I.

General Principles of Cell Injury and Stress Responses

1. Explain the concept of homeostasis and how cells respond to stress and injurious stimuli,
including reversible injury, irreversible injury, and adaptive changes (hypertrophy, hyperplasia, atrophy,
and metaplasia).

Homeostasis refers to the steady state that cells normally maintain under physiological conditions. It
represents a dynamic equilibrium where cellular structures and functions are preserved in response to
normal metabolic demands. Cells maintain homeostasis by regulating ion concentrations, energy
supply, and structural integrity through various metabolic and regulatory mechanisms.

However, when cells are exposed to stressful conditions or injurious stimuli, they can undergo a range of
responses depending on the nature, duration, and severity of the insult. These responses include:

1. Adaptation
When a cell encounters a stressor that is not immediately lethal, it can achieve a new steady state through
adaptive changes. These include:

● Hypertrophy: An increase in the size of cells resulting in an increase in the size of the affected organ.
It typically occurs in non-dividing cells (e.g., cardiac muscle). Hypertrophy is driven by mechanical
stress (e.g., increased workload) and trophic signals (e.g., growth factors, hormonal stimulation). For
example, myocardial hypertrophy in hypertension is a response to increased mechanical load.
● Hyperplasia: An increase in the number of cells in a tissue, occurring in tissues capable of proliferation
(e.g., epithelium, hematopoietic tissue). It can be physiological (e.g., hormonal hyperplasia of the breast
during pregnancy) or pathological (e.g., endometrial hyperplasia due to excess estrogen stimulation).
● Atrophy: A decrease in cell size and number, resulting in reduced tissue or organ size. Atrophy can be
caused by decreased workload (disuse atrophy), loss of innervation, diminished blood supply,
inadequate nutrition, or aging (senile atrophy). It involves decreased protein synthesis and increased
protein degradation via the ubiquitin-proteasome pathway and autophagy.
● Metaplasia: A reversible change in which one differentiated cell type is replaced by another cell type
better able to withstand the adverse environment. A classic example is the replacement of ciliated
columnar epithelium by squamous epithelium in the respiratory tract of chronic smokers. This change is
often due to the reprogramming of stem cells, not direct conversion of mature cell types.

2. Reversible Cell Injury

If the injurious stimulus is of short duration or mild intensity, cell injury is reversible. Reversible injury is
characterized by:

● Cellular swelling due to failure of energy-dependent ion pumps in the plasma membrane, leading to
ion and fluid accumulation.
● Fatty change, particularly in cells involved in lipid metabolism (e.g., hepatocytes), resulting from the
accumulation of triglyceride-containing lipid vacuoles.
● Plasma membrane blebbing, mitochondrial swelling, and detachment of ribosomes from the rough ER
may also be observed.

Despite these changes, if the insult is removed, the cell can recover fully and return to normal function.

3. Irreversible Cell Injury and Cell Death

When the stress is persistent or severe, the injury becomes irreversible, leading to cell death, which can
occur through:

● Necrosis: A form of unregulated cell death resulting from severe damage to membranes and
organelles. It elicits an inflammatory response due to the release of intracellular contents. Morphologic
changes include nuclear karyolysis, pyknosis, or karyorrhexis, cytoplasmic eosinophilia, and disrupted
membranes.
● Apoptosis: A regulated process of programmed cell death that serves to eliminate unwanted or
damaged cells with minimal inflammation. It involves activation of specific caspases, chromatin
condensation, DNA fragmentation, and formation of apoptotic bodies that are phagocytosed.

2. Identify the major causes of cell injury, including hypoxia, physical agents, chemical toxins,
infectious agents, immunologic reactions, genetic defects, and nutritional imbalances.

Cell injury occurs when the cell’s ability to maintain homeostasis is overwhelmed by external or internal insults.
These injurious stimuli vary in nature, severity, and duration, and they can affect different cellular components
such as the plasma membrane, mitochondria, DNA, or protein-synthesizing machinery. The major causes of
cell injury include:

1. Hypoxia
Hypoxia is defined as a deficiency of oxygen, which impairs aerobic oxidative respiration. It is a common and
critical cause of cell injury and can result from several underlying conditions:

● Ischemia (loss of blood supply due to obstruction of arterial flow or reduced venous drainage) is the
most common cause of hypoxia.
● Cardiorespiratory failure, which results in inadequate oxygenation of the blood.
● Anemia, which reduces the oxygen-carrying capacity of blood.
● Carbon monoxide poisoning, which inhibits oxygen binding to hemoglobin.
● Severe blood loss, leading to systemic hypoperfusion.

Hypoxia primarily affects energy production and can lead to reversible injury; however, if prolonged, it can
progress to irreversible injury and cell death.

2. Physical Agents
Various physical agents can inflict mechanical and structural damage on cells and tissues. These include:

● Mechanical trauma, such as blunt force or penetrating injuries, causing disruption of cellular integrity.
● Extreme temperatures:
○ Cold causes vasoconstriction and ice crystal formation.
○ Heat can denature proteins and damage membranes.
● Radiation, particularly ionizing radiation, which induces DNA damage through free radical formation.
● Electric shock, which disrupts electrical impulses and can cause thermal burns and arrhythmias.
● Changes in atmospheric pressure, such as in decompression sickness or blast injuries, which may
cause gas emboli or tissue rupture.

3. Chemical Agents and Drugs

Chemical agents, ranging from environmental toxins to therapeutic drugs, can cause cellular injury through
direct or indirect mechanisms:

● Direct toxicity, where the chemical itself interacts with cellular components (e.g., mercuric chloride
binding to sulfhydryl groups of proteins).
 ● Metabolic activation of chemicals to reactive intermediates, as seen with carbon tetrachloride
(CCl₄) or acetaminophen, leading to lipid peroxidation and membrane damage.
● Alcohol, pesticides, cyanide, and chemotherapeutic agents are common examples of injurious
chemicals.

These substances may interfere with membrane integrity, protein synthesis, or mitochondrial function.

4. Infectious Agents
Infectious agents include a broad spectrum of pathogens such as:

● Viruses, which can directly kill host cells or trigger immune-mediated damage.
● Bacteria, which produce toxins and induce inflammatory responses.
● Fungi, protozoa, and helminths, which can cause tissue injury via direct invasion, obstruction, or
immune-mediated mechanisms.

Pathogens may cause injury by disrupting cellular processes, inducing cytopathic effects, or eliciting harmful
host immune responses.

5. Immunologic Reactions
While the immune system is essential for defense, its responses can become maladaptive and injurious:

● Autoimmune reactions, where the immune system attacks self-antigens (e.g., systemic lupus
erythematosus).
● Allergic reactions, resulting from hypersensitivity to environmental antigens, which can lead to tissue
damage (e.g., asthma).
● Chronic inflammation, where prolonged immune activation causes collateral tissue injury.

Immune-mediated cell injury is often due to complement activation, cytotoxic T lymphocyte activity, or the
release of inflammatory mediators.

6. Genetic Derangements
Genetic abnormalities can contribute to cell injury by:

● Producing defective proteins (e.g., in cystic fibrosis or sickle cell disease).

● Inducing metabolic derangements due to enzyme deficiencies (e.g., lysosomal storage diseases).
● Increasing susceptibility to injury by interfering with repair mechanisms or apoptosis regulation (e.g.,
BRCA mutations in cancer).
● Causing congenital malformations and developmental anomalies.

These defects can be inherited or acquired and may predispose cells to injury under stress.

7. Nutritional Imbalances
Proper nutrition is essential for maintaining cellular function, and both deficiencies and excesses can cause
harm:

● Protein-calorie deficiencies (e.g., marasmus, kwashiorkor) impair cell metabolism and structure.
● Vitamin deficiencies (e.g., vitamin C in scurvy, vitamin D in rickets) affect enzymatic and structural
functions.
● Excessive nutrition, such as obesity and hyperlipidemia, contributes to diseases like atherosclerosis,
type 2 diabetes, and fatty liver disease.
Malnutrition can compromise immune function, wound healing, and resistance to injury.

