Cell Injury, Cell Death, and

Adaptations
 Introduction to Pathology

Pathology is the study (logos) of disease (pathos).

Pathology is the study of the structural, biochemical and functional
changes in cells, tissues and organs that underlie disease.
 Why pathology serves as the bridge between the basic sciences and
clinical medicine ?
It is the scientific foundation for all of medicine. Because –
Pathology attempts to explain the whys and wherefores of the S/S of
patients for their clinical care and therapy.
Here we uses some techniques. Such as morphologic,
microbiologic, immunologic, and molecular technique.
 Cont….
Study of pathology divided into –
General Pathology and
Systemic Pathology

General Pathology – Concern with common reactions of

cells and tissue to injurious stimuli.
Systemic Pathology – Examines the alterations and
underlying mechanisms in disease of particular organ
system.
 Cont…
The four aspects of a disease process that form the core of
pathology are –

Causation (Etiology), - Genetic and environmental

Biochemical and molecular mechanisms (Pathogenesis),
Structural (Morphologic) changes, and
Functional alterations in cells and organs, the resulting
clinical consequences (Clinical manifestations).
 Cont…..
Pathogenesis – refers to the sequence of molecular,
biochemical and cellular events that lead to
the development of the disease.
- Explain how the underlying etiologies produce
the morphologic and clinical manifestation of disease.
- Example – cystic fibrosis (Defective gene and
gene products, biochemical and morphological events)
 Cont….
Clinical manifestations –
The end results of genetic, biochemical, and
structural changes in cells and tissues are functional
abnormality that leads to the clinical manifestations of
disease as well as its progression ( clinical course and
outcome).

Clinicopathologic correlation is very important in the study of

disease.
Cellular Responses to Stress & Noxious Stimuli
FIGURE :
Stages of the
cellular
response to
stress and
injurious
stimuli.
 Cont…..
Cell injury : If the limits of adaptive responses are exceeded or if
cells are exposed to damaging insults, deprived of critical
nutrients, or compromised by mutations that affect essential
cellular functions, a sequence of events follows that is termed
cell injury.

Cell injury is reversible up to a certain point, but if the injurious

stimulus is persistent or severe, the cell suffers irreversible injury
and ultimately undergoes cell death.
 Causes of Cell Injury

• Oxygen Deprivation
• Physical Agents
• Chemical Agents and Drugs.
• Infectious Agents.
• Immunologic Reactions
• Genetic Derangements
• Nutritional Imbalances.
 REVERSIBLE CELL INJURY
Reversible cell injury is characterized by functional and
structural alterations in early stages or mild forms of
injury, which are correctable if the damaging stimulus is
removed.
Two features of reversible cell injury can be recognized
under the light microscope:
i) Generalized swelling of the cell and
ii) Fatty change.
 Cont…
Generalized swelling of the cell and its organelles, blebbing of
the plasma membrane, detachment of ribosomes from ER and
clumping of nuclear chromatin.
- Failure of Na+ - K+ plasma membrane
pumps.
- Mitochondrial damage.

 Fatty change – Organs that are actively involved in lipid

metabolism.
 Morphology (Cellular swelling)

- Earliest manifestation of almost all forms of injury to

cells .
- When it affects many cells, it causes pallor, increased
turgor, and increased weight of the affected organ.
- On M/E small clear vacuoles may be seen within the
cytoplasm; these represent distended and pinched-off
segments of the ER. ( Hydropic change or vacuolar
degeneration).
 Cont…
- The cytoplasm of injured cells appears red
(eosinophilc) when stained with hematoxylin and eosin (H&E)
due to loss of RNA, which binds the blue hematoxylin dye. The
eosinophilia becomes more pronounced with progression
toward necrosis.
 Cont….
The ultrastructural changes of reversible cell injury include:
1. Plasma membrane alterations, such as
blebbing, blunting, and loss of microvilli
2. Mitochondrial changes, including swelling
and the appearance of small amorphous densities
3. Accumulation of myelin figures in the
cytosol .
 Cont….
Myelin figures - Composed of phospholipids derived from
damaged cellular membranes.

4. Dilation of the ER, with detachment of

polysomes;
5. Nuclear alterations, with disaggregation of
granular and fibrillar elements.
 CELL DEATH
Two principal types of cell death –
1) Necrosis and
2) Apoptosis
These are differ in their mechanism, morphology ,
and roles in physiology and disease.
 NECROSIS
(Accidental cell death)
Necrosis is a pathologic process that is the consequence of
severe injury.
Necrosis is characterized by denaturation of cellular
proteins, leakage of cellular contents through damage
membranes, local inflammation and enzymatic digestion of
the lethally injured cell.
When damage to membranes is severe, lysosomal enzymes
enter the cytoplasm and digest the cell.
 Cont….
Cellular contents also leak through the damaged plasma
membrane into the extracellular space, where they elicit a
host reaction (inflammation).

Necrosis-associated leakage of intracellular proteins through

damage plasma membrane and ultimately into the
circulation is the basis for blood tests that detect tissue
specific cell injury.
 Cont….
• Morphology:
Necrotic cells show increased eosinophilia in hematoxylin and
eosin (H & E) stains, attributable in part to the loss of cytoplasmic
RNA (which binds the blue dye, hematoxylin) and in part to denatured
cytoplasmic proteins (which bind the red dye, eosin).
The necrotic cell may have a more glassy homogeneous
appearance than do normal cells, mainly as a result of the loss of
glycogen particles.
When enzymes have digested the cytoplasmic organelles,
the cytoplasm becomes vacuolated and appears moth-eaten. Dead
cells may be replaced by large, whorled phospholipid masses called
myelin figures.
 Cont….
Myelin figures are either phagocytosed by other cells or further
degraded into fatty acids; calcification of such fatty acid residues
results in deposition of calcium rich precipitate.

