2

Samir Al Bashir

Qussai Shrouf

Karam Awni AlKhasawneh

References:

1- Lecture.
2- Fundamentals of pathology (Pathoma)
3- Robbins basic pathology.
4- Slides.

Quick revision
Cell response happens when the homeostasis of the cell is changed, in order
to:
Remember:
1- Protect the cell. If the stimulus is chronic and mild -->adaptation.
2- Do its function as much as possible.
If the stimulus is acute and severe-->cell injury.

➢ Cellular response include:

1. Adaptation: (all of these mechanisms are reversible)

• Hypertrophy: increase in the cell size. Happens in dividing and non-

dividing cells (especially non-dividing).
• Hyperplasia: increase in the cells number. Happens in dividing cells
only.
• Atrophy: decrease in the cell size. The same mechanism which takes the
cell to atrophy might take it to Necrosis and Apoptosis.
• Metaplasia: The transformation from mature cell type to another
mature cell type. (Provides protection).

o NOTE:
In order to protect the tissue from being transformed into dysplasia and
malignancy; we need to stop the causative agent of the pathological
metaplasia and hyperplasia.
2. Cell Injury:
a. Reversible: All changes that happen here won’t affect the cell
membrane and the nucleus (they’re protected); because when the
stimulus is removed the cell will return back to its normal state.

❖ Changes that happen during reversible injury (with respect of the cell
membrane and nuclear material):

1- Increase in the cell size (swelling): because there's a defect in ion pumps
that means that Na will remain inside (fluid will follow the Na) and sometimes
fats remain inside too. That’s why the cell swells.

2- Loss of villi and loss of adhesion and attachment between cells (with respect
of cell membrane).

3- Mitochondria and ER will be enlarged and de-activated.

4- The nuclear material chromatin will be clumped in order to protect itself.

o NOTE: In the cell injury, if the causing agent (stimulus) disappears the cell
might go back to normal but if the stimulus increases; the cell won’t
handle more stress so that leads to irreversible cell injury.

b. Irreversible (cell death): happens when the stimulus is severe enough

to cause proteins denaturation inside the cell (chromatin will change
and lysosomal enzymes will go out and cause destruction in the cell and
sometimes denaturation is severe enough to denature these enzymes).

The contents of the cell (organelles, proteins, enzymes) will be changed,

and the tissue will be denatured.

3. Apoptosis: a process of programmed cell death that occurs in multi-

cellular organisms.

4. Intracellular accumulation; calcification.

5. Cellular aging.
 ➢ Cell response depends on :
1- The type of the cell
2- Severity of the stimulus.

NOTE:
When leakage happens in the cell it might have two types:

1- Leakage inside the cell itself ---->the cell control it by itself

2- Leakage from the cell to outside which let the neutrophils interfere to clean
cell death.

 Enzymes digest everything inside the cell even the cell membrane=
leakage will happen= neutrophils will notice the problem= they will start
digesting = macrophages follow to clean the mess after the necrosis.

Necrosis
Necrosis: irreversible cell injury which involves group of adjacent cells
(cellular level). It’s always pathological.

• Necrosis affects group of adjacent cells affects the tissue.

• Necrosis elicits inflammation
• The enzymes responsible for digestion of the cell are derived from
lysosomes and may come from dying cell itself or leukocytes
• In necrosis the cellular membrane is damaged which might lead to
leakage.
• Necrosis might happen in association with ischemia, infections and
inflammations.
• Digestion by neutrophils will lead to inflammation.

Note
lysosomal enzymes help in destroying organs inside the cell and cell membrane; so
leakage will happen and neutrophils will come to fix and clean up the mess

When these enzymes are denaturized they won't be able to digest the cell
membrane so delay will happen because there is less leakage.
➢ Morphologic alterations in cell injury irreversible injury(Necrosis)
Result from:

1- Denaturation of intracellular proteins

2- Enzymatic digestion of cells.

1. Loss of membrane integrity.

2. Digestion of enzymes: from lysosomes of dying cells and from
leukocytes (inflammatory response).

-Structural changes need time to develop.

3. Increased eosinophilia in H&E stain.

4. Vacuolation due to digestion of cytoplasmic organelles.

5. Plasma and organelle membrane discontinuities.

6. Myelin figures: aggregates of damaged cell membranes (phospholipids).

They either phagocytosed by other cells or further degraded into fatty acids
and calcify.