3. Differentiate between reversible and irreversible cell injury, including the key morphologic and
biochemical features associated with each.

Cell injury is a dynamic process, and whether it is reversible or irreversible depends on the nature and duration
of the insult, as well as the type and state of the affected cell. Reversible injury represents the early stages of
cellular damage that can be corrected if the stimulus is removed, whereas irreversible injury leads to cell
death and is not recoverable even with removal of the stressor.

1. Reversible Cell Injury

Definition:
A type of cell injury where the damaging stimulus is mild or transient, allowing the cell to return to its normal
state once the stress is removed.

Key Morphologic Features:

● Cellular swelling (hydropic change):

Caused by failure of energy-dependent ion pumps in the plasma membrane, leading to sodium and
water influx.
● Plasma membrane blebbing and loss of microvilli:
Due to cytoskeletal disruption.
● Mitochondrial swelling:
Due to loss of osmotic control, but with preservation of membranes.
● Dilation of the endoplasmic reticulum (ER):
Ribosomes may detach from the ER, impairing protein synthesis.
● Fatty change:
Most often seen in organs involved in lipid metabolism (e.g., liver, heart), where lipid vacuoles
accumulate in the cytoplasm.

Key Biochemical Features:

● Reduced ATP production:

Due to impairment of oxidative phosphorylation.
● Accumulation of lactic acid and intracellular acidosis:
Resulting from anaerobic glycolysis.
● Disruption of protein synthesis:
Due to detachment of ribosomes from ER.
● Reversible changes in intracellular ion concentrations:
Including increased intracellular calcium, which is still regulated to a degree.

Outcome:
With removal of the insult, the cell can restore normal structure and function.

2. Irreversible Cell Injury

Definition:
A state in which damage to cell structures is so severe that recovery is no longer possible, resulting in cell
death, either by necrosis or apoptosis.

Key Morphologic Features:

● Severe mitochondrial damage with loss of membrane potential and rupture:

Leading to the release of pro-apoptotic proteins or inability to generate ATP.
 ● Plasma membrane damage:
Resulting in loss of cellular contents and uncontrolled ion flux.
● Lysosomal membrane rupture:
Leading to leakage of hydrolytic enzymes and autolysis of the cell.
● Nuclear changes:
These are hallmark features of irreversible injury and include:
○ Pyknosis: Nuclear shrinkage and increased basophilia.
○ Karyorrhexis: Fragmentation of the nucleus.
○ Karyolysis: Fading of nuclear basophilia due to DNA degradation.

Key Biochemical Features:

● Profound and sustained ATP depletion.

● Massive influx of calcium:
Activates destructive enzymes (phospholipases, proteases, endonucleases, ATPases).
● Activation of cell death pathways:
Especially the intrinsic apoptotic pathway when mitochondria are damaged.
● Oxidative damage:
From reactive oxygen species (ROS), leading to lipid peroxidation, protein modification, and DNA
strand breaks.

Outcome:
The cell undergoes death via:

● Necrosis, if the damage is uncontrolled and extensive.

● Apoptosis, if the injury activates regulated pathways of programmed cell death.

Feature Reversible Injury Irreversible Injury

ATP levels Decreased (mild to moderate) Depleted (severe and prolonged)

Cell membrane Maintained Lost (leakage of contents)

integrity

Ion homeostasis Disrupted but restorable Irrecoverable calcium influx and

membrane damage

Mitochondrial function Swelling without rupture Severe damage with loss of potential and
rupture

Nuclear changes None or reversible Pyknosis, karyorrhexis, karyolysis

Morphologic changes Cell swelling, fatty change, Lysosomal rupture, plasma membrane
membrane blebs breakdown

Outcome Recovery possible Cell death (necrosis or apoptosis)

 II. Cell Death: Necrosis, Apoptosis, and Other Mechanisms
4. Define necrosis and describe its morphologic patterns (e.g., coagulative, liquefactive, caseous, fat,
fibrinoid, gangrenous) and clinical correlations.

Necrosis is a form of unregulated, pathological cell death resulting from irreversible injury, most often
caused by ischemia, toxins, infections, or trauma. It is characterized by the loss of membrane integrity,
uncontrolled enzymatic digestion, and leakage of cellular contents, which typically elicit a robust
inflammatory response in the surrounding tissue.

The morphologic patterns of necrosis reflect underlying causes, tissue types, and the mechanism of injury.
These patterns help pathologists deduce the nature and timing of tissue damage.

1. Coagulative Necrosis
Definition:
Characterized by the preservation of tissue architecture for a few days following cell death due to protein
denaturation being more dominant than enzymatic digestion.

Morphologic Features:

● Cell outlines remain visible.

● Eosinophilic, anucleate cells.
● Inflammatory infiltrates develop over time.

Typical Causes:

● Ischemia in most solid organs (except the brain).

Clinical Correlation:

● Myocardial infarction is a classic example, where ischemia causes death of cardiac muscle fibers,
preserving the outline for days.

2. Liquefactive Necrosis
Definition:
Characterized by complete enzymatic digestion of dead cells, resulting in liquid, viscous tissue.

Morphologic Features:

● Loss of architecture.
● Soft, liquefied area often containing neutrophils and cellular debris (pus).

Typical Causes:

● Focal bacterial or fungal infections (due to the accumulation of leukocytes and enzymes).
● Hypoxic death in the central nervous system.

Clinical Correlation:
 ● Cerebral infarction leads to liquefactive necrosis due to the high lipid content and enzymatic activity of
brain tissue.
● Abscesses form in response to pyogenic infections.

3. Caseous Necrosis
Definition:
A form of necrosis that combines elements of coagulative and liquefactive necrosis, producing a cheese-like
(caseous) appearance.

Morphologic Features:

● Granular, amorphous debris enclosed within a granulomatous inflammatory border.

● Tissue architecture is obliterated.
● Central area of necrosis surrounded by macrophages and lymphocytes.

Typical Causes:

● Tuberculosis (most common).

● Some fungal infections.

Clinical Correlation:

● Pulmonary TB often shows caseous necrosis in lung lesions and hilar lymph nodes.

4. Fat Necrosis
Definition:
Necrosis involving adipose tissue, typically due to lipase-mediated digestion of fat, leading to fatty acid
release and calcium soap formation (saponification).

Morphologic Features:

● Pale, chalky white areas.

● Ghost-like outlines of necrotic adipocytes.
● Associated with calcification.

Typical Causes:

● Acute pancreatitis, where pancreatic lipases digest peripancreatic fat.

● Trauma to fatty tissues, such as the breast.

Clinical Correlation:

● In acute pancreatitis, fat necrosis may extend to mesenteric fat and omentum, contributing to
peritonitis.

5. Fibrinoid Necrosis
Definition:
A microscopic pattern of necrosis involving immune complexes and plasma proteins that become deposited
in the walls of blood vessels, often associated with immune-mediated vascular injury.
Morphologic Features:

● Bright pink, amorphous, fibrin-like appearance on H&E stain.

● Loss of vessel wall integrity.

Typical Causes:

● Immune vasculitis.
● Severe hypertension.
● Autoimmune diseases such as systemic lupus erythematosus.

Clinical Correlation:

● Seen in polyarteritis nodosa and other forms of necrotizing vasculitis.

6. Gangrenous Necrosis
Definition:
Not a distinct pattern of necrosis under the microscope but a clinical term describing extensive tissue
necrosis, typically of a limb, secondary to ischemia.

Dry Gangrene

● Represents coagulative necrosis of tissue due to ischemia.

● Tissue appears dry, black, and shriveled.
● No significant bacterial superinfection.

Wet Gangrene

● Superimposed bacterial infection on ischemic tissue, leading to liquefactive changes due to

inflammation.
● Tissue is swollen, soft, and foul-smelling.

Clinical Correlation:

● Diabetic foot ulcers, severe peripheral vascular disease, or bowel infarction are common settings.
● Requires urgent surgical intervention to prevent systemic sepsis.