Nuclear changes appear in one of three patterns, all due to

nonspecific breakdown of DNA
Karyolysis - The basophilia of the chromatin may
fade.(Loss of DNA)
Pyknosis - characterized by nuclear shrinkage and
increased basophilia.
Karyorrhexis, the pyknotic nucleus undergoes
fragmentation.
Morphologic Alterations in Cell Injury
FIGURE : Schematic illustration of the morphologic changes in cell injury culminating in necrosis
 Patterns of Tissue Necrosis
Coagulative necrosis –
- The architecture of dead tissues is preserved
(Some days).
- Texture of the affected tissue is firm.
- The injury denatures not only structural proteins
but also enzymes and so blocks the proteolysis of the dead
cells; as a result, intensely eosinophilic cells with indistinct or
reddish nuclei may persist (Days or weeks).
 Cont….
- Necrotic cells are broken down by lysosomal
enzyme of infiltrating leukocytes, which also remove the
debris of the dead cells by phagocytosis
- Ischemia caused by obstruction in a vessel may
lead to coagulative necrosis of the supplied tissue in all organs
except the brain.
A localized area of coagulative necrosis is called an
infarct.
FIGURE : Coagulative necrosis. A, A wedge-shaped kidney infarct (yellow). B, Microscopic view of the edge of
the infarct, with normal kidney (N) and necrotic cells in the infarct (I) showing preserved cellular outlines with loss
of nuclei and an inflammatory infiltrate (which is difficult to discern at this magnification).
 Cont….
Liquefactive necrosis : Digestion of the dead cells, resulting in
transformation of the tissue into a viscous liquid.
- It is seen in focal bacterial or, occasionally,
fungal infections.
- Because microbes stimulate the
accumulation of leukocytes and the liberation of enzymes from
these cells.
- The necrotic material is frequently creamy
yellow because of the presence of leukocytes and is called pus.
- For unknown reason hypoxic death of cells
within the central nervous system often manifests as liquefactive
necrosis.
 Cont….
Gangrenous necrosis (Clinical term):Typically coagulative
necrosis. It is usually applied to a limb, generally the lower
leg, that has lost its blood supply and has undergone
necrosis involving multiple tissue planes.
Wet gangrene : When bacterial infection is
superimposed there is more liquefactive necrosis because of
the actions of degradative enzymes in the bacteria and the
attracted leukocytes.
 Cont….
Caseous necrosis (Foci of tuberculous infection) : The term
caseous (cheeselike) is derived from the friable white
appearance of the area of necrosis.

On microscopic examination, the necrotic area appears

as a structureless collection of fragmented or lysed cells and
amorphous granular debris enclosed within a distinctive
inflammatory border; this appearance is characteristic of a focus
of inflammation known as a granuloma.
 Cont….
Fat necrosis : Focal areas of fat destruction, typically resulting from
release of activated pancreatic lipases into the substance of the
pancreas and the peritoneal cavity.(Acute Pancreatitis)
e.g : acute pancreatitis.

On H/E the necrotic areas contain the shadowy outlines of

necrotic fat cells, with basophilic calcium deposits, surrounded by an
inflammatory reaction.
FIGURE : Fat necrosis. The areas of white chalky deposits represent foci of fat necrosis with
calcium soap formation (saponification) at sites of lipid breakdown in the mesentery.
 Cont….
Fibrinoid necrosis : Special form of vascular damage usually
seen in immune reactions involving blood vessels.
It typically occurs when complexes of antigens
and antibodies are deposited in the walls of arteries.
Deposits of these immune complexes, together
with plasma protein that has leaked out of vessels, result in a
bright pink and amorphous appearance in H&E stains, called
“fibrinoid” (fibrin-like) by pathologists.
The immunologically mediated vasculitis
syndromes in which this type of vascular injury is seen.
FIGURE : Fibrinoid necrosis in an artery. The wall of the artery shows a circumferential
bright pink area of necrosis with inflammation (neutrophils with dark nuclei).
 Cont….
Ultimately, in the living patient
- Most necrotic cells and their contents
disappear due to enzymatic digestion and phagocytosis of the
debris by leukocytes.
- If necrotic cells and cellular debris are not
promptly destroyed and reabsorbed, they provide a nidus for
the deposition of calcium salts and other minerals and thus
tend to become calcified. (Dystrophic calcification)
 Apoptosis

Apoptosis is a pathway of cell death that is induced by a

tightly regulated suicide program in which cells destined to
die activate intrinsic enzymes that degrade the cells
genomic DNA and nuclear and cytoplasmic proteins.
Apoptotic bodies - Apoptotic cells break up into plasma
membrane bound fragments, which contain portions of the
cytoplasm and nucleus.
 Cont…
Find me and eat me signals for phagocytosis -
While the plasma membrane remains intact, but its surface
components are altered so as to produce find me and eat me
signals for phagocytosis.