7. Marked dilatation of mitochondria and appearance of large densities.

8. Nuclear changes: breakdown of DNA

a. Karyolysis: loss of DNA, fade of basophilia.

b. Pyknosis: nuclear shrinkage and increased basophilia.

c. Karyorhexis: fragmentation of the pyknotic nucleus, disappearance of the

nucleus.

Types of necrosis depend on:

1-type of the tissue involved.

2- Causative agent.
 ➢ Types or patterns of necrosis :
1- Coagulative necrosis:
We’ve said that sometimes the denaturation will be severe enough to cause
denaturation in the enzymes that means that the contents will be digested
except for the cell membrane (the cell membrane will last for several days) so
it’ll have an abnormal cell border; neutrophils will take a lot of time to come
because there’s no leakage from the cell membrane this will delay the cleaning
of the cell.

So this preservation of the architecture of dead tissue for at least some days is
called Coagulative necrosis.

It includes: - Denaturation of structural proteins and enzymes.

- Eosinophilic anucleated (no nucleus) cells.

Cells are removed by inflammatory leukocytes.

Ischemia in any organ except the brain may lead to coagulative necrosis.

Coagulative necrosis can happen in any organ in the body except: 1- brain .2-in
cases of infectious

Coagulative necrosis. 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).
 In the previous picture:

1. B: normal connective tissue, there’s a nucleus and separated cell

membranes.

2. I: loss of nuclei (no blue area) this means that the cell is digested from
inside except for the cell membrane; preserved cellular outlines it’ll be
digested in 2-3 days by neutrophils and macrophages.

3. N+I are necrotic

In conclusion, necrosis is a cell death associated with a neutrophilic reaction

2-Liquefactive necrosis: digestion of dead cells resulting into a liquid

viscous mass.

- Happens in focal bacterial or fungal infections and in hypoxic death in

central nervous system especially the brain.

Creamy yellow due to accumulation of dead leukocytes (pus) will form .as
shown in the figure.
The figure shows an infarct in the brain,
showing dissolution of the tissue.

Total fluid area enzymes will digest

everything there

- Fluid status regeneration is very difficult here

3- Gangrenous necrosis: Not a definite type (mixed).

- Used clinically in describing lower limb coagulative necrosis secondary to
ischemia.

Lower limb ischemia in case of diabetes; diabetics are at risk of having bacterial
infections that will cause coagulative necrosis, so it’s a mix of coagulative and
infection that’s why it’s not a distinct type (at early stage it starts as a
coagulative necrosis then liquefactive necrosis).

- Once infected by bacteria it becomes wet gangrene (liquefaction).

4-Caseous necrosis: "cheese like”

Collection of fragmented or lysed cells with amorphous
granular eosinophilic debris surrounded by histiocytes
(macrophages), known as granuloma.

it causes infection and special type of necrosis inside

the organ in which there are granuloma formation

EX: inside the lung as shown in the figure.

This type will happen in the cases of tuberculosis and it

will have caseation and granuloma

‫ عند مرض السل حيث تتجمع الخاليا و تصبح مثل الجبن تسمى‬caseous necrosis ‫يحدث الــ‬
granuloma .

5-Fat necrosis :( destruction of fat)

Happens in areas that are close to the adipose tissue

Ex: pancreatic enzymes (lipases) release in acute pancreatitis. The pancreatic

enzyme will digest the adjacent fat tissue .The fatty acids (result from the
breakdown of fat) will combine with calcium leading to the formation of white
chalky areas (Saponification). As shown in the figure below.
6-Fibrinoid necrosis: Immune reactions involving blood vessels.
Complexes of antigens and antibodies are deposited in the walls of arteries.

Immune complexes deposits along

with fibrin result in a bright pink
material on H&E.

Example: vasculitis. As shown in the

figure.

**Necrosis causes a tissue change in

pathological irreversible cell injury

➢ Fate of necrotic tissue:

Our body will fill any empty places with one of these mechanisms:

• Phagocytosis : will clean the situation

• Replacement by scar to close the area.
• Regeneration if the cells are able to divide and produce more tissues.
• Calcification.
 Apoptosis
• Apoptosis: its irreversible cell injury (cell death) happens in cellular
level affect one cell individual and it might be pathological or
physiological

Another definition

• Apoptosis: a pathway of cell death induced by a “suicide” program in

which activation of degrading enzymes takes place.

