CELLULAR INJURY,

ADAPTATION AND CELLULAR

DEATH
 Cellular adaptation
 Cells adjust to stress and other dangerous
stimuli by adjusting their steady state.
This adjustment may be in the form of:
 1. Increase in the number of cells (Hyperplasia).
 2. Alterations in the size of cells (Hypertrophy
and atrophy).
 3. Alteration in cellular differentiation
(metaplasia).
 4. Intracellular accumulations.
Cellular response to stress and injury
 Hyperplasia
 Increase in the size of a tissue or organ as a
result of increase in the number of its cells.
 Occurs in tissue capable of mitotic division and
DNA synthesis.
 Hypertrophy involves increased production of
GF, GFRs and activation of intracellular
signalling pathway.
 These cause production of transcription factors
that turn on some cellular genes including cell
cycle regulators.
 Hyperplasia – 2 types: physiologic and
pathologic
 Physiologic hyperplasia may be:
 Hormonal (enlargement of the breast at
puberty and of uterus in pregnancy).
 Compensatory (hyperplasia of remaining
kidney after unilateral nephrectomy,
hepatocyte regeneration after resection).
 Pathologic hyperplasia
 Commonly results from excessive and
persistent hormonal stimulation, eg
endometrial hyperplasia and BPH.
 EH results from hormonal imbalance of the
menstrual cycle leading to hyperestrinism.
 The mitogenic activity of oestrogen on the
endometrium is mediated by EGF, TGF-a.
 This leads to abnormal uterine bleeding.
 Pathologic hyperplasia
 In BPH there is excessive stimulation of the
prostate by androgens leading to enlargement
of the prostate gland.
 Hyperplasia – a benign process but when
persistent in some cases can lead to
malignancy.
Endometrial hyperplasia
 Hypertrophy
 Increase in the size of an organ as a result of
increase in the size of its cells. No new cells are
produced.
 There is synthesis of more structural
components of the cells.
 Hypertrophy and hyperplasia may occur in
cells capable of mitotic division.
 Hypertrophy
 Increase in the size of an organ as a result of
increase in the size of its cells. No new cells are
produced.
 There is synthesis of more structural
components of the cells.
 Hypertrophy and hyperplasia may occur in
cells capable of mitotic division.
 Hypertrophy
 Hypertrophy involves signal transduction
pathways leading to the induction of genes
which stimulate synthesis of cellular proteins.
 Eventually the limit is reached where cellular
hypertrophy is no longer possible.
 Hypertrophy can be physiologic or pathologic
and may result from increased functional
demand or hormonal stimulation.
 Hypertrophy
 Enlargement of the uterus during pregnancy
and increase in the size of the breasts during
lactation are examples of hypertrophy (and
hyperplasia) induced by hormones.
 Cardiac hypertrophy in hypertension is an
example of pathological hypertrophy.
Cardiac hypertrophy
 Atrophy
 Decrease in the size of the cell due to loss of cell
substance.
 Atrophy also may be physiologic or pathologic.
 Regression of embryonic structures –
notochord, thyroglossal duct in the foetus are
examples of physiologic atrophy.
 Causes of atrophy
 1. Decreased workload eg atrophy of skeletal
muscle after immobilisation in POP.
 2. Loss of innervation eg flaccid paralysis and
muscle wasting in poliomyelitis (LMN paralysis).
 3. Diminished blood supply eg cerebral atrophy
in the elderly as a result of artherosclerotic
narrowing of cerebral vessels.
 4. Inadequate nutrition eg chronic malnutrition
(marasmus), the cachexia of chronic
inflammation and cancer.
 Causes of atrophy
 5. Loss of endocrine stimulation eg atrophy of
the breast and endometrium after menopause.
 6. Senile atrophy eg brain atrophy in the
elderly.
 7. Pressure atrophy. Compression of an organ
by a mass can lead to atrophy of that organ,
probably 2o to ischaemia.
 Atrophy
 Increased protein degradation plays a role in
atrophy. Cellular proteins may be degraded by:
 Lysosomal enzymes –acid hydrolases.
 Ubiquitin-proteasome pathway
 TNF-mediated proteolysis
Cerebral atrophy
Testicular atrophy
 Metaplasia
 A reversible change in which a fully
differentiated cell is replaced by another fully
differentiated cell.
 Columnar to squamous metaplasia is
commonly seen. Commonly a result of chronic
irritation.
 Columnar to squamous metaplasia of
respiratory tract epithelium in smokers.
 Metaplasia
 Columnar to squamous metaplasia of GB
epithelium in cholelithiasis.
 Squamous to columnar metaplasia can occur at
the lower end of oesophagus (Barret’s
oesophagus).
 Persistent metaplasia may lead to carcinoma.
Barret’s oesophagus
 cell injury results when cells are stressed so
severely that they are no longer able to adapt
or when cells are exposed to inherently
damaging agents.
 Injury may progress through a reversible stage
and culminate in cell death
 Reversible cell injury
 Initially, injury is manifested as functional and
morphologic changes that are reversible if the
damaging stimulus is removed.
 The hallmarks of reversible injury are reduced
oxidative phosphorylation, adenosine
triphosphate (ATP) depletion, and cellular
swelling caused by changes in ion
concentrations and water influx.
 Irreversible injury and cell death.
 With continuing damage, the injury becomes
irreversible, at which time the cell cannot
recover.
 There is no definite biochemical event that
signify point of no return
 Severe mitochondrial damage and loss of
membrane permeability signify irreversible
damage
 Irreversibly injured cells invariably undergo
morphologic changes that are recognized as cell
death.
 There are two types of cell death, necrosis and
apoptosis, which differ in their morphology,
mechanisms, and roles in disease and
physiology
 Reversible response to injury
 Cellular adaptive changes (hypertrophy, hyperplasia,
atrophy, and metaplasia).