Does not elicit an inflammatory reaction in the host -

The dead cell and its fragments are rapidly devoured, before the
contents have leaked out, and therefore cell death by this pathway
does not elicit an inflammatory reaction in the host.
 CAUSES OF APOPTOSIS
Apoptosis occurs in two broad contexts:
1. As part of normal physiologic processes,
and
2. As a pathophysiologic mechanism of cell
loss in many different diseases.
 Cont…
Apoptosis in Physiologic Situations:
- Normal phenomenon that serves to
eliminate cells that are no longer needed.
Or
- As a mechanism to maintain a constant
number of various cell populations in tissues.
- It is estimated that humans tum over
almost 1 million cells per second!
- Death of cells by apoptosis and their
removal by phagocytes central to this process.
 Cont…
It is important in the following physiologic situations:
The removal of supernumerary cells (in excess of the
required number) during development.
Cell death is critical for involution of
primordial structures and remodeling of maturing tissues.
Involution of hormone-dependent tissues on hormone
withdrawal, 66such as endometrial cell breakdown during
the menstrual cycle, ovarian follicular atresia in menopause
and the regression of the lactating breast after weaning.
 Cont….
 Cell turn over in proliferating cell populations, such as
immature lymphocytes in the bone marrow and thymus that
fail to express useful antigen receptors, B lymphocytes in
germinal centers, and epithelial cells in intestinal crypts, so as
to maintain a constant number (homeostasis)
Elimination of potentially harmful self-reactive lymphocytes,
to prevent reactions against one's own tissues.
Death of host cells that have served their useful purpose,
such as neutrophils in an acute inflammatory response, and
lymphocytes at the end of an immune response.
 Cont….
Apoptosis in Pathologic Conditions:
- Eliminates cells that are injured beyond
repair without eliciting a host reaction, thus limiting collateral
tissue damage.
- Death by apoptosis is responsible for
loss of cells in a variety of pathologic states :
 Cont….
DNA damage -
- Radiation and cytotoxic anticancer drugs can
damage DNA, (either directly or via production of free radicals).
- If repair mechanisms cannot correct the
damage, the cell triggers intrinsic mechanisms that induce
apoptosis.
- In these situations, apoptosis has a protective
effect by preventing the survival of cells with DNA mutations
that can lead to malignant transformation.
 Cont…
 Accumulation of misfolded proteins –
Cell death triggered by improperly folded
intracellular proteins and the subsequent endoplasmic
reticulum (ER) stress response.
Excessive accumulation of these protein in
the ER leads to a condition called ER stress.
 Cont…
Apoptosis can be induced during certain infections
particularly viral infections, as a result of the virus
itself (as in adenovirus and HIV infections) or the host immune
response (as in viral hepatitis).
An important host response to viruses consists of
cytotoxic T lymphocytes (CTLS) specific for viral proteins,
which induce apoptosis of infected cells in an attempt to
eliminate reservoirs of infection.
 Cont…
 Apoptosis may also contribute to pathologic atrophy in
parenchymal organs after duct obstruction, such as occurs in
the pancreas, parotid gland, and kidney.
Morphologic and Biochemical Changes in Apoptosis
Before discussing underlying mechanisms, the morphologic
and biochemical characteristics of apoptosis are described :

MORPHOLOGY:
• Cell shrinkage
• Chromatin condensation
• Formation of cytoplasmic blebs and apoptotic bodies
• Phagocytosis of apoptotic cells or cell bodies, usually by
macrophages.
 Cont…
• Cell shrinkage - Cell size is reduced, the cytoplasm is dense
and eosinophilic and the organelles, although relatively
normal, are more tightly packed. This contrasts with
necrosis, in which an early feature is cell swelling, not
shrinkage.
• Chromatin condensation - The chromatin aggregates
peripherally under the nuclear membrane, into dense
masses of various shapes and sizes. The nucleus itself may
break up into two or more fragments.
 Cont…
• Formation of cytoplasmic blebs and apoptotic bodies -The
apoptotic cell first shows extensive surface membrane
blebbing which is followed by fragmentation of the dead
cells into membrane bound apoptotic bodies composed of
cytoplasm and tightly packed organelles, with or without
nuclear fragments
• Phagocytosis of apoptotic cells or cell bodies, usually by
macrophages - The apoptotic bodies are rapidly ingested by
phagocytes and degraded by the phagocyte's lysosomal
enzymes.
 Cont…

In H&E-stained tissue,
The apoptotic cell appears as a round or oval
mass of intensely eosinophilic cytoplasm with fragments of
dense nuclear chromatin
 Cont….
Biochemical Features of Apoptosis
Activation of Caspases
DNA and Protein Breakdown
Membrane Alterations and Recognition by
Phagocytes.
 Mechanisms of apoptosis
Apoptosis results from the activation of enzymes called caspases (so
named because they are proteases containing a cysteine in their
active site and cleave proteins after aspartic residues). Caspases exist
as inactive proenzymes and must undergo enzymatic cleavage to
become of active.
 The process of apoptosis may be divided into an initiation phase,
during which some caspases become catalytically active and unleash
a cascade of other caspases, and
 An execution phase, during which the terminal caspases trigger
cellular fragmentation.
 Cont…
Two distinct pathways converge on caspase activation: The
mitochondrial pathway and the death receptor pathway.
The Mitochondrial (Intrinsic) Pathway of Apoptosis
The mitochondrial pathway is responsible for
apoptosis in most physiologic and pathologic situations.
The Extrinsic (Death Receptor – Initiated) Pathway of
Apoptosis
This pathway is initiated by engagement of plasma membrane
death receptors.
 Cont…
• The Execution Phase of Apoptosis
The intrinsic and extrinsic pathways converge to
activate a caspase cascade that mediates the final phase of
apoptosis.
 Disorders Associated with Dysregulated Apoptosis
Disorders associated with defective apoptosis and increased cell
survival.
Thus, defective apoptosis may be the basis of autoimmune
disorders.
Disorders associated with increased apoptosis and excessive cell
death. These diseases are characterized by a loss of cells and include
(1) neurodegenerative diseases, manifested by loss of specific
sets of neurons, in which apoptosis is caused by mutations and
misfolded proteins
(2) ischemic injury, as in myocardial infarction and stroke and
(3) death of virus-infected cells, in many viral infections.
 Features of Necrosis and Apoptosis
Feature Necrosis Apoptosis

Cell size Enlarged (swelling) Reduced (shrinkage)

Nucleus Pyknosis ➙ Fragmentation into

karyorrhexis ➙ nucleosome-size
karyolysis fragments

Plasma membrane Disrupted Intact; altered

structure, especially
orientation of lipids
Feature Necrosis Apoptosis
Cellular contents Enzymatic digestion; may Intact; may be released in
leak out of cell apoptotic bodies