Type of Key Morphology Common Causes Clinical Examples

Necrosis

Coagulative Preserved architecture, Ischemia in solid organs Myocardial infarction

eosinophilic cells

Liquefactive Digested tissue, abscess or Brain infarction, infections Stroke, abscess

cavity

Caseous Granular debris, Mycobacterial/fungal Tuberculosis

granulomatous border infection

Fat Chalky deposits, Pancreatitis, trauma to fat Acute pancreatitis

saponification
 Fibrinoid Eosinophilic vessel walls Immune reactions, Polyarteritis nodosa
hypertension

Gangrenous Dry: mummified; Wet: swollen Ischemia ± infection Diabetic gangrene,

and infected bowel infarction

5. Explain the mechanisms and physiologic/pathologic roles of apoptosis, including intrinsic

(mitochondrial) and extrinsic (death receptor) pathways, and their relevance in development, immune
regulation, and disease.

Apoptosis is a form of regulated or programmed cell death characterized by energy-dependent,

genetically controlled mechanisms that result in controlled demolition of intracellular components without
inciting inflammation. Unlike necrosis, apoptosis preserves plasma membrane integrity until late stages,
ensuring that cell contents do not leak and trigger inflammation.

MORPHOLOGIC FEATURES OF APOPTOSIS

● Cell shrinkage
● Chromatin condensation and margination
● Formation of apoptotic bodies (membrane-bound cell fragments)
● Phagocytosis by macrophages or neighboring cells without inflammation

TWO MAIN PATHWAYS OF APOPTOSIS

1. Intrinsic (Mitochondrial) Pathway

Trigger:

● DNA damage (e.g., radiation, toxins)

● ER stress from misfolded proteins
● Growth factor withdrawal
● Hypoxia
● Other intracellular stress signals

Key Molecular Players:

● BCL-2 family proteins:

Regulate mitochondrial outer membrane permeability.
○ Anti-apoptotic: BCL-2, BCL-XL, MCL-1
○ Pro-apoptotic (activators): BIM, BID, BAD
○ Pro-apoptotic (effectors): BAX and BAK (form mitochondrial pores)
● Mitochondrial outer membrane permeabilization (MOMP):
Leads to release of cytochrome c into the cytosol.
● Cytochrome c:
Binds to apoptotic protease activating factor-1 (Apaf-1) → forms apoptosome.
● Apoptosome:
Activates initiator caspase-9, which in turn activates executioner caspases (caspase-3 and -6).

Outcome:
Proteolysis of cytoskeletal and nuclear proteins, DNA fragmentation, apoptotic body formation.

2. Extrinsic (Death Receptor-Initiated) Pathway

Trigger:
Engagement of cell surface death receptors by their ligands.

Key Molecular Players:

● Death receptors:
Belong to TNF receptor family; major ones include:
○ Fas (CD95)
○ TNF receptor 1 (TNFR1)
● Ligands:
○ FasL (on activated T cells)
TNF-α (in inflammation)
● Receptor-ligand binding: Leads to formation of the death-inducing signaling complex (DISC).
● DISC: Recruits and activates initiator caspase-8 (or caspase-10).
● Execution phase: Caspase-8 activates executioner caspases → proteolysis and apoptosis.
● Cross-talk with intrinsic pathway: Caspase-8 can cleave BID, a pro-apoptotic BCL-2 family member,
amplifying mitochondrial apoptosis.

PHYSIOLOGIC ROLES OF APOPTOSIS

1. Embryogenesis and development:
○ Digit separation
○ Neural pruning
○ Involution of Müllerian ducts in males
2. Hormone-dependent involution:
○ Endometrial shedding during menstruation
○ Regression of lactating breast after weaning
3. Cell turnover in proliferating tissues:
○ Intestinal epithelium, hematopoietic cells
4. Elimination of self-reactive lymphocytes (negative selection):
○ Central to prevention of autoimmunity
5. Termination of immune responses:
○ Removal of activated T cells via Fas-FasL

PATHOLOGIC ROLES OF APOPTOSIS

1. DNA damage:
○ From radiation, cytotoxic drugs, hypoxia
○ Trigger p53-mediated intrinsic apoptosis
2. Misfolded protein accumulation (ER stress):
○ Seen in neurodegenerative diseases (e.g., Alzheimer’s, Huntington’s)
3. Viral infections:
○ Viruses like HIV can induce or block apoptosis of immune cells
4. Cell death in tumors and tumor regression:
○ Apoptosis induced by chemotherapy or immune attack
5. Pathologic atrophy in organs with duct obstruction:
○ E.g., pancreas, parotid glands, kidneys

CLINICAL CORRELATIONS
● Cancer: Tumor cells often acquire resistance to apoptosis by overexpressing anti-apoptotic proteins
(e.g., BCL-2 in follicular lymphoma).
● Autoimmune diseases: Mutations in Fas or FasL can result in autoimmune lymphoproliferative
syndrome (ALPS).
 ● Neurodegeneration: Abnormal apoptosis implicated in Alzheimer's, Parkinson's, and Huntington's
diseases.
● Ischemia-reperfusion injury: ROS and calcium overload induce apoptosis and necrosis in affected
tissues.

6. Distinguish between necrosis and apoptosis, both morphologically and mechanistically, and relate
their features to clinical scenarios.

I. Morphologic Features
Feature Necrosis Apoptosis

Cell size Enlarged (cell swelling) Reduced (cell shrinkage)

Nucleus Pyknosis → karyorrhexis Fragmentation into nucleosome-sized fragments

→ karyolysis

Plasma membrane Disrupted Intact, but with altered structure (e.g., blebbing);
membrane remains functional until late

Cell contents Enzymatic digestion; may Intact; contained within apoptotic bodies
leak out of cell

Adjacent inflammation Frequent (due to leakage of Absent (due to rapid phagocytosis of apoptotic
cell contents) bodies)

Physiologic vs. Always pathologic (due to Often physiologic (e.g., embryogenesis, immune
Pathologic role irreversible injury) regulation); also pathologic

II. Mechanistic Features

Mechanism Necrosis Apoptosis

Energy requirement Passive (ATP-independent) Active (ATP-dependent)

Trigger Severe injury (ischemia, toxins, Physiologic signals or mild cellular stress
infections) (DNA damage, withdrawal of growth factors,
ER stress)

Key mediators Enzymatic digestion by lysosomal Caspases (initiator and executioner); BCL-2
hydrolases; calcium overload; family proteins; cytochrome c
ROS

Mitochondrial Secondary and destructive Primary in intrinsic pathway: release of

involvement cytochrome c and pro-apoptotic factors
 Signaling pathways Unregulated, random, and Highly regulated via intrinsic (mitochondrial)
catastrophic and extrinsic (death receptor) pathways

III. Clinical Scenarios and Relevance

Necrosis: Clinical Examples

1. Myocardial Infarction (Ischemic necrosis):

○ Coagulative necrosis due to prolonged ischemia of cardiac muscle.
○ Release of intracellular enzymes like troponins and CK-MB is diagnostic.
2. Cerebral Infarction:
○ Liquefactive necrosis predominates due to enzymatic digestion of CNS tissue.
○ Common in stroke, leading to cystic cavities.
3. Tuberculosis:
○ Caseous necrosis within granulomas; cheesy appearance.
○ Seen in pulmonary TB and lymphadenitis.
4. Acute pancreatitis:
○ Fat necrosis of peripancreatic fat due to lipase-mediated digestion.
○ Chalky white deposits (saponification) may be observed.
5. Gangrenous necrosis:
○ Dry gangrene: Coagulative necrosis from vascular compromise (e.g., peripheral arterial
disease).
○ Wet gangrene: Superimposed infection leads to liquefaction and inflammation.