Hydropic Degeneration (Cell Swelling): The result of

excess fluid in the cell cytoplasm.

Fatty Change (Steatosis): Excess fat in the form of

small or large droplets (micro- or macrovesicular
steatosis).
 Causes of Cell injury
 Oxygen deprivation, Hypoxia , Ischaemia
Cardiorespiratory failure, anaemia, CO poisoning
 Physical Agents: (mechanical trauma, burns,
frostbite, sudden changes in pressure
(barotrauma), radiation, electric shock).
 Chemical Agents: glucose, salt, water, poisons
(toxins), drugs, pollutants, insecticides,
herbicides, carbon monoxide, asbestos, alcohol,
narcotics, tobacco.
 Infectious Agents: prions, viruses, rickettsiae,
bacteria, fungi, parasites.
 Immunologic Reactions: anaphylaxis,
autoimmune disease.
 Genetic Derangements: Congenital
malformations, normal proteins
(hemoglobinopathies), enzymes (storage
diseases).
 Nutritional Imbalances: protein-calorie
deficiencies, vitamin deficiencies; excess food
intake (obesity, atherosclerosis).
 Lysosomal storage diseases
 A category of disease first discovered in 1963
 the diseases have been with us longer
 The result of an inborn error of metabolism,
an enzyme deficiency or lack of function,
such that catabolism of the substrate is
incomplete, so that it accumulates in the
lysosomes (in the cytoplasm), causing the
cells to become morphologically and
functionally deranged.
 Gaucher's disease - deficiency of the
enzyme glucocerebrosidase results in the
accumulation of glucocerebroside in the
phagocytic cells of the body and also in
the central nervous system.
 Others include Tay-Sach's Disease,
Niemann-Pick Disease,
Mucopolysaccharidoses, Glycogen
Storage Diseases (Pompe disease, von
Gierke's disease, and McArdle syndrome),
and Ochronosis
 Mechanism of cellular injury
 The cellular response to injurious stimuli depends
on the type of 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 functional and biochemical
abnormalities in one or more of several essential
cellular components
Most important target of cellular injury
 (1) aerobic respiration involving mitochondrial
oxidative phosphorylation and production of
ATP
 (2) the integrity of cell membranes, on which
the ionic and osmotic homeostasis of the cell
and its organelles depends
 (3) protein synthesis
 (4) the cytoskeleton
 (5) the integrity of the genetic apparatus of the
cell.
 ATP DEPLETION
 High-energy phosphate in the form of ATP is
required for many synthetic and degradative
processes within the cell.
 These include membrane transport, protein
synthesis, lipogenesis,and the deacylation–
reacylation reactions necessary for phospholipid
turnover
 ATP is produced in two ways.
 The major pathway in mammalian cells is oxidative
phosphorylation of adenosine diphosphate
 The second is the glycolytic pathway, which can
generate ATP in the absence of oxygen using
glucose derived either from body fluids or from
the hydrolysis of glycogen.
CONSEQUENCE OF ATP DEPLETION
 The activity of the plasma membrane energy-
dependent sodium pump (ouabain-sensitive
Na+,K+-ATPase) is reduced.
----K moves out and Na moves in accompanied by
water leading to cellular swelling
 Cellular energy metabolism is altered.