Adjacent Frequent No
inflammation
Physiologic or Usually pathologic Often physiologic, means
pathologic role (culmination of of eliminating unwanted
irreversible cell injury) cells; may be pathologic
after some forms of cell
injury, especially DNA
damage
 Removal of Dead Cells
The formation of apoptotic bodies breaks cells up in "bite-
sized" fragments that are edible for phagocytes.
 In healthy cells, phosphatidylserine is present on the inner
leaflet of the plasma membrane, but in apoptotic cells this
phospholipid "flips" out and is expressed on the outer layer
of the membrane, where it is recognized by several
macrophage receptors.
Cells that are dying by apoptosis also secrete soluble factors
that recruit phagocytes,
 Cont…
Macrophages themselves may produce proteins that bind to
apoptotic cells (but not live cells), leading to their
engulfment.
Apoptotic bodies may also become coated with natural
antibodies and proteins of the complement system, notably
Clq, which are recognized by phagocytes.
 Cont…
Thus, numerous ligands induced on apoptotic cells serve as
"eat me" signals and are recognized by receptors on
phagocytes that bind and engulf these cells. This process of
apoptotic cell phagocytosis is called efferocytosis; it is so
efficient that dead cells disappear often within minutes,
without leaving a trace.
In addition production of pro-inflammatory cytokines is
reduced in macrophages that have ingested apoptotic cells.
Together with rapid clearance, this limits inflammatory
reactions even in the face of extensive apoptosis.
 Other Mechanisms of Cell Death
Several other ways by which cells die have been described -
1. Necroptosis (Programmed necrosis/Capase
independent)
2. Pyroptosis(form of apoptosis) – Occurs in cell
infected by microbes. At the same time trigger local
inflammation.
3. Ferroptosis(Distinctive type of cell death) – Iron
dependent pathway of cell death induced by lipid peroxidation.
 Cont….
Necroptosis(Programmed necrosis/Capase independent) - As the
name indicates the form of cell death is a hybrid that shares
aspects of both necrosis and apoptosis.
Morphologically, and to some extent biochemically, it
resembles necrosis, as both are characterized by loss of ATP,
swelling the cell and organells, generation of reactive oxygen
species (ROS), release of lysosomal enzymes, and ultimately
rupture of the plasma membranes.
Mechanistically, it is triggered by signal transduction
pathways that culminate in cell death, a feature similar to
apoptosis.
 Cont….
• Both in physiologic and pathologic conditions
For example, physiologic necroptosis occurs during the
formation of the mammalian bone growth plate
In pathologic states, it is associated with cell death in
steatohepatitis, acute pancreatitis, ischemia-reperfusion injury, and
neurodegenerative diseases such as Parkinson disease.
Necroptosis also acts as a backup mechanism in host
defense against certain viruses that encode capase inhibitors (eg.
cytomegalovirus)
 Autophagy
Autophagy is a process in which a cell eats its own contents.
 It is a survival mechanism in times of nutrient deprivation,
when the starved cell lives by cannibalizing itself and
recycling the digested contents.
In this process intracellular organelles and portions of
cytosol are first sequestered from the cytoplasm in an
autophagic vacuole, which subsequently fuses with
lysosomes to form an autophagolysosome, and the cellular
components are digested by lysosomal enzymes.
 Autophagy

FIGURE: Cellular stresses, such as nutrient deprivation, activate autophagy genes that create vacuoles in
which cellular organelles are sequestered and then degraded following fusion of the vesicles with
lysosomes. The digested materials are recycled to provide nutrients for the cell.
 Cellular Responses to Stress & Noxious Stimuli
Homeostasis
Adaptations are reversible functional and structural responses to
changes in physiologic states(e.g. pregnancy) and some pathologic
stimuli, during which new but altered steady states are achieved,
allowing the cell to survive and continue to function.
The adaptive response may consist
• Hypertrophy (increase in the size of cells) and an increase in functional
activity.
• Hyperplasia, an increase in their number,
• Atrophy - a decrease in the size and metabolic activity of cells,
• Metaplasia - a change in the phenotype of cells.
Cell death, the end result of progressive cell injury, is one of
the most crucial events in the evolution of disease in any
tissue or organ.
It results from diverse causes, including ischemia
(reduced blood flow), infection, and toxins. Cell death is also a
normal and essential process in embryogenesis, the
development of organs, and the maintenance of homeostasis.
There are two principal pathways of cell death, necrosis and
apoptosis.
Nutrient deprivation triggers an adaptive cellular response
called autophagy that may also culminate in cell death.
Metabolic derangements in cells and sublethal, chronic
injury may be associated with intracellular accumulations of
a number of substances, including proteins, lipids, and
carbohydrates. Calcium is often deposited at sites of cell
death, resulting in pathologic calcification.

Finally, the normal process of aging itself is accompanied by

characteristic morphologic and functional changes in cells.
Adaptations of Cellular Growth & Differentiation
HYPERTROPHY
Hypertrophy refers to an increase in the size of cells,
resulting in an increase in the size of the organ.
Hypertrophy can be physiologic or pathologic
Caused by increased functional demand or by stimulation by
hormones and growth factors.
The most common stimulus for hypertrophy of muscle is
increased workload.
In the heart, the stimulus for hypertrophy is usually chronic
hemodynamic overload, resulting from either hypertension
or fault valves.
 Mechanisms of Hypertrophy
Hypertrophy is the result of increased production of cellular
proteins.
Hypertrophy can be induced by the linked actions of
mechanical sensors (that are triggered by increased work
load), growth factors (including TGF-β), and vasoactive
agents (such as endothelin-1).
These stimuli work coordinately to increase the synthesis of
muscle proteins that are responsible for the hypertrophy.
 Cont…..
HYPERPLASIA
Hyperplasia is an increase in the number of cells in an
organ or tissue, usually resulting in increased mass of the organ
or tissue.
Hyperplasia can be physiologic or pathologic.
Physiologic Hyperplasia can be divided into:
(1) hormonal hyperplasia, which increases
the functional capacity of a tissue when needed, and
(2) compensatory hyperplasia, which
increases tissue mass after damage or partial resection.
 Cont…..
Pathologic Hyperplasia caused by excesses of hormones or
growth factors acting on target cells. e.g :
Endometrial hyperplasia
Benign prostatic hyperplasia

