Inflammation

Introduction
Definition: Inflammation is a local response (reaction) of living vascularized tissues
to endogenous and exogenous stimuli. The term is derived from the Latin
"inflammare" meaning to burn. Inflammation is fundamentally destined to localize
and eliminate the causative agent and to limit tissue injury. Thus, inflammation is a
physiologic (protective) response to injury. Inflammation is itself not to be
considered as a disease but as a salutary operation consequent‫ ينتج عنها‬either to some
violence or to some diseases”.
Causes: Causes of inflammation are apparently causes of diseases such as:
1. physical agents - mechanical injuries, alteration in temperatures and pressure,
radiation injuries.
2. chemical agents- including the increasing lists of drugs and toxins.
3. biologic agents (infectious)- bacteria, viruses, fungi, parasites
4. immunologic disorders- hypersensitivity reactions, autoimmunity,
immunodeficiency states etc
5. genetic/metabolic disorders- examples gout, diabetes mellitus etc…

Nomenclature:
The nomenclatures of inflammatory lesion are usually indicated by the suffix 'itis'.
Thus, inflammation of the appendix is called appendicitis and of meninges as
meningitis, etc.… However, like any rule, it has its own exceptions examples
pneumonia, typhoid fever, etc….
Classification:
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Inflammation is classified based on duration of the lesion and histologic
appearances into acute and chronic inflammation.

Acute inflammation

A. Acute inflammation is an immediate and early response to an injurious agent and

it is relatively of short duration, lasting for minutes, several hours or few days.
B. It is characterized by exudation of fluids and plasma proteins and the emigration
of predominantly neutrophilic leucocytes to the site of injury.
The five cardinal signs of acute inflammation are
1. Redness (rubor) which is due to dilation of small blood vessels within
damaged tissue as it occurs in cellulitis.
2. Heat (calor) which results from increased blood flow (hyperemia) due to
regional vascular dilation
3. Swelling (tumor) which is due to accumulation of fluid in the extravascular
space which, in turn, is due to increased vascular permeability.
4. Pain (dolor), which partly results from the stretching & destruction of tissues
due to inflammatory edema and in part from pus under pressure in, as abscess
cavity. Some chemicals of acute inflammation, including bradykinins,
prostaglandins and serotonin are also known to induce pain.
5. Loss of function: The inflamed area is inhibited by pain while severe swelling
may also physically immobilize the tissue.
Events of acute inflammation:
Acute inflammation is categorized into an early vascular and a late cellular responses.
1) The Vascular response has the following steps:
a) Immediate (momentary) vasoconstriction in seconds due to neurogenic or chemical
stimuli.

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b) Vasodilatation of arterioles and venules resulting in increased blood flow.
c) After the phase of increased blood flow there is a slowing of blood flow & stasis
due to increased vascular permeability that is most remarkably seen in the post-
capillary venules. The increased vascular permeability oozes protein-rich fluid into
extravascular tissues. Due to this, the already dilated blood vessels are now packed
with red blood cells resulting in stasis. The protein-rich fluid which is now found in
the extravascular space is called exudate. The presence of the exudates clinically
appears as swelling.
Chemical mediators mediate the vascular events of acute inflammation.

2) Cellular response
The cellular response has the following stages:
A. Migration, rolling, pavementing‫ تراصف‬, & adhesion of leukocytes
B. Transmigration of leukocytes
C. Chemotaxis
D. Phagocytosis
Normally blood cells particularly erythrocytes in venules are confined to the central
(axial) zone and plasma assumes the peripheral zone. As a result of increased
vascular permeability,
more and more neutrophils accumulate along the endothelial surfaces (peripheral
zone).
A) Migration, rolling, pavementing, and adhesion of leukocytes
 Margination is a peripheral positioning of white cells along the endothelial
cells.
 Subsequently, rows of leukocytes tumble slowly along the endothelium in a
process known as rolling.
 In time, the endothelium can be virtually lined by white cells. This appearance
is called pavementing.
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  Thereafter, the binding of leukocytes with endothelial cells is facilitated by cell
adhesion molecules such as selectins, immunoglobulins, integrins, etc which
result in adhesion of leukocytes with the endothelium.

