion (integrin conformation)
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PAF (platelet activating factor)

Specific mediators (contd)

Cytokines

Protein cell products that act as a message to other cells, telling them how to behave. IL-1, TNF- and -, IFN- are especially important in inflammation. Increase endothelial cell adhesion molecule expression, activation and aggregation of PMNs, etc., etc., etc.
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Specific mediators (contd)

Nitric Oxide

short-acting soluble free-radical gas with many functions Produced by endothelial cells, macrophages, causes:

Vascular smooth muscle relaxation and vasodilation Kills microbes in activated macrophages Counteracts platelet adhesion, aggregation, and degranulation
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Function of nitric oxide (NO) in blood vessels and macrophages, produced by two NO synthase (NOS) enzymes. NO causes vasodilatation, and NO free radicals are toxic to microbial and mammalian cells 47

Specific mediators (contd)

Lysosomal components

Leak from PMNs and macrophages after demise, attempts at phagocytosis, etc. Acid proteases (only active within lysosomes). Neutral proteases such as elastase and collagenase are destructive in ECM. Counteracted by serum and ECM antiproteases.
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Possible outcomes of acute inflammation

Complete resolution

Little tissue damage Capable of regeneration In tissues unable to regenerate Excessive fibrin deposition organized into fibrous tissue

Scarring (fibrosis)

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Outcomes (contd)

Abscess formation occurs with some bacterial or fungal infections Progression to chronic inflammation

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Events in the resolution of inflammation: (1) return to normal vascular permeability; (2) drainage of edema fluid and proteins into lymphatics or (3) by pinocytosis into macrophages; (4) phagocytosis of apoptotic neutrophils and (5) phagocytosis of necrotic debris; and (6) disposal of macrophages. Macrophages also produce growth factors that initiate the subsequent process of repair
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Types of Acute Inflammation

Type
Classic type

Features
Hyperemia; exudation with fibrin and neutrophils; neutrophil leukocytosis in blood. Paucity of neutrophils in exudate; lymphocytes and plasma cells predominant; neutropenia, lymphocytosis in blood. Marked edema and numerous eosinophils; eosinophilia in blood. Marked fluid exudation.

Common Causes
Bacterial infections; response to cell necrosis of any cause. Viral and rickettsial infections (immune response contributes). Certain hypersensitivity immune reactions

Acute inflammation without neutrophils Allergic acute inflammation Serous inflammation (inflammation in body cavities) Catarrhal inflammation (inflammation of mucous membranes) Fibrinous inflammation Necrotizing inflammation, hemorrhagic inflammation Membranous (pseudomembranou s) inflammation

Burns; many bacterial infections.

Marked secretion of mucus.

Infections, eg, common cold (rhinovirus); allergy (eg, hay fever).

Excess fibrin formation. Marked tissue necrosis and hemorrhage.

Many virulent bacterial infections. Highly virulent organisms (bacterial, viral, fungal), eg, plague (Yersinia pestis), anthrax (Bacillus anthracis), herpes simplex encephalitis, mucormycosis. Toxigenic bacteria, eg, diphtheria bacillus (Corynebacterium diphtheriae) and Clostridium difficile.

Necrotizing inflammation involving mucous membranes. The necrotic mucosa and inflammatory exudate form an adherent membrane on the mucosal surface. Exaggerated neutrophil response and liquefactive necrosis of parenchymal cells; pus formation. Marked neutrophil leukocytosis in blood.

Suppurative (purulent) inflammation

Pyogenic bacteria, eg, staphylococci, streptococci, gramnegative bacilli, anaerobes.

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Inflammation
Acute

Causative agent

Pathogens, injured tissues

Major cells involved

Neutrophils, mononuclear cells (monocytes, macrophages)

Primary mediators Onset Duration

Vasoactive amines, eicosanoids Immediate Few days

Outcomes

Healing, abscess formation, chronic inflammation

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Chronic inflammation

Lymphocyte, macrophage, plasma cell (mononuclear cell) infiltration Tissue destruction by inflammatory cells Attempts at repair with fibrosis and angiogenesis (new vessel formation) When acute phase cannot be resolved

Persistent injury or infection (ulcer, TB) Prolonged toxic agent exposure (silica) Autoimmune disease states (RA, SLE)
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Mononuclear phagocyte system

Macrophages

Scattered all over (microglia, Kupffer cells, sinus histiocytes, alveolar macrophages, etc. Circulate as monocytes and reach site of injury within 24 48 hrs and transform Become activated by T cell-derived cytokines, endotoxins, and other products of inflammation
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Mononuclear phagocyte system (contd)

T and B lymphocytes

Antigen-activated (via macrophages and dendritic cells) Release macrophage-activating cytokines (in turn, macrophages release lymphocyteactivating cytokines until inflammatory stimulus is removed) Terminally differentiated B cells Produce antibodies
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Plasma cells

Mononuclear phagocyte system (contd)

Eosinophils

Found especially at sites of parasitic infection, or at allergic (IgE-mediated) sites

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Granulomatous Inflammation

Clusters of T cell-activated macrophages, which engulf and surround indigestible foreign bodies (mycobacteria, H. capsulatum, silica, suture material) Resemble squamous cells, therefore called epithelioid granulomas
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Lymph Nodes and Lymphatics

Lymphatics drain tissues

Flow increased in inflammation Antigen to the lymph node Toxins, infectious agents also to the node

Lymphadenitis, lymphangitis Usually contained there, otherwise bacteremia ensues Tissue-resident macrophages must then prevent overwhelming infection
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Patterns of acute and chronic inflammation

Serous

Watery, protein-poor effusion (e.g., blister) Fibrin accumulation Either entirely removed or becomes fibrotic Presence of pus (pyogenic staph spp.) Often walled-off if persistent
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Fibrinous

Suppurative

Patterns (contd)

Ulceration

Necrotic and eroded epithelial surface Underlying acute and chronic inflammation Trauma, toxins, vascular insufficiency

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Systemic effects

Fever

One of the easily recognized cytokinemediated (esp. IL-1, IL-6, TNF) acutephase reactions including

Anorexia Skeletal muscle protein degradation Hypotension

Leukocytosis

Elevated white blood cell count

Systemic effects (contd)

Bacterial infection (neutrophilia) Parasitic infection (eosinophilia) Viral infection (lymphocytosis)

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