CELLULAR INJURY AND NECROSIS

Dr. Thuaibah Hashim

Learning Objectives
List the causes of cell injury and explain their mechanisms. Define sublethal and lethal injuries. Describe their morphological changes. Describe the patterns of necrosis with clinical examples. Describe intracellular accumulations and pathologic calcification.

CAUSES OF INJURY
1. 2. 3. 4. 5. 6. 7. Oxygen deprivation Physical agents Chemical agents and drugs Infectious agents Immunologic reactions Nutritional imbalances Genetic derangements

Acquired

1. Oxygen deprivation
HYPOXIA
Oxygen deficiency, affects oxidative respiration common cause of injury and cell death. eg. respiratory failure eg. anaemia, CO poisoning

ISCHAEMIA = shortage of blood supply

often due to blockage of artery or veins. Hypoxia + deficiency of metabolic substrate

**Ischaemic tissues are more rapidly and severely injured than hypoxic tissues.

2. Physical Agents
Mechanical trauma Extreme temperatures (burns & cold) Sudden change in atmospheric pressures Radiation Electrical shock

3. Chemicals & Drugs

The list of chemicals that may produce cell injury defies compilation.
Caustic agents: Acids & Alkali Alcohol & narcotic drugs Therapeutic drugs Insecticides, Pesticides Herbicides Environmental and air pollutants Simple chemicals eg. glucose and salt in hypertonic concentrations may cause cell injury directly or by deranging electrolyte homeostasis. Even O2, in high concentrations, is severely toxic.

4. Infectious agents
Viruses (cytopathic effects) Bacteria Fungi Parasites Worms etc

5. Immunological Reactions
Bodys defense mechanism, may in fact, cause cell injury. eg. anaphylactic reactions (hypersensitivity) eg. autoimmune diseases

6. Nutritional imbalances
Deficiencies: Common protein-calorie malnutrition, severe degree leads to death of tissuesindividuals. Specific vitamin deficiencies. Excesses: Excess of lipids predispose to atherosclerosis.

7. Genetic Defects
eg. Chromosomal abnormality Downs syndrome eg. Single amino acid substitution in Hb S sickle cell anaemia. eg. Enzyme abnormality gene defects -- inborn errors of metabolism (Production of substances which are toxic to cells)

EFFECTS OF INJURIES ON CELLS/TISSUES

TYPES OF INJURIES
1. SUBLETHAL INJURY (Removal of injurious agents allows recovery to normal state) 2. LETHAL INJURY (No possible recovery)

EFFECTS ON CELLS
REVERSIBLE DAMAGE 1.1 Hydropic degeneration 1.2 Fatty Change IRREVERSIBLE DAMAGE 2.1 Apoptosis 2.2 Necrosis

Mechanisms of cell injury

The biochemical mechanisms responsible for cell injury are complex. With most stimuli, multiple mechanisms contribute to injury, and in the case of many injurious stimuli,the actual biochemical locus of injury remains unknown. Basic principles:
Depends on type of injury, its duration and severity. Depends on type of injured cells, its status and adaptability.(eg. Cardiac muscle withstands hypoxia 2030 mins, Striated muscle withstands hypoxia 2-3 hrs)

MECHANISM OF INJURY
Interdependance of cellular organelles Damage of one component leads to secondary damage of other components. Cell death occurs when threshold of accumulated damage is passed Cell response ranges from recoverable damage to instant death Primary targets of damaging stimuli: 1. Cell membrane 2. Mitochondria 3. Cytoskeleton 4. Protein synthesis 5. Cellular DNA

Pathogenesis of ischaemic/hypoxic injuries

Decreased generation of cellular ATP.
Plasma membrane energy-dependent Na pump fails Na accumulate intracellular cell swelling, dilated ER. Anaerobic glycolysis lactic acidosis activity of cellular enzymes. Failure of calcium pump. Disruption of protein synthetic apparatus. Damage to mitochondrial and lysosomal membranes. Proteins may become misfolded unfolded protein response leading to cell injury.