Apoptosis: Clinical Examples

1. Embryogenesis:
○ Removal of interdigital webs and regression of embryonic structures via apoptosis.
2. Negative selection of lymphocytes:
○ Prevents autoimmunity by removing self-reactive T and B cells in the thymus and bone marrow.
3. Viral infections (e.g., HIV):
○ CD4+ T cells may undergo apoptosis via Fas-FasL or mitochondrial pathways.
4. Cancer therapy (radiation or chemotherapy):
○ Induces DNA damage → p53 activation → apoptosis in tumor cells.
○ Apoptosis resistance (e.g., via BCL-2 overexpression in follicular lymphoma) leads to therapy
failure.
5. Neurodegenerative diseases (e.g., Alzheimer’s):
○ Abnormal protein accumulation triggers ER stress and apoptosis of neurons.
6. Graft-versus-host disease (GVHD):
○ Cytotoxic T cells induce apoptosis in host epithelial cells via FasL and perforin pathways.

While necrosis is typically a passive, pathologic process caused by overwhelming damage that leads to
inflammation and tissue destruction, apoptosis is often a controlled, physiologic process essential for tissue
homeostasis. Apoptosis may also occur pathologically in certain contexts such as DNA damage, misfolded
protein accumulation, or immune cell regulation failure.

Understanding the differences between necrosis and apoptosis is critical in clinical medicine. For example,
infarcted tissue may provoke an inflammatory response requiring management, while diseases involving
dysregulated apoptosis (e.g., cancer or autoimmunity) demand targeted therapeutic strategies that modulate
apoptotic pathways.
 7. Describe other forms of regulated cell death, such as necroptosis, pyroptosis, and ferroptosis, and
outline their pathophysiologic relevance.

1. Necroptosis
Definition and Mechanism

Necroptosis is a form of regulated necrosis that is caspase-independent but programmed, combining the
molecular regulation of apoptosis with the morphologic features of necrosis (e.g., cell swelling, plasma
membrane rupture).

● Initiated by death receptors (e.g., TNFR1) binding to TNF-α.

● In situations where caspase-8 is inhibited or absent, downstream signaling diverges from apoptosis.
● Key mediators:
○ RIPK1 and RIPK3 (Receptor-interacting protein kinases)
○ Activation of MLKL (mixed lineage kinase domain-like protein) leads to membrane disruption
and necrotic cell death.

Morphology

● Similar to necrosis: cellular swelling, organelle dilation, membrane rupture, and inflammation.

Pathophysiologic Relevance

● Ischemic injury (e.g., myocardial or cerebral infarction) when caspase activation is blocked.
● Inflammatory diseases such as inflammatory bowel disease (IBD) and pancreatitis.
● Neurodegeneration and viral infections (some viruses block caspase-8 to induce necroptosis).

2. Pyroptosis
Definition and Mechanism

Pyroptosis is a form of proinflammatory programmed cell death, seen primarily in innate immune cells
such as macrophages and dendritic cells. It is caspase-dependent, but distinct from apoptosis due to its
inflammatory consequences.

● Triggered by pathogen-associated molecular patterns (PAMPs) and damage-associated

molecular patterns (DAMPs).
● Activation of inflammasomes (e.g., NLRP3) leads to:
○ Activation of caspase-1 and caspase-11 (in mice)/caspase-4 and -5 (in humans).
○ Caspase-1 cleaves pro–IL-1β and pro–IL-18 into active inflammatory cytokines.
Gasdermin D is cleaved, and its N-terminal fragment forms pores in the plasma membrane,
causing cell lysis.

Morphology
 ● Cell swelling, plasma membrane pore formation, nuclear condensation, and release of IL-1β and
IL-18.
● Ends in cell lysis and inflammation.

Pathophysiologic Relevance

● Sepsis and endotoxic shock (through massive cytokine release).

● Gout (due to uric acid crystal-induced inflammasome activation).
● Atherosclerosis, neurodegenerative diseases, and certain autoimmune disorders.
● Host defense against intracellular pathogens, such as Salmonella, Shigella, and Listeria.

3. Ferroptosis
Definition and Mechanism

Ferroptosis is an iron-dependent form of regulated cell death characterized by accumulation of lipid

peroxides. It is morphologically, biochemically, and genetically distinct from both apoptosis and necrosis.

● Triggered by loss of activity of glutathione peroxidase 4 (GPX4).

● Inadequate detoxification of reactive oxygen species (ROS) leads to lipid peroxidation.
● Requires the presence of free intracellular iron, which catalyzes ROS generation through the Fenton
reaction.

Morphology

● Condensed mitochondria with reduced cristae and ruptured outer membrane.

● No nuclear fragmentation (unlike apoptosis).
● No inflammation (contents remain contained until cell rupture).

Pathophysiologic Relevance

● Ischemia-reperfusion injury, especially in brain and kidney.

● Neurodegenerative disorders such as Parkinson’s disease and Alzheimer’s disease.
● Tumor suppression and cancer therapy: Some tumors are vulnerable to ferroptosis inducers, making
this pathway a therapeutic target.
● Acute organ injuries: Renal tubular necrosis and hepatic ischemia.

Feature Necroptosis Pyroptosis Ferroptosis

Key Mediators RIPK1, RIPK3, MLKL Inflammasome (e.g., GPX4 inhibition, iron, lipid
NLRP3), caspase-1, peroxides
gasdermin D

Caspase No (caspase-independent) Yes (caspase-1, 4, 5, 11) No

involvement

Morphology Necrosis-like: swelling, Swelling, membrane pore Mitochondrial damage, lipid

membrane rupture formation, cytokine release peroxidation

Inflammation Yes Yes No (until secondary necrosis)

Clinical Ischemia, Sepsis, IBD, host defense, Brain ischemia, cancer

relevance neurodegeneration, atherosclerosis therapy, neurodegeneration
 infection

8. Discuss autophagy as a survival mechanism and its dual role in adaptation and cell death,
particularly in conditions of nutrient deprivation and degenerative diseases.

Autophagy (from the Greek auto- meaning “self” and phagy meaning “eating”) is a highly conserved
catabolic process by which cells degrade and recycle their own intracellular components through
lysosomal pathways. It is a critical survival mechanism during periods of nutrient deprivation and cellular
stress, and also plays a role in development, immunity, aging, and disease pathogenesis.

Mechanism of Autophagy
The process of autophagy proceeds in three major steps:

1. Initiation and formation of isolation membrane (phagophore):

○ Stimulated by stress conditions such as nutrient deprivation.
○ Controlled by the mTOR (mechanistic target of rapamycin) pathway, which inhibits
autophagy under nutrient-rich conditions.

2. Elongation and formation of autophagosome:

○ Cytoplasmic organelles or proteins are enclosed in a double-membraned vesicle called the
autophagosome.

3. Fusion with lysosome and degradation:

○ The autophagosome fuses with a lysosome to form an autolysosome, where contents are
degraded by acid hydrolases.
○ The breakdown products are released into the cytosol for reuse (e.g., amino acids, fatty acids,
nucleotides).

Types of Autophagy
1. Macroautophagy: Major form involving the formation of autophagosomes.
2. Microautophagy: Direct lysosomal engulfment of cytoplasmic material.
3. Chaperone-mediated autophagy: Selective degradation of soluble proteins with the help of
chaperones and specific lysosomal receptors.

Physiologic Roles of Autophagy

1. Adaptation to Nutrient Deprivation:
○ Under starvation, autophagy provides internal sources of nutrients by degrading cellular
components to sustain essential metabolic functions.
○ Especially critical in early neonatal life, fasting states, and some disease conditions.

2. Organelle Quality Control:

○ Removes damaged or superfluous organelles (e.g., mitophagy removes dysfunctional
mitochondria).
○ Prevents accumulation of defective components that can generate reactive oxygen species
(ROS) or misfolded proteins.

3. Host Defense:
○ Autophagy eliminates intracellular pathogens (e.g., Mycobacterium tuberculosis), contributing to
innate immunity.
Autophagy in Cell Death
Though autophagy is primarily cytoprotective, excessive or dysregulated autophagy can lead to a form of
cell death known as autophagic cell death (type II programmed cell death). Unlike apoptosis (type I) and
necrosis, autophagic cell death is characterized by extensive autophagic vacuolization of the cytoplasm
without chromatin condensation.

● Occurs when the balance between degradation and synthesis is disrupted.