-----Anaerobic glycolysis is favoured, glycogenolysis

increases, there is lactic acid and inorganic
phosphate accumulation leading to reduce pH
 Failure of the Ca2+ pump leads to influx of
Ca2+
-----With damaging effects on numerous cellular
components
 structural disruption of the protein synthetic
apparatus due to prolonged or worsening
depletion of ATP
-------manifested as detachment of ribosomes
from the rough endoplasmic reticulum and
dissociation of polysomes into Monosomes
 proteins may become misfolded in cells
deprived of oxygen or glucose
-------misfolded proteins trigger a cellular
reaction called the unfolded protein response
that may lead to cell injury and even death.
 Mitochondrial damage
 Mitochondria can be damaged by increases of
cytosolic Ca2+, oxidative stress, breakdown of
phospholipids through phospholipase A2 and
sphingomyelin pathways,and by lipid breakdown
products such as free fatty acids and ceramide.
------There is formation of a high-conductance
channel,the so-called mitochondrial permeability
transition, in the inner mitochondrial membrane
This is initially reversible but may progress to
irreversibility if injury persist
INFLUX OF INTRACELLULAR CALCIUM
AND LOSS OF CALCIUM HOMEOSTASIS
 Cytosolic free calcium is maintained at extremely
low concentrations (<0.1 μmol) compared with
extracellular levels of 1.3 mmol, and most
intracellular calcium is sequestered in
mitochondria and endoplasmic reticulum.
 gradients are modulated by membrane-associated,
energy-dependent Ca2+,Mg2+-ATPases.
 Ca accumulation trigger many enzymatic reaction
i.e ATPase, Phospholipase, endonucleases and
proteases
 Apoptosis is also activated
ACCUMULATION OF OXYGEN-DERIVED
FREE RADICALS (OXIDATIVE STRESS)
 Reduced reactive oxygen products are
generated unavoidably in the process of energy
generation when oxygen is reduced to water.
 An imbalance between free radical-generating
and radicalscavenging systems results in cell
injury seen in many pathologic conditions.
Processes that initiate free radicals in cells
include
 Absorption of radiant energy (e.g., ultraviolet light,
xrays).
 Enzymatic metabolism of exogenous chemicals or drugs
 The reduction-oxidation reactions that occur during
normal metabolic processes
 Transition metals such as iron and copper donate or
accept free electrons during intracellular reactions
and catalyze free radical formation
 Nitric oxide (NO), an important chemical mediator
generated by endothelial cells, macrophages, neurons
and other cell types can act as a free radical
Cellular mechanism of dealing with free
radicals
 Antioxidants either block the initiation of free
radical formation or inactivate (e.g., scavenge)
free radicals and terminate radical damage eg
vit A,C, E and Glutathione
 Binding of Fe and Cu by transferrin, ferritin,
lactoferrin, and ceruloplasmin
 Enzymes which acts as free radical–scavenging
systems and break down hydrogen peroxide
and superoxide anion e.g. Catalase, superoxide
dismutase, Glutathione Peroxidase
DEFECTS IN MEMBRANE PERMEABILITY
 Early loss of selective membrane permeability
leading ultimately to overt membrane damage is a
consistent feature of most forms of cell injury
 Ischaemia, ATP depletion, Bacteria toxin, lytic
complement pathways, viral proteins and
numerous chemical and physical agent could cause
this defect
 Biochemical Pathways that contributes to this
damage include
 Mitochondrial dysfunction.
 Loss of membrane phospholipids
 Cytoskeletal abnormalities
 Reactive oxygen species
 FATE OF CELLS IN
IRREVERSIBLE CELL INJURY
 Irreversibly injured cells invariably undergo
morphologic changes that are recognized as cell
death.
 There are two types of cell death, necrosis and
apoptosis, which differ in their morphology,
mechanisms, and roles in disease and
physiology
 Necrosis
 Arises as a result of severe damage to the cell
 There is loss of membrane permeability
 Lysosomal enzyme enter the cytoplasm and
digest the cells
 There is leakage of cellular content to the
surrounding which result in inflammation
 Necrosis is always a pathologic process
 Apoptosis
 Noxious stimuli affecting the DNA usually
induce apoptosis
 This is characterized by nuclear dissolution
without complete loss of membrane integrity
 apoptosis serves many normal functions and is not
necessarily associated with cell injury
 Apoptosis is also called programmed cell death
 There is overlap and common pathway for
necrosis and apoptosis
 some types of stimuli may induce either
apoptosis or necrosis, depending on the
intensity and duration of the stimulus, the
rapidity of the death process, and the
biochemical derangements induced in the
injured cell.
 NECROSIS
4 MAJOR TYPES
 Coagulative
 Liquefactive
 Caseous
 Fat
 Coagulative
 Caused by ischemia.
 Ischemia results in decreased ATP, increased
cytosolic Ca++, and free radical formation, which
each eventually cause membrane damage.