Ischaemia-Reperfusion injury
Depending upon the duration of ischaemia, restoration of blood flow may result in 3 different consequences: 1. Short duration, reversible injury cell restored to normal. 2. Longer duration reperfusion paradoxically deteriorates the already injured cell = Ischaemia-Reperfusion injury due to increased generation of oxygen free radicals or reactive oxygen species (superoxide, H2O2, OH-). 3. Irreversible injury during ischaemia itself no role of reperfusion.

Pathogenesis of chemical injury

Direct cytotoxic effects.
Combine with components of cell. eg. mercury binds to cell membrane protein permeability.

Conversion to reactive metabolites

Metabolic activation to yield ultimate toxin. Target cells may not be the same cells that metabolise the chemicals Eg. CCl4 converted to CCl3. causing toxic liver necrosis.

Pathogenesis of physical injury

Ionizing radiation can hydrolyze water into H+ and OH- free radicals. OH- radical produce injury by:
Lipid peroxidation Protein oxidation DNA damage

Morphology of Sublethal Injury

The term degeneration denote morphology of reversible injury. Cellular change: HYDROPIC DEGENERATION. (a.k.a CLOUDY SWELLING, VACUOLAR DEGENERATION)

Hydropic degeneration
Commonest and earliest form of cell injury Results from impaired regulation of cellular volume esp sodium.
Plasma membrane Sodium pump Supply of ATP

Hydropic degeneration
Gross:
Enlarged organs eg kidney, liver Cut surface bulges outwards, slightly opaque. (hence the term cloudy swelling)

Microscopic:
Cells swollen Microvasculature is compressed Small clear intracytoplasmic vacuoles (represents distended cisternae of ER.)

Hydropic degeneration
Ultrastructural changes (refer diagram)
Dilated ER Detachment of polysomes from surface of RER Mitochondrial swelling Blebs on plasma membrane, distortion of microvilli, loosening intercellular attachment, myelin figures. Nuclear alteration: disaggregation of granular and fibrillar elements.

Intracellular Accumulations
Substances in abnormal amounts due to deranged cell metabolism. Mild degree causes reversible injury. Normal constituents eg. lipid, carbo, protein Abnormal substances
Exogenous (eg product of infectious agents) Endogenous (eg inborn error of metabolism, storage diseases. )

Pigments
Exogenous (eg coal dust) Endogenous (eg melanin, hemosiderin)

Process of intracellular accumulations

FATTY DEGENERATION
Fatty change due to hypoxia, toxic substances or metabolites, infection. Occurs occasionally in all organs but is most common in the liver (central role in fat metabolism) Injured cells are not able to metabolise lipids & hence triglycerides accumulate in cytoplasm Gross appearance: Fatty livers are enlarged, yellow, greasy Microscopically, cells become enlarged, sometimes nucleus displaced to the side giving crescent shape appearance. Cytoplasm contain varying amounts of lipid (clear area due to lipid being removed during processing) microvesicular / macrovesicular. Fatty cyst, lipogranuloma.

QuickTime and a decompressor are neede d to see this pictu

Photomicrograph of normal liver : Liver cell plates & acinar/lobular arrangement :central vein & portal tracts with sinusoids

Photomicrograph of normal liver (higher magnification)

Photomicrograph of liver with fatty change due to chronic venous congestion, changes predominantly around central vein

Fatty change in liver (high power)

Cholesterol and cholesterol esters

Accumulation of cholesterol is seen in several pathologic processes:
Atherosclerosis Cholesterol accumulates in smooth muscle cells and macrophages in walls of arteries Xanthomas Cholesterol accumulates in macrophages and mesenchymal cells in soft tisue due to hyperlipidemia Foamy (lipid-laden) macrophages Found in inflammation and necrosis due to phagocytosis of membrane lipids of injured cells by macrophages

Proteins
Excess of proteins may cause morphologically visible accumulations within cells appearing as rounded eosinophilic droplets or masses in the cytoplasm Occurs due to excessive synthesis, absorption or defects in cellular transport Example:
Prolonged proteinuria causing reabsorption of protein and formation of protein droplets in proximal convoluted tubules