● The threshold between adaptive autophagy and destructive autophagy is context-dependent and
incompletely understood.

Pathophysiologic Relevance of Autophagy

1. Nutrient Deprivation
● In nutrient-deficient states, autophagy is upregulated to maintain energy homeostasis.
● Mice deficient in autophagy-related genes (e.g., Atg5 or Atg7) show rapid tissue degeneration upon
fasting.

2. Neurodegenerative Diseases
● Alzheimer's disease, Parkinson’s disease, Huntington’s disease, and amyotrophic lateral
sclerosis (ALS) are associated with accumulation of misfolded or aggregated proteins, which are
normally cleared by autophagy.
● Impaired autophagy contributes to proteinopathy and neuronal dysfunction.

3. Cancer
● Dual role:

○ Tumor suppression: Removes damaged organelles, limits genomic instability, and prevents
chronic inflammation.
○ Tumor promotion: Established tumors may exploit autophagy to survive in hypoxic or nutrient-
poor environments.

4. Infections
● Autophagy restricts intracellular replication of certain microbes.
● Some pathogens (e.g., Shigella, Legionella) have evolved mechanisms to evade or inhibit autophagic
degradation.

5. Aging and Longevity

● Decline in autophagic efficiency is linked to aging.
● Enhancing autophagy (e.g., via caloric restriction) has been shown to extend lifespan in model
organisms.

Morphologic Features of Autophagy

● Presence of cytoplasmic vacuoles containing fragments of organelles.
● Electron microscopy shows double-membrane autophagosomes.
● Lack of nuclear fragmentation or inflammation (unlike apoptosis or necrosis).
 III. Mechanisms of Cell Injury
9. Describe the major mechanisms of cell injury, including:

○ Mitochondrial dysfunction and ATP depletion

Mitochondria are critical for energy (ATP) production through oxidative phosphorylation. Injury to mitochondria
or conditions that impair ATP synthesis (e.g., hypoxia, toxins, increased cytosolic Ca²⁺, oxidative stress)
compromise cell viability.

Key Consequences:
● Failure of energy-dependent processes, such as membrane transport, protein synthesis, and lipid
metabolism.
● Disruption of ion gradients, leading to cellular swelling due to Na⁺ and water influx.
● Detachment of ribosomes from the rough endoplasmic reticulum, inhibiting protein synthesis.
● Opening of the mitochondrial permeability transition pore (MPTP), causing loss of membrane
potential and further ATP decline.
● Release of pro-apoptotic proteins, such as cytochrome c, initiating apoptosis.

ATP depletion to less than 5–10% of normal levels is particularly catastrophic and typically leads to irreversible
injury.

○ Membrane damage

Loss of membrane integrity—whether in the plasma membrane, mitochondrial membranes, or lysosomal

membranes—is a critical feature of irreversible cell injury.

Causes:
● ROS-induced lipid peroxidation
● Decreased phospholipid synthesis due to ATP depletion
● Phospholipid degradation by activated phospholipases
● Cytoskeletal damage caused by protease activation
● Physical injury or toxins

Consequences:
● Plasma membrane damage causes ion dysregulation and influx of Ca²⁺ and water.
● Mitochondrial membrane damage leads to loss of ATP generation and leakage of apoptotic proteins.
● Lysosomal membrane damage results in the release of lytic enzymes into the cytosol, degrading
cellular components and accelerating necrosis.
○ Loss of calcium homeostasis

Intracellular calcium is normally maintained at very low cytosolic concentrations, being sequestered in the
mitochondria and endoplasmic reticulum.

Pathogenic Role:
● Cell injury causes influx of Ca²⁺ from the extracellular space and release from internal stores.
● Elevated cytosolic Ca²⁺ activates a number of enzymes, including:
○ Phospholipases → membrane damage
○ Proteases → cytoskeletal breakdown
 ○ Endonucleases → DNA fragmentation
○ ATPases → worsening ATP depletion
○ Mitochondrial permeability transition is triggered, leading to loss of membrane potential and
pro-apoptotic signaling.

Thus, loss of calcium homeostasis contributes to both necrosis and apoptosis.

○ Oxidative stress and free radical generation

Reactive oxygen species (ROS) are produced during normal mitochondrial respiration and are usually
neutralized by antioxidants. However, excessive ROS production or defective removal results in oxidative
stress.

Major ROS:
● Superoxide anion (O₂•⁻)
● Hydrogen peroxide (H₂O₂)
● Hydroxyl radical (•OH) — most reactive

Sources of ROS:
● Mitochondrial electron transport chain
● Inflammatory cell activation (e.g., neutrophils, macrophages)
● Enzymatic metabolism of exogenous chemicals
● Radiation and ischemia-reperfusion injury

Pathologic Effects:
● Lipid peroxidation → membrane damage
● Protein modifications → misfolding, loss of function
● DNA damage → mutations and apoptosis

Antioxidants (e.g., glutathione, vitamins E and C) and enzymes (e.g., superoxide dismutase, catalase,
glutathione peroxidase) protect against ROS damage.

○ DNA and protein damage

Injury to DNA and proteins can be induced by:

● Radiation
● Chemotherapeutic agents
● ROS
● Errors in metabolism

DNA Damage:
● Triggers cellular DNA repair pathways.
● If damage is excessive or repair fails, it leads to apoptosis, often via p53 activation.

Protein Damage:
● Accumulation of misfolded or aggregated proteins impairs cellular function.
● Misfolded proteins activate endoplasmic reticulum (ER) stress and the unfolded protein response
(UPR), leading to either adaptive or apoptotic outcomes.

Persistent damage beyond repair capacity typically results in cell death, often by apoptosis.
 ○ Endoplasmic reticulum (ER) stress and the unfolded protein response

The ER is responsible for proper protein folding. Accumulation of unfolded or misfolded proteins causes ER
stress, which activates the unfolded protein response (UPR) to restore normal function.

Adaptive UPR Mechanisms:

● Decrease overall protein synthesis.
● Increase chaperone production (e.g., BiP/GRP78) to assist protein folding.
● Enhance protein degradation through proteasomes.

Transition to Apoptosis:
● If the adaptive response fails and stress persists:
○ Activation of pro-apoptotic pathways (e.g., CHOP, caspases).
○ Contributes to degenerative diseases (e.g., Alzheimer’s, Huntington’s), diabetes mellitus, and
ischemic injury.

10. Explain oxidative stress, including the sources, types, and pathologic effects of reactive oxygen
species (ROS), as well as the body’s antioxidant defenses.

Oxidative stress refers to a state in which the production of reactive oxygen species (ROS) exceeds the
capacity of the cell’s antioxidant defense systems to neutralize them. This imbalance leads to oxidative
damage of cellular components including lipids, proteins, and nucleic acids. Oxidative stress is implicated in
the pathogenesis of various conditions, including cancer, neurodegenerative diseases, ischemia-reperfusion
injury, and aging.

Sources of Reactive Oxygen Species (ROS)

ROS are chemically reactive molecules containing oxygen, generated both under physiologic and pathologic
conditions:

1. Mitochondrial respiration (physiologic): Partial reduction of oxygen during oxidative phosphorylation

generates superoxide (O₂•⁻), which is normally converted to less harmful species.
2. Enzymatic reactions: Enzymes like cytochrome P450, xanthine oxidase, and nitric oxide synthase
produce ROS during metabolism of drugs and toxins.
3. Inflammatory cells: Activated leukocytes (especially neutrophils and macrophages) produce ROS via
the NADPH oxidase system as part of the respiratory burst to kill pathogens.
4. Ionizing radiation: Splits water into hydroxyl radicals (•OH), a highly reactive ROS.
5. Metabolism of exogenous chemicals: Certain drugs, toxins, and carcinogens can undergo redox
cycling and ROS generation.
6. Reperfusion injury: Restoration of blood flow after ischemia increases oxygen supply, which
paradoxically results in a burst of ROS.