Hyperplasia is distinct from cancer, but pathologic

hyperplasia constitutes a fertile soil in which cancerous
proliferation may eventually arise.
 Mechanisms of Hyperplasia

Hyperplasia is the result of growth factor–driven proliferation

of mature cells and, in some cases, by increased output of new
cells from tissue stem cells.
 Cont…..
ATROPHY
Atrophy is reduced size of an organ or tissue resulting from a
decrease in cell size and number.
Atrophy can be physiologic or pathologic
Physiologic atrophy is common during normal development.
Some embryonic structures, such as the
notochord and thyroglossal duct, undergo atrophy during fetal
development.
The uterus decreases in size shortly after
parturition, and this is a form of physiologic atrophy.
 Cont…..
Pathologic atrophy depends on the underlying cause and can be local
or generalized. The common causes of atrophy are the following:
Decreased workload (atrophy of disuse)
Loss of innervation (denervation atrophy).
Diminished blood supply
Inadequate nutrition
Loss of endocrine stimulation.
Pressure.
Brown atrophy : Lipofuscin granules, when present in sufficient
amounts, they impart a brown discoloration to the tissue.
 Mechanisms of Atrophy
Atrophy results from decreased protein synthesis and increased
protein degradation in cells.
Protein synthesis decreases because of reduced metabolic
activity.
The degradation of cellular proteins occurs mainly by the
ubiquitin-proteasome pathway. Nutrient deficiency and disuse
may activate ubiquitin ligases, which attach the small peptide
ubiquitin to cellular proteins and target these proteins for
degradation in proteasomes.
In many situations, atrophy is also accompanied by increased
autophagy, with resulting increases in the number of autophagic
vacuoles.
Autophagy (self eating) is the process in which the starved cell eats
its own components in an attempt to find nutrients and survive.

 Autophagic vacuoles are membranebound vacuoles that contain

fragments of cell components. The vacuoles ultimately fuse with
lysosomes, and their contents are digested by lysosomal enzymes.

Some of the cell debris within the autophagic vacuoles may resist
digestion and persist as membrane-bound residual bodies that may
remain as a sarcophagus in the cytoplasm. An example of such
residual bodies is the lipofuscin granules,

When present in sufficient amounts, they impart a brown

discoloration to the tissue(brown atrophy).
 METAPLASIA
• Metaplasia is a reversible change in which one differentiated cell
type (epithelial or mesenchymal) is replaced by another cell type.
• The most common epithelial metaplasia is columnar to squamous
as occurs in the respiratory tract in response to chronic irritation.
• Epithelial metaplasia is a double-edged sword and, in most
circumstances, represents an undesirable change.
• Moreover, the influences that predispose to metaplasia, if
persistent, may initiate malignant transformation in metaplastic
epithelium.
 Cont…..
Thus, a common form of cancer in the respiratory tract is composed
of squamous cells, which arise in areas of metaplasia of the normal
columnar epithelium into squamous epithelium.
Metaplasia from squamous to columnar type may also occur, as in
Barrett esophagus, in which the esophageal squamous epithelium is
replaced by intestinal-like columnar cells under the influence of
refluxed gastric acid. Cancers may arise in these areas; these are
typically glandular (adeno)carcinomas.
Connective tissue metaplasia is the formation of cartilage, bone, or
adipose tissue (mesenchymal tissues) in tissues that normally do not
contain these elements. For example, bone formation in muscle,
designated myositis ossificans.
Mechanisms of Metaplasia

Metaplasia does not result from a change

in the phenotype of an already differentiated cell type; instead
it is the result of a reprogramming of stem cells that are
known to exist in normal tissues, or of undifferentiated
mesenchymal cells present in connective tissue.

In a metaplastic change, these precursor cells

differentiate along a new pathway.
 Mechanisms of Cell Injury
The cellular response to injurious stimuli depends on the
nature of the injury, its duration, and its severity.
The consequences of cell injury depend on the type, state,
and adaptability of the injured cell.
Cell injury results from different biochemical mechanisms
acting on several essential cellular components.
Any injurious stimulus may simultaneously trigger multiple
interconnected mechanisms that damage cells.
FIGURE : The principal mechanisms of cell injury, and their biochemical and functional effects,
are shown.
DEPLETION OF ATP
MITOCHONDRIAL DAMAGE
INFLUX OF CALCIUM AND LOSS OF CALCIUM HOMEOSTASIS
ACCUMULATION OF OXYGEN-DERIVED FREE RADICALS (OXIDATIVE STRESS)
Free radicals are chemical species that have a single unpaired electron
in an outer orbit.
e.g: HNO2, nitrite;
H2O2, hydrogen peroxide;
NO, nitric oxide; ,
superoxide anion;
OCl-, hypochlorite;
H, hydroxyl radical;
ONOO-, peroxynitrite;
ROS, reactive oxygen species;
SOD, superoxide dismutase.
 Properties of the Principal Free Radicals Involved in Cell Injury

Properties H2O2 H ONOO-

MECHANISMS Incomplete Generated by Generated Produced by
OF reduction SOD from from H2O by interaction of
PRODUCTION of O2 during and by hydrolysis, e.g., and
oxidative oxidases in by radiation; NO generated
phosphorylatio peroxisomes from H2O2 by by NO synthase
n; by Fenton in many cell
phagocyte reaction; from types
oxidase in (endothelial
leukocytes cells,
leukocytes,
neurons,
Properties H2O2 ONOO-

