Necrosis

ANMC GENERAL PATHOLOGY

LECTURE SERIES
Cell, Cell Injury, Cell Death,
and Adaptations
 Quick Recap
 Reversible Cellular Injury is harm done to a
cell that can be undone once the stress on
the cell is removed.

 Severe or prolonger reversible cellular injury

will eventually lead to irreversible cell injury. 

 Irreversible Cellular Injury is cell death via

apoptosis or necrosis that is permanent

 Each type of cellular damage is characterized

by specific cellular changes.
 • Hallmark of Reversible Cell Injury = Decreased ATP & Cellular
Swelling

• Hallmark of Irreversible Cell Injury = Membrane Damage

Reversible cellular injury is most often described in the setting of

ischemia. There is a decrease in ATP because the cell is not receiving
enough blood (oxygen and glucose). This decrease in ATP triggers the
cascade that leads to cellular swelling.
• Define necrosis and compare and contrast the forms of necrosis
produced in response to different etiologic agents with respect to
their variable clinical and morphologic features.
 Necrosis is a pathologic process that is the consequence of severe
injury.

A more conceptual description is:

Spectrum of morphological changes that follows cell death in living

tissues
Largely resulting from the progressive degradative action of enzymes
on lethally injured cells
The main causes of necrosis include

loss of oxygen supply (ischemia),

exposure to microbial toxins,
burns and other forms of chemical and physical injury, and
unusual situations in which active proteases leak out of cells
and damage surrounding tissues (as in pancreatitis)

• All of these initiating triggers lead to irreparable damage of numerous

cellular components
 Mechanisms

Denaturation of cellular proteins,

Leakage of cellular contents through damaged
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.

Cellular contents also leak through the damaged plasma

membrane into the extracellular space, where they elicit a
host reaction (inflammation).

Some specific substances released from injured cells have

been called damage-associated molecular patterns
(DAMPs).
DAMPs
• These include
ATP (released from damaged mitochondria),
Uric acid (a breakdown product of DNA), and
numerous other molecules that are normally confined within
healthy cells and whose release is an indicator of severe cell
injury.
• These molecules are recognized by receptors (pattern recognition
receptors) present in macrophages and most other cell types,

• and trigger phagocytosis of the debris as well as the production of

cytokines that induce inflammation
Inflammatory cells produce more proteolytic
enzymes,

and the combination of phagocytosis and enzymatic

digestion

usually leads to clearance of the necrotic cells.

Clinical link

Necrosis-associated leakage of intracellular

proteins through damaged plasma
membranes and ultimately into the
circulation is the basis for blood tests that
detect tissue-specific cellular injury.
Example
• Cardiac muscle cells, for example, express cardiac-specific variants of
the contractile protein troponin,
• while bile duct epithelium expresses a specific isoform of the enzyme
alkaline phosphatase and
• hepatocytes express transaminases.

• Necrosis of these cell types and associated loss of membrane integrity

is reflected in increased serum levels of these proteins, which serve as
biomarkers that are used clinically to assess and quantify tissue
damage.
How early?
• Cardiac-specific troponins can be detected in the blood as early as 2
hours after myocardial cell necrosis, well before histologic evidence of
myocardial infarction becomes apparent.

• Because of their sensitivity and specificity, serial measurement of

serum cardiac troponins has a central role in the diagnosis and
management of patients with myocardial infarction
Morphology
Must Know Morphologic Features
CYTOPLASM: MEMBRANES:
• Eosinophilia • breakdown of plasma membrane
• and organellar membranes;
NUCLEUS: • abundant myelin figures;
• nuclear shrinkage (pyknosis)
• fragmentation (karyorrhexis) CONTENTS:
• and dissolution (karyolysis) • Leakage and enzymatic digestion
of cellular contents
• Dead cells may be replaced by large whorled phospholipid
precipitates called myelin figures, which are either phagocytosed by
other cells or further degraded into fatty acids

• calcification of such fatty acid residues results in deposition of

calcium-rich precipitates.
By electron microscopy, necrotic cells are
characterized by

• Discontinuities in plasma and organelle membranes,

• Marked dilation of mitochondria with the appearance of large
amorphous densities,
• Intracytoplasmic myelin figures,
• Amorphous debris, and
• Aggregates of fluffy material representing denatured protein
 “Point of no return”

• It is useful to consider the possible events that determine when

reversible injury becomes irreversible and progresses to necrosis.

• The clinical relevance of this question is obvious— if we can answer it,

we may be able to devise strategies for preventing cell injury from
having permanent deleterious consequences.
Although the “point of no return,” at which the damage
becomes irreversible, is still largely undefined
• Two phenomena consistently characterize irreversibility:

1. The inability to reverse mitochondrial dysfunction (lack of oxidative

phosphorylation and ATP generation) even after resolution of the
original injury, and
2. Profound disturbances in membrane function.