Apoptotic cells break into fragments called “apoptotic bodies”, which contain
portions of the cytoplasm and nucleus. Apoptotic bodies will become targets
for phagocytosis before their contents leak out and so there would be no
inflammatory reaction.

Apoptosis is also called (programmed cell death) because signals might come
from outside the cell to activate the enzymes inside the cell that leads to cell
destruction (self-destruction ‫ )انتحار‬because:

1- There is no need for the cell anymore.

2- The cell is infected by a disease.

➢ Activation of the degrading enzymes lead to:

1. "Degrade the cells’ own nuclear DNA and cytoplasmic proteins."

Physiological example of apoptosis: in fetus, some cells will undergo atrophy

(reversible) when there is no need for these cells. Sometimes the body will
reactivate these cells in need. But when there’s no need for these cells they
will undergo apoptosis (reversible).

Pathologic example:

DNA damage, accumulation of misfolded proteins (Excessive accumulation of

these proteins in the ER called ER stress).

Certain infections (viral ones).

 ➢ The morphological changes in apoptosis:
1- Shrinkage of the cell: dense cytoplasm, tightly packed organelles.

2-Chromatin condensation: peripherally under the nuclear membrane.

3- Formation of cytoplasmic blebs and apoptotic bodies: blebbing then

fragmenting into membrane bound apoptotic bodies composed of cytoplasm
and tightly packed organelles with or without nuclear fragments.

4- Phagocytosis of apoptotic cells or bodies by macrophages.( during the

process of apoptosis some inner phospholipids that bind in the membrane
will go from inside to bind to the outside of the cell membrane to introduce
the cell directly to macrophages so there will be no neutrophils so there will
be no inflammation. )

5-On H&E apoptotic cell appears intensely eosinophilic or shrunken basophilic

fragment surrounded by halo.

In these figures show the cell shrinkage and the appearance of the halo.
➢ Biochemical features :

• Apoptosis results from the activation of enzymes called caspases.

• The activation of caspases depends on a finely tuned balance between
productions of pro- and anti-apoptotic proteins.
• There is a balance inside the cell between anti-and pro-apoptotic
protein. (life of the cell depend on this balance )

• Examples: note :

pro-apoptotic protein -->leads to apoptosis

1- When the cell receives growth hormones or
growth factors; the cell will produce anti- anti-apoptotic protein --> against apoptosis
apoptotic proteins.
2- When the anti-apoptotic proteins are higher than pro-apoptotic --
>apoptosis won't start but when the pro-apoptotic proteins are higher
than anti-apoptotic--> this will activate caspases then apoptosis will
start.

• Activation of Caspases:
- Two types: initiators (caspases 9&8) and executioners (caspase 3&6).

• Two distinct pathways converge on caspase activation:

1-The mitochondrial pathway (internal/intrinsic)

2- Death receptor pathway (external/extrinsic).

• Membrane alterations and recognition: changes make cells

recognizable by phagocytes.
Movement of some phospholipids (phosphatidylserine) from the
inner leaflet to the outer leaflet of the membrane to bind to the
receptors of the phagocytes.
 ➢ Mechanisms of apoptosis:

- All cells contain intrinsic mechanisms that signal death or survival

signals.
- Apoptosis results from an imbalance in these signals.
• Initiation: intrinsic and extrinsic.
• Execution.

The Mitochondrial (Intrinsic) pathway of apoptosis:

• Major mechanism (90% of apoptosis).
• Happens inside the cell.
• Release of mitochondrial molecules (cytochrome c) into the cytosol.
• when the mitochondrial membrane become permeable
"Cytochrome c" leak out to cytoplasm, which will trigger the Caspase
activation and apoptotic death.
• Release is controlled by “pro” and “anti” apoptotic proteins called (Bcl)
family.
• Bcl family; 20 members.
• Growth factors and other survival signals stimulate production of anti-
apoptotic proteins (Bcl-2, Bclx & Mcl-1) in cytoplasm and mitochondrial
membranes.
• Anti-apoptotic protein like (Bcl2"the major anti-apoptotic",
Mcl-1&Bclx) prevent releasing of cytochrome c
• When there is a lack of anti-apoptotic protein the" cytochrome c "will
be released from the mitochondrial membrane to the cytoplasm.
• Mitochondrial (intrinsic) pathway is triggered by: loss of survival
signals, DNA damage and accumulation of misfolded proteins (ER
stress); associated with leakage of pro-apoptotic proteins from
mitochondrial membrane into the cytoplasm “cytochrome c", where
they trigger caspase activation.
• Activation of Caspases: - Two types: initiators (caspase 9&8) and
executioners (caspase 3&6).
 • Cytochrome c binds to Apaf-1(apoptosis activating factor) forming
apoptosome which binds to caspase-9 (the critical initiator caspase).