MECHANISMS Conversion to H2O2 Conversion to H2O Conversion to H2O Conversion to

OF and O2 by SOD and O2 by catalase by HNO2 by
INACTIVATION (peroxisomes), glutathione peroxiredoxins
glutathione peroxidase (cytosol,
peroxidase mitochondria).
(cytosol,
mitochondria
PATHOLOGIC Stimulates Can be converted Most reactive Damages lipids,
EFFECTS production H to oxygen derived proteins, DNA
of degradative and OCl-, which free radical;
enzymes in destroy microbes principal ROS
leukocytes and other and cells; can act responsible for
cells; may directly distant from site damaging lipids,
damage lipids, of production proteins, and DNA
proteins, DNA; acts
close to site of
 Generation of Free Radicals
Free radicals may be generated within cells in several ways:
The reduction-oxidation reactions that occur during normal
metabolic processes.
During normal respiration, molecular O2 is reduced by the
transfer of four electrons to H2 to generate two water molecules.
Absorption of radiant energy (e.g., ultraviolet light, x-rays). For
example, ionizing radiation can hydrolyze water into H and
hydrogen (H) free radicals.
Rapid bursts of ROS are produced in activated leukocytes
during inflammation.
 Cont…..
Enzymatic metabolism of exogenous chemicals or drugs can
generate free radicals that are not ROS but have similar effects
(e.g., CCl4 can generate CCl3).
Transition metals such as iron and copper donate or accept
free electrons during intracellular reactions and catalyze free
radical formation, as in the Fenton reaction (H2O2 + Fe2+ ➙ Fe3+
+ OH + OH-).
Nitric oxide (NO), an important chemical mediator generated
by endothelial cells, macrophages, neurons, and other cell
types, can act as a free radical and can also be converted to
highly reactive peroxynitrite anion (ONOO-) as well as NO2 and
NO3-.
 Removal of Free Radicals
Free radicals are inherently unstable and generally decay
spontaneously.
In addition, cells have developed multiple non enzymatic
and enzymatic mechanisms to remove free radicals and
there by minimize injury. These include the following:
Antioxidants either block the initiation of free radical
formation or inactivate (e.g., scavenge) free radicals.
Examples are the lipid-soluble vitamins E and A as well as
ascorbic acid and glutathione in the cytosol.
 Cont…..
As we have seen, iron and copper can catalyze the formation of
ROS. The levels of these reactive metals are minimized by
binding of the ions to storage and transport proteins (e.g.,
transferrin, ferritin, lactoferrin, and ceruloplasmin), thereby
minimizing the formation of ROS.
A series of enzymes acts as free radical scavenging systems and
breaks down H2O2 and .
These enzymes are lo-cated near the sites of generation of
the oxidants and include the following:
1. Catalase, present in peroxisomes, decomposes H2O2
(2H2O2 ➙ O2 + 2H2O).
 Cont…..
2. Superoxide dismutases (SODs) are found in many cell
types and convert to H2O2 (2 + 2H ➙ H2O2 + O2).
3. Glutathione peroxidase also protects against injury by
catalyzing free radical breakdown. (H2O2 + 2GSH ➙ GSSG
[glutathione homodimer] + 2H2O, or 2OH + 2GSH ➙ GSSG +
2H2O).
 Pathologic Effects of Free Radicals
The effects of ROS and other free radicals are wide-ranging,
but three reactions are particularly relevant to cell injury:
Lipid peroxidation in membranes - In the presence of
O2, free radicals may cause peroxidation of lipids within
plasma and organellar membranes. Oxidative damage is
initiated when the double bonds in unsaturated fatty acids of
membrane lipids are attacked by O2-derived free radicals, The
lipid free radical interactions yield peroxides, which are
themselves unstable and reactive, and an autocatalytic chain
reaction ensues (called propagation), which can result in
extensive membrane damage.
 Cont…..
Oxidative modification of proteins – Oxidative
modification of proteins may damage the active sites of
enzymes, disrupt the conformation of structural proteins, and
enhance proteasomal degradation of unfolded or misfolded
proteins, raising havoc throughout the cell.
Lesions in DNA - Free radicals are capable of causing
single- and double-strand breaks in DNA, cross-linking of DNA
strands, and formation of adducts. Oxidative DNA damage has
been implicated in cell aging and in malignant transformation
of cells.
Clinico-Pathologic Correlations: Selected Examples of Cell
Injury & Necrosis