• Injury to lysosomal membranes results in the enzymatic dissolution of

the injured cell that is characteristic of necrosis.
Patterns Of Necrosis
Patterns of Tissue Necrosis
• When large numbers of cells die, the tissue or organ is said to be
necrotic; thus, a myocardial infarct is necrosis of a portion of the heart
caused by death of many myocardial cells.

• Necrosis of tissues has several morphologically distinct patterns, which

are important to recognize because they provide clues about the
underlying cause.

• Although the terms that describe these patterns are somewhat dated,
they are often used and their implications are understood by
pathologists and clinicians.
• Coagulative necrosis
• Liquefactive necrosis,
• Gangrenous necrosis (Clinical term)
• Caseous necrosis
• Fat necrosis
• Fibrinoid necrosis
Coagulative necrosis
• Coagulative necrosis is a form of necrosis in which the
architecture of dead tissue is preserved for a span of at least
some days.

• The affected tissue has a firm texture.

• 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 for days or weeks.
• Ultimately, the necrotic cells are broken down by the action
of lysosomal enzymes derived from 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.
A large portion of the
small intestine is infarcted.
The dark red to grey
infarcted bowel contrasts
with the pale pink normal
bowel at the bottom.

Some organs such as

bowel with anastomosing
blood supplies, or liver
with a dual blood supply,
are harder to infarct.

This bowel was caught in a

hernia and the mesenteric
blood supply was
constricted by the small
opening to the hernia sac.
Coagulative necrosis.

A wedge-shaped kidney
infarct (yellow)
Microscopic view of the edge of
the infarct:

with normal kidney and necrotic

cells in the infarct showing
preserved cellular outlines with
loss of nuclei and an
inflammatory infiltrate
Microscopically, the renal cortex
has undergone anoxic injury at
the left so that the cells appear
pale and ghost-like.

There is a hemorrhagic zone in

the middle where the cells are
dying or have not quite died
along with damaged blood
vessels that are leaking, and
then normal renal parenchyma at
the far right.

This is an example of
coagulative necrosis.
The contrast between
normal adrenal cortex and
the small pale infarct is
good.

The area just under the

capsule is spared because
of blood supply from
capsular arterial branches.

This is an odd place for an

infarct, but it illustrates
the shape and appearance
of an ischemic (pale)
infarct well.
Liquefactive necrosis,
• In contrast to coagulative necrosis, Liquefactive necrosis is
characterized by 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 mostly unknown reasons, hypoxic death of cells

within the central nervous system often manifests as
liquefactive necrosis
Liquefactive necrosis.

An infarct in the brain,

showing dissolution of
the tissue.
The liquefactive necrosis leads to
resolution with cystic spaces as
the necrotic tissue is removed
Grossly, the cerebral
infarction at the
upper left in this
image, in the
distribution of the
middle cerebral
artery, demonstrates
liquefactive necrosis.

Eventually, the
removal of the dead
tissue leaves behind
a cavity.
This is liquefactive necrosis in
the brain of a patient who
suffered a "stroke" with focal
loss of blood supply to a
portion of cerebrum.

This type of infarction leads to

necrosis which is marked by
loss of neurons and neuroglial
cells and the formation of a
clear space at the center left.

As it resolves, the liquefied

area becomes a cystic space.
 At high magnification,
liquefactive necrosis of the
brain demonstrates many
macrophages at the right
which are cleaning up the
necrotic cellular debris.

The job description of a

macrophage includes
janitorial services such as
this, particularly when there
is lipid debris.
The two lung abscesses seen here are
examples of liquefactive necrosis in which
there is a liquid center in an area of tissue
injury.

One abscess appears in the upper lobe

and one in the lower lobe.

Liquefactive necrosis is typical

of organs in which the tissues
have a lot of lipid (such as
brain) or when there is an
abscess with lots of acute
inflammatory cells whose
release of proteolytic enzymes
destroys the surrounding
tissues.
The liver shows a small
abscess here filled with
many neutrophils.

This abscess is an example

of localized liquefactive
necrosis.

Grossly, such an abscess

appears yellow to tan
because it is filled with pus
(purulent exudate).
Gangrenous necrosis
• Gangrenous necrosis is not a specific pattern of cell death, but the
term is commonly used in clinical practice.

• It is usually applied to a limb, generally the lower leg, that has

lost its blood supply and has
undergone necrosis (typically coagulative necrosis)
involving multiple tissue planes.
Dry versus wet
• When bacterial infection is superimposed

There is more liquefactive necrosis because of the

actions of degradative enzymes in the bacteria and the
attracted leukocytes

Giving rise to so-called wet gangrene.