B). Transmigration of leukocytes

 Leukocytes escape from venules and small veins but only occasionally from
capillaries. The movement of leukocytes by extending pseudopodia through the
vascular wall occurs by a process called diapedesis .
 The most important mechanism of leukocyte emigration is via widening of
inter-endothelial junctions after endothelial cells contractions. The basement
membrane is disrupted and resealed thereafter immediately.
C). Chemotaxis:
 Chemotaxis is a unidirectional attraction of leukocytes from vascular channels
towards the site of inflammation within the tissue space guided by chemical
gradients (including bacteria and cellular debris) .
 The most important chemotactic factors for neutrophils are components of the
complement system (C5a), bacterial and mitochondrial products of arachidonic
acid metabolism such as leukotriene B4 and cytokines , Interleukin-L(IL-8).
All granulocytes, monocytes and to lesser extent lymphocytes respond to
chemotactic stimuli.
 How do leukocytes "see" or "smell" the chemotactic agent? This is because
receptors on cell membrane of the leukocytes react with the chemo-attractants,
resulting in the activation of phospholipase C that ultimately leads to release of
cytosolic calcium ions and these ions trigger cell movement towards the stimulus.

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D) Phagocytosis
Phagocytosis is the process of engulfment and internalization by specialized cells
of particulate material, which includes invading microorganisms, damaged cells,
and tissue debris. These phagocytic cells include polymorphonuclear leukocytes
(particularly neutrophiles), monocytes and tissue macrophages.
Phagocytosis involves three distinct steps.
1). Recognition and attachment of the particle to be ingested by the leukocytes:
Phagocytosis is enhanced if the material to be phagocytosed is coated with certain
plasma proteins called opsonins. These opsonins promote the adhesion between the
particulate material and the phagocyte’s cell membrane.
2). Engulfment: During engulfment, extension of the cytoplasm (pseudopods) flow
around the object to be engulfed, eventually resulting in complete enclosure of the
particle within the phagosome created by the cytoplasmic membrane of the
phagocytic cell. As a result of fusion between the phagosome and lysosome, a
phagolysosome is formed and the engulfed particle is exposed to the degradative
lysosomal enzymes.
3) Killing or degradation
The ultimate step in phagocytosis of bacteria is killing and degradation.

Morphology of acute inflammation

Characteristically, the acute inflammatory response involves production of exudates.
An exudate is an edema fluid with high protein concentration, which frequently
contains inflammatory cells.
􀂾 A transudate is simply a non-inflammatory edema caused by cardiac, renal,
Under-nutritional, & other disorders.

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There are different morphologic types of acute inflammation:
1) Serous inflammation
This is characterized by an outpouring of a thin fluid that is derived from either the
blood serum or secretion of mesothelial cells lining the peritoneal, pleural, and
pericardial cavities.
Abscess Definition: An abscess is an accumulation of pus with tissue destruction and
a cavity formation.
Examples:
— Pulmonary abscesses.
— Cerebral abscesses.
— Kidney abscesses.
— Liver abscesses.

2) Fibrinous inflammation
 More severe injuries result in greater vascular permeability that ultimately
leads to exudation of larger molecules such as fibrinogens through the vascular
barrier.
 Fibrinous exudate is characteristic of inflammation in serous body cavities
such as the pericardium (butter and bread appearance) and pleura.
Course of fibrinous inflammation include:
 Resolution by fibrinolysis
 Scar formation between parietal and visceral surfaces i.e. the exudates get
organized
 Fibrous strand formation that bridges the pericardial space.

Types of Fibrinous Inflammation

•Fibrinous Parenchymal Inflammation

•Fibrinous Serosal Inflammation

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•Fibrinous Mucosal Inflammation ( Croupous and Diphtheria

3) Suppurative (Purulent) inflammation

This type of inflammation is characterized by the production of a large amount of
pus. Pus is a thick creamy liquid, yellowish or blood stained in color and composed
of:
 A large number of living or dead leukocytes (pus cells)
 Necrotic tissue debris
 Living and dead bacteria
 Edema fluid

4) Catarrhal ‫ نزلي‬inflammation
This is a mild and superficial inflammation of the mucous membrane. It is
commonly seen in the upper respiratory tract following viral infections where
mucous secreting glands are present in large numbers, eg. Rhinitis.
5) Pseudomembranous inflammation
 The basic elements of pseudomembranous inflammation are extensive confluent
necrosis of the surface epithelium of an inflamed mucosa and severe acute
inflammation of the underlying tissues. The fibrinogens in the inflamed tissue
coagulate within the necrotic epithelium. The fibrinogen, which contain the
neutrophilic polymorphs, red blood cells, bacteria and tissue debris form a false
(pseudo) membrane which forms a white or colored layer over the surface of
inflamed mucosa.
 Pseudomembranous inflammation is exemplified by Diphtheritic infection of the
pharynx or larynx.