Morphology of excess protein accumulations

Glycogen
Excessive intra-cellular glycogen deposits are seen in abnormalities of glycogen and glucose metabolism:
Eg: Glycogen storage diseases

Pigments
Exogenous pigments:
Anthracosis (accumulation of carbon in macrophages of lungs and lymph nodes) Tattooing (injected pigment)

Endogenous pigments:
Lipofuscin
The wear and tear pigment Microscopically seen as yellow-brown, fine, intra-cytoplasmic granules Usually associated with old age / atrophy (brown atrophy)

Melanin
Derived from melanocytes Microscopically seen as a brown-black pigment

Hemosiderin
Derived from hemoglobin Often seen in hemorrhage, rupture of vessels, vascular congestion

Lipofuscin

Lipofuscin deposits in cardiac fibres (brown atrophy of the heart) in old age

Melanin

Melanin pigment in a nevus (mole)

Hemosiderin deposits

Morphology of Lethal Injury

Necrosis Apoptosis

NECROSIS
Spectrum of morphologic changes that follow cell death in living tissue Largely resulting from progressive degradative action of enzymes on the lethally injured cells. Autolysis: enzymes derived from own lysosomes Heterolysis: enzymes from immigrant leukocytes. Also results from denaturation of proteins

Morphology of cell necrosis

Cytoplasm:
increased eosinophilia due to
1. 2. Loss of normal basophilia imparted by RNA increased eosin binding to denatured proteins

Vacuolated and moth eaten when cytoplasmic organelles have been digested

Nucleus:

karyolysis Pyknosis Karyorrhexis Ultimately: nucleus disappear, dead cells replaced by myelin figures or calcified, phagocytosed by other cells.

PATTERNS OF NECROSIS (mass of cells)

COAGULATIVE NECROSIS
protein denaturation

LIQUEFACTIVE NECROSIS
enzyme digestion

CASEOUS NECROSIS FIBRINOID NECROSIS FAT NECROSIS

Coagulative necrosis
refers to preservation of basic outline of the coagulated cell for a span of at least some days. is due to denaturation of not only structural proteins, but also enzymes, thus blocking proteolysis of the cell. is characteristic of ischaemic death of cells in all tissues except brain.

Myocardial infarction: coagulative necrosis

Dead (necrotic) Myocardium. Cardiac cells appear more eosinophilic, loss of nuclei, cellular outlines maintained

Collection of neutrophils (normally not present) as part of acute inflammatory process, reaction to dead tissue

Liquefactive necrosis
1. Dead tissue becomes liquefied due to digestion of tissue by enzymes released by dead cells eg abscess (collection of neutrophils, release of enzymes destruction of cells & liquefied)
Characteristic of bacterial infections bcos they stimulate accumulation of inflammatory cells. . 2. Dead tissue becomes liquefied ?due to high content of water eg Infarction of cerebral tissue

Liquefactive necrosis in brain after an infarction

f n n f

Microscopic appearance of necrotic/infarcted brain with dead neuronal cells becoming disintegrated (n), and intercellular spaces accumulating fluid (f). Finally becomes pale acellular area

Liquefactive necrosis
Subcutaneous abscess with collections of pus

Kidney: coagulative necrosis

Kidney: Liquefactive necrosis

Caseous necrosis
Combine features of coagulative and liquefactive necrosis. Cheesy white gross appearance. Microscopic: Structureless, eosinophilic granular debris. Typically seen in tuberculosis.

Caseous necrosis

c
m

Microscopic appearance of lung with caseous/caseation necrosis (c) appearing as eosinophilic & amorphous surrounded by viable epithelioid cells, multinucleated (Langhans) giant cells (m) & scanty lymphocytes.