Types of Reactive Oxygen Species (ROS)

1. Superoxide anion (O₂•⁻): Generated in mitochondria; relatively weak but can be converted to more
potent species.
2. Hydrogen peroxide (H₂O₂): Produced by dismutation of superoxide via superoxide dismutase (SOD);
membrane-permeable and forms hydroxyl radicals via the Fenton reaction.
3. Hydroxyl radical (•OH): Most damaging ROS; formed from H₂O₂ in the presence of free iron (Fenton
reaction).
4. Peroxynitrite (ONOO⁻): Formed from nitric oxide (NO) and superoxide; damages lipids, proteins, and
DNA.
Pathologic Effects of ROS (Oxidative Damage)
ROS can injure cells through several mechanisms:

1. Lipid peroxidation of membranes: ROS attack double bonds in polyunsaturated fatty acids, initiating
autocatalytic chain reactions that disrupt membrane integrity, leading to increased permeability and loss
of function.
2. Protein modification: Oxidation of amino acid side chains alters enzyme activity and structural
proteins; formation of protein-protein cross-links may lead to misfolding or aggregation.
3. DNA damage: ROS cause single- and double-strand breaks, base modifications (e.g., 8-oxoG), and
cross-linking, potentially resulting in mutations, cell cycle arrest, or apoptosis.

Antioxidant Defense Systems

Cells utilize a combination of enzymatic and nonenzymatic antioxidants to neutralize ROS:

Enzymatic Antioxidants

● Superoxide dismutase (SOD): Converts superoxide into hydrogen peroxide.

● Catalase: Located in peroxisomes; converts H₂O₂ into water and oxygen.
● Glutathione peroxidase: Reduces H₂O₂ and lipid peroxides using reduced glutathione (GSH) as a
cofactor.

Nonenzymatic Antioxidants

● Glutathione (GSH): Tripeptide that acts as a reducing agent, especially in mitochondria.

● Vitamins E and C: Lipid- and water-soluble scavengers, respectively.
● Ferritin and transferrin: Bind free iron, preventing the Fenton reaction
● Uric acid, bilirubin: Additional scavengers of ROS.

IV. Clinicopathologic Correlations of Cell Injury

11. Outline the pathogenesis and progression of ischemic and hypoxic injury, including the concepts
of reversible injury, irreversible injury, and ischemia-reperfusion injury.

Hypoxia refers to reduced oxygen availability to tissues, which may occur due to decreased oxygen in the
blood or impaired oxygen delivery/utilization by cells.

Ischemia is a more severe form of hypoxia caused by reduced or interrupted blood flow, resulting in
decreased delivery of both oxygen and nutrients (e.g., glucose) and impaired removal of metabolic wastes.

● Ischemia generally causes more rapid and severe injury than hypoxia alone because of combined
oxygen and substrate deprivation.

Pathogenesis of Cell Injury in Hypoxia and Ischemia

The fundamental problem in hypoxic and ischemic injury is energy (ATP) depletion due to impaired oxidative
phosphorylation in mitochondria. The downstream effects include:

a. ATP Depletion

● ATP production falls rapidly when oxygen is insufficient.

● Energy-dependent cellular processes fail, including:
 ○ Na⁺/K⁺-ATPase pump dysfunction → sodium and water enter the cell → cell swelling
(hydropic change).
○ Ca²⁺ pump failure → intracellular calcium accumulation activates destructive
enzymes.
○ Reduced protein synthesis due to ribosome detachment.
● Anaerobic glycolysis compensates transiently, leading to lactic acid buildup → intracellular
acidosis, which further damages cell structures.

b. Mitochondrial Dysfunction

● Decreased ATP production worsens mitochondrial function.

● Opening of the mitochondrial permeability transition pore (MPTP) can occur, leading to loss of
mitochondrial membrane potential and release of pro-apoptotic proteins.

c. Membrane Damage

● Lipid peroxidation of membranes occurs due to ROS generation.

● Plasma membrane damage leads to loss of osmotic balance and leakage of intracellular enzymes.
● Lysosomal membrane rupture releases hydrolytic enzymes that digest cell components

Reversible vs. Irreversible Injury

● Reversible Injury: If oxygen and nutrient supply are restored early, cells can recover. Morphologic
features include:
○ Cellular swelling due to ionic imbalance.
○ Fatty change (steatosis) in cells involved in lipid metabolism.
○ Ultrastructural changes such as plasma membrane blebbing, mitochondrial swelling, and
dilation of the ER.

● Irreversible Injury: Prolonged ischemia leads to irreversible damage characterized by:

○ Severe mitochondrial damage (unable to generate ATP).
○ Massive influx of calcium activating destructive enzymes.
○ Extensive membrane damage causing leakage of cellular contents.
○ Nuclear changes: pyknosis (chromatin condensation), karyorrhexis (fragmentation), karyolysis
(dissolution).
○ Cell death via necrosis (and possibly apoptosis).

The point of no return depends on cell type and duration/severity of ischemia (e.g., neurons are more sensitive
than skeletal muscle).

Ischemia-Reperfusion Injury
Restoration of blood flow (reperfusion) after ischemia paradoxically can exacerbate injury by several
mechanisms:

● Generation of Reactive Oxygen Species (ROS)- Sudden oxygen availability leads to a burst of ROS
from mitochondria and activated inflammatory cells.
○ ROS cause lipid peroxidation, protein oxidation, DNA damage, and further membrane injury.
● Inflammatory Cell Activation- Neutrophils recruited to the site release proteases and ROS, worsening
tissue damage.
● Complement Activation- Enhances inflammation and cell injury
● Calcium Overload- Reperfusion causes rapid intracellular calcium influx, activating degradative
enzymes.

Ischemia-reperfusion injury is clinically relevant in myocardial infarction, stroke, organ transplantation, and
resuscitation after shock.
 Stage Features Outcome

Early reversible ATP depletion, cellular swelling, fatty change, Recovery possible with prompt
injury ultrastructural changes restoration of blood flow

Late irreversible Mitochondrial dysfunction, membrane rupture, Cell death by necrosis; tissue
injury nuclear changes, enzymatic digestion infarction

Reperfusion ROS generation, inflammation, calcium Exacerbation of injury, secondary

phase overload tissue damage

12. Describe the mechanisms of chemical (toxic) injury, distinguishing between direct toxicity and
metabolic activation of toxins, and provide examples (e.g., CCl₄, acetaminophen).

Chemical injury to cells occurs when exogenous substances disrupt normal cellular functions, leading to cell
damage or death. These injuries arise through two primary mechanisms:

1. Direct Toxicity
● In direct toxicity, the chemical itself is inherently reactive or interacts directly with critical cellular
components, causing damage without requiring metabolic modification.
● These chemicals can bind to membrane lipids, proteins, or DNA, disrupting their function and integrity.
● This direct interaction often leads to rapid and immediate cellular injury.

Examples:

● Mercuric chloride (HgCl₂): Binds sulfhydryl groups in proteins, impairing enzyme function.
● Cyanide: Binds cytochrome oxidase in mitochondria, inhibiting oxidative phosphorylation and ATP
production.

2. Metabolic Activation (Bioactivation) of Toxins

● Many chemicals are not directly toxic but require conversion into reactive metabolites by cellular
enzymes to exert their damaging effects.
● This metabolic activation usually occurs in the smooth endoplasmic reticulum, especially in the liver,
by the cytochrome P450 enzyme system.
● The reactive metabolites can bind covalently to cellular macromolecules (proteins, lipids, DNA), leading
to oxidative stress, membrane damage, and cell death.

Examples Illustrating These Mechanisms

Carbon Tetrachloride (CCl₄)
● Mechanism: Metabolic activation.
 ● CCl₄ is inert itself but is metabolized by hepatic cytochrome P450 enzymes to form the highly reactive
trichloromethyl free radical (CCl₃•).
● This radical initiates lipid peroxidation of the smooth endoplasmic reticulum membranes, disrupting
membrane integrity and function.
● The result is cell swelling, membrane damage, and leakage of enzymes, leading to hepatocyte
necrosis.
● CCl₄ injury also impairs protein synthesis, further damaging the liver.
● Clinically, this manifests as centrilobular hepatic necrosis and fatty change (steatosis).