Hemorrhagic Inflammation

Definition: Exudative inflammation involving microvascular injury with massive

microvascular bleeding, producing an exudate with a high erythrocyte content.

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Effects of acute inflammation:
A. Beneficial effects
1. Dilution of toxins: The concentration of chemical and bacterial toxins at the
site of inflammation is reduced by dilution in the exudate and its removal from
the site by the flow of exudates from the venules through the tissue to the
lymphatics.
2. Protective antibodies: Exudation results in the presence of plasma proteins
including antibodies at the site of inflammation. Thus, antibodies directed against
the causative organisms will react and promote microbial destruction by
phagocytosis or complement-mediated cell lysis.
3. Fibrin formation: This prevents bacterial spread and enhances phagocytosis
by leukocytes.
4. Plasma mediator systems provisions‫ احكام‬: The complement, coagulation,
fibrinolytic, & kinin systems are provided to the area of injury by the process
of inflammation.
5. Cell nutrition: The flow of inflammatory exudates brings with it glucose,
oxygen and other nutrients to meet the metabolic requirements of the greatly
increased number of cells. It also removes their solute waste products via
lymphatic channels.
6. Promotion of immunity: Micro-organisms and their toxins are carried by the
exudates, either free or in phagocytes, along the lymphatic's to local lymph
nodes where they stimulate an immune response with the generation of
antibodies and cellular immune mechanisms of defense.
B. Harmful effects
1. Tissue destruction: Inflammation may result in tissue necrosis which may, in
turn, incite inflammation.
2. Swelling: The swelling caused by inflammation may have serious mechanical
effects at certain locations. Examples include acute epiglottitis with
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 interference in breathing; Acute meningitis and encephalitis with effects of
increased intracranial pressure.
3. Inappropriate response: The inflammatory reactions seen in hypersensitivity
is inappropriate (i.e. exaggerated).

Course of acute inflammation

Acute inflammation may end up in:
1. Resolution ‫ انحالل‬: i.e. complete restitution of normal structure and function of the
tissue, eg. lobar pneumonia.
2. Healing by fibrosis (scar formation).
3. Abscess formation . However, if it is left untouched, it may result in:-
a) Sinus formation - when an abscess cavity makes contact with only one
epithelial lining.
b) Fistula formation: when an abscess tract connects two epithelial surfaces. Or
very rarely to septicemia or Pyemia with subsequent metastatic abscess in
heart, kidney, brain etc.

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Chronic inflammation

Definition: Chronic inflammation is a prolonged inflammatory process (weeks or

months) where an active inflammation, tissue destruction and attempts to repair are
proceeding simultaneously.
Causes of chronic inflammation:
1. Persistent infections
Certain microorganisms associated with intracellular infection such as tuberculosis,
leprosy, certain fungi etc characteristically cause chronic inflammation. These
organisms are of low toxicity and evoke delayed hypersensitivity reactions.
2. Prolonged exposure to non-degradable but partially toxic substances: either
endogenous lipid components which result in atherosclerosis or exogenous
substances such as silica and asbestos.
3. Progression from acute inflammation: Acute inflammation almost always
progresses to chronic inflammation following:
a. Persistent suppuration as a result of un-collapsed abscess cavities, foreign body
materials (dirt, cloth, wool, etc), or a sinus/fistula from chronic abscesses.
4. Autoimmunity. Autoimmune diseases such as rheumatoid arthritis and systemic
lupus erythematosis are chronic inflammations from the outset.
Cells of chronic inflammation:
1. Monocytes and Macrophages are the primary cells in chronic inflammation.
Macrophages , in the liver (Kupffer cells), spleen, lymph nodes (sinus
histiocytes), lungs (alviolar macrophages), bone marrow, brain (microglia),
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 skin (Langerhan’s cells), etc…. These cells constitute the mononuclear-
phagocytic system. Macrophages are scavenger cells of the body.
2. . T-Lymphocytes are primarily involved in cellular immunity with
lymphokine production, and they are the key regulator and effector cells of the
immune system.
3. . B-lymphocytes and Plasma cells produce antibody directed either against
persistent antigen in the inflammatory site or against altered tissue components.
4. . Mast cells and eosinophils appear predominantly in response to parasitic
infestations & allergic reactions.
5. Neutrophils. Though neutrophils are hallmarks of acute inflammatory
reactions, large numbers of neutrophils may be seen in some forms of chronic
inflammation, notably chronic osteomyelitis, actinomycosis, & choric lung
diseases induced by smoking and other stimuli.