Gross appearance of lung: Caseation necrosis of lymph node : Friable fragmented whitish area of necrosis in hilar lymph node

Caseation necrosis
l
C

m e

Microscopic appearance of lung (a high magnification) with caseous necrosis appearing as eosinophilic & acellular area (c) surrounded by viable epithelioid cells (e), multinucleated (Langhans) giant cells (m) & scanty lymphocytes (l)

Fat necrosis
1. ENZYMATIC FAT NECROSIS
Occurs in the abdomen (peritoneal cavity). Fat tissue lysed by enzymes (pancreatic lipase), released fatty acids combine with calcium to produce grossly visible chalky white areas. Histo: shadowy outline of necrotic fat cells, with basophilic calcium deposits, surrounded by inflammatory reaction. eg fat saponification following Acute Pancreatitis

2. TRAUMATIC FAT NECROSIS

Injury to fatty tissue causes necrosis. Necrosis of fat cells associated with calcification, may mimic cancer. eg Traumatic fat necrosis in breast

a a n

Microscopic appearances of pancreas (low power) showing residual pancreatic acini (a) and a area of necrosis (n) in picture 1. In picture 2 necrosis is extensive and haemorrhagic (n) and viable fat is present (f) f

n f

PICTURE 1 n

Enzymatic fat necrosis in pancreas and adjacent fatty tissue in acute pancreatitis

PICTURE 2

Traumatic fat necrosis in the breast

s f

Microscopic appearance of breast tissue (high power) with traumatic fat necrosis. The area of necrosis is not obvious now but it demonstrates collections of foamy macrophages (f) which have engulfed necrotic fat to remove it from the area in the breast

Fibrinoid necrosis
Deposition of fibrin-like material which has the staining properties of fibrin. Encountered in various examples of immunologic tissue injury, arterioles in malignant hypertension, peptic ulcer etc. Histo: Brightly eosinophilic hyaline-like deposit.

Fibrinoid necrosis

Microscopic appearance of kidney with fibrinoid necrosis of arteriolar wall in Malignant (accelerated) hypertension, appearing as eosinophilic acellular area

Pathologic calcification
Abnormal deposition of calcium salts in soft tissues 2 types:
Dystrophic calcification Serum calcium is normal Metastatic calcification Serum calcium is raised (hypercalcemia)

Dystrophic calcification
Localized calcium deposition in non-viable or dying tissues in the presence of normal serum calcium. Occurs in arteries in atherosclerosis, damaged heart valves and areas of necrosis. Calcium can be intracellular, extracellular or both. Calcification may be visualised on radiographs.

Dystrophic calcification

Metastatic calcification
Generalized calcium deposition throughout the body due to increase in serum calcium (hypercalcemia) 4 principal causes:
Increased secretion of parathyroid hormone (hyperparathyroidism)
Eg: Parathyroid tumours or ectopic secretion by other malignant tumours (eg small cell carcinoma of the lung)

Destruction of bone tissue

Eg: Bone tumours (primary and secondary)

Vitamin D related causes

Eg: Vitamin D intoxication

Renal failure
Causing secondary hyperparathyroidism

Apoptosis
Cell death through activation of an internal suicide program. Purpose: Eliminate unwanted cells selectively with minimal disturbance to surrounding cells and host.
Protein cleavage by caspases. Protein cross-linking by transglutaminase Internucleosomal cleavage of DNA Plasma membrane alteration eg flipping of phosphatidylserine to outer layer recognition of cells by phagocytes.

Necrosis vs Apoptosis

Feature Cell size Nucleus

Necrosis Enlarged (swelling)

Apoptosis Reduced (shrinkage)

Pyknosis karyorrhexis Fragmentation into karyolysis nucleosome size fragments Intact; altered structure, especially orientation of lipids

Disrupted Plasma membrane Cellular Enzymatic digestion; contents may leak out of cell Adjacent Frequent
inflammation Physiologic Invariably pathologic or pathologic (culmination of role

Intact; may be released in apoptotic bodies No

Often physiologic, means of eliminating unwanted cells; may be pathologic after some forms of cell injury, especially DNA damage

irreversible cell injury)

STRESS Increased functional demand Persistent ADAPTATION Mild

Reversible cell injury Severe

Hypertrophy Hyperplasia

Atrophy Metaplasia Dysplasia

Irreversible cell injury

Relief of stress NECROSIS

NORMAL CELL

Learning Objectives
List the causes of cell injury and explain their mechanisms. Define sublethal and lethal injuries. Describe their morphological changes. Describe the patterns of necrosis with clinical examples. Describe intracellular accumulations and pathologic calcification.