 Decreased ATP results in increased anaerobic

glycolysis, accumulation of lactic acid, and therefore
decreased intracellular pH.
 Decreased ATP causes decreased action of Na+ / K+
pumps in the cell membranes, leading to increased
Na+ and water within the cell (cell swelling).
 Other changes: Ribosomal detachment from
endoplasmic reticulum; blebs on cell membranes,
swelling of endoplasmic reticulum and
mitochondria.
 Up to here, the changes are reversible if
oxygenation is restored by reversing the ischemia.
 If the ischemia continues, necrosis results, causing
the cytoplasm to become eosinophilic, the nuclei
to lyse or fragment or become pyknotic
(hyperchromatic and shrunken). In the early
stages of necrosis, the cells remain for several
days as ghosts of their former selves, allowing one
to still identify them and the tissue (in contrast to
the other types of necrosis).
 The cellular reaction is polys, followed by a
granulation tissue response.
Ischaemic necrosis Myocardiac infarction
NORMAL MYOCARDIUM
MYOCARDIAL INFARCT.
 Liquefactive
 Usually caused by focal bacterial infections,
because they can attract polymorphonuclear
leukocytes. The enzymes in the polys are
released to fight the bacteria, but also
dissolve the tissues nearby, causing an
accumulation of pus, effectively liquefying
the tissue (hence, the term liquefactive).
MENINGITIS
 Caseous
 A distinct form of coagulative necrosis seen in
mycobacterial infections (e.g., tuberculosis),
or in tumor necrosis, in which the coagulated
tissue no longer resembles the cells, but is in
chunks of unrecognizable debris.
 Usually there is a giant cell and
granulomatous reaction, sometimes with
polys, making the appearance distinctive.
TB LUNG.
 Fat Necrosis
 A term for necrosis in fat, caused either by
release of pancreatic enzymes from pancreas
or gut (enzymic fat necrosis) or by trauma to
fat, either by a physical blow or by surgery
(traumatic fat necrosis).
 The effect of the enzymes (lipases) is to
release free fatty acids, which then can
combine with calcium to produce
detergents (soapy deposits in the tissues).
 Histologically, one sees shadowy outlines
of fat cells (like coagulative necrosis), but
with Ca++ deposits, foam cells, and a
surrounding inflammatory reaction.
 AUTOLYSIS
 Lysis of tissues by their own enzymes,
following the death of the organism.
 Therefore,the key difference is that there is
no vital reaction (i.e., no inflammation).
 Autolysis is essentially rotting of the tissue.
 Early autolysis is indistinguishable from
early coagulative necrosis due to ischemia,
unless the latter is focal.
 APOPTOSIS
 Planned or programmed cell death. A recently
popularized concept, referring to orderly and
often single cell death
 used to explain such diverse processes as
destruction of cells during embryogenesis,
developmental involution of organs (thymus,
e.g.), cell breakdown during menstrual cycles,
involution of the ovary, death of crypt
epithelium in the gut, and pathologic atrophy
of hormone dependent tissues.