Differentiation points between acute and chronic inflammations include:

Characteristics Acute inflammation Chronic inflammation
Duration Short Relatively long
Pattern Stereotyped‫نمطي‬ varied
Predominant cell Neutrophils plasma cells , Macrophages,
Lymphocytes
Tissue destruction Mild to moderate Marked
Fibrosis Absent Present
Inflammatory reaction Exudative Productive

Classification of chronic inflammation:

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Chronic inflammation can be classified into the following two types based on
histologic features:
1) Nonspecific chronic inflammation: This involves a diffuse accumulation of
macrophages and lymphocytes at site of injury that is usually productive with new
fibrous tissue formations. E.g. Chronic cholecystitis.

2) Specific inflammation (granulomatous inflammation):

Definition: Granulomatous inflammation is characterized by the presence of
granuloma. A granuloma is a microscopic aggregate of epithelioid cells. Epithelioid
cell is an activated macrophage, with a modified epithelial cell-like appearance
(hence the name epithelioid). The epitheloid cells can fuse with each other & form
multinucleated giant cells. So, even though, a granuloma is basically a collection of
epithelioid cells, it also usually contains multinucleated giant cell & is usually
surrounded by a cuff of lymphocytes and occasional plasma cells.
Two types of giant cells:
a. Foreign body-type giant cells which have irregularly scattered nuclei in presence
of indigestible materials.
b. Langhans giant cells in which the nuclei are arranged peripherally in a horse –
shoe pattern which is seen typically in tuberculosis, sarcoidosis etc…
Giant cells are formed by fusion of macrophages perhaps by a concerted attempt of
two or more cells to engulf a single particle.

Pathogenesis:
There are two types of granulomas, which differ in their pathogenesis.
A. Foreign body granuloma

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These granulomas are initiated by inert foreign bodies such as talc, sutures (non-
absorbable),fibers, etc… that are large enough to preclude ‫ يتف[[ادى‬phagocytosis by a
single macrophage and do not incite an immune response.

B. Immune granulomas
Antigen presenting cells (macrophages) engulf a poorly soluble inciting agent. Then,
the macrophage processes the antigen.

Major causes of granulomatious inflammation include:

a) Bacterial: Tuberculosis, Leprosy, Syphilis.
b) Fungal: Histoplasmosis, Cryptococcosis, Coccidioidomycosis, Blastomycosis
c) Helminthic: Schistosomiasis
d) Protozoal: Leishmaniasis, Toxoplasmosis
e) Chlamydia: Lymphogranuloma venerum
f) Idiopathic: Acidosis, Primary biliary cirrhosis

I. Systemic Effects of Inflammations

The systemic effects of inflammation include:
a. Fever b. Endocrine & metabolic responses c. Autonomic responses
d. Behavioral responses e. Leukocytosis f. Leukopenia g. Weight loss
a. Fever:- Fever is the most important systemic manifestation of inflammation. It is
coordinated by the hypothalamus & by cytokines (IL -1, IL-6, TNF-α) released from
macrophages and other cells.
b. Endocrine and metabolic responses include:
- The liver secrets acute phase proteins such as Complement and coagulation proteins
- Glucocorticoids (increased)
- Vasopressin (decreased)
c. Autonomic responses include:
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- Redirection of blood flow from the cutaneous to the deep vascular bed.
- Pulse rate and blood pressure (increased)
- Sweating (decreased)
d. Behavioral responses include: - chills, anorexia‫ فقدان الشهية‬, somnolence, and malaise‫توعك‬
.
e. Leucocytosis is also a common feature of inflammation, especially in bacterial
infections. Its usual count is 15,000 to 20,000 cells/mm3. Most bacterial infections
induce neutrophilia. Some viral infections such as infectious mononucleosis ‫ مرض مونو‬, &
mumps‫ نك[[اف‬cause lymphocytosis. Parasitic infestations & allergic reactions such as
bronchial asthma & hay fever induce eosinophilia.
f. Leukopenia is also a feature of typhoid fever and some parasitic infections.
g. Weight loss is thought to be due to the action of IL-1 and TNF-α which increase
catabolism in skeletal muscle, adipose tissue and the liver with resultant negative
nitrogen balance.

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