• ISCHEMIC AND HYPOXIC INJURY

• ISCHEMIA-REPERFUSION INJURY

• CHEMICAL (TOXIC) INJURY

 ISCHEMIC AND HYPOXIC INJURY
• Hypoxia, referring to reduced oxygen availability, may occur in a
variety of clinical settings.
• Ischemia, the supply of oxygen and nutrients is decreased most often
because of reduced blood flow as a consequence of a mechanical
obstruction in the arterial system. It can also be caused by reduced
venous drainage.
Ischemia tends to cause more rapid and severe cell and tissue
injury than does hypoxia in the absence of ischemia.
If ischemia persists, irreversible injury and necrosis ensue.
 ISCHEMIA-REPERFUSION INJURY
• Restoration of blood flow to ischemic tissues can promote recovery of
cells if they are reversibly injured.
• However, under certain circumstances, when blood flow is restored to
cells that have been ischemic but have not died, injury is paradoxically
exacerbated and proceeds at an accelerated pace.
• As a consequence, reperfused tissues may sustain loss of cells in
addition to the cells that are irreversibly damaged at the end of
ischemia. This process, called ischemia-reperfusion injury, is clinically
important because it contributes to tissue damage during myocardial
and cerebral infarction and following therapies to restore blood flow.
 Intracellular Accumulations
One of the manifestations of metabolic derangements in
cells is the intracellular accumulation of abnormal amounts
of various substances.
The stockpiled substances fall into two categories:
(1) a normal cellular constituent, such as
water, lipids, proteins, and carbohydrates, that accumulates in
excess; or
(2) an abnormal substance, either exogenous,
such as a mineral or products of infectious agents, or
endogenous, such as a product of abnormal synthesis or
metabolism.
 Cont….
The substance may be located in either the cytoplasm
(frequently within phagolysosomes) or the nucleus.
Many processes result in abnormal intracellular
accumulations, but most accumulations are attributable to
four types of abnormalities :
1. A normal endogenous substance is produced
at a normal or increased rate, but the rate of metabolism is
inadequate to remove it.
Examples : Fatty change in the liver and
reabsorption protein droplets in the tubules of the kidneys .
 Cont….
2. An abnormal endogenous substance, typically the
product of a mutated gene, accumulates because of defects in
protein folding and transport and an inability to degrade the
abnormal protein efficiently.
Examples include the accumulation of mutated
α1-antitrypsin in liver cells and various mutated proteins in
degenerative disorders of the central nervous system.
 Cont….
3. A normal endogenous substance accumulates
because of defects, usually inherited, in enzymes that are
required for the metabolism of the substance.
Examples include diseases caused by genetic
defects in enzymes involved in the metabolism of lipid and
carbohydrates, resulting in intracellular deposition of these
substances, largely in lysosomes.
 Cont….
4. An abnormal exogenous substance is
deposited and accumulates because the cell has neither the
enzymatic machinery to degrade the substance nor the ability
to transport it to other sites.
Accumulations of carbon particles and
non metabolizable chemicals such as silica are examples of
this type of alteration.
 LIPIDS
All major classes of lipids can accumulate in cells:
Triglycerides, cholesterol/cholesterol esters, and
phospholipids. Phospholipids are components of the myelin
figures found in necrotic cells.
In addition, abnormal complexes of lipids and
carbohydrates accumulate in the lysosomal storage diseases.
 Steatosis (Fatty Change)
Abnormal accumulations of triglycerides within parenchymal
cells.
Often seen in the liver because it is the major organ involved in
fat metabolism, but it also occurs in heart, muscle, and kidney.
The causes of steatosis include toxins, protein malnutrition,
diabetes mellitus, obesity, and anoxia.
In developed nations the most common causes of significant
fatty change in the liver (fatty liver) are alcohol abuse and
nonalcoholic fatty liver disease, which is often associated with
diabetes and obesity.
FIGURE: Fatty liver. A, Schematic diagram of the possible mechanisms leading to accumulation of triglycerides in
fatty liver. Defects in any of the steps of uptake, catabolism, or secretion can result in lipid accumulation. B, High-
power detail of fatty change of the liver. In most cells the well-preserved nucleus is squeezed into the displaced rim of
cytoplasm about the fat vacuole.
 Cont…..
Morphology of fatty change of liver-
Gross- The organ is enlarged, soft and bright yellow.
Microscopy- Within the cells, fat appears as small clear
cytoplasmic droplets or large vacuoles (signet ring
appearance).

Method of detection of fat in histology

Frozen section of the fresh or formalin-fixed tissue.
Stain- Sudan-IV, Oil red-O (Orange-red color to the
contained lipids).
 PROTEINS
• Intracellular accumulations of proteins usually appear as
rounded, eosinophilic droplets, vacuoles, or aggregates in the
cytoplasm.

FIGURE: Protein reabsorption droplets in the

renal tubular epithelium
 Cont…
HYALINE CHANGE:
The term hyaline usually refers to an alteration within
cells or in the extracellular space that gives a homogeneous,
glassy, pink appearance in routine histologic sections stained
with hematoxylin and eosin.
GLYCOGEN:
Excessive intracellular deposits of glycogen are seen in
patients with an abnormality in either glucose or glycogen
metabolism.
 PIGMENTS
• Pigments are colored substances, some of which are normal
constituents of cells (e.g., melanin), whereas others are abnormal and
accumulate in cells only under special circumstances. Pigments can be
exogenous, coming from outside the body, or endogenous,
synthesized within the body itself.

FIGURE : Lipofuscin granules in a cardiac

myocyte shown by light microscopy (deposits
indicated by arrows).
 Pathologic Calcification
Pathologic calcification is the abnormal tissue deposition of
calcium salts, together with smaller amounts of iron, magnesium,
and other mineral salts.

There are two forms of pathologic calcification.

Dystrophic calcification
Metastatic calcification
 Cont…..
Dystrophic calcification: When the deposition occurs locally
in dying tissues.
It occurs despite normal serum levels of calcium and in
the absence of derangements in calcium metabolism.
Metastatic calcification: When the deposition of calcium
salts in otherwise normal tissues
It almost always results from hypercalcemia
secondary to some disturbance in calcium metabolism.
 DYSTROPHIC CALCIFICATION
• Dystrophic calcification is encountered in areas of necrosis.
• Calcification is almost always present in the atheromas of
advanced atherosclerosis.
• It also commonly develops in aging or damaged heart valves,
• Macroscopically : Fine, white granules or clumps, often felt
as gritty deposits. Sometimes a tuberculous lymph node is
virtually converted to stone.
 Cont…..
Morphology: Histologically, with the usual hematoxylin and
eosin stain, calcium salts have a basophilic, amorphous
granular, sometimes clumped appearance.
They can be intracellular, extracellular, or in both
locations.
In the course of time, heterotopic bone may be
formed in the focus of calcification.
 Cont…
• The progressive acquisition of outer layers may create
lamellated configurations, called psammoma bodies because
of their resemblance to grains of sand. Some types of
papillary cancers (e.g., thyroid) are apt to develop
psammoma bodies.
 METASTATIC CALCIFICATION
Metastatic calcification may occur in normal tissues
whenever there is hypercalcemia.
 There are four principal causes of hypercalcemia:
(1) increased secretion of parathyroid hormone
(PTH) with subsequent bone resorption, as in
hyperparathyroidism due to parathyroid tumors, and ectopic
secretion of PTH-related protein by malignant tumors.
 (2) destruction of bone tissue, secondary to
primary tumors of bone marrow (e.g., multiple myeloma,
leukemia) or diffuse skeletal metastasis (e.g., breast cancer),
accelerated bone turnover (e.g., Paget disease), or
immobilization;
(3) vitamin D–related disorders, including
vitamin D intoxication, sarcoidosis (in which macrophages
activate a vitamin D precursor), and idiopathic hypercalcemia
of infancy (Williams syndrome),;
and
 Cont…..
(4) renal failure, which causes retention of
phosphate, leading to secondary hyperparathyroidism.