Acetaminophen (Paracetamol)
● Mechanism: Metabolic activation leading to toxicity.
● At therapeutic doses, acetaminophen is mainly conjugated and eliminated safely.
● In overdose, excess acetaminophen is metabolized by cytochrome P450 enzymes to the reactive
intermediate N-acetyl-p-benzoquinone imine (NAPQI).
● Normally, NAPQI is detoxified by conjugation with glutathione.
● When glutathione stores are depleted, NAPQI binds covalently to cellular proteins and lipids, causing
oxidative stress and massive hepatocyte necrosis, particularly in the centrilobular region.
● This is clinically significant as acute liver failure.

Mechanism Description Example

Direct toxicity Chemical directly injures cellular Cyanide, mercuric chloride

components

Metabolic Chemical metabolized into reactive CCl₄ (free radical formation),

activation intermediates causing injury Acetaminophen (NAPQI)

V. Cellular Adaptations
13. Define and differentiate the major forms of cellular adaptation:
● Hypertrophy: mechanisms and examples (e.g., myocardial hypertrophy)
● Hyperplasia: physiologic vs. pathologic
● Atrophy: mechanisms and clinical relevance
● Metaplasia: common types and potential for progression to dysplasia and cancer

Cells adapt to changes in their environment or stress through reversible changes in size, number, or type,
aimed at maintaining homeostasis. The principal forms of adaptation include hypertrophy, hyperplasia, atrophy,
and metaplasia.

1. Hypertrophy
Definition:
Hypertrophy is an increase in the size of cells, resulting in an enlargement of the affected tissue or organ. It
occurs in cells incapable of division (e.g., cardiac muscle cells).

Mechanisms:
 ● Hypertrophy is driven by increased synthesis of cellular proteins and organelles to support the greater
functional demand.
● Key signaling pathways involve:
○ Activation of mechanical sensors (e.g., stretch receptors).
○ Growth factors (e.g., insulin-like growth factor 1, transforming growth factor-β).
○ Intracellular signaling cascades (e.g., phosphoinositide 3-kinase/Akt pathway).
● These lead to increased transcription and translation of genes encoding contractile proteins and
structural components.

Examples:

● Myocardial hypertrophy:
○ Occurs in response to increased workload, such as hypertension or valvular heart disease.
○ Initially compensatory to enhance cardiac output.
○ Can be concentric (pressure overload) or eccentric (volume overload).
○ Pathologic hypertrophy can progress to heart failure.

2. Hyperplasia
Definition:
Hyperplasia is an increase in the number of cells in a tissue or organ due to increased cell proliferation. It
occurs only in cells capable of division.

Types:

● Physiologic hyperplasia:
○ Hormonal hyperplasia: e.g., proliferation of glandular epithelium of the female breast at puberty
and during pregnancy.
○ Compensatory hyperplasia: e.g., regeneration of liver after partial hepatectomy.
● Pathologic hyperplasia:
○ Excessive hormonal stimulation or growth factors.
○ Example: endometrial hyperplasia caused by prolonged estrogen stimulation.
○ May predispose to neoplasia but itself is a controlled and reversible process.

3. Atrophy
Definition:
Atrophy is the reduction in the size and function of a cell, tissue, or organ due to loss of cell substance.

Mechanisms:

● Decreased protein synthesis and increased protein degradation by ubiquitin-proteasome pathway.

● Autophagy (self-digestion) of cellular components in lysosomes.
● Often results from diminished workload, loss of innervation, decreased blood supply, inadequate
nutrition, aging, or pressure.

Clinical Relevance:

● Muscle atrophy after immobilization or nerve injury.

● Cerebral atrophy in neurodegenerative diseases.
● Endometrium atrophy after menopause.

4. Metaplasia
Definition:
Metaplasia is a reversible change in which one differentiated cell type is replaced by another cell type better
able to withstand the adverse environment.

Common Types:

● Squamous metaplasia:
○ Columnar epithelium replaced by stratified squamous epithelium.
○ Seen in respiratory tract of smokers.
● Barrett esophagus:
○ Squamous epithelium replaced by intestinal-type columnar epithelium due to chronic acid reflux.

Potential for Progression:

● While metaplasia is adaptive, chronic stress may lead to genetic mutations.

● This can progress to dysplasia (disordered growth and differentiation), which is a precancerous state.
● For example, Barrett esophagus can progress to esophageal adenocarcinoma.

Adaptation Definition Mechanism Examples/Clinical Relevance

Hypertrophy Increase in cell size Increased protein synthesis via Myocardial hypertrophy due to
growth pathways hypertension

Hyperplasia Increase in cell Increased cell proliferation via Physiologic: breast

number hormonal or growth factors enlargement; Pathologic:
endometrial hyperplasia

Atrophy Decrease in cell Decreased protein synthesis, Muscle atrophy after

size and function increased degradation denervation; brain atrophy
(proteasome, autophagy)

Metaplasia Replacement of one Reprogramming of stem cells Squamous metaplasia in

cell type by another to more resistant phenotype smoker’s airway; Barrett
esophagus

VI. Intracellular Accumulations and Pathologic Calcification

14. Describe the major types of intracellular accumulations (lipids, proteins, glycogen, pigments), their
causes, and pathologic consequences. Provide clinical examples such as steatosis, cholesterol
accumulation, and hemosiderin deposition.

Intracellular accumulations refer to the buildup of various substances within the cytoplasm or nucleus of cells.
These may result from metabolic derangements, defects in protein folding or transport, enzyme deficiencies, or
excessive uptake of substances. Accumulations can be transient and reversible or lead to cellular dysfunction
and disease.

1. Lipid Accumulations
Types and Causes:

● Steatosis (fatty change):

○ Accumulation of triglycerides within parenchymal cells, especially hepatocytes.
○ Caused by alcohol abuse, diabetes mellitus, obesity, and toxins.
○ Mechanisms include increased free fatty acid delivery, impaired oxidation, and decreased
apoprotein synthesis.
● Cholesterol and Cholesterol Esters:
○ Accumulate in macrophages and other cells.
○ Seen in atherosclerosis (foam cells), xanthomas, and cholesterolosis of the gallbladder.

Pathologic Consequences:

● Steatosis may cause reversible cell injury but chronic accumulation can lead to inflammation, fibrosis,
and organ dysfunction.
● Cholesterol accumulation contributes to plaque formation and vascular disease.

Clinical Example:

● Hepatic steatosis: Common in alcoholic liver disease and nonalcoholic fatty liver disease.
● Atherosclerosis: Foam cells laden with cholesterol in arterial intima.

2. Protein Accumulations
Causes and Mechanisms:

● Excessive synthesis or defective secretion of proteins (e.g., Russell bodies in plasma cells).
● Defects in protein folding, leading to accumulation of misfolded proteins.
● Impaired degradation of proteins by proteasomes or lysosomes.

Pathologic Consequences:

● May cause cellular dysfunction and stress, including ER stress.

● In some diseases, protein aggregates are toxic (e.g., neurodegenerative diseases).

Clinical Example:

● Russell bodies: Eosinophilic inclusions in plasma cells due to immunoglobulin accumulation.

● Alpha-1 antitrypsin deficiency: Accumulation of misfolded protein in hepatocytes causing liver
disease.

3. Glycogen Accumulations
Causes:

● Excessive or abnormal glycogen deposition in cells.

● Seen in glycogen storage diseases due to enzyme deficiencies.
● Can occur in poorly controlled diabetes mellitus due to increased glucose availability.

Pathologic Consequences:

● Usually does not cause significant cell injury but may distort cellular architecture.