 Usually recognized by single cell necrosis

without an inflammatory response.
 Apoptosis is a pathway of cell death that is
induced by a tightly regulated intracellular
program in which cells destined to die
activate enzymes that degrade the cells’
own nuclear DNA and nuclear and
cytoplasmic proteins.
 The cell’s plasma membrane remains
intact, but its structure is altered in such a
way that the apoptotic cell becomes an
avid target for phagocytosis.
 The dead cell is rapidly cleared, before its
contents have leaked out, and therefore
cell death by this pathway does not elicit
an inflammatory reaction in the host
 morphology
 • Cell shrinkage. The cell is smaller in size; the
cytoplasm is dense; and the organelles, although
relatively normal, are more tightly packed.
 • Chromatin condensation.

----This is the most characteristic feature of

apoptosis. The chromatin aggregates
peripherally, under the nuclear membrane, into
dense masses of various shapes and sizes. The
nucleus itself may break up, producing two or
more fragments.
 • Formation of cytoplasmic blebs and
apoptotic bodies.
 The apoptotic cell first shows extensive
surface blebbing, then undergoes
fragmentation 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 degraded
within lysosomes, and the adjacent healthy
cells migrate or proliferate to replace the
space occupied by the now deleted
apoptotic cell.
 Plasma membranes are thought to
remain intact during apoptosis, until the
last stages, when they become permeable
to normally retained solutes
 microscopically
 apoptosis involves single cells or small clusters of cells.
 The apoptotic cell appears as a round or oval mass of
intensely eosinophilic cytoplasm with dense nuclear
chromatin fragments
 Because the cell shrinkage and formation of apoptotic
bodies are rapid and the fragments are quickly
phagocytosed, considerable apoptosis may occur in
tissues before it becomes apparent in histologic sections.
 In addition, apoptosis—in contrast to necrosis—does
not elicit inflammation, making it more difficult to
detect histologically.
 CRYSTALS
 CALCIUM
 CHOLESTEROL
 URATE
 CALCIUM PYROPHOSHATE
 CALCIUM
 Deposits of hematoxylin (blue) stained
chunky or granular material in the cells or
tissues. Comes in two major types.
 Dystrophic Calcification:
• Calcium deposits in areas of tissue damage, scarring or
necrosis.
• Patient's calcium and phosphate levels are normal.
• Example: calcification in coronary artery in
atherosclerosis, or calcification of the aortic valve in
calcific aortic stenosis.
68
 Metastatic calcification
 Calcium deposits in tissues due to increased
Calcium and or Phosphate concentrations in
the tissues.
 The tissues were formerly normal.
 Examples are calcification of the lung and
other tissues in hyperparathyroidism, or as a
result of phosphate infusions given
therapeutically.
 Cholesterol:
 Deposits of extracellular lipid, in the form of
crystals.
 The lipid is dissolved out with solvents during
tissue processing, leaving only cholesterol clefts
behind.
 Usually the cholesterol is deposited in damaged
scarred tissue in the coronary arteries
(atherosclerosis)
 can be deposited in a more soluble form in foam
cells (such as in xanthomas, or in xanthomatous
deposits in hypercholesterolemia, cholesterolosis of
the gall bladder, etc.).
 Often associated with calcium deposits (dystrophic
calcification) in the case of atherosclerosis.
 Urates
 Urate crystals are deposited in gout, as the
result of hyperuricemia.
 They are usually deposited in cartilage of the
ear, and in soft tissues around joints.
 The deposits can excite a giant cell response
and scarring of the tissues.
 The resulting lesion is called a tophus, or
gouty tophus, and has a chalky white
appearance grossly.
 Urates dissolve in water and hence in
formalin. To be preserved, they must be
submitted in 100% alcohol
 Calcium Pyrophospate
 This crystal is deposited in the soft tissues
around joints as well, and can mimic gout in
its presentation, gross and microscopic
appearance.
 The condition is therefore known as
pseudogout.
 The crystals can be distinguished
microscopically using polarized light and a
red filter.