• Sites: Metastatic calcification may occur widely throughout

the body but principally affects
the interstitial tissues of the gastric mucosa,
kidneys,
lungs,
systemic arteries, and
pulmonary veins.
 Cellular Aging
Cellular aging is the result of a progressive decline in cellular function and
viability caused by genetic abnormalities and the accumulation of cellular and
molecular damage due to the effects of exposure to exogenous influences.
 ?????Question
 what do you mean by cellular adaption? Name it’s types with
example.
Define atrophy, hypertrophy and hyperplasia. Mention the organs or
conditions in which both hypertrophy and hyperplasia occur
simultaneously.
Define autolysis. Differentiate between necrosis and autolysis.
 Define necrosis & apoptosis. Mention three important differences
between necrosis and apoptosis.
 What do you mean by metaplasia? Mention the common sites of
metaplasia? What are the advantages of metaplasia?
 ?????Question
 Define necrosis. What are the types of necrosis with example?
 Define free radicals. Mention the different types of free radicals.
How free radicals act?
What do you mean by caseous necrosis? What are the changes occur
in caseous necrosis? In which conditions it is common?
Define metaplasia. What are it’s types? What are the advantages and
disadvantages of metaplasia?
Define apoptosis. What are the morphological changes seen in
apoptosis? What are it’s causes?
 ?????Question
• Define pathologic clacification. What are it’s types with example.
• What are the disadvantages of excess calcium intake.
• Define metaplasia. Mention it’s types with example of each.
• Define necrosis. What are the nuclear changes in necrosis?
• Define hyperplasia. Mention types with example.
• What is the importance of hyperplasia?
• Define free radical. What are the free radicals. How the free radicals
are destroyed?
 ?????Question
What do you mean by dystrophic calcification and metastatic
calcification?
What do you mean by hypertrophy and hyperplasia? Mention three
important differences between hypertrophy and hyperplasia.
Define apoptosis. Mention three important examples of apoptosis.
Mention the mechanism of cellular swelling due to ischemia.
Define necrosis. What are the types of necrosis with example? What
morphological changes occur in necrosis?
What do you mean by fatty change? How fatty changes occur in
liver?
 ?????Question
• What is cell injury? What are the types? Name five important causes
of cell injury.
• Define necrosis. What are the differences between coagulation
necrosis and caseous necrosis? Mention example of each.
• What do you mean by fatty change? Name the organs in which fatty
change occur. Mention the important causes of fatty change.
• What do you mean by atrophy, hypertrophy and hyperplasia?
Mention examples of each.
• Name four chemical agent that causing cell injury. How can you
differentiate hypoxia from ischemia?
 ?????Question
What are the importance of apoptosis? Give three pathological
examples of apoptosis.
Define free radical. Tell three examples of oxygen-derived free
radicals. How free radical H2O2 is inactivated?
Name three the infectious agent causing cell injury.
What are the effects of decreased ATP in cell injury?
What are the hallmarks of irreversible cell injury?
 ?????Question
Tell two example of liquefactive necrosis,
 Tell four causes of cell injury with examples.
 What is pathological calcification? What are the types of pathological
calcification? Give three important causes of metastatic calcification.
 Define apoptosis. Tell three physiological & pathological examples of
apoptosis.
Tell two examples of endogenous antioxidants? Tell three effect of
free radical.
 ?????Question
Why metaplasia is called double edged sword?
Tell two examples of columnar metaplasia.
Tell two examples of connective tissue metaplasia.
What are the antioxidants? What are the mechanisms of membrane
damage?
Define gangrene. What are the types of gangrene?
Tell three differences between dry & most gangrene.
Define Hyperplasia. Tell three differences between hyperplasia &
neoplasia.
Tell one example of pathological hypertrophy.
 ?????Question
• What changes occur in cytoplasm in irreversible cell injury.
• Give two examples of immunologic insult that causing cell injury.
• Define metaplasia. What are the types of metaplasia?
• Tell three examples of squamous metaplasia.
• What are the importance of metaplasia?
• Tell two examples of connective tissue metaplasia,.
• Between hypertrophy & hyperplasia which one is better & why?
 ?????Question
• Define metaplasia. Tell for causes of atrophy with examples.
• What are the difference between coagulative and caseous necrosis.
• Give three examples of coagulation necrosis.
• Name four chemicals which causes cell injury.
• Tell four important causes of cell injury.
• What are the types of oxygen deprivation?
• Name important nutritional deficiencies that causing cell injury.
 ?????Question
• What do you mean by reperfusion injury?
• What are the mechanisms of reprfusion injury?
• Name two examples of fat necrosis.
• What are the types of calcification? What is pathological calcification?
• Tell three examples of metastatic calcification.
• What are the types of basic necrosis?
• Tell three differences between coagulative & caseous necrosis?
 ?????Question
Define cell injury.
Tell four morphological changes that occur in a cell during irreversible
cell injury.
Define dystrophic calcification. Tell three examples of dystrophic
calcification. Tell three causes of hypercalcaemia.
What is atolysis & heterolysis? Tell three morphological changes that
occur in a cell during apoptosis.