• Other mitochondrial proteins (Smac/DIABLO) enter the cytoplasm

blocking the inhibitors of apoptosis (Bcl-2 and Bcl-xl) the function of
which is block the activation of caspases.

The Mitochondrial
(Intrinsic) pathway
of apoptosis

The Death Receptor (Extrinsic) pathway: bypasses mitochondria

• There are emergency receptors (TNF) located at the outer

surface of the cell. If the brain sends a message to these
receptors they’ll activate caspases directly bypassing the
mitochondrial pathway.
• Initiated by plasma membrane death receptors (TNF receptor
family).
• Death domain: cytoplasmic structure involved in protein-
protein interactions.
 • TNF-1 with related protein called Fas (CD95) expressed on the
surface of many cells.
• Caspases will be activated (so the cell will go apoptosis) initiators
(caspase 9&8) -->initiators phase ...then caspase 9&8 will activate
executioners (caspase 3&6).
• Activation of DNase, degradation of structural components of
nuclear matrix (fragmentation of nuclei).
• Its ligand FasL is expressed on activated T-cells.

intrinsic
and
extrinsic
pathway

NOTE:

In intrinsic pathway; the caspases are activated

inside the cell➢ Apoptosis
in mitochondria.

summary:
In extrinsic pathways the caspase activation
comes from outside signals bends on TNF
receptors found on the outer side of the
• Regulated mechanism
plasma membrane
of cell death that
BUT
serves to eliminate
Both of the pathways will lead to
unwanted apoptosis and
and
changed cell morphology that I mentioned
before.
 irreversibly damaged cells, with the least possible host reaction.
• Characterized by enzymatic degradation of proteins and DNA, initiated
by caspases; and by recognition and removal of dead cells by
phagocytes.
• Mitochondrial (intrinsic) pathway is triggered by loss of survival signals,
DNA damage and accumulation of misfolded
• proteins (ER stress); associated with leakage of
• Pro-apoptotic proteins from mitochondrial membrane into the
cytoplasm, where they trigger caspase activation.
• Inhibited by anti-apoptotic members of the Bcl family, which are
induced by survival signals including growth factors.
• Death receptor (extrinsic) pathway is responsible for elimination of self-
reactive lymphocytes and damage by cytotoxic T lymphocytes; is
initiated by engagement of
• Death receptors (members of the TNF receptor family) by ligands on
adjacent cells.

Links for recommended videos by the doctor:

 https://www.youtube.com/watch?v=o_A2u8K5KNo

 https://www.youtube.com/watch?v=5EZV-QsSuTk
 SUMMARY

cellular
respones

cellular Intracellular
Apoptosis . Injury Adaptation
againg accumulation

reversible hypertrophy

irreversible hyperplasia

atrophy
Remember:

If the stimulus is chronic and mild -->adaptation .

metaplasia
If the stimulus is acute and severe-->cell injury .

Reversible cell injury Irreversible cell injury

Nuclear material will Nuclear material will
clamped denature (Karyolysis
Pyknosis , Karyorhexis)
won't denature Rupture of lysosomes
No Protein denaturation Denaturation of proteins
Plasma membrane will not Plasma membrane leakage;
rupture rupture and denaturation
(because of the lysosomal
enzymes )
 Necrosis

Coagulative Gangrenous Fibrinoid Fat Caseous Liquefactive

describing lower
can happen in any limb coagulative tuberculosis happens in bacterial
ex:pancreatic
organ except brain
and enfection cases
necrosis secondary
to ischemia.;due to
vasculitis
ex: enzymes (lipases) forming granuloma infections and in
brain
inside the lung
diapetes

➢ Irreversible cell death could be either necrosis or apoptosis

necrosis
Always pathological
Happens in cellular level Involves
more than one cell (adjacent cells )
Damage in nuclear material
Swelling of the cell
Inflammation happens because of the
attraction of neutrophils
apoptosis
Could be pathological or physiological
Happens in cellular level Affect one
cell
Damage in the nuclear material by cell
enzymes
Shrinkage of the cell
No inflammation happens because
there is no attraction of neutrophils
(attraction will happen to
macrophages directly because of the
phospholipids )