Clinical Example:

● Glycogen storage diseases: Various enzyme defects leading to hepatomegaly and muscle weakness.
● Diabetic nephropathy: Glycogen accumulation in renal tubular cells.
4. Pigment Accumulations
Types:

● Endogenous Pigments:
○ Lipofuscin:
■ "Wear-and-tear" pigment, a product of lipid peroxidation.
■ Accumulates in aging cells, especially heart and liver.
■ Usually inert, but indicates past oxidative injury.
○ Hemosiderin:
■ An iron-containing pigment derived from hemoglobin breakdown.
■ Accumulates in macrophages in cases of hemorrhage, hemolysis, or iron overload.
● Exogenous Pigments:
○ Carbon (anthracotic pigment):
■ Inhaled environmental pollutant, accumulates in lung macrophages.

Pathologic Consequences:

● Pigment accumulation can indicate prior injury or systemic disease.

● Excess hemosiderin deposition (hemosiderosis) may cause tissue damage through iron-catalyzed free
radical formation.

Clinical Examples:

● Hemosiderin deposition:
○ In bruises (resorption of hemorrhage).
○ Systemic iron overload diseases (hemochromatosis).
● Anthracosis:
○ Black pigmentation in lungs of urban dwellers and smokers.

Accumulation Composition Causes/Mechanism Clinical Example Pathologic

Type Consequence

Lipids Triglycerides, Metabolic derangement, Hepatic steatosis, Cell dysfunction,

cholesterol toxins, increased uptake atherosclerosis inflammation

Proteins Misfolded or Defective secretion, Russell bodies, alpha- ER stress,

excess proteins folding defects 1 antitrypsin deficiency toxicity

Glycogen Glycogen Enzyme defects, excess Glycogen storage Usually benign,

glucose diseases, diabetes possible
distortion

Pigments Lipofuscin, Aging, hemorrhage, Aging cells, bruises, Tissue damage

hemosiderin, environmental hemochromatosis, (iron overload)
carbon anthracosis
 15. Differentiate between dystrophic and metastatic calcification, including their mechanisms and
clinical implications.

Dystrophic Calcification
● Deposition of calcium salts in dead or dying tissues, despite normal serum calcium and phosphate
levels.

Mechanism:

● Occurs locally at sites of tissue injury or necrosis.

● Damaged or necrotic cells release intracellular calcium and phosphates.
● Membrane-bound vesicles from dead cells serve as nucleation sites for calcium phosphate
crystallization.
● Local factors such as altered pH and increased phosphatase activity promote mineralization.
● Serum calcium levels remain normal; systemic calcium metabolism is not disturbed.

Common Sites and Causes:

● Areas of caseous necrosis in tuberculosis.

● Atherosclerotic plaques.
● Damaged heart valves.
● Infarcted myocardium.
● Old thrombi.

Clinical Implications:

● Usually indicates previous tissue injury.

● May cause organ dysfunction if extensive (e.g., valvular calcification leading to stenosis).
● Can be detected radiographically and sometimes mistaken for tumors.

Metastatic Calcification
● Deposition of calcium salts in otherwise normal tissues due to hypercalcemia or abnormalities in
calcium-phosphate metabolism.

Mechanism:

● Elevated serum calcium and/or phosphate levels lead to precipitation of calcium phosphate in tissues.
● Causes of hypercalcemia include:
○ Hyperparathyroidism (primary or secondary).
○ Vitamin D intoxication.
○ Sarcoidosis (granulomatous diseases producing vitamin D).
○ Bone destruction (e.g., multiple myeloma, metastases).
○ Renal failure (leading to secondary hyperparathyroidism and phosphate retention).
● Calcification tends to occur in tissues that lose acid quickly (alkaline environment), such as lungs,
kidneys, gastric mucosa, and blood vessels.

Common Sites:

● Kidney tubules and interstitium.

● Pulmonary alveoli.
● Gastric mucosa.
● Blood vessel walls.
Clinical Implications:

● May impair organ function depending on extent and site.

● Indicates systemic disturbance of calcium metabolism.
● Requires investigation and management of underlying hypercalcemia.

Feature Dystrophic Calcification Metastatic Calcification

Serum Calcium Normal Elevated (hypercalcemia)

Tissue Involved Dead or necrotic tissues Normal tissues

Mechanism Local calcium phosphate precipitation Deposition due to increased serum

at sites of injury or necrosis calcium/phosphate levels

Common Sites Areas of necrosis, atherosclerotic Kidney, lungs, gastric mucosa, blood vessels
plaques, valves, infarcts

Clinical Marker of tissue damage; may cause Sign of systemic calcium metabolism
Significance organ dysfunction disorder; may impair organ function

VII. Cellular Aging

16. Explain the mechanisms of cellular aging, including telomere shortening, DNA damage
accumulation, defective protein homeostasis, and the role of nutrient sensing pathways (e.g.,
insulin/IGF signaling, mTOR).

Cellular aging is a complex, multifactorial process characterized by the progressive decline in cellular function
and regenerative capacity, eventually leading to organismal aging and increased vulnerability to disease.
Several interconnected mechanisms contribute to cellular aging, including genetic and environmental factors.

1. Telomere Shortening
● Telomeres are repetitive nucleotide sequences at chromosome ends that protect chromosomal DNA
from degradation and prevent end-to-end fusion.
● During each round of DNA replication, the DNA polymerase cannot fully replicate the ends of linear
chromosomes, causing progressive telomere shortening.
● When telomeres reach a critically short length, cells enter replicative senescence or undergo apoptosis
to prevent genomic instability.
● Telomerase, an enzyme that elongates telomeres, is active in germ cells and some stem cells but not in
most somatic cells.
● Telomere shortening is a key molecular clock limiting cellular replicative potential.

2. DNA Damage Accumulation

 ● DNA damage occurs continuously due to endogenous metabolic byproducts (e.g., reactive oxygen
species), environmental insults (UV, radiation), and replication errors.
● Although DNA repair mechanisms exist, the efficiency declines with age.
● Accumulated DNA damage leads to mutations, genomic instability, and altered gene expression,
promoting cellular dysfunction.
● Persistent DNA damage can trigger cellular senescence or apoptosis, limiting tissue renewal.

3. Defective Protein Homeostasis (Proteostasis)

● Proteostasis involves the synthesis, folding, trafficking, and degradation of proteins to maintain cellular
function.
● Aging impairs molecular chaperones and proteolytic systems such as the ubiquitin-proteasome
pathway and autophagy.
● This leads to accumulation of misfolded, aggregated, or damaged proteins, contributing to cellular
toxicity.
● Protein aggregates are characteristic in age-related diseases such as Alzheimer’s and Parkinson’s.

4. Nutrient Sensing Pathways

● Cellular aging is modulated by conserved nutrient-sensing pathways that regulate metabolism, growth,
and stress responses.
● Key pathways include:
○ Insulin/Insulin-like Growth Factor (IGF) Signaling:
■ Downregulation of this pathway is associated with increased lifespan in model
organisms.
■ Reduced IGF signaling enhances stress resistance and promotes maintenance
mechanisms.
○ Mechanistic Target of Rapamycin (mTOR):
■ mTOR integrates nutrient availability and growth signals.
■ Increased mTOR activity promotes growth and protein synthesis but reduces autophagy.
■ Inhibition of mTOR (e.g., by rapamycin) extends lifespan in animal models by enhancing
autophagy and reducing cellular stress.
● These pathways balance growth and repair processes, and their dysregulation contributes to aging
phenotypes.

Additional Mechanisms (Brief Mention)

● Mitochondrial Dysfunction: Increased production of reactive oxygen species and impaired energy
metabolism.
● Epigenetic Alterations: Changes in DNA methylation and histone modifications affecting gene
expression.
● Stem Cell Exhaustion: Reduced regenerative capacity of tissues due to stem cell aging.

Mechanism Description Effect on Aging

Telomere Shortening Progressive loss of chromosome end caps Cellular senescence and
limiting replication limited proliferation

DNA Damage Persistent DNA lesions due to reduced repair Genomic instability,
Accumulation efficiency senescence, apoptosis

Defective Impaired protein folding and degradation leading Cellular dysfunction and
Proteostasis to toxic aggregates toxicity
Nutrient Sensing Dysregulated insulin/IGF and mTOR pathways Altered growth, reduced
Pathways affecting metabolism and stress responses autophagy, aging