This is gangrene of the lower
extremity.

In this case the term "wet"

gangrene is more applicable
because of the liquefactive
component from superimposed
infection in addition to the
coagulative necrosis from loss of
blood supply.

This patient had diabetes mellitus

with severe peripheral vascular
disease
Caseous necrosis

• Caseous necrosis is encountered most often in

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
Caseous necrosis.

Tuberculosis of the
lung, with a large area
of caseous necrosis
containing yellow-white
and “cheesy” appearing
debris
Microscopically, caseous
necrosis is characterized by
acellular pink areas of necrosis,
as seen here at the upper right,
surrounded by a granulomatous
inflammatory process

As macrophages release
chemicals that digest cells, the
cells begin to die. As the cells
die they disintegrate but are
not completely digested and
the debris of the disintegrated
cells clump together creating
soft granular mass that has the
appearance of cheese
Fat necrosis
• Fat necrosis refers to focal areas of fat destruction, typically resulting
from release of activated pancreatic lipases into the substance of the
pancreas and the peritoneal cavity. This occurs in the abdominal
emergency known as acute pancreatitis

• In this disorder, pancreatic enzymes leak out of damaged acinar cells

and liquefy the membranes of fat cells in the peritoneum, releasing
triglyceride esters that are split by pancreatic lipases.
Saponification & Morphology
• Fatty acids are generated that combine with calcium to produce
grossly visible chalky-white areas (fat saponification), which enable
the surgeon and the pathologist to grossly identify the underlying
disorder.

• On histologic examination, the necrotic areas contain

the shadowy outlines of necrotic fat cells,
basophilic calcium deposits, and
an inflammatory reaction
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
 This is fat necrosis of the
pancreas.
Cellular injury to the
pancreatic acini leads to
release of powerful enzymes
which damage fat by the
production of soaps, and
these appear grossly as the
soft, chalky white areas seen
here on the cut surfaces.
• Microscopically, fat
necrosis adjacent to
pancreas is seen here.
• There are some
remaining steatocytes at
the left which are not
necrotic.
• The necrotic fat cells at
the right have vague
cellular outlines, have
lost their peripheral
nuclei, and their
cytoplasm has become a
pink amorphous mass of
necrotic material
Fibrinoid necrosis

• Fibrinoid necrosis is a 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.
Morphology
• Deposits of these immune complexes, together with plasma
proteins 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
Fibrinoid necrosis in an
artery.

The wall of the artery shows

a circumferential bright pink
area of necrosis with
inflammation
(neutrophils with dark
nuclei).
• Sequelae
• 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. This is dystrophic
calcification.
Acute myocardial infarct,
predominantly of the posterolateral
left ventricle, demonstrated
histochemically by a lack of staining by
triphenyltetrazolium chloride in areas
of necrosis

The staining defect is due to the

lactate dehydrogenase leakage that
follows cell death.

Note the myocardial hemorrhage at

one edge of the infarct that was
associated with cardiac rupture, and
the anterior scar, indicative of an old
infarct
One-day-old infarct showing
coagulative necrosis and wavy
fibers (elongated and narrow, as
compared with adjacent normal
fibers at right).
Widened spaces between the dead
fibers contain edema fluid and
scattered neutrophils.
Dense polymorphonuclear
leukocytic infiltrate in an
acute myocardial infarction
that is 3 to 4 days old.
Removal of necrotic
myocytes by phagocytosis
(approximately 7 to 10
days)
Granulation tissue
characterized by
loose collagen and
abundant
capillaries-
Masson’s trichrome,
rendering
collagenous
connective tissue a
deep blue color
Healed myocardial infarct in which
the necrotic tissue has been replaced
by a dense collagenous scar.
The residual cardiac muscle cells
show evidence of compensatory
hypertrophy - Masson’s trichrome,
rendering collagenous connective
tissue a deep blue color
• Quick recap
DAMPs
• These include
ATP (released from damaged mitochondria),
uric acid (a breakdown product of DNA), and
numerous other molecules that are normally confined within
healthy cells and whose release is an indicator of severe cell
injury.
Although the “point of no return,” at which the damage
becomes irreversible, is still largely undefined
• Two phenomena consistently characterize irreversibility:

1. The inability to reverse mitochondrial dysfunction (lack of oxidative

phosphorylation and ATP generation) even after resolution of the
original injury, and
2. Profound disturbances in membrane function.

• Injury to lysosomal membranes results in the enzymatic dissolution of

the injured cell that is characteristic of necrosis.
Assignment

• Refer to Page 40

• Write a short note on nuclear changes in Necrosis